Dying Mothers Maternal Mortality in Rural Indonesia

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Dying mothers: Maternal mortality in rural Indonesia

M. Cameron Hay
Published online: 12 May 2010.
To cite this article: M. Cameron Hay (1999) Dying mothers: Maternal mortality in rural Indonesia, Medical Anthropology:
Cross-Cultural Studies in Health and Illness, 18:3, 243-279, DOI: 10.1080/01459740.1999.9966157
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Dying Mothers: Maternal Mortality in

Rural Indonesia
M. Cameron Hay
The Safe Motherhood Initiative was adopted by the World Health Organization to decrease the high rates of maternal mortality in developing countries.
Towards this goal, various studies identified a short list of causes of maternal
mortalities and recommended corrective programs. Indonesia put a number of
such programs into effect, yet the maternal mortality rates have actually risen
rather than fallen. This paper suggests that the causes of maternal mortality are far more complex than the public health literature indicates. Detailing
the ethnographic cases of two maternal deaths on the rural island of Lombok, this paper emphasizes the complex social reality in which obstetric emergencies occur and within which people explain them. Using the insights these
cases provide, the paper concludes with suggestions for ways of decreasing
maternal mortality in Indonesia.
Key Words: death; maternal mortality; Safe Motherhood; Sasak; Lombok; Indonesia
It has been estimated that over half a million women die annually
either while pregnant or within forty-two days of giving birth
(WHO 1996). In an effort to decrease this number, the World Health
Organization adopted a Safe Motherhood Initiative in 1987, calling
for projects to study the factors contributing to these mortalities
(Herz and Measham 1987). Consequently, a considerable literature
has developed focusing on one or more of the following six factors:
(1) lack of access to birth control; (2) lack of safe abortion alternatives; (3) poor access to biomedical care because of distance and corresponding transportation difficulties; (4) poor use of biomedical
facilities because of women's low status; (5) untrained traditional birth
M. CAMERON HAY is a recent Ph.D. graduate from the Anthropology Department at Emory
University in Atlanta, Georgia 30322. Her interests include ethnomedicine, the politics of
health care, intersubjectivity, identity construction, and creativity.
243
244
M. Cameron Hay
attendants (TBAs); and (6) poorly equipped and staffed biomedical

facilities.1 Each of these six factors is a medial cause of the larger social
and structural environs. In addition, the literature recognizes proximate or direct causes of mortality: hemorrhage; infection; toxemia/
eclampsia; obstructed labor; or abortion (Herz and Measham 1987:10).
These proximate causes are obstetric emergencies, which are usually
preventable or treatable with prompt and adequate biomedical care.
In countries with easy access to good biomedical care, the maternal mortality ratio hovers at 6 to 10 deaths per 100,000 births, whereas in the vast majority of the world, the maternal mortality ratio
ranges between 200 to 1,800 deaths per 100,000 births (WHO 1996).
Because biomedicine is presumed capable of preventing most deaths,
recommendations foreground (1) training TBAs in basic biomedical
obstetrics and in how to refer emergency cases; (2) expanding
biomedical networks to handle obstetric emergencies efficiently;
and (3) making biomedically safe abortions available (e.g., BarnesJosiah et al. 1998; Kwast 1996; Thouw 1992; Thaddeus and Maine
1990; Herz and Measham 1987). In sum, the Safe Motherhood literature suggests that prompt access to adequate biomedical care
would reduce maternal mortalities.
Statistics, ungrounded anecdotes, and sweeping comparisons of
developing countries abound in the Safe Motherhood literature, but
where are the women who are dying? Because of the relative infrequency of maternal mortality, the anthropological literature lacks
first-hand accounts of such deaths, though it is rich in other areas of
reproduction.2 Anthropologists have shown that human reproduction is a cultural event, dependent on social relationships and cultural meanings (e.g., Browner and Sargent 1996). Many have shown
that reproduction problems can only be addressed when biomedical
solutions are integrated into programs addressing larger social and
cultural contexts. For example, some have noted that maternal mortality rates reflect women's social and economic power, suggesting
that those women with strong social connections and with control over
even meager economic resources are less likely to die from pregnancy
or childbirth (MacCormack 1994b; Myntti 1993). Taking such arguments seriously, a program called WARMI involved organizing village
women in Bolivia to identify and prioritize their childbirth concerns,
and work together to implement their own solutions using community
and biomedical resources. The results show early indications of dramatically decreasing local maternal mortality rates (HowardGrabman et al. 1993; see also Howard-Grabman 1993a, 1993b).
Dying Mothers 245
This paper presents ethnographic data detailing the events surrounding the deaths of two Sasak women in Indonesia and exploring people's tentative interpretations of those deaths. I utilize
Inhorn's idea of causal proximity, which recognizes multiple causes
without privileging a priori one over the other. Causal proximity
arranges causes by increasing distance from the body: there are
proximate or body-near causes like using birth control or experiencing hemorrhage, medial or body-distant causes like the skills of a
midwife or access to transportation, and ultimate causes like fate
(1994:163-166). Proximate causes are the ones easiest to act upon by
direct intervention whereas ultimate causes are least susceptible to
intervention. This typology is ambiguous; what might be proximate
from the perspective of biomedical specialists might be medial from
the perspective of villagers and vice versa. But for our purposes, the
typology usefully categorizes causes without inherently emphasizing one type over another. Causes are not necessarily mutually
exclusive and the assigning of causes is motivated as people seek
compelling explanations for the deaths of mothers. I will argue that
the socially and personally motivated explanations emphasize certain proximate, medial, and ultimate causes, which must be
addressed if maternal mortality rates are to decrease. Indeed, my
two cases undermine the "access" theory, arguing that accessible
health care, including local, biomedically-trained mid wives, does
not necessarily reduce maternal mortalities. It also suggests that in
Indonesia, strong social position and control of household finances
is not enough to reduce mortalities. This paper concludes with a discussion of what strategies might have made a difference.
MATERNAL MORTALITY IN INDONESIA
Maternal mortality ratios are notoriously difficult to calculate (Rosenfield 1989; Barnes 1991; Graham et al. 1989; Graham and Campbell 1992; Wirawan and Linnan 1994), and in Indonesia national
estimates range from 390 to 647 deaths per 100,000 births (Iskander
et al. 1996:10, 12; Mboi 1995:183).3 In 1970, the Indonesian government began promoting birth control and has been remarkably
successful in reducing the national fertility rate from 5.6 to 2.9 in 1994
(CBS 1992, 1995; Schiffman 1997:19-20)." Later, the government
began a program to train TBAs in hygienic delivery techniques,
obstetric emergencies, and birth control distribution (e.g., Peng
24:6 M. Cameron Hay

1979; PIP 1980; Grace 1996). In 1989 the national bidan-ke-desa (midwife to the village) program was launched to place biomedical
midwives in villages. In spite of all this, and perhaps because of
increased accuracy in reporting, according to two surveys, the
maternal mortality rates have actually risen during the 1980s and
early 1990s (Iskander et al. 1996:10; Shiffman 1997:5; Wirawan and
Linnan 1994:307) .5 All of the studies of maternal mortality in Indonesia have been in urban hospitals or in rural areas of highly
developed islands (e.g., Chi et al. 1981, Iskander et al. 1996; Fortney
et al. 1988), even though rural women in underdeveloped islands
probably have higher maternal mortality rates (Chi et al. 1981:262).
For example, the Sasak people of Lombokthe island immediately
east of Baliare estimated to have the highest maternal mprtality
ratio in all of Indonesia.6 Based on interviews with Sasaks asking
what is done during maternal crises, Grace (1996:145, 164) found
that women neither understand nor trust biomedicine, but she
emphasizes that the primary problem is a lack of funding:
Were antenatal care made available in every subclinic and at health posts in
the more isolated hamlets, the coverage [of women] would increase substantially. Were more money spent on training belian nganak [TBAs] and
voluntary health workers, birthing procedures would become safer, and
information would be disseminated far more widely and rapidly. Were
emergency medical services in hospital [sic] free or subsidized for the poor,
women's reluctance to use them would be reduced. (1996:164-165; italics in
original)
My own materials substantiate much of her argument but diverge
from it, particularly in these final recommendations. My data show
that the close proximity of biomedical antenatal care; the use of
biomedically trained TBAs; and the possibility of obtaining a certificate of poverty, which waives most hospital fees, do not effect
whether or not a woman dies.
The two cases presented here are typical in terms of the direct
causes of the deaths: both women hemorrhaged with retained placentas. In Indonesia, studies have found that between 50-64% of
maternal deaths are directly caused by hemorrhaging (Iskander
et al. 1996:52; Fortney et al. 1988:26; Kwast 1996:52), which corresponds to the international estimates suggesting that between a third
and one-half of all maternal mortalities result from hemorrhaging
(Herz and Measham 1987:10). Postpartum hemorrhaging is associated with high parity, nutritional anemia, retention of the placenta,
Dying Mothers 247
prolonged labor, as well as lacerations and uterine ruptures. It is an

