Our data exposed a range of issues regarding the use of delivery care services in six villages of West Java Province. Five major topics emerged: (1) Reasons for using the services of traditional birth attendants at childbirth; (2) Reasons for having a home delivery; (3) Reasons for using trained delivery attendants and institutional delivery; (4) The partnership practice between the midwife and traditional birth attendants; and (5) Community perceptions about the village midwife and traditional birth attendant. Topics (1) and (2) are discussed separately since they will provide more information about why some community members still preferred traditional birth attendants and/or home delivery services. A woman might be assisted by trained delivery attendants but preferred to deliver at home.
Reasons for using the service of traditional birth attendants
From 119 mothers participating in this study, more than 40% used traditional birth attendants at childbirth. The participants' reasons for using the services of traditional birth attendants can be classified into five main categories, economic and pragmatic, trust and tradition, perceived need, access to services and community members' perceptions of care providers' knowledge and skills.
Economic and pragmatic reasons
Cost was one of the main reasons stated by participants in all villages for using the services of traditional birth attendants. The average delivery cost for a midwife of IDR 350,000 (~USD 35) was perceived as unaffordable by some community members. In addition, the flexibility of the payment method for traditional birth attendants was more convenient.
We don't have much money. We need to pay around 400 [400,000~USD 40] for a village midwife. For a traditional birth attendant... we can pay around 100 [100,000~USD 10]. Just depends on how much we have. We can even pay them by instalments. (Focus group discussion with mothers, Sukarame, Garut)
I'm struggling with my daily expenses, how can you expect me to pay a village midwife? (In-depth interview with a mother, Sukajaya, Garut)
Even though some community members had Jamkesmas cards to enable them to access free health care services, the services of traditional birth attendants were still preferred.
There are so many people seeking care from traditional birth attendants. We have already explained that if you have Jamkesmas, you do not have to pay anything to use midwives' services. But then they said they were still afraid that they would be required to pay. One day they also said they were ashamed of using the midwives services without paying anything.
(In-depth interview with a cadre, Sukarame, Garut)
Furthermore, misunderstanding about the eligibility of Jamkesmas was also found in the community.
Jamkesmas is only used for the village midwife service. Other than that [e.g. private midwife] you cannot use it. (In-depth interview with a cadre, Batu Nunggal, Sukabumi)
People were afraid that they will be neglected [by a health provider] if they used Jamkesmas. (In-depth interview with a community leader, Panyutran, Ciamis)
Socio-cultural - Trust
Our study found that being part of the community, speaking the local language, living in the community and sharing the same culture meant that traditional birth attendants have developed the feeling of trust in the community.
Traditional birth attendants are much closer to the community. They have been treated as a respected person by the villagers. Sometimes the village midwife could not adapt really well with the surroundings; whereas for traditional birth attendants, they grow together with the community. Psychologically, they trust the traditional birth attendants more. (In-depth interview with health office staff, Garut)
Socio-cultural - Tradition
Another factor that influenced the use of traditional birth attendants was being told by other family members such as the older sister, parents, or husbands to use their services. A long-time tradition in the community of using the service of traditional birth attendants, who had been the only delivery service providers for many years before the National Health System started, was also mentioned as a reason for community members to use their services during childbirth.
Perceived need
Some participants argued that the services of a health professional (a village midwife) are required only for those experiencing obstetric complications. Some community members stated that the midwife's services would be sought only if the condition could not be handled by the traditional birth attendant.
In this village, the first assistant from whom we seek care is the traditional birth attendant. If the delivery starts to be complicated, we then call midwives.
(Focus group discussion with fathers, Limus Nunggal, Sukabumi)
They think deliveries assisted by midwives are only for those with delivery complications... If traditional birth attendants cannot manage the deliveries, then they would call us. Otherwise, calling midwives is unnecessary. (In-depth interview with a village midwife, Sukajaya, Garut)
There are many cases like this, for example an obstructed labour with excessive bleeding, or retained placenta cases. They just wait until the traditional birth attendants could no longer manage it. Sometimes we arrived late and the mother already had severe oedema and was in a very weak condition.
