Friday, 29 August 2014

Working together to save mothers and babies in Sulawesi

Ratna with her son Ralvin at the local health centre in Galesong
©UNICEF Indonesia/2014/Ramadana
GALESONG, South Sulawesi, August 2014 - It was ten o’clock at night when Ratna Adam started to feel labour pains. She was at home in the seaside village of Galesong, Takalar District in South Sulawesi. Her fisherman husband was away working in Kalimantan, so the first person she called was Basse Cama, a Traditional Birth Attendant (TBA).

Ibu Basse has been helping women in Galesong give birth for 33 years and is a respected member of the community. She lives about a five minute walk from Ratna, so she hurried over to help the expectant mother.

Reassured by the older woman’s presence, Ratna agreed with her suggestion that it was time to seek help at the local health centre. Ratna had a seven year old daughter, but her second pregnancy had ended in a still birth so she was anxious that this time round, everything should go smoothly. Ibu Basse found a motorised rickshaw to take them to the clinic, and soon the women were on their way.

At the health centre they were greeted by Syarhruni, a young midwife who was on duty that night. Ratna’s baby was in the breech position – with its legs instead of its head pointing down. After two hours of contractions, one of the baby’s feet had appeared but Syarhruni could see that Ratna was making little further progress in her labour, so she decided she should be transferred to a hospital.

With red lights blazing, Ratna was rushed by ambulance to Takalar hospital, a half hour drive away. Ibu Basse stayed by her side, massaging her swollen belly and reassuring her that everything would be alright.

“I believe her presence brought me good luck and she helped to take away some of my pain,” says Ratna about Ibu Basse.

Trusted Presence
A few years ago, women in Galesong relied entirely on TBAs to help them through labour. The TBAs provided moral support and their birth rituals, like massaging the mother’s belly, were thought to ensure a smooth delivery.

Older and more familiar than the young, new midwives who came to the village, the TBAs were trusted by mothers. But they didn’t know how to spot the signs of a complication in delivery, like eclampsia or a breech birth. Nor would they routinely seek assistance from others, particularly health care providers.

The Ministry of Health, supported by development partners like UNICEF has been working to change this. In 2007, they initiated a programme that brought together midwives and TBAs from five health centres in two sub-districts of Takalar for a joint training programme to get them working together for improved women’s health. The TBAs were shown how to recognise danger signs in pregnancy and labour, and were trained in the importance of persuading pregnant women to see a midwife.

The midwives were taught that the TBAs could help them to reach more women and make sure they attended deliveries.

The TBAs and midwives in Galesong now work together and complement each other’s skills to help pregnant mothers – the midwives bring their up-to-date technical skills and the TBAs bring their long-established links and credibility in the community.

Around 12 women used to die every year in Takalar district due to complications in pregnancy and childbirth. Since the training programme began in 2007, that number has dropped to zero.

The programme has also been expanded at national level as it is a first step to improve the uptake of maternal and newborn health care service in the puskesmas (health centres). It has been included as a minimum service standard in puskesmas for the maternal health programme.

The referral system in Takalar is still not perfect. After half an hour in the ambulance, Ratna and Ibu Basse reached Takalar hospital but they were greeted by bad news. The obstetrics specialist was away and there was no-one there with enough expertise to help.

By this point, both the baby’s legs were visible but its body seemed stuck. The women got back in the ambulance and headed back through Galesong and onwards to the city of Makassar.

An hour later, they reached the hospital there, and with the help of expert care and oxygen, Ratna was able to deliver her baby boy naturally. Ralvin was born at 2.30am.

Baby Ralvin with (from left to right) his father, mother and TBA Ibu Basse
©UNICEF Indonesia/2014/Ramadana

There may still be glitches in the referral system but thanks to the collective efforts of Ibu Basse and Syarhruni, Ratna received medical care in time.

Two months later, Ratna and Ralvin are doing well. “I think Ibu Basse helped to bless my delivery,” says Ratna. “I couldn’t have done it without her.”