Regulating Midwives: Foreclosing Alternatives in the Policymaking Process in West Java, Indonesia

Abstract

AbstractPromotion of “skilled birth attendants” (SBAs) in global maternal health policy has prompted a range of policy responses to “traditional birth attendants” (TBAs). In Indonesia the response has been to develop a national policy of partnership between SBAs (bidan) and TBAs (dukun bayi). This policy aims to ensure the presence of an SBA at every birth yet offers a role for TBAs. In this chapter I examine the development of a district regulation on partnership, promoted within the context of decentralization policies enacted in Indonesia from 1999. The district regulation aimed to strengthen the national policy in a location in West Java where TBAs remain popular. Drawing on 10 months of fieldwork from 2012 to 2013 at a district health office and on observations of its outreach programs, I elucidate how the regulation on partnership was promoted through the policy entrepreneurship of certain key figures in the district health office. They argued that the partnership regulation was the fastest means to improve maternal health. But casting a spotlight on the relationship between SBAs and TBAs diverted attention away from other health system challenges including under-resourced medical facilities and a weak referral system. Three contexts played into this process of bringing the partnership issue to the fore: global policies promoting SBAs and sidelining TBAs; pressure to achieve the Millennium Development Goal (MDG) on maternal mortality; and the limited financial power and decision space afforded to districts under decentralization in Indonesia. In this context, the regulation offered a viable path for demonstrating commitment to improving maternal health outcomes, yet one that failed to address broader constraints in the health system that contribute to persistent high maternal mortality rates.