“With patience and persistence I have established a relationship of trust with villagers and traditional birth attendants”, says midwife Sri from Bandung, Indonesia. Back in 2003 she opened her private practice at home, alongside her work at the Regency Government Hospital at Ujung Berung in West Java to make maternity services in her region more accessible. For Sri it was not only infrastructure that posed a challenge but also the culture to deliver with a traditional birth attendant called “paraji”. Paraji are often older women with no formal education in midwifery, who have attended many births and provide care based on their experience and ancient traditions. These practices are deeply rooted in the culture but often do not take necessary skills into account to prevent mortal complications.
Sri desperately wanted to reduce maternal and newborn mortality in her region, but she knew that she couldn’t just impose her midwifery skills on the people. “I started walking from house to house in several villages to find out who is about to give birth this month”, recalls midwife Sri her initial efforts. She wanted to make herself visible and accessible to the childbearing women as well as the parajis. Whenever the villagers sent for her, by night, in the early morning or during the heat of noon and in pouring rain, Sri would always show up. She was there, no matter the time or the weather. Often when Sri came to the village to assist in a delivery, she would find people asking her for more medical advice. She never hesitated to help; she provided medication or referred to the doctor. With her willingness to help beyond midwifery care she demonstrated her sincere intentions and was able to show the villagers that she was there for them. Midwife Sri was often the first contact in the health system for many of the people in the village and thanks to her services they were able to develop trust for other health workers. “Being the first point of contact, midwives are Ambassadors for other health workers”, is Sri convinced.
She continued to work alongside the paraji in the villages and also incorporated some of their practices into her care such as massages or the use of certain herbs. Acknowledging and integrating the parajis practices when they are beneficial for the mother’s and newborn’s health, helped to further develop the relationship. Parajis now trust midwife Sri so much that they bring their patients to Sri’s practice at home. This change of behavior was also supported by a new governmental rule that deliveries at a midwife’s practice are free of charge and there is a monetary incentive for parajis that refer their patients to a midwife. Sri now also is consulted in difficult cases, for example the case of a breech position (the baby’s feet are facing the uterus instead of the head). The mother was advised by a Gynecologist that she needed to have a cesarean, but she was much too scared of such a surgery. She then decided to give birth at home with a paraji, who immediately called midwife Sri. When Sri arrived, she was shocked to be dealing with a breech birth and also felt uncomfortable working against the regulation, as breech positions are not allowed to be delivered at home. Sri admits that she often feels confused about the government’s regulation and the real situation demanding immediate action and care for the patient. Also in this situation, for the sake of the mother and the baby, midwife Sri left regulatory demands behind and fully concentrated on the birth. Baby and mother are healthy and happy and very grateful to Sri. It is for these situations that Sri worked so hard for almost a decade to establish trust with parajis. That they would call her in such delicate moments and she would be able to intervene, provide midwifery care and save lives.