emergency situation requiring prompt, efficient, and skilled care as
well as access to medication and fluids for transfusions (e.g., Herz
and Measham 1987:12). In Indonesia, the medial problems often
compounding hemorrhaging are many, including delays in recognizing emergency situations and seeking biomedical care, transportation difficulties, inadequate treatment at hospitals and clinics,
and shortages of medicine, blood, and functioning equipment (e.g.,
Iskander et al. 1996; Thouw 1992:246; Chi et al. 1981:264). Yet there
are no data showing how these potential problems overlap and
become salient during hemorrhaging emergencies. Maternal mortality is a relatively rare occurrence and is usually studied indirectly
in interviews (e.g., Grace 1996; Wirawan and Linnan 1994; Iskander
et al. 1996). I had the dubious distinction of doing fieldwork in a
community where mothers die frequently, and my materials suggest that the processes surrounding the deaths of rural Indonesian
women are more complex than the "access" approach, which dominates the Indonesian literature, could solve.
ETHNOGRAPHIC BACKGROUND
Inaq Hin and Inaq Marni lived and died in the hamlet of Pelocok7 on
the island of Lombok in eastern Indonesia. Pelocok is the rural hamlet, populated by approximately eight hundred Sasak peasants,
where I lived for twenty months from 1993 to 1995. Pelocok's peasants have access to gardens and irrigated fields as well as forest
wood and vegetation. Nonetheless, nutritionally and economically,
households are poor because land holdings are small and drought
and monsoon rains almost annually ruin crops. Most people are
malnourished, ingesting few vitamin-rich foods with their rice diet;
many women, even when not pregnant or lactating, have irregular
and light menses suggestive of anemia. Women control household
finances, such as they are. Economically, an average household of
five to ten persons earns roughly 200,000Rp ($91) annuallybarely
sufficient for a minimal diet, clothing, and basic ritual obligations
and completely insufficient for costly emergencies. For example,
one woman who did deliver in a hospital, even with a certificate of
poverty to minimize her expenses, went into debt to pay the medicine bills amounting to over 110,OOORp ($50). Poverty is a real and
defining aspect of rural Sasak life.
248 M. Cameron Hay

Lombok hosts two and a half million inhabitants, the majority of
whom are ethnically Sasak. Roughly eighty percent of the population lives in rural areas like Pelocok. Inexplicably, other provinces of
the approximate population as West Nusa Tenggara (consisting of
Lombok and Sumbawa) have over twice its biomedical facilities and
receive over twice as much money per capita from the national government for health expenditures (Mboi 1995:188-198). Nonetheless,
small clinics (PosYanDu) are situated within an hour's walk for most of
the rural population (Kantor Statistik 1988). And in the 1990s, many
childbirth posts (Pondok Salinan di Desa or PoLinDes) were built as
part of the bidan-ke-desa program, including one in Pelocok.
Prior to 1995, Pelocok's closest biomedical facility was a small
clinic an hour's walk away, and the closest hospital was more than
an hour's drive away over a dirt road, impassable during much of
the rainy season. In 1995 two structural changes made biomedicine
more accessible: the road was paved, and a childbirth post with a
resident midwife was opened. One of the maternal deaths I discuss
took place before the structural changes and the other afterwards,
thus providing a good comparison of the differenceor lack
thereofstructural access to biomedicine makes.
MIDWIFERY IN RURAL LOMBOK
As for most people in the world, Sasak births are managed by specialists (Trevathan 1997). Where bidans, biomedically trained midwives, are available, a minority of Sasaks will seek their care. But for
the vast majority, the specialist of choice is a TBA. While a mother
retains veto rights, she almost always follows the advice of her midwife. When a woman goes into labor, the husband goes to get a
TBA, giving trust and responsibility to whomever is chosen. The
TBA is expected to be able to deal with any problems that arise
although she may call on shamans to assist her. Because the TBA is
responsible for a mother's health, one could expect that she would
be held accountable for a maternal death.8
The arrival of the bidan, Rini, did not much affect this pattern of
midwifery in Pelocok. For Sasaks, biomedical knowledge has pragmatically recognized benefits but it is largely distrusted. From her
arrival in April of 1995 until I left the field in November, the bidan
was chosen to attend only one birth and then only because none of
the four TBAs in the area were available.
Dying Mothers 249
j an (1993:169-197) discusses two ways of training midwives:

experientially, during which knowledge is transferred during a lifetime of hands-on experience, and didactically, during which knowledge is transferred verbally in a classroom. All Sasak TBAs are
trained experientially, becoming midwives after raising their own
families and after years of daily apprenticeship with mothers or
aunts (see also Laderman 1983). Additionally, some TBAs take the
government's midwifery courses in biomedical techniques to supplement their experiential training.9 Some Sasaks denigrate these
latter TBAs, perceiving them as less capable than the ones whose
experiential training does not need supplementation. For others, the
courses enhance the TBA's reputation. But biomedical midwives,
trained solely in the didactic mode of education, have a poor reputation among Sasak peasants. The training of the bidan stationed at
the childbirth post in Pelocok consisted of one year of classroom
study, learning basic obstetric processes, catching fifteen babies
under supervision, and training in administrative paperwork. The
bidan was fresh out of high school, unmarried, childless, and a
stranger to the hamlet. These are the typical characteristics of bidans
in Lombok's bidan-ke-desa program, and rural Sasaks do not tend
to trust their lack of experience and their didactic training. They
trust their TBAs.
My accounts of these cases are partial, restricted mostly by my
error in judging the seriousness of the circumstances and leaving
the sites of relevant events and also by my linguistic limitations,
particularly in the first case. These are the stories of Inaq Hin and
Inaq Marni and their TBA- and biomedical-midwife-attended births
and deaths.
CASE 1: THE DEATH OF INAQ HIN
In April of 1994, Pelocok was an exceptionally isolated place. The

only path connecting it to the distant market town and even more
distant hospital was pock-ridden and traversable only two or three
times daily on a lurching dump truck. There was no childbirth post>
and the closest clinic was over an hour's walk on narrow footpaths.
I had begun studying the local Sasak dialect in January of 1994. By
the 6th of April, my language skills were elementary, and I had
become enmeshed in other people's concerns. That morning I had
promised to go to market and purchase fertilizer for an ailing crop,
250 M. Cameron Hay

but first I went to see Inaq Hin who a child had said had a sick stomach (sakit Han), a euphemism for being in labor. It was 8:00 in the
morning.
Inaq Hin had not experienced any obvious problems with her
pregnancy. She had remained active, preparing foods, working in
the fields, and busying herself with her many children. She was in
her mid-thirties and had never used birth control. In her tiny house
that morning, Inaq Hin was squatting on the dirt floor, holding onto
a bamboo beam in the mat wall. Her older sister was squatting
behind her, alternately rubbing Inaq Hin's stomach and pressing on
her hips.
Papuq Isa, the ancient TBA who had caught generations of children, was already there. The hut was dim, lit only by the open front
door, which let in a long rectangle of morning sun. Inaq Hin had
had a "sick stomach" for about an hour. Papuq Isa explained, as she
temporarily replaced the sister supporting Inaq Hin, that the trick
was to find the right spot and massage it to make the pain of labor
easier. I sat with them for half an hour in that quiet, unconcerned
atmosphere. Inaq Hin was obviously in pain during the contractions, but she never let out a peep.
Then a woman came saying that the truck to the market had
come. I didn't want to leave, but Papuq Isa said that it would still be
a long time before the birth. Naive about high parity birth experiences, I mistakenly assumed that labor usually lasts eight or more
hours. I was sure, since she had just started labor, I would be home
by the time she gave birth. We left at 8:30.
We returned at roughly 1:00 p.m., and a neighbor rushed up saying that Papuq Isa had asked me to come with my book. Trouble,
I thought. Why else would a TBA seek help from my book? I
grabbed Where There is No Doctor (Werner 1992) and hurried to Inaq
Hin's house.
The day had clouded over, and with all the people in the small
hut, it was a dim, stuffy place. Inaq Hin's mother was there as well
as another sister, seven or eight female neighbors, and there was
now a newborn. I couldn't see the child, but his occasional cries
were announcement enough. He had been born "not long after I had
left" and "not yet asar (noon)," so probably at about 10:30 a.m., but
the placenta still hadn't come out.
Inaq Hin reclined against her sister, her legs straight out in front.
The mat underneath Inaq Hin was puddled with blood that oozed
onto the dirt floor. Her eyes were closed in her pale face, her black
Dying Mothers 251
hair streaming wildly about her.10 Women were busy fanning her
with cloths and rubbing her arms, temples, and shoulders. Papuq
Isa sat between Inaq Hin's legs with her bloodied hand just inside
the vagina. Papuq Isa answered my questions, that yes, she was losing a lot of blood and the placenta didn't want to come out. I asked
about going to a clinic or hospital. Various women answered, no,
that I should just look in my book. There was no money. There was
no transportation. It was too far. Papuq Isa leaned towards me
whispering that even if we could find a truck, Inaq Hin was too
weary (lelah, tired unto death) to make the trip.
I read quickly. The book said to gently massage the womb until it
became hard and, if the afterbirth still did not come out, to carefully
push the womb downwards. I felt her stomach, squelching my own
panic that I didn't know what I was doing. The womb was easy to
find, a hard lump, but as Papuq Isa said, it was moving. When
I found it on the right side, it would slip over to the left and vice
versa. I carefully began to massage the stomach trying to stop the
hemorrhaging, then showed another woman how to continue
the massage while I read on, cursing myself for not having read the
book beforehand. Papuq Isa drew out a hand full of congealed
blood and shook it onto the floor. Someone covered it with dirt to
quench the smell. The bleeding stopped.
The bleeding stopped, but Inaq Hin had every sign of going into
shock and the afterbirth still hadn't been delivered. I brought some
juice that I'd purchased at the market, added a bit of salt, and gave it
to Inaq Hin who took a couple of sips. I tried in vain to get people to
let her lay down prone. Leaning close to Papuq Isa, I whispered that
there was nothing more I could do and that if we couldn't make
Inaq Hin lay prone and get her to a hospital, well
Papuq Isa looked at me and shook her head. I put the book down
and sat gently holding Inaq Hin's leg. A cry went up: "Remember.
Remember your name. Hin? Remember your family." Her mother
gave a pained cry: "Oh my child. Oh my child." "La-illahha-illa'allah,"
the words of a Muslim chant associated with death, broke out from
several corners of the hut. A child sat crying. A neighbor with glistening eyes, said, "She is now dying."
Amaq Hin hurried in only seconds after the initial wails and cries
of "Remember!" The wails and chanting quieted. Those who
couldn't stop crying, like the mother, went to the back of the hut.
Amaq Hin squatted down behind Inaq Hin, letting her recline
against his chest. "Hin?" he whispered to the limp, upturned face of
252 M. Cameron Hay

