Change and continuity : the influence of policy on the practice of a traditional birth attendant in Eastern Indonesia

Indonesian women continue to experience high rates of maternal mortality despite decades of policies and programs designed to improve maternal health outcomes. The Indonesian province of East Nusa Tenggara (NTT), one of the poorest in Indonesia, has disproportionately high rates of maternal deaths and many women deliver at home with a traditional birth attendant (TBA). This case study explored the experiences of one TBA working in NTT and her perceptions of how maternal health policies have impacted on her practice over three decades. The TBA lives on a remote island in NTT where the district centre and nearest hospital are located on a nearby island. Travel between the islands is by boat, however travel between the islands can be cut off due to inclement weather. This qualitative case study used ethnographic methods including narrative style interviews and participant observation. Information collected was thematically analysed and categorised into three themes: ‘becoming and being a TBA’, ‘attitudes towards maternal health policy’, and the ‘impact of maternal health policy’. Although a range of health policies have influenced the TBA’s practice, the TBA identified the NTT province Revolusi Kesehatan Ibu dan Anak (Revolusi KIA) policy as the most prominent maternal health policy impacting her practice. This policy mandating facility deliveries has dramatically decreased her role in delivering babies, with many births now taking place at the health clinic where homebirths had previously been the norm. Although her role has changed, the TBA continues to play an active and arguably essential role in the provision of acceptable and adequate maternal health care services to the women in her village. The TBA’s role in the provision of maternal health care is integral as there continue to be barriers to women accessing formal health care services. These barriers include poor acceptability of services to women, difficulties accessing health care, and widespread health system dysfunction. In these circumstances, the TBA continues to provide assistance in pregnancy, childbirth and postnatally where women may otherwise receive little or no quality care. However, as current policies restrict the involvement of TBAs in delivery and TBA training has ceased, TBAs are at risk of becoming deskilled and ceasing to exist in the community. This is problematic as it will increase women’s reliance on a system that is currently undependable, and potentially remove the only option for experienced attendance at birth for many women. These findings demonstrate the importance of understanding the impact of policy at the local level and why policies should be locally tailored. It is argued that TBAs should be acknowledged as part of the solution to improving maternal mortality in Indonesia, particularly in remote areas and must be genuinely partnered with as valuable and respected providers of maternal health care. Improvements to the current health system and addressing social and economic determinants of health are also critical to improving health outcomes for women in this province.