Developing Maternity Care to Reverse Patterns of Violence and Inequality in West Papua

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By: Els Tieneke Rieke Katmo, PhD, Lecturer in Social Agribusiness, University of Papua. Els is a gender studies scholar with a doctorate from Flinders University, Australia and an MA from the University of Indonesia.; Jenny Munro, PhD, Senior Lecturer in Anthropology, University of Queensland. Jenny is a medical anthropologist who works in Indonesia and the Pacific Islands.

Reproductive abandonment refers to conditions that discourage and inhibit relations of desired reproduction, in its social, biological, infrastructural, and environmental senses. For example, in parts of the world, medical technologies that could facilitate life, birth and reproduction are largely absent or facilitate violence, such as the use of violent practices toward women in labour.

Reproductive abandonment speaks to the need for reproductive justice. As Loretta Ross and Rickie Solinger define it, “reproductive justice goes beyond the pro-choice/pro-life debate and has three primary principles: (1) the right not to have a child; (2) the right to have a child; and (3) the right to parent children in safe and healthy environments.” Clearly, there is a need for maternal healthcare that reflects local understandings, cultures, politics, and histories. Building on this approach, the core question of our research in West Papua was, what does maternity care need to do and look like to reverse patterns of violence and inequality?

Aspects of reproductive abandonment that affect maternal health in West Papua include colonisation, racism, state violence, and unwanted reproductive interventions. Dutch colonialism and missionisation in the early twentieth century actively tried to destroy Indigenous reproduction and sexualities. Despite an active independence movement, Indonesia claimed West Papua from the Dutch and its authority was formalised in the 1960s. West Papuans have struggled to create families under life-negating structural conditions. With varying degrees of global complicity, Indonesia has promoted the dispossession of West Papuans through extractive capitalism, racism and cultural diminishment, military operations and human rights violations, the in-migration of 1.5 million newcomers from other parts of Indonesia, and environmental destruction. There are generally stark differences between the socio-economic status of most Indigenous Papuans and newcomers, with migrants economically advantaged and dominating professional roles and the private sector.

Health interventions from the state are difficult to separate from this history of violence. Like many low-income countries, there are no fertility treatments available in West Papua, only fertility preventions such as birth control. Birth control implants were heavily promoted in West Papua from the 1990s. In some areas women were coerced, leading to trauma and distrust in the healthcare system.  The military is often used to implement health programs, adding to an atmosphere of fear and tension around health care. Generally speaking, there is scepticism toward the health care system because it ignores West Papuans’ cultural and historic experiences, and this extends to maternal health.

With so many challenges, it is not surprising that the maternal mortality rate in West Papua is approximately double the Indonesian national average of 120 to 305 deaths per 100,000 live births, depending on method of calculation. In 2010, the MMR in one region of West Papua was estimated at 573 women per 100,000 live births. The maternal mortality rate appears to be controversial, because since 2015 the government presents MMR in West Papua in combination with MMR from several other eastern Indonesian island regions. This is in line with a broader tendency to not disaggregate health statistics according to ethnicity or Indigenous heritage, which obfuscates the truth about disparities.

In this context, women’s birthing experiences are deeply political. As global and national efforts to improve maternal health narrowed in on increasing women’s use of antenatal care and giving birth in hospitals, we wanted to know how West Papuans were interpreting these messages, and what they experienced when they followed this advice. We interviewed mothers who had used antenatal care or given birth in a health facility, along with some fathers.

We found participants embraced antenatal care. Most had no hesitation engaging with formal health services, and had their own additional informal practices such as walking and other exercises, eating a balanced diet, listening to music, talking to the fetus, relaxation, massage, and drinking coconut milk. Given that historically Papuan expertise and local knowledge has been excluded from the formal health care system, and medical interactions have often been disappointing, it seems that with antenatal care there is a real opportunity to reverse that pattern by formalising and celebrating local culture in antenatal care.

In contrast to antenatal care, hospital births were largely reported as negative experiences.  Many women and men observed that labour wards were stressful, undignified, and unsupportive.  Some women said that if they kept quiet and did not ask the nurses for help, then they were treated well, but they saw that women who were emotional, loud, or assertive were criticised or ignored.

However, even more concerning for our participants was that many said they felt pressured into having a caesarean section (CS) delivery, often without clear justification. Papuans we spoke with considered vaginal birth to be ‘normal’, with benefits for baby and mother, and preferred to avoid CS because of potential injury or long-term effects. Some worried that they would be sterilised without their consent, and that having a CS would mean always delivering by CS in the future, making pregnancies riskier and limiting the number of children they could have. Some participants reported avoiding going to the hospital until the last minute or preferring to give birth at home. For many of our participants, what doctors wanted prevailed, showing the extent of hierarchical relations between patients and doctors.

People we spoke with wanted maternity care in which they were permitted to exert agency by expressing their preferences, questioning decisions, and asking for clarifications. They wanted care from professionals who know about the violence that has surrounded their experience with health care historically and understand the need to restore trust. This may be achieved through an emphasis on building rapport and relationships, providing reassurance, and including patients in decision making processes. Healthcare providers in the field of maternal health must ensure their practices and interactions reverse patterns of inequality and violence. There is an undeniable need and opportunity for local maternity care policies and programmes that prioritize West Papuans’ unique historical and cultural contexts.