Introduction
One of the millennium development goals (MDGs) is to have lower than 102 maternal deaths for each 100,000 live births in every nation across the globe by 2015. In 1991, Indonesia recorded 390 maternal deaths in every 100,000 live births, 228 deaths in 2007, and 220 fatalities in 2010 (Belton, Myers & Ngana, 2014). By 2012, Indonesia had a risk of one maternal death in every 150 women.
This figure was the highest in Southeast Asia compared to one risk in every 4000 women in developed countries (Webster, 2012). Informed by these statistical observations, this paper claims that Indonesia lags in terms of attaining the MDGs on maternal health. This situation requires urgent government intervention that addresses economic constraints and cultural beliefs that limit accessibility to quality maternal healthcare.
The Millennium Development Goals
In 2000, the UN member states ratified the millennium development goals (MDGs). The deadline for achieving the eight MDGs was set as 2015. The deliverables include suppression of famine and scarcity of resources, achievement of worldwide O-level schooling, recognition and upgrading of feminine positions, and encouragement of gender parity. They also include a decrease of babyhood death, improving motherly wellbeing, addressing the issue of sicknesses such as HIV/AIDS and malaria, augmentation of ecological sustainability, and the enlargement of comprehensive network to advance shared expansion of nations (United Nations, 2014).
With only one year remaining to the 2015 deadline, the United Nations (2014) reports that many of the goals have been met. However, others such as maternal health are yet to be realised, especially in low-income and developing nations such as Indonesia.
In 1990, about half of people living in developing nations earned less than $1.25 every day. However, the United Nations (2014) confirms that a significant reduction of extreme poverty has been achieved. By 2010, the number of people earning less than $1.25 reduced by 22%, which is equivalent to 700 million people. The target of the MDGs was to reduce extreme poverty by half. Between 2011 and 2013, 173 million lesser people suffered chronic hunger compared to the situation during 1990 and 1992 (The United Nations, 2014).
Indeed, the very primary goal for MDGs was met in 2010. Goal number 2, which enhances access and completion of primary schooling for all children, faces challenges since some children live in war torn areas. Indeed, not even one nation has reached a 100% mark, although North Africa recorded 99% enrolment by 2012 (The United Nations, 2014).
Although goal three was to eliminate disparities in terms of access to secondary and primary level education by 2005, and at all educational levels by 2015, the United Nations (2014) reports that there are still high disparities in higher institutions of learning. Women are generally underrepresented not only in the labour markets but also in political participation. However, significant progress continues to be achieved (The United Nations, 2014).
The target for a reduction of infant mortality by more than two-thirds has not yet been achieved. However, in 2012, infant mortality reduced by more than half of the 1990 levels. Apart from environmental sustainability, the world has made incredible efforts towards the achievement of the other MDGs. However, success in achieving the goals is not homogenous across all nations. Some nations are still struggling with problems that are targeted by MDGs. For example, maternal health is now an issue of national focus in Indonesia.
Progress towards a Promotion of Maternal Health in Indonesia
Maternal health refers to women’s health during pregnancy before and after childbirth. It includes perspectives such as family planning, postnatal, prenatal, and preconception care in the effort to lower maternal mortality and maternal morbidity (Bernstein, Say & Chowdhury, 2008). From the goal of reduction of maternal mortality by 102 in every 100, 000 live births, it implies that low maternal mortality rates indicate improved maternal health. In Indonesia, historical, cultural, and structural factors can reveal the lagging state of the nation in terms of achievement of the millennium development goal on maternal health.
Historically, Indonesian women used traditional birth assistants who resided within their communities. However, increased integration of Indonesians with other nations has fostered change in the historical approach to child delivery. The major driving force includes the increasing literacy level, which erodes the traditional myth about the roles of village-based midwives and health care services that are provided by the government of Indonesia through the ministry of health.
To curb the high maternal mortality rates, the government initiated the village midwifery services programme in 1989 (Immpact 2007). The programme aimed at placing trained midwives in all villages to facilitate safe child delivery, which would in turn reduce maternal mortality. However, Titaley, Hunter, Dibley, and Heywood (2010) confirm that some people, especially in the rural areas prefer traditional midwives to trained midwives who are placed in every village.
Nevertheless, the increasing interaction of Indonesians with the global communities helps create a cultural change so that seeking professional child delivery services can change from being a reserve for the rich to an activity that captures even low socioeconomic people in the Indonesian rural areas. Increased deliveries under the care of trained health professionals provide evidence concerning this perception shift (Titaley et al., 2010).
Several elements constitute the structural factors that influence maternal health in any nation. They include relatives, administration, financial system, job status, schooling, health systems, rural/urban populace structure and transport, civilisation, built surroundings, public health infrastructure, sexual characteristics, religious beliefs, social hierarchies, and housing among others. Among these factors, the government, job situation, health systems, rural/ urban population arrangement, and community health infrastructure are crucial in influencing maternal health in the Indonesian context.
Indonesia has an elected constitutional republic form of government. The nation has a democratic political system. The government develops and implements policies that lead to better health outcomes. It prioritises the provision of various public goods, including education and health. Indonesian government investments in various programmes, which promote maternal health such as desa siaga, tabulin, and village midwifery programmes, support this assertion (Titaley et al., 2010). In 2012, the government also identified maternal health as an issue of public focus (Webster, 2012).
