High maternal mortality has long been a critical problem in Indonesia. Complications of abortion, which include hemorrhage and infection, account for 15% to 30% of the country's maternal deaths.

Unfortunately, the situation is expected to worsen, according to Dr. Izhar M. Fihir, who manages AVSC's program in Indonesia. Recent economic and political crises in the country have "caused a shortage of contraceptives," he says, "which will lead to more unintended pregnancies" and may increase the incidence of abortion. Because abortion is illegal in Indonesia, it is often performed under unsafe conditions, increasing the risk of complications and, consequently, maternal deaths.

To help reduce the consequences of unsafe abortion, AVSC initiated a postabortion care (PAC) program in Indonesia in September 1997. The program aims to improve the quality and availability of emergency services for managing postabortion complications, postabortion family planning counseling and services, and referrals for other reproductive health services.

Understanding how women in Indonesia seek treatment for complications of abortion, and the delays inherent in that process, is key to ensuring the effectiveness of AVSC's PAC program and reducing maternal deaths.

Utilizing Local Resources

When Indonesian women experience pain or other symptoms after an abortion, they often seek the assistance of midwives or birth attendants living in the villages. One reason is because they tend to prefer traditional remedies, such as the use of herbs and massage, over medical treatment for dealing with unintended pregnancies, says Ninuk Widyantoro, a training consultant in PAC counseling for AVSC.

Another reason, according to Widyantoro, is that the women in this mostly Muslim country feel more comfortable being examined by midwives than doctors for such conditions. "In our culture," she says, "we cover up, especially [the genital area]. Most women are embarrassed when they have a discharge or [other symptoms]."

Pluses and Minuses

Seeking treatment from local practitioners saves a woman time that might be spent traveling to a far-away health care facility. It also helps maintain her confidentiality by eliminating the need to explain a long absence from home or routine duties.

But this approach can be harmful for women who are suffering from abortion complications. Many of the village-based midwives and birth attendants are untrained in recognizing symptoms of critical conditions. Thus, they often cannot offer the women the treatment they need or refer them to an appropriate treatment facility, such as a puskesmas, or primary-level community health center. This delay in receiving treatment can be dangerous and even fatal, since many of the more serious complications can be prevented by early recognition and treatment of symptoms.

Bringing Services Home

Implementing strategies to avoid treatment delays is part of the goal of AVSC's PAC program in Indonesia.

One aspect of the program centers on training village-based midwives and birth attendants in recognizing symptoms of abortion complications and stabilizing clients for referral to the puskesmas or district hospital. Efforts are also under way to train doctors and clinic-based midwives who work in the puskesmas in improving their skills for managing postabortion cases.

The program is also working to improve and increase the availability of services in puskesmas and other facilities at the provincial level where women are likely to use them. Instituting PAC services closer to the community, at the primary-care level, is key, says Fihir. "The program's complete success will only be achieved when it is integrated into the mainstream of the country's maternal health movement."

Leah Kennedy is a freelance writer and editor for AVSC International.