Martin Luther King Jr. once said that “of all of the forms of inequality, injustice in health is the most shocking and the most inhumane.” Yet in the sprawling Indonesian archipelago, this unfortunately still is very much the order of the day.

Early-age mortality rates in Indonesia are above the region’s average: according to a 2013 UNICEF report, Indonesia ranks seven out of 11 Southeast Asian countries for its neonatal, infant and under-5 mortality.

But there are substantial variations among Indonesia’s regions, with some, such as Ende district on the island of Flores in East Nusa Tenggara, still having child mortality rates that are well above the global average.

A new study by Macquarie University, published in the Journal of Biosocial Science, provides new insights into mothers’ pregnancy and early-age survival experiences in the relatively underdeveloped Ende district. Our study found that most mothers have little knowledge about the danger signs of children’s illnesses and that only a very few mothers received such information during their antenatal visits. There are also reports of unprofessional attitudes by midwives. As a result, mothers have difficulties making health-related decisions.

Indonesia’s hundreds of disparate districts face significant challenges in reducing child mortality and achieving universal health coverage by 2019, but our study in Ende suggests several priority areas for consideration.

Child mortality and health services

Ende’s population has relatively poor health. It ranks 316 out of 500 districts surveyed nationwide as part of the Ministry of Health’s Public Health Development Index; areas outside urban Ende mostly have high child mortality rates.

Our study found that while most deliveries in Ende take place at health facilities, such as community primary care health centers (Puskesmas), sole reliance on traditional birth attendants remains significant among rural mothers for reasons such as financial problems, village midwife unavailability, midwives’ poor professional performance and geographical distance, as well as conflict of interest arising from traditional birth attendants’ dual role as family members.

The study suggests that to improve child survival rates, local governments could make improvements to midwives’ training and availability. Improved and mandatory recurrent training should focus on how midwives communicate with mothers, as well as the range of services they are qualified to provide, such as family planning and ultrasound diagnostics.

Improve health education for mothers

Most mothers reported to us that they did not receive enough information from midwives during their pregnancy visits. Some mothers whose babies died say they were not even told the cause of death by health personnel.

The study points to an urgent need for midwives and other health personnel, especially those working in maternal and child health programs, to improve mothers’ health education, .

Other studies have shown how improving health personnel’s skills and knowledge through regular training and courses can reduce the number of infant deaths. The Ministry of Health has suggested all district-level health offices build ongoing partnerships between midwives and traditional birth attendants to reduce maternal, neonatal and child mortality. However, the national government has no authority to enforce its suggestions at the provincial or district level.

We also identified issues of geographical and gender inequality at play.

Distance and gender

The current maternal, neonatal and child health program in Ende has failed to reach underserved populations in rural and remote areas.

Rural mothers face challenges in caring for their pregnancies and children due to the long distances they must travel to their closest health facility, the uneven quality and distribution of midwives and unequal distribution of benefits for the national health insurance scheme.

We found that mothers from the rural northern and western parts of the district had not received cards that would have entitled them to access the now-defunct Jamkesmas, which allow them to take part in the public health insurance scheme. As a result, these mothers bore greater out-of-pocket costs and lower health care utilization. It is hoped that the government’s new universal insurance program (JKN), which is administered by the Social Security Organizing Body (BPJS), will make it easier for poorer mothers to meet their health needs — but it’s unclear when that will happen.

Alarmingly, however, we also found instances where the complete absence of midwives and other child health service-related personnel had resulted in deaths. We therefore recommend immediately increasing the numbers and quality of midwives in rural and remote areas.

The lower social position and weaker bargaining power of women compared to their husbands also creates difficulties for their health-related decisions. Local customs and traditions also affect mothers’ behavior when it comes to the health of their children.

Improving women’s education and empowering women in health-seeking decision-making has been found in other economically disadvantaged populations to significantly reduce early-age deaths and improve child health. This is something that also needs to be pursued in Indonesia.

In short, to reduce early-age mortality in Indonesia, district governments should:

• Improve the quality of midwives and other health service personnel by require mandatory, recurrent in-service training that focuses on health education and patient communication;
• Improve the distribution of essential health workers, such as doctors, midwives and nurses, with the required skills and knowledge, to boost the quality and performance of primary health care;
• Implement continuous and locally appropriate health promotion and health education for mothers, fathers, relatives and community leaders;
• Prioritize continuous collaboration and inclusive dialogue, including the private sector, to reduce fragmentation of efforts.