his wife. There was no response. He held her, her head resting on
his shoulder. The neighbors and relatives at her sides kept lifting
her arms and crossing them across her stomach. A woman stretched
her arm from behing two other women to cup Inaq Hin's jaw and
keep it closed. Amaq Hin's eyes were dry as he supported his dying
wife. Papuq Isa crept over to one side and moved a sarong uncovering a bright red, little boy. Papuq Isa started massaging the uncut
cord, pushing it toward the mother with one hand, pinching it close
to the baby with the other. Quite a picturean ancient woman leaning over a kicking newborn, cutting his tie with his dead mother
who was supported by his expressionless father.
It was 1:45 p.m. While the family gathered inside, women gathered outside the hut talking in low voices about how she had died:11
"There was so much blood." "The child was quick, it was the placenta that was the problem. It didn't want to come out." "She did
not yell during the birth of the child. She was very strong." "Very
strong, but afterwards, she was worn out." "She was very tired." "I
heard her call once saying 'where is my child?' That is what she
said." The women were interrupted by a loud wail. Men and
women rushed into the hut, and a moment later Inaq Hin's mother
was led out. She was quiet now, but tears were streaming down
her face. As she stumbled away, she reached up and twisted her
fallen hair into a bun. The voices continued: "That is her mother." "It
was her fate." "She had so many other children with no problem."
"Fate."
A few moments later, Papuq Isa came out to wash the baby. He
looked small, maybe two kilograms, but his cries sounded healthy.
She bathed him about five feet from where men had started making
the bamboo platform to carry the mother's body to the cemetery.
At 2:15, the loudspeaker, in its distorted voice, came from the
mosque announcing that Inaq Hin had died and people could start
gathering for the funeral (belangar)}2 It began to rain. I was talking
with Inaq and Amaq Mol:
Cameron:
Inaq Mol:
Does it happen often that women die in childbirth?

Often. But it's also happens that the afterbirth won't
come out for three days, for a week, and nothing
happens. The woman is fine. It was Inaq Hin's fate
(nasib). She died so quickly.
Amaq Mol: Amaq Hin only knows death.
Dying Mothers 253
He went on to say that Amaq Hin's mother had died a few months
before my arrival and one of his children had died just last year.
Amaq Hin's mortuary costs were so high that year, Amaq Mol speculated, that he would have to sell some of his land.
I went outside at about 3:00 to watch the streams of people arriving
for the burial. Women continued to talk about how Inaq Hin had died.
My name was mentioned. I heard voices describe how I had hurried
from the truck and given her something to drink. No one was acting as
if I was to blame, which was some relief but not much. I learned that
this was Inaq Hin's eighth child, three of whom had died, and that one
of Inaq Hin's sisters wouid take the infant and nurse it.
At 4:30 we left for the cemetery. There were maybe fifty of us, a
large crowd for a burial. Amaq Hin, still expressionless, watched
from under a dripping banana leaf someone else held for him. The
kiayis (religious leaders) prayed, the body was covered, and we
scurried silently home.
Nine days later, the last of Inaq Hin's primary mortuary rituals was
combined with her infant's molang-malik ritual. The molang-malik ritual contains a series of events that close the period of vulnerabilities
following birth and create a social being by giving the infant a name.
Generally the name is chosen by the TBA to fit the time, date, and circumstances of the child's birth and therefore to be compatible with
the child's spirit, but the kiayi (religious leader) can change the name
if he thinks it does not fit well.13 Papuq Isa had struggled to decide on
a name for Inaq Hin's child. She favored the name of Millon, which
means, "left behind" and is often given to children of parents who
have died. But others were more in favor of Nasib, "fate." Lo Nasib has
a more negative connotation, as if saying the child is fated to die. At
the molang-malik, Inaq Hin's sister, Inaq Sum, carried him to the kiayi.
First kiayi:
Inaq Sum:
First kiayi:
Second kiayi:
First kiayi:
Inaq Sum:
What is his name?

The boy "Left Behind."
No. The boy "Fate."
The boy "Fate."
The boy "Fate?"
No, the boy "Left Behind."
Sai aran iniqne?

Lo Millon.
Ndeq. Lo Nasib.
Lo Nasib.
Lo Nasib?
Lo Millon.
Then the first kiayi officially named him Lo Millon. He had been
given the more hopeful name.
254 M. Cameron Hay

The infant was nonetheless tiny, jaundiced, and his lips were blue
on the mouth that hung open as he kept his head tilted back in the
woman's arms. I suspected tetanus, cleaned his umbilical stump
with hydrogen peroxide, and offered to take him to a clinic. I told his
grandmother, gently, that there was a strong possibility the infant
would die. "Sakar" was her reaction. "Sakar" was the reaction of the
other women: it was in God's hands. Nearly two weeks after his
birth, I learned for the first time that Inaq Hin's sister, almost from
the first, had only fed the increasingly sickly child rice water and
masticated rice.14 She was "afraid" to nurse him, perhaps because
she feared for the health of her own nursing infant if she also nursed
the sickly Lo Millon. His aunt and his grandmother wore themselves out seeking help from various healers, although they never
accepted my offers to take them to a clinic or to buy him formula.
He died on his 24th day as was his fate. And people commented
that he had followed the fate of his mother.
EXPLAINING DEATH, FOREGROUNDING FATE
Fate is an ultimate cause, a force wholly beyond human control.