(In-depth interview with a health centre midwife, Ciamis)
Access to services
Three reasons related to the issues of accessibility to health care services were physical distance, time constraints, and the availability of a health care provider. In rural areas there was better access to the traditional birth attendants compared to the village midwife. Some rural villages had more than ten traditional birth attendants compared with only one village midwife.
The village midwife service is ... too far away. It is impossible to contact the health personnel at ten o'clock at night. It is impossible. Better to use the services of traditional birth attendants.
(In-depth interview with a religious leader, Sukajaya, Garut)
At night time, the major problem is we have a poor road condition...especially during the rainy season. It is difficult to find the midwife by yourself.
(In-depth interview with a father, Panyutran, Ciamis)
The delivery was at night and it was an emergency. The baby was already out. The closest was the traditional birth attendant so I just ran to ask for her help.
(In-depth interview with a father, Sukajaya, Garut)
Sometimes the midwife was not at home. Sometimes her husband also did not allow her to go out at night. He was afraid something bad might happen along the way.
(Focus group discussion with mothers, Sukajaya, Garut)
The traditional birth attendants live closer than the midwife. There is only one village midwife for the whole village, so she also has limited ability to serve the whole community, maybe because she is tired, or needs to travel out of the village.
(In-depth interview with a midwife coordinator, Sukaresmi, Garut)
The social distance between the village midwife and the community was also an issue. Some community members were hesitant to seek a midwife's services even if they had received a Jamkesmas card that makes them eligible to use services for free.
The midwife assured me not to worry since I have Jamkesmas. But I feel ashamed for waking her up in the middle of the night. For me it is fine with traditional birth attendants. We are used to them. Yet for the midwife, I feel ashamed for not having any money to pay her.
(In-depth interview with a mother, Sukarame, Garut)
For some community members, village midwives were also perceived as too young and inexperienced; whereas traditional birth attendants were more mature, patient and caring compared with the midwife.
They say the traditional birth attendants are more patient. They gently touch your stomach and do not easily feel upset. This attitude is different from midwives. Sometimes after the physical examination, the midwife leaves if she thinks it is not the time for delivery yet. In contrast, the traditional birth attendant will wait patiently and accompany the woman all along.
(In-depth interview with a traditional birth attendant, Batu Nunggal, Sukabumi)
Reasons for a home delivery
Almost 80% of mothers participating in this study delivered at home. Similar reasons were given by the participants when asked about home delivery to the ones given for use of a traditional birth attendant at childbirth.
Economic reasons
Particularly among those who did not have the Jamkesmas, cost was one of the major reasons for not having an institutional delivery.
You need around IDR 2 million [~USD 200] to deliver in the hospital. With traditional birth attendants, even 50,000 [~USD 5] is fine. Our husbands only work as manual labours. Where can we get the money to pay the midwife or to deliver in the hospital? (Focus group discussion with mothers, Limus Nunggal, Sukabumi)
I prayed that day, "Lord please do not let my wife deliver our baby in the hospital. We do not have any money."
(Focus group discussion with fathers, Benteng, Ciamis)
Perceived need
There is a perception that delivery is a natural rite of passage for women, and thereby home delivery is preferred unless complications occur or someone tells them to deliver at health facilities.
If there were some problems then the mother will be brought to the health centre, otherwise she will deliver at home.
(In-depth interview with a community leader, Panyutran, Ciamis)
Access to services
In addition to the costs, physical distance was an issue for community members living far away from the health facilities and, therefore, home delivery was preferred.
Maybe distance is an obstacle in addition to the costs. You need to ride a motorcycle to reach the health facility. So people prefer having the health professional to come to their houses, especially at night time when it is hard to get transport.
(In-depth interview with the head of health centre, Garut)
The midwife's place is too far away. It is too far to go to deliver my baby.
(Focus group discussion with mothers, Sukajaya, Garut)
Convenience
The convenience of home delivery related to the responsibilities pregnant women felt towards other family members.
If we delivered at the midwife's place, we automatically needed to stay overnight. Maybe for one or two days. I have two young children at home, 4 and 2 years old. Who will take care of them? I look at it that way. So I better deliver at home.
