By Sri Kusyuniati, Country Director, Indonesia
An edited version of this article was first published in The Jakarta Post on September 16, 2020.
In her 1949 book The Second Sex, Simone de Beauvoir states: “She [woman] is defined and differentiated with reference to man and not he with reference to her; she is the incidental, the inessential as opposed to the essential. He is the Subject, he is the Absolute — she is the Other.” Though the book was released seven decades ago, its theory of women as ‘others’ is practiced even today in many parts of the world.
Women have frequently been excluded from decision-making, including from discussions about their own health. In resource-poor settings, girls often suffer from poor nutrition during childhood and adolescence, which is further exacerbated during pregnancy. Women are often responsible for preparing the meals, yet they eat last and least, with no special consideration for their nutrition if they become pregnant. A malnourished mother is more likely to give birth to low birthweight and malnourished babies. Prenatal nutrition and poor nutrition in infancy and early childhood are linked to stunting and development of non-communicable diseases in adulthood, including obesity, hypertension, heart disease and diabetes.1
In Indonesia, nearly half of pregnant women are anaemic.2 Anaemia among pregnant women adversely affects the development of the foetus and increases the risk of mortality and morbidity for the mother and newborn. This has contributed to 27.67% of children suffering from stunted growth in the country.3
The Government of Indonesia has been working to reduce stunting rates, including the launch of its national strategy “Integrated Nutrition Interventions for Stunting Reduction and Prevention” in August 2017. Despite this, most communities have limited awareness about nutrition and its role in pregnancy and birth outcomes. For reduction efforts to be successful, a multi-stakeholder approach that addresses gender norms, and involves families and communities is necessary.
Compromised health and nutrition during pregnancy
The number of public healthcare facilities and medical professionals in Indonesia has increased over the past few years, yet many women still deliver their babies in their homes. Women who deliver at home may not have access to skilled birth attendants or emergency care, increasing the risks of maternal and newborn mortality and morbidity. Additionally, women belonging to lower socio-economic families, in high-risk groups, including those that are too young or old, anaemic or have poor nutritional status, and with less access to healthcare are at a greater risk of maternal and infant morbidity and mortality.
In a number of Indonesian communities, superstitious beliefs and customs present additional barriers for women to access antenatal care. Some ethnicities restrict women from accessing health services without the presence of a male or elderly female relative, further delaying medical attention. Some communities believe that if a woman dies at the time of delivery she will go directly to heaven – these deaths are called ‘syahi.’ This undermines efforts being made to safeguard the mother’s life.
Inequitable access to information
In many marginalized communities, health information is mostly shared via community health centers (CHCs). Given the current pandemic, most CHCs are shut to prevent disease transmission and critical health information is instead being disseminated online, through webinars, conference calls, WhatsApp or text messages. While 39% of women now own a smartphone4 they are not necessarily the user of the device and mobile phone and technology usage remains low among women. For those that do have access to a device, many have seen their household responsibilities increase and have limited free time to read these messages. As a result, women are not receiving information critical for their own health.
Disproportionate impact of the pandemic
In a society where women and girls often struggle to access basic needs, such as a healthy diet, education, clean water, and sexual and reproductive health services, these needs are being pushed further out of reach due to the restrictions imposed by COVID-19. Studies have shown that due to direct and indirect effects of COVID -19, an increase in maternal and newborn and infant mortality is expected in low- and middle-income countries.5 Women are at the frontline of the pandemic at home as well as in the healthcare sector and are feeling the consequences most acutely. Indonesian women also account for over 60% of informal sector jobs in the country,6 where adherence to social distancing protocols may be difficult. Government responses to the pandemic need to account for the inordinate impact of COVID-19 on women.
Improving women’s health and nutrition
Many activists have been fighting for equal representation of women in decision-making. Including women in household discussions about their own health and nutrition is a crucial first step to bring about change. Information must also be made more accessible, by leveraging common media like radio and television, and influencers like religious leaders and health workers, to disseminate key health messages. Building capacities of women’s self-help groups in municipalities and engaging adolescent girls who possess mobile phones to pass on nutrition messages to pregnant women are also important measures.
While it is necessary to increase awareness of maternal and child health issues for all women, it is equally important to educate and engage men about women’s health concerns. Ensuring male participation during Posyandu sessions is an effective strategy to explain the special needs of women during and post pregnancy.
Behaviour change communication tools, which rely on graphic and illustrative messaging, have proven to be effective in reaching large populations, particularly those with low levels of literacy. Designing these tools not just for healthcare staff at CHCs, but also for the beneficiaries to take home, can help critical health messages and essential nutrition actions resonate. An example of this is Nutrition International’s Iron & Folic Acid (IFA) Compliance Card which was introduced to record daily IFA supplementation for pregnant women. Not only did it help women keep a record of the IFA supplements, it also acted as a reminder for them and their family members to ensure they were taken. In addition, the card became a useful monitoring tool for the health workers at the facility and community level and was adopted by the Ministry of Health for national use in the Maternal and Child Health Handbook.
Pregnancy is a joyous yet a vulnerable time for every woman. Ensuring she receives adequate nutrition and care is essential for her own health and survival, as well as her baby. The Government of Indonesia has made concerted efforts to improve maternal nutrition and reduce stunting rates, but there is still more work to do. As attention and resources are devoted to stemming the damage of COVID-19, the world cannot overlook the impact on women who already face steep barriers to access basic services, which are exacerbated by the coronavirus response. Helping them overcome these barriers now is essential to ensuring they – and we – come out of this global pandemic stronger, more resilient and ready to build a better future for all.
1 Brumana L, Arroyo A, Schwalbe NR, et al Maternal and child health services and an integrated, life-cycle approach to the prevention of non-communicable diseases BMJ Global Health 2017; 2:e000295.
2 48.9% pregnant women are anaemic in Indonesia Riskesdas (Basic Health Research) 2018
3 Riskesdas (Basic Health Research) 2018
4 Pew Research Center, February 2019, “Smartphone Ownership Is Growing Rapidly Around the World, but Not Always Equally”
5 ‘Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study’ Article published on May 12, 2020 https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30229-1/fulltext ‘Impact of COVID-19 on maternal and child health’ Article published on August 3, 2020 https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30328-4/fulltext
6 Center of Statistic Bureau, 2019 “Indonesia Statistic 2019”