In terms of earning and employment, the industrial sector is the leading contributor of the country’s GDP. In this sector, manufacturing and mining comprise the leading employers akin to the high possession of oil and various mineral resources. Employment opportunities are available in the fabric, shoe, electronic, gold mining, coal mining, oil mining, and vehicle companies among others (Indonesia Investments, 2014). However, based on the World Bank’s statistics, the nation has an uneven distribution of wealth. 16% of Indonesians survived on lower than $1.25 by 2011 while 43% relied on lower than $2 (South China Morning Post, 2014). Indeed, South China Morning Post (2014) informs that income disparity index rose from 0.35 in 2005 to 0.41 in 2012. It was above the 0.40 mark that is necessary to cause social unrest according to the UN.
Health systems and public health infrastructure plays critical roles in enhancing maternal health. Unfortunately, Indonesia has a poor distribution of health care providers and shortage of caregivers. In fact, the few available caregivers possess poor qualifications (Agus, Horiuchi & Porter, 2012). Indeed, even with government interventions such as the village midwifery programme, poor healthcare system and structure complicates the challenge of addressing maternal health. Webster (2012) asserts that the government has privatised the training of village midwives. The situation has led to poor training and corruption during the offering of certificates to the trainees.
Unqualified people can also purchase practice licenses (Webster, 2012). Many of the poor folks reside in countryside regions. The urban pupation is mostly composed of the working class. Many of the village midwives prefer living in urban areas. This case has led to one resident midwife serving more than five villages in some regions (Bernstein, Say & Chowdhury, 2008). The rural urban population structure is fragmented in terms of socioeconomic status.
Indonesia has a population of about 240 million people who occupy in excess of 17, 000 islands. It ranks third in terms of the most populous nations across the globe. A large population implies diversity in terms of belief, traditions, linguistics, and customs. These differences range from the Hindu ritual that is practiced in Bali Island to compliance with Sharia law in Sumatra. Traditional system of beliefs, Christianity, and Buddhism also constitute the main religious affiliations. Before the establishment of a common Indonesian nationalism that is driven by national motto (Tunggal Ika), people’s ways of life were shaped by different political, economic, and social histories (South China Morning Post, 2014).
Tunggal Ika, which is translated as unity in diversity, recognises the role of cultural diversities in shaping the Indonesian spirit of nationalism. Cultural beliefs influence maternal health in terms of the place where women deliver. Among rural residents in Java, the traditional belief that women should deliver at home under the care of traditional midwife persists (Titaley et al., 2010). Indeed, rural Muslim women of Bali believe that pregnancy constitutes a normal life cycle for any woman and that seeking the help of paraji during delivery is a necessary cultural requirement (Agus, Horiuchi & Porter, 2012).
Analysis/discussion
Several factors influence the ability of Indonesia to meet the millennium development goals of reducing maternal mortality to 102 deaths per 100,000 live births. From the sociological imagination template, historical, cultural, and structural factors are essential determinants of improved maternal health in Indonesia. The factors that mostly affect the capacity of Indonesia to achieve the MDGs target are the ones, which hinder or limit accessibility to quality maternal care. They include cultural beliefs and economic wellbeing of the citizens (Spector, Agrawal, Kodkany, Lipsitz, Lashoher, 2012).
High cost of maternal care, poor quality of obstetric services during emergency, and/or the evident low number of heath attendants continue to plague the Indonesian women. Additionally, steps such as addressing the problems of shortage of maternal health care providers and ensuring their better distribution are also pivotal in terms of boosting maternal health and reducing maternal mortality (World Bank, 2013; Ministry of Health, 2013). Consistent with the identified most significant social determinant of maternal health in Indonesia, Agus and Horiuchi (2012) identified traditional beliefs as part of the most important factors that make women select traditional birth attendants rather than trained village midwives.
Report by UNFPA concluded that women in rural Indonesia “were affected by cultural traditions that had implications on their wellbeing, including the denial of modern medicine during childbirth” (Wulandari & Whelan, 2011, p.868).
Economic wellbeing of Indonesians is also an important factor that contributes to high maternal mortality. Supratikto, Wirth, Achadi, Cohen, and Ronsmans (2002) confirm that 37% of total maternal mortality in Indonesia is contributed by economic constraints. In case effort is not put to improve economic constraints and/or overcome myths and false beliefs on child delivery and childcare, the overall outcome is failure of Indonesia to achieve the millennium development goal on maternal health by 2015.
Efforts made by the government of Indonesia to reduce maternal mortality are inspired by MDGs. In fact, the World Health Organisation (WHO) childbirth checklist programme that was developed through MDGs guidelines has proved instrumental in enhancing maternal health in Indonesia (Spector et al., 2012). Working towards the goal has led to more government expenditure through maternal health promotion programmes. However, a programme such as desa siaga has affected families and communities by creating more familial and communal responsibilities for maternal health. Thus, it is recommended for the Indonesian government to deprivatise the training of midwives and/or commit more resources in training and monitoring the operations of healthcare professionals who deal with maternal health.
Conclusion
Resolution of the current maternal health problems in Indonesia constitutes an important issue for the government before the expiry of the 2015 deadline for nations to have reduced their maternal deaths to 102 in every 100, 0000 live births. This target requires the addressing of socials determinants for maternal health. Economic constraints and cultural beliefs that hinder accessibility to quality and professional maternal care in Indonesia require urgent attention by the government in a bid to meet the 2015 vision of achieving MDGs.
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