Krulfield (1966), in examining Sasak notions of fate, suggests that
fate is a useful explanatory tool because it does not rock the social
boat. Sasaks, like other Indonesians, prefer to smooth over rather
than propagate conflict (e.g., Geertz 1983; Siegal 1986; Errington
1989; Barth 1993), and fate is a useful explanation to that end. Yet,
instead of foregrounding function, I prefer to ground our understanding of fate in Sasak usage. I suggest that nasib, an ultimate
cause, was used to explain Inaq Hin's and her infant's deaths
because people perceived that all relevant resources had been utilized, knowledge had been exhausted, and, well, death is an everyday occurrence. As one neighbor said, "Inaq Hin died because her
time was finished. It is certain that if her time wasn't gone, the
medicine of Papuq Isa would have been strong enough for her."
Papuq Isa's abilities were not seen as inadequate; Inaq Hin died
because her predetermined time to live was over.
Her son died because he shared his mother's fate, almost as a contagion.15 But although the newborn was particularly vulnerable to
death, he was not given the name Lo Nasibhe was not assumed to
be fated to die. Nasib is only clear after an event. Thus, up until the
moment of death, people do everything they can and utilize all
Dying Mothers 255
appropriate knowledge available to aid a person in living. Usually,

there is no pre-emptive "what will be will be" attitude. Yet, in the
case of this newborn, his grandmother and other women repeatedly
used the word sakar, putting his health in Allah's hands. They did
not stop seeking treatments that could heal him, but neither did
they go to extraordinary lengths, such as going to a clinic for treatment. They did all that was appropriate, but after the child died, it
was clear that nasib had thwarted all their efforts.
A general verdict of fate does not exclude other causes of death.
Women, particularly middle-aged women, continued to refer to
Inaq Hin's death in discussions of childbirth. "It happens often.
When the placenta doesn't come out, sometimes a woman dies."
"She gave birth then couldn't stop bleeding and therefore died."
"That was her eighth child. It is said, the more children, the more
likely one is to die." These proximate and medial causes, compatible
with the overarching designation of fate in which no one is at fault,
expressed anxieties about childbirth. A young woman, in her
second trimester of pregnancy who was barely an acquaintance of
Inaq Hin and was not present at her death, told me two months later
of her fears of childbirth because she had dreamed of her own death
"like Inaq Hin." Inaq Hin's death explicitly prompted two neighbors, who had already had six and eight children respectively, to go
on the pill to prevent the maternal deaths that they now imagined
for themselves. The anxiety that Inaq Hin's death provoked in pregnant women was also attested to by the parade of women going to
bolang-olang in the stream the day after her death, in order to prevent sharing Inaq Hin's fate.16 Fate is hopefully preventable, if one
recognizes all of one's vulnerabilites and does all the correct preventive practices. These women went on the pill and bathed in the
stream in hopes of alleviating their own vulnerabilities. But they
continued to worry that the pill would be harmful, that they would
bleed too much, and that it would be their fate to die.
Nasib for Sasaks means that death is predetermined by Allah and,
as such, must be submitted to. Yet, in the worries of women about
using the pill and in the efforts to treat Inaq Hin's sickly infant, it is
clear that the notion does not make people try less to avoid death
and suffering. In this, and in their use of the Arabic word nasib,
Sasaks are similar to the rest of the Muslim world (e.g., Inhorn
1994:213ff). The Qur'an teaches both predestination and man's free
choice; on balance, the emphasis is on God's omnipotence and the
importance of submitting to it, rather than predestination itself
256 M. Cameron Hay

(Ringgren 1967:56; Bousfield 1983:102).17 Yet, this cannot explain
why Sasaks disregarded nasib in their interpretations of other
deaths, such as Inaq Marni's below. Moreover, however much
people's interpretations and actions with respect to Inaq Hin's death
can be associated with a notion of nasib, they did not emerge necessarily because of that conceptthe name of the infant and the pregnant women's bathing to avoid contagion argue against drawing
such a simple conclusion.
In the events of Inaq Hin's death and people's interpretations of
it, there was no one to blame because of the limit to knowledge.
Even the most complete healing knowledge must bow down before
nasib. For people in Pelocok, everything possible had been attempted, and Inaq Hin was given space to die with dignity, surrounded
and supported by loved ones. Papuq Isa was in no way negligent.
Neither she nor I were ever held responsible, to my knowledge.
Indeed, within a week, Papuq Isa attended another birth and gave
prenatal care to other women. Their trusted TBA with her wealth
of experience had in no way failed them. Inaq Hin's death was a
matter of fate.
CASE 2: THE DEATH OF INAQ MARNI
It was 1995. The childbirth post (PoLinDes) had been open for a
month. From the childbirth post, it was an easy walk of only 270
yards along the now paved road to the hut of Inaq Marni. Inaq
Marni had been to the clinic for only one pregnancy examination,
a week before she delivered. The bidan, Rini, later recollected that
she had told Inaq Marni to give birth in the clinic because she was
a high-risk case. This was her eleventh pregnancy, and she was
a grandmother in her forties. But Inaq Marni wanted to stay home,
attended by a TBA.
On the 24th of May, Inaq Marni went into labor. The TBA this
time was Inaq Hapim, a woman in her late forties, who had had
eight children and had amassed a large clientele in the ten years she
had been a midwife. Inaq Hapim was unique among Pelocok's
TBAs because she had taken the government's training course in
midwifery. It was precisely this training that made Inaq Hapim suspect to some in Pelocok, who tended to legitimate the powers of
secret healing knowledge over knowledge that is publicly gained:
Dying Mothers 257
"Inaq Hapim, bah. She, her knowledge is very small. She had to go
to the government to study. But Papuq Isa [the TBA for Inaq Hin's
case] her knowledge is complete. She does not need to go study,
because she already knows it all." For others, including Inaq Marni,
Inaq Hapim's knowledge and skills were highly valued.18
Inaq Marni had been in labor since the middle of the night.
I arrived just after noon and waited in the hut for six hours. The
composition of women waiting with me shifted constantly but
there were never fewer than eight of us plus Inaq Hapim and Inaq
Marni in the cramped space. The companionship was calming and
comforting. Inaq Marni occasionally lay down for a few moments,
but otherwise she squatted, holding onto the waist of a person who
sat on an overturned log, supporting Inaq Marni under her arms.
Inaq Marni was quiet except for barely audible moans. We conversed in subdued voices, sometimes about the harvest or whose
sandals were whose, but increasingly about the slowness of the
birth. I had my tape recorder on, but only bits of conversations
were clear above the hum of whispered voices and crying children.
Each time a woman breezed in, she would ask, "Has it come out
yet?"
Inaq
Hapim:
Patience. Patience. It's not Sabar. Sabar. Ndeqne kerea train, you know, (pause, ta'an kan. Tene langan
as the women shift around
making room for the woman to sit in the doorway)
tetokol. Dendeqne iniq,

ndeqne tauq sugul iye.
Here is where you should

sit down. Not there, then
the baby won't know
how to come out.
Inaq Uli:
So, it's going to come out
Kan genne sugul iye kane
now? (she moves)
Inaq
Hapim:
Inaq
Senan:
Inaq Uli:
Of course in a little bit.
Tetuhne bareh.
Can you already see the

Gitaqne bayiq wah?
baby?
The bidan [Rini] knows
Bidan bebayaq tauq iye
how to make babies come pecatan anak.
quickly.
258 M. Cameron Hay
Inaq
Mol:
Inaq
Hapim:
Inaq Uli:
Inaq
Mol:
But it won't be much

longer and then it will
come out and we will all
see it. {loudly interrupting
Inaq Uli at the word
"bebayaq")
Right.
Inaq laguq ndeq suwe gene

sugul ampokne pude-pude
gitaq.
But she
(stops when
Inaq Mol interrupts her)
Now it will really come
out, in just a little bit.
Why should one go [to
the bidan] when it is
going to come out? It
would be a wasted trip.
Laguq iye....
Ooq.
Kane gene sugul gati, karen

sebendat gati. Soq lalu kane
gene sugul lewat dengan?
As the jumbled voices continued, Inaq Ju whispered to me "Inaq

Hapim is embarrassed to say a spell (jampi) for Inaq Marni's
vagina." A group of women started scolding a child that sat in the
doorway, telling her to clear the doorway because one must not
block a threshold during a birth. Various voices talked about who
should be sent to find Amaq Jamil, a shaman, for a spell for water to
make the birth easier. Another woman suggested borrowing a certain holy object to make the birth easier and asked Inaq Hapim to
confirm that it would be a good idea.
Inaq
Hapim:
Inaq
Senan:
The stomach is still having

contractions. It's not necessary.
You're right, it's not
necessary.
Voices
Inaq Nun Oh, this hasn't yet waited
too long for the child, (implying that the labor is not
taking too long or that the
baby is not full term)
Inaq, tianne masih polak.