(Focus group discussion with mothers, Cibadak, Sukabumi)
They just said they do not want to bother anyone. Delivery in the midwife's place means someone needs to go and accompany you. At home they can just wait for the delivery time while doing some household chores.
(In-depth interview with a cadre, Sukarame, Garut)
Reasons for using trained delivery attendants and institutional delivery
Our study found that delivery complications at childbirth were a main reason for using the service of health workers at childbirth (55% of the mother respondents) and for having institutional delivery (20% of the mother respondents).
Those who seek midwives services are usually those who have difficulties delivering their babies.
(In-depth interview with a community leader, Panyutran, Ciamis)
If there is no problem we use traditional birth attendants. But if it looks like the traditional birth attendant could not manage it, we will call a midwife.
(In-depth interview with a mother, Cibadak, Sukabumi)
We called the village midwife, and she asked us to bring me to her place. But then she was not able to help me because I had hypertension. So they brought me to the hospital.
(Focus group discussion with mothers, Sukarame, Garut)
Some respondents stated that the competency of midwives and better equipment were amongst the reasons for community members to use their childbirth services. Furthermore, advice from midwives was another reason for mothers to have an institutional delivery.
It is better to use the midwife service. It is a guaranteed treatment.
(In-depth interview with a father, Sukarame, Garut)
The traditional birth attendant does not have a complete range of equipment in case something happens. If we have the midwife, we do not have to go anywhere anymore. So we just go straight to the midwife.
(Focus group discussion with mothers, Limus Nunggal, Sukabumi)
Because I felt pain so I checked with the midwife. She said I was in labour and I was not allowed to go home.
(Focus group discussion with mothers, Sukarame, Garut)
The partnership practice between midwife and traditional birth attendants
Health professionals in all six villages were aware of the partnership programs between midwives, traditional birth attendants and cadres. However, the implementation varied across villages. In one village in Ciamis district, the partnership was successfully endorsed by the Desa Siaga program engaging the village midwife, traditional birth attendants and cadres. In fact, in this village a penalty was given by the Desa Siaga officers (mainly the village community leaders from the village) to the delivery attendant if both the village midwife and traditional birth attendants were not present at childbirth (see quotation below).
The delivery should be assisted by both a traditional birth attendant and a midwife. There was an agreement in all sub-districts, if I am not mistaken. You have to pay 500,000 [~USD 50], divided between traditional birth attendants and village midwife... a penalty will be applied if for example the traditional birth attendant was the only attendant at delivery. (In-depth interview with a cadre, Benteng, Ciamis)
In other villages, the partnership program was not conducted according to the guidelines.
We have disseminated the partnership program to the community... But we still have some problems with traditional birth attendants... maybe the remuneration was too little. We have even had the meeting together with the doctor [from the health centre], and sub-district office staff... but still it is not working. (In-depth interview with a cadre, Sukajaya, Garut)
The traditional birth attendants have been asked to work together. But it is difficult. They used to say that the baby is already out [they did not call village midwife]. (In-depth interview with a village midwife, Sukarame, Garut)
The implementation of the partnership program was also hindered by the fact that traditional birth attendants in some villages preferred to work independently without the assistance of health professionals, unless perceived necessary.
If it could not be managed, we then called the midwife. Otherwise, we will just manage it ourselves.
(Focus group discussion with traditional birth attendants, Limus Nunggal, Sukabumi)
It [partnership program] is difficult here. If something happened then they called the midwife. (In-depth interview with a village midwife, Limus Nunggal, Sukabumi)
The data provided positive feedback about the role of village midwives in the community. They were perceived as diligent, kind, friendly, responsive, alert and willing to provide health services. Nevertheless, the role of traditional birth attendants was considered essential especially in remote areas. Having both a midwife and a traditional birth attendant present at a delivery was perceived important so that the tasks and responsibilities could be shared together.
We prefer having both of them. Before calling the midwife, we called the traditional birth attendant. The traditional birth attendant will gently touch the mother, and have some special prayers for that. For us village people, that is helpful. The midwife can take care of the child; the traditional birth attendant can look after the mother. If only a midwife is available, she might not be able to handle everything. There should be both of them.
(Focus group discussion with fathers, Benteng, Ciamis)