Neh ndaq ulaq iniq.
Ndeqne ulaq tetuq.
Aduh, iniq ndeqman suwe

unti anak.
Dying Mothers 259
Inaq
Hapim:
Inaq Uli:
Not yet.
She got pregnant at the

same time as Inaq Ecok
She is like this one.
Inaq Nur: Not yet ready.
Many
Not yet.
voices:
Ndeq man.
Iniq iye betian barang Inaq
Ecok. Iye maran sini, ne.
Ndeq man ne.
Ndeq man.
Jumble of voices
Inaq Min: Why hasn't she given

Kan ndeqne beanakl
birth?
Inaq Uli: There is no one giving birth Ne, ndeq dengan beanak
here. If it isn't born now, if Inaq. Munne ndeq kane,
it reaches the limit of the
lalang Juni ndeqne summonth of June, won't it be buhl
healthy?
Tene nyet.
Inaq Mol: It is wet-cold here.
Kan ne mirikan lekan
Inaq
It has been like this since
Hapim:
early morning, {unclear
onet.
whether she means the coldness of the room, or of Inaq
Marni's skin)
Inaq Adi: Why doesn't the baby want Sang ndeq meleh datang
to come?
bayakne?
Of course it wants to.
Melet iye, ngene.
Inaq
Senan:
Inaq Nur: Send Cameron for the
Suruq aloq Cameron joq
bidan.
Inaq
Hapim:
Bidan.
We've decided against that. Burungne tipatne.
Thus it went, voices meandering in the small, dark hut. In these bits
of conversation, there were themes that kept resurfacing and were
never finally addressed, but once an opinion had been strongly stated,
that opinion stood whenever the topic was renewed. For example,
Inaq Mol's vocalness about not going to the bidan withstood all
attempted contradictions, and in her words she subtly expressed
260 M. Cameron Hay

both a lack of confidence in the bidan and faith in the abilities of
Inaq Hapim. Inaq Hapim could not appropriately defend her own
honor and capabilities by speaking out against going to the bidan
because only her silence would be proof of her confidence in her
own knowledge and abilities. The second time someone suggested
the bidan, Inaq Hapim could quietly reinforce Inaq Mol's earlier
statement, giving it the tone of final authority.
During the hour of taped conversation, nothing was done about
Inaq Marni's condition. The women satisfied themselves in conversation that they needed only to wait. Had the concern about the
length of labor, repeatedly expressed by various women, been reiterated rather than dismissed, this concern might have resulted in
action, perhaps even overturning Inaq Mol's statement and going
to the bidan. But instead, concern was always smoothed over by
others' calls for patience, expressions that there was nothing to do
but wait, assertions that the birth was immanent, and suggestions that
it was only false labor. Indeed, because the birth was taking so
long and her contractions had so subsided, I assumed it was false labor.
I left to go to a ritual, planning to return within an hour, but I was
at various rituals until well past midnight.
The next morning, I had a dawn funeral to attend followed immediately by a wedding. There I heard news that Inaq Marni had given
birth to a child, born dead, but that she was fine. At about 1:00 p.m.,
I saw one of Inaq Marni's neighbors who confirmed the news
about the still-born child but added that, in fact, Inaq Marni was not
fine because there was still a child inside of her. She was having
twins! Although Sasaks have no taboos about twins (cf. Boon 1990),
twins are considered dangerous because they almost always die.
I finally recognized the danger Inaq Marni was in, and I scolded
myself for not having extricated myself from my ritual obligations
sooner.
I found Inaq Marni newly arrived at the childbirth post. Rini, the
bidan, was starting an IV; she had to try five times before succeeding because Inaq Marni's blood pressure was so low. The cement
room was corridor-likeperhaps three yards long and a yard and a
half wide. There was a glass window at one end filled with the faces
of women and children. Everything was glaringly white and
smelled of antiseptic. Inaq Marni looked exhausted and pale on the
plastic-covered bed.
Inaq Marni asked me what the needles and bag, the IV, were for. I
explained they were to help the flow of her waters inside her urat
Dying Mothers
261
(blood vessels), adding that she would be all right. Inaq Marni said
that she wanted to go home. I answered that her family was still
around her, they were just outside, and that here the bidan could
help with the birth of her second child, making it easier for her. Rini
barred Inaq Marni's mother from entering the room and tried to
send Inaq Hapim out saying that the room was too small for her to
be there. Inaq Marni whimpered a soft complaint, and I added that
it was important for Inaq Hapim to stay and be with Inaq Marni.
Inaq Hapim climbed up onto the bed and scrunched herself against
the far wall at Inaq Marni's knees. Rini had her working space and
Inaq Marni still had her TBA. I asked when the first baby had been
born. Inaq Hapim answered, "Earlier." Rini finished taking Inaq
Marni's blood pressure, grabbed my wrist, and took me outside,
complaining:
The dukun [Inaq Hapim] said the baby was born this morning." But she
lied. It was born last night at eight o'clock. She lied to me. That's over
twelve hours. She should have been brought to me long ago. It is so hard
with the commoners (rakyat). I should have been there from the beginning of labor. Then maybe the first child wouldn't have died She needs
to go to the hospital. Her contractions are very weak. But she doesn't want
to go. A problem of money. I told her how dangerous her condition is. She
said "Whatever the outcome, I'm not going to the hospital." Then she said she
wants to go home again. The commoners, they don't have understanding.
I tried to explain that actually it was less a matter of money than of
fear. Hospitals are reputed to be places of death. They are unimaginably far away, lonely and scary places. I tried to explain that
rural Sasaks understand death as a matter of fate, so they think,
"Why go far away to die?" Calmed a bit, Rini sent a boy to get her
supervisor from a distant town, and went back inside.
Her supervisor, a nurse (perawat), arrived almost an hour later. He
and Rini discussed the patient's condition, complained about her
refusal to go to the hospital, and discussed a drug, oxytocin, which
induces contractions. But the bidan didn't have the drug, and the
supervisor's clinic hadn't had any in weeks. After a while he left to
find oxytocin and never returned.
As time went on, the yard of the childbirth post filled with at least
seventy-five women and children, curious about Inaq Marni and
how the bidan was assisting in the birth. "Inaq Marni didn't want to
come here. She cried when the bidan made her come." "This is what
Inaq Marni said, 'I don't care if I die, but I don't want to leave my
262 M. Cameron Hay

home/" "You should have been there Eron [Cameron]. Amaq Drian
and Amaq Jumil had to carry her here. She can't walk." "Is she
going to have an operation?" "Why won't it come out?" "What is
the bidan doing?" "Will she go to the hospital?" "She looked like it
wasn't possible that she would live." "I would not go to the bidan to
give birth. I only use Papuq Isa." "Inaq Hapim, she doesn't know
how to jampi (say healing spells)." I divided my time escaping to the
breathable air outside with the crowd and going back into the birthing room to be of whatever assistance I could.
Inaq Marni was given water and a little rice. She lay prone, no one
supporting her from behind. Inaq Hapim was silent on the bed,
lightly rubbing Inaq Marni's legs, but otherwise doing nothing. She
never attempted to massage her, say a spell for her, or question the
bidan. For her part, Rini, appearing nervous, gave injections and
probed Inaq Marni's body while openly complaining about how
uncooperative Inaq Marni was being by not consenting to go to a
hospital.
At 2:50 Rini pulled me aside, saying she thought she would have
to pull the second baby out because it's heartbeat was fading and
Inaq Marni was dangerously weak. I explained the bidan's concerns
to Inaq Hapim and Inaq Marni, who acquiesced. Rini gave an injection of something to help with the pain and I left to avoid fainting
from the antiseptic smells. At 3:00 p.m. it was born, and I was immediately called in. There was a foul stench coming from the blood and
yellowish-green liquid puddling between Inaq Marni's bent legs
and around the fetus. The fetus had crooked, underdeveloped legs,
but otherwise, the body was oval-shaped with a crevice going
the length of the body hiding a dark red organ and white tissue in
its folds, the heart or liver perhaps. I tried not to let my horror show
on my face as I took Inaq Marni's hand. The fetus had been placed so
she couldn't see it but Inaq Hapim and Rini talked freely, poking it
and saying, "It wouldn't have become human," "This would have
been an arm," and "See no anus." Rini asked if Inaq Marni had taken
any medicine during pregnancy. Inaq Marni gave no response. What
was there to say to such an unspoken accusation at such a time?
Outside, the gathered women described the fetus they had not
seen. Almost immediately people began referring to Inaq Sahri's
deformed fetus, also a twin, born a few years before. That fetus had
been completely round. "Does it have a head?" "Inaq Sahri's baby
had no head." "Does it have skin?" "Does it have arms?" "It is like
Inaq Sahri's. That is the way with twins."
Dying Mothers
263
Amaq Drian, Inaq Marni's husband, was not among the crowd.
At 2:00 p.m. I had watched as he walked down the road to stand in
front of the childbirth post for a few minutes. Then he turned
around and went north again. At about 3:30 he arrived again, this
time sitting on the front porch. He wasn't allowed in to see his wife
and didn't ask. He just stood outside the door and then sat down
silently. Amaq Drian's expression never changed, but his eyes
betrayed his worry. At one point he looked at me questioningly.
I said, "The child was born dead, but the mother is still fairly strong."
He replied, "It doesn't matter about the child, what is important is
that the mother live." Then he was silent again.
The afterbirth wouldn't come out. Rini was close to panic when she
consulted me: "If I only had some oxytocin. But they don't allow us to
have it here, at a PoLinDes. They think we would use it too much. But
in a case like this.... The afterbirth isn't coming out. I've tried Mbak.20
I've pulled gently on the cord. I've massaged the stomach. I should do
a manual, but I am not brave. She is so weak already." She turned again
and asked Inaq Marni to let herself be taken to the hospital. The answer was no, Inaq Marni wanted to go home. "See, what can I do,
Mbak?" complained Rini. By 5:00, Inaq Marni was fading quickly, and
her husband was let into the room. Rini asked again, "Do you want to go
to the hospital?" There was no reply. Rini said then in her city Sasak
dialect:
You don't want me to take you to the hospital. Then my responsibility ends
here. Earlier I wanted to take you to the hospital, right, but she said no [now
talking to Amaq Drian]. Right. She would not let me take her no matter
what happened. I have done everything I could, but she needed to go to the
hospital. My responsibility is ended. [Turning to me and switching to Indonesian] I am at the end of my ability (puas). There is nothing more I can do.
She won't go to the hospital. From the beginning I wanted to take her to the
hospital. I can't be responsible now.
Inaq Marni whispered, "I want to go home." Inaq Marni and the
dead fetus were carried home. Rini left on a futile mission to find a
doctor willing to make a house call. I headed home, exhausted and
depressed. Three times I was stopped with questions about Inaq
Marni's condition. Twice I was asked if Inaq Marni had been begebuk, and one woman answered herself saying, "I think she wasn't
begebuk." A gebuk is the strip of cloth tied above the stomach during labor to encourage the baby and placenta to go down and out of
264 M. Cameron Hay
the body. These women implied that the bidan and the TBA had
failed to do this basic childbirth assisting technique.
Inaq Marni died that night.
EXPLAINING DEATH, FOREGROUNDING ERRORS
In their conversations and remarks about Inaq Marni, the people of

Pelocok did not say it was simply her fate. Instead they pointed to
medial and proximate errors. Voices rang with accusations against
Inaq Marni herself, as well as the TBA and the bidan. Among Inaq
Marni's errors, women accused her of not being conscientious (rajin)
in following the food taboos of pregnancy and in ignoring the gossip
about the danger of using contraceptive pills, taking the pill for five
years before this pregnancy. Many noted that she had made another
error in choosing Inaq Hapim rather than a more knowledgeable
TBA. Inaq Hapim was blamed for not treating Inaq Marni sufficiently with healing spells (kurang tejampiq). Moreover, people said that
Inaq Hapim had forgotten to prepare Inaq Marni's dewa (spirit) adequately before labor and that this had hindered the birth.21 The bidan
was also held responsible because she should have treated Inaq Marni with healing spells too, but, as was usually noted, the bidan did
not know healing spells at all (Jkurangne gati tauqshe doesn't know
anything). Both care givers were at fault for not remembering basics
about aiding delivery, such as tying a cloth above the stomach (begebuk). In sum, according to the voices commenting on Inaq Marni's
death, her death was caused by ineptitude due to too little or forgotton knowledge: Inaq Marni had not remembered the appropriate
prevention measures nor had she known enough to choose a better
TBA, and the two midwives had not known the healing knowledge
necessary to properly prevent and treat the difficulties of childbirth.
These accusations of blame were motivated. By noting Inaq Marni's errors, women emphasized the things they could do to prevent
it from happening to themselves, such as avoiding taboo foods and
birth control pills. By pointing fingers at Inaq Hapim as a lesser
TBA, the trust they put into other TBAs was not called into question. By noting the errors of the bidan, people reinforced the superiority of Sasak medicine {owal Sasak) over biomedical knowledge,
arguing that the bidan did not know the important knowledge for
managing a birth. In short, in ascribing this death to a series of errors,
people's confidence in the potency of Sasak secret knowledge was
Dying Mothers 265

not challenged. All that was at stake was the reputations of particular midwives.
Their reputations suffered. Until I left the field, seven months
after Inaq Marni's death, the bidan was never permitted to catch a
birth of someone in Pelocok.22 It would be unfair to argue that this
avoidance resulted from Inaq Marni's death because it had been just
as keen beforehand. Had Inaq Marni lived, the bidan might have
received more business, particularly from women nervous about
giving birth. Inaq Marni's death only reinforced people's distrust of
the bidan's abilities. Perhaps because Sasak medicine was considered superior to biomedicine, the bidan's role in Inaq Marni's death
was of relatively little account in people's gossip about Inaq Marni.
It was largely Inaq Hapim's reputation as a TBA that suffered in
conversations. Her crime was not one of negligence but rather "She
is not enough," "She knows nothing," or, according to a more generous woman, "[She doesn't have] enough knowledge." Her knowledge was deemed lacking because she did not say spells, use
sufficient massages, or tie a cloth above Inaq Marni's stomach. Yet
these accusations, voiced behind Inaq Hapim's back, did not prevent people from calling on her. People in other hamlets used her
regularly. Even people in Pelocok used her, but now she was called
only when no other TBA was available. Successful, healthy births
did nothing to rebuild her reputation. Two months later and after
assisting in numerous other healthy births, a woman's baby, like
Inaq Marni's first child, died during delivery. Promptly the accusations again flew about Inaq Hapim's lack of knowledge: "Babies all
just die if Inaq Hapim is the midwife."
For her part, Inaq Hapim avoided speaking of Inaq Marni. She
attended all the funeral rituals as was proper, but never in the following seven months did I hear Inaq Hapim speak of Inaq Marni,
not even in response to my own leading questions. For example, one
week after Inaq Marni's death, I asked her just how many births had
she assisted in the last two weeks. She rattled off six names, even
mentioning one where the child had been stillborn, but did not
mention Inaq Marni. Because she would not speak of it, I do not
know whether she held herself accountable for Inaq Marni's death.
Either way, many people in Pelocok did.
Rini, the bidan, blamed herself, as well as the TBA, Inaq Marni,
and the community at large. Indeed the day after Inaq Marni's
death, Rini tried to quit her job because she did not think she was
capable of being a bidan, but her superiors would not let her. In
266 M. Cameron Hay

speaking to me often about the case, Rini expressed her continued
disquiet over it. She blamed Inaq Hapim for not telling her about
the labor from the beginning and for delaying during the prolonged
labor, which exposed Inaq Marni to infection. She blamed Inaq Marni for not heeding her advice to come to the childbirth post for
delivery because it was a high-risk pregnancy, for refusing to go to
the hospital, for being generally uncooperative, and for perhaps taking drugs during pregnancy. She blamed the community in general
for their ignorance and the lack of easily available transportation.
Notably, Rini did not blame the lack of oxytocin, the lack of blood
for a transfusion, her own lack of confidence to remove the placenta,
or the inefficiencies of her supervisor and the doctor who would not
make a house call. Nor did Rini ever doubt that biomedicine could
have prevented Inaq Marni's death, had not the medial causes gotten in the way.
In all of the dialogues, finger pointing, and regrets following Inaq
Marni's death, the word nasib (fate) never emerged. Unlike Inaq
Hin's death, Inaq Marni's death was perceived as preventable. The
difference was not one of religious belief, for had I asked, people
certainly would have responded that of course it was Inaq Marni's
fate to die when she did. But in Inaq Marni's case, ultimate causality
was backgrounded behind human error. For other women in the
community, the errors were ones they themselves could avoid by
choosing a more knowledgeable TBA, not going to the childbirth
post, not taking birth control, and adhering to food taboos. For the
bidan, the errors could be remedied by taking birth control and
avoiding pregnancy, utilizing a bidan, being willing to go to the
hospital, and learning generally to trust biomedicine. Not only were
these explanations motivated by particular concerns and understandings, they were crossed. The villagers would not have understood the bidan's explanations anymore than she understood theirs,
even when I tried to explain them to her.
DISCUSSION: WHY DID THEY DIE?
[T]here is no final meaning to be found in shocking events such as these. There is

only the ceaseless flow of meaning making, as people use whatever resources they
can summon to make sense of senseless acts. Periodically they stop up the flow, in
a temporary holding actionwe usually call it "an explanation." (Shore
1996:378)
Dying Mothers 267
Explanations and memories are people's interpretations of events,

which are motivated by personal salience. The memories of the men
in the community tended to mark not the manner of deaths but the
social situation of each woman as a man's wife, empathizing with
the difficult financial burdens and burdens of finding a new wife
that maternal death imposed. The explanations of women in the
community foregrounded the events of the deaths, associating
death in childbirth with their own fears about fertility. They sought
to learn about the proximate and medial causes they supposed
made Inaq Hin and Inaq Marni vulnerable to death so that they
themselves could prevent it. The bidan's explanations were detailed
with the faults of others but marked with guilt that she had failed
to prevent a preventable death. These explanations suggest that
people highlight causes of death according to their own concerns.
Maternal death resonates deeply within people, prompting them to
come up with motivated explanations to understand the events and,
to the extent allowed by fate, hopefully prevent recurrences.
If we distance ourselves, we can compare these deaths and examine their proximate, medial, and ultimate causes. The proximate
causes in both cases were similar. Both women were older, with
high parity and probable nutritional anemia, each of which could
have contributed to the retention of their placentas and the hemorrhaging. Inaq Marni's case was further complicated by the twin
pregnancy, her prolonged labor, and the infection implied by the
smell and pus that accompanied the delivery of the deformed fetus.
The medial causes contributing to the deaths partially follow the
factors highlighted in the maternal mortality literature discussed at
the beginning of this paper. Access to safe abortions was irrelevant
in both cases as was access to birth control: both had had access to
birth control before becoming pregnant and either chose not to use
it (as had Inaq Hin) or had stopped using it (as had Inaq Marni).
Nor is status and strong social relationships relevant in matters of
health care on Lombok: Sasak women are valued as wives and
mothers, with husbands never hesitating in seeking expensive care
for them if they think it might helprecall the words of Inaq Marni's husband, all that was important to him was that she live. And in
both cases, the women had a significant, supporting social network
as demonstrated by the number of people waiting with them during
labor. The problem of distance and lack of transportation was relevant in both cases. Inaq Hin did not seek biomedical care in part
because of the distance and the lack of easy transportation. But with
268 M. Cameron Hay

a biomedical care facility nearby, Inaq Marni still did not seek biomedical careit was forced upon her by the bidan. Moreover, even
with a paved road and access to better transportation, Inaq Marni
could not be convinced to go to the hospital. This suggests that paving roads and building local biomedical clinics is not, in itself,
enough to decrease mortalities. The lack of TBA biomedical training
was a factor in the first death, but Inaq Hapim had had the government's training. Surely after over twenty-four hours of labor and a
stillborn baby, a TBA who had taken the government's midwifery
course would recognize it as a crisis situation, yet Inaq Hapim did
not seek help from the nearby bidan, which suggests that the courses
are ineffective. In addition the inefficiency of biomedical personnel
and poor biomedical equipment and supplies were factors in Inaq
Marni's death. Still, this list of the medial causes, which a health
ministry might recognize, is incomplete.
In the voices and reactions of people in Pelocok other important
medial causes emerge. First is the centrality of conversation in managing illness, even crisis situations. In the conversations surrounding the dying of Inaq Marni, we heard people trying to make
meanings, to find potential answers for their concerns about her
delay in delivery, difficulties in the actual childbirth, deformed
fetus, and quickly fading strength. These conversations do not follow a single, decision-making thread. Such conversations are a normal and essential part of everyday interaction, and it is through
them that tentative ideas are either legitimated and acted upon or
dismissed. Even the bidan needed the legitimization of other
people's voices, mine and her supervisor's, confirming her own
before she acted. Albeit essential to interpretation and action, conversations did delay potentially life-saving actions. In emphasizing
the importance of conversation and suggesting that it delayed treatment, I am not arguing that the primary problem of maternal mortality in Indonesia is a problem of delay (cf. Iskander et al. 1996).
Rather, I am arguing that health care occurs necessarily within webs
of conversations, which may contribute to the processes of maternal
death if notes of concern are smoothed over rather than allowed to
flower in a conversation. The second medial cause that my data
highlight is the issue of cost. Thaddeus and Maine (1990:12-15)
argue that cost is not a significant factor in decisions to seek biomedical care. In fact, for people in Pelocok cost was frequently mentioned, and their overall poverty does make it a highly pertinent,
although not overriding, concern, influencing decisions of resort.
Dying Mothers 269
Third is the complex issue of trust in the care giver. Papuq Isa and
Inaq Hapim were trusted TBAsthe former more widely so than
the latter, yet both were more trusted than the bidan. Some suggested
that Rini was not trusted because she was childless, yet I was called
upon in Inaq Hin's case, and I had never given birth. I suggest that
trust certainly involves credentials, but equally it is a matter of
being able to communicate and empathize with people in their own
termssomething the bidan was incapable of doing. The final factor that my data highlight is that comfort and familiarity play a role
in resort and willingness to accept recommendations. I could not
convince people to lay Inaq Hin down and raise her legs because it
was an unfamiliar form of treatment. The bidan's strange equipment was frightening to Inaq Marni, yet she calmed when I
explained it to her. For health care to be accepted in Pelocok, it cannot be alienating: it must be made familiar and explained in terms
that make sense to the inhabitants. These four complex factors
emerge from the cases as important medial causes in these mothers'
deaths.
One potential medial cause needs to be mentioned because of its
absence. These deaths did not occur because of Sasak perceptions of
biomedicine per se. My materials concur with Grace's (1996) in suggesting that rural Sasaks are perfectly willing to utilize biomedical
treatment. In calling on me to look in my book, filled with biomedical knowledge, that knowledge was seen pragmatically as a useful
resource. The woman who suggested that the bidan be called during Inaq Marni's drawn-out labor was suggesting this as another
option of the same quality as seeking a holy object to hurry childbirth. Inaq Marni herself went willingly to the bidan for a prenatal
examination and only rebelled against the bidan's insistence that
she give birth in the childbirth post. Those villagers who were wary
of biomedicine had problems with it for the baggage it carriesthe
cost, the patronizing tones, the strangeness of unexplained procedures and isolated spaces, and the lack of choice they have once
they submit to itbut not with the technologies themselves.
The cases suggest that ultimate causes, which are completely
ignored in the maternal mortality literature, are important to how
people explain and cope with maternal death. Sakar, and to a lesser
extent nasib, imply that there are limits beyond which a person
need not go to try and prevent death. Moreover, the verdict of nasib
in the death of Inaq Hin denied doubt in the knowledge of Sasak
traditional medicine, whereas the lack of nasib in explaining Inaq
270 M. Cameron Hay
Marni's death, left room for questioning the knowledge of biomedicine represented by both the bidan and the biomedically trained
TBA. Because noted ultimate causes are motivated and salient
explanations, they should not be lightly dismissed as irrelevant.
These two cases highlight complexities of maternal death that the
relatively easy fixes the government has put into effectestablishing family planning programs, training TBAs, paving roads, and
putting biomedical midwives in villagesdo not address. Rural
Sasaks need more than access to biomedical care. The data are filled
with voices confronting messy realities and uncertain outcomes.
Sometimes the voices are hardly communicating, slipping past each
other like ships in a night as between the bidan and the villagers. In
their motivated explanations of Inaq Hin and Inaq Marni's deaths
are hints of ways maternal mortalities might be prevented.
WHAT MIGHT MAKE MOTHERHOOD SAFE?
These two cases of maternal death in a small, rural community

occurred thirteen months apart. There were three cases of maternal
mortality out of a total number of 36 births during my 20-month
tenure from 1993-1995 in Pelocok. These numbers are too small to
give a statistically accurate maternal mortality ratio, yet, they imply
that a woman's chance of dying in childbirth in Pelocok is 1 in 12.
But a public health worker wanting to prevent future mortalities
would quickly become baffled. Sasak women have free, easy access
to birth control. The government holds annual training sessions for
TBAs like Inaq Hapim. The bidan-ke-desa program has placed biomedically trained midwives in villages throughout the island.
Paved roads are being built to the most remote areas, making transportation easier. Village heads can provide certificates of poverty to
cut hospital costs. Despite all these infrastructural improvements,
women continue to die.
The answers are not so easy because, as we have seen, the causes
are not so simple. Trust, mutual respect, and communication between representatives of biomedicine and rural Sasaks are part of
what is needed to decrease maternal mortality on Lombok. In cases
like Inaq Marni's, when biomedicine has the opportunity to treat
patients, it must not betray people's trust. Biomedical facilities need
to have adequate supplies and adequately trained personnel. Fortney
et al. (1988:31) recommend making oxytocin available to midwives
Dying Mothers
271
(bidans) and even TBAs trained in its use, which, had it been
available, might have prevented both deaths discussed here.
Equally important, personnel must be well trained. The bidan recognized that Inaq Marni required a manual placental removal to have
a chance of survival, but although trained in it, she was not brave
enough to do one. Her presumably more-experienced supervisor
disappeared ostensibly to find a drug, rather than sending someone
else and staying to assist the bidan through a crisis situation. Similar
errors should be preventable with truly adequate preparation in
emergency procedures as well as adequate access to medications.
Even more important, biomedical personnel must focus on learning
to communicate with rural Sasaks. Medical students in the United
States usually get some training in conducting culturally sensitive
patient interviews and having a respectful bedside manner (Brown
and Ballard 1990). Training in cultural sensitivity in Indonesia
would be very difficult, for it would involve overcoming dominant
ideologies that rural peasants, particularly those who do not limit
their number of children, are backwards, primitive, and ignorant.23
Nonetheless, culturally sensitive seminars on the various cultural,
political, economic, and religious dynamics on the island could
make inroads against these ideologies, educating biomedical personnel who are motivated to serve rural populations in nonpatronizing, respectful ways of communicating with patients. For
example, if biomedical care givers took seriously the notion of fate,
they could use it to their advantage. If they explained deaths with
the concept of fate rather than complaining of the errors of patients
and the community, patient's families also might be less likely to
allocate blame and begin to recognize biomedical care givers as
people with some understanding of cosmic forces.
Equally important, decreases in maternal mortality rates could be
promoted with relatively simple programs that foreground the
interpretations and activities of villagers. To inform rural Sasaks of
the facilities available and reduce fear of using them, a project as
simple as giving rural women guided field trips to area clinics and
hospitals could help dramatically. If the field trips included informal
conversations (rather than lectures) with doctors, nurses, and bidans
where rural women were encouraged to ask questions about equipment and procedures, the biomedical option could begin to be less
alien. Even though Sasak women control household finances, they
could still benefit from a program like WARMI such as the one outlined for West Java (Sibley and Armbuster 1997). By empowering
272 M. Cameron Hay

women to cope with emergency situations, this kind of program
might effectively change patterns of conversation so that voiced concerns would be treated seriously rather than simply brushed aside as
they were in Inaq Marni's case. In short, programs that supported
rural woman in their attempts to manage childbirth and to understand their biomedical optionsin addition to the infrastructural
resources already in place and continual improvement in biomedical
equipment and personnel trainingmight be enough to dramatically
increase pregnant women's chances of surviving childbirth on Lombok.
ACKNOWLEDGMENTS
This paper profited from initial discussions on maternal mortality
with Lynn Sibley and Mary Kroeger as well as from bibliographic
citations suggested by George Armelagos, Lynn Sibley, and Marcia
Inhorn. I thank Jeremy Schiffman for permission to cite his unpublished paper. For reading and providing helpful comments on earlier drafts of this paper, I want to thank Bradd Shore, Fredrik Barth,
Mari Yerger, Marcia Inhorn, and four anonymous reviewers. I also
thank Nora Poling and Peter Brown for their comments and editing.
NOTES
1. For general reviews of the factors leading to maternal mortality and literature
reviews, see Herz and Measham 1987; Thaddeus and Maine 1990; World Federation PHA 1986; Maine n.d.; Sundari 1992. For studies focused on specific factors see
the following: on abortion, see LeGrand 1992; Baker and Khasiani 1992; on distance
and transportation, see Maine n.d.; Rosenfield 1989; on women's status, see PuentesMarkides 1992; Jacobson 1991; on TBAs, see Jordan 1989; Harrison 1989; Fleming 1994;
and on biomedical equipment and staffing, see Berardi et al. 1989; Barnes 1991.
2. For general overviews of the literature in the anthropology of reproduction, see the
literature reviews (Browner and Sargent 1996; Ginsburg and Rapp 1991; McClain
1982) and the edited volumes (Lock and Kaufert 1998; Franklin and Ragone 1998;
Davis-Floyd and Sargent 1997; Rice and Manderson 1996; MacCormack 1994a; Kay
1982). For other studies see the following: on childbirth, see Jordan 1993; Laderman
1982, 1983; on traditional birth attendants, see Jordan 1989, 1993; Jeffery and Jeffery
1993; on reproductive decision making, see Sargent 1989; on ecology of maternal
health, see Townsend and McElroy 1992; on infertility, see Inhorn 1994, 1996.
3. The difficulty of estimating maternal mortality rates derives primarily from
poorly organized vital registration systems and failure to identify cause of
death. By some estimates, under reporting of maternal deaths is as high as 50%
(Rosenfield 1989; see also WHO 1996). The most promising method is the sisterhood
Dying Mothers
4.
5.
6.
7.
8.
9.
10.
11.
273
method in which women are interviewed and questioned about any of their sisters or other female relatives who died during pre-, peri- or post-natal periods
(e.g., Graham et al. 1989).
These statistics are disproportionately weighted in favor of urban fertility rates,
which have indeed dropped dramatically primarily because the urban population is easier to count. It has been argued that drops in fertility rates of rural, agricultural populations lag significantly behind those of urban populations because
of higher child mortality, the need for child labor, and the security adult children
provide for aged parents (Nag et al. 1978; see also Nag 1980; Browner and Sargent 1996). In rural Lombok, although KB has been active since the 1970s, it was
only some of the women beginning their families in the early 1990s, who talked of
limiting their children. Other women continued to produce large families even if
they did use birth control intermittently. I suspect that actual fertility rates have
not dropped as dramatically as the official statistics suggest.
According to the Indonesia Demographic and Health Survey 1994 (CBS 1995) estimates of maternal mortality ratios increased from 326 deaths per 100,000 live
births in the 1981-1982 time period to 360 deaths per 100,000 live births in the
1984-1988 time period to 390 deaths per 100,000 live births in the 1989-1994 time
period. Figures on the maternal mortality ratio in Bali cited in Wirawan and Linnan show 282 deaths per 100,000 live births in 1978, 331 deaths per 100,000 live
births in 1982, and 359 deaths per 100,000 live births in 1991. This latter ratio suffered from such high under reporting that it was adjusted to 718 deaths per
100,000 live births (1994:307).
Although officials at the provincial Department of Health, Dr. Setyoko M., former director of that provincial Department of Health and current director of
Lombok's largest public hospital, and the writings of Grace (1996) all maintain
that Lombok's maternal mortality ratio was the highest in the archipelago, the
precise figures remain elusive.
Pelocok is a pseudonym, as are all other proper names of Sasak people. There
were actually three maternal deaths in Pelocok during my fieldwork, but I only
witnessed the two discussed here.
Laderman notes that Malay TBAs are also held accountable for maternal deaths.
While occasional mishaps can be acceptably explained, an increasing record of
problems motivates patients to find another TBA (1982:86; 1983:119). Similarly,
one could expect patients in Lombok to choose TBAs based on their reputation
for assisting in normal, healthy births.
From the accounts of Sasak TBAs who took the midwifery training courses, the
courses were remarkably similar in communicative failure as the one described
in Jordan 1993.
As is true in many parts of Indonesia, a woman's hairstyle has symbolic value.
Hair tied in a bun is a symbol of being a normal, proper, married female participant in society. But whenever someone is ill or in childbirth, her hair is let down.
Significantly, as soon as the placenta is delivered, the first thing people do is tie
the woman's hair back up in a bun for her. Childbirth is a liminal space, marked
by hairstyle, during which a woman's normal social roles are suspended. Similarly, as Inaq Hin's mother leaves the house after wailing loudly over her daughter's death, the first thing she does is reach up to put her own hair in a bun.
When did she actually die? I do not know. I was too upset to think about taking
her pulse, even if it had been appropriate. For these Sasaks, death occurs when a
274 M. Cameron Hay
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
person no longer remembers and has no physical animation. Biomedically, Inaq

Hin probably slipped into shock and a coma, and then finally diedprobably
within fifteen minutes of the first cries for her to "Remember!"
Belangar requires more than just arriving at the house of one who has died.
Women must bring a basket of the essential foodstuffs of lifeuncooked rice,
shrimp paste, salt, chilies, tobacco, betel nut, lime, acacia leaf, coins, and string
to contribute to the household that now must provide the funeral rituals. Men
must bring money, from 200-1,000Rp, which they place as inconspicuously as
possible in a small basket or container in the middle of the circle of men.
The Sasak commonly use the word dewa (god, spirit) or epe (shadowy twin) to refer
to a spiritsimilar to the Judeo-Christian concept of soulthat animates bodies.
Rice water is the excess water drained from a pot after rice, almost always refined
white rice, has been boiled. Masticated rice is cooked rice that has been chewed
by someone else, usually the mother or an older sibling, which, in its mushed
state, is fed to the infant.
The concept of contagion is generally absent in Pelocok. If pushed, even during
epidemics, people will say disease travels through the will of God. But there is
something about death in childbirth that has elements of contagion. Other pregnant women become vulnerable to dying in childbirth if they do not ritually
bathe after another woman's death. Newborns of women who die in childbirth
are generally considered vulnerable to death, more so than other newborns.
Bolang-olang is a thorough cleansing with soap and water of a pregnant
woman's body, her clothing, her pillows, and her sleeping mats. After the bath,
the woman covers her hair and body with a mixture of turmeric and grated coconut that has been specially blessed. All this "so that we don't follow Inaq
So-and-so" and die also.
For examples of passages on predestination in the Qur'an see 3:145, 9:51, 39:42,
and 76:30; for examples of passages on man's choice in the Qur'an see 3:130-141,
39:54-59, 76:29 (Ali 1989).
When asked, people would say they used Inaq Hapim precisely because she had
the government's training, because she was a friend, because she had delivered a
woman's other children or the children of friends and family, and/or because
she was a more orthodox Muslim than the other belians.
The bidan, Rini, always spoke Indonesian to me, even when I responded in
Sasak. She spoke Sasak only with people she considered rakyat (commoners or
peasants), speaking Indonesian with everyone else. In Indonesian the only word
for midwife is bidan, but perhaps because she did not want to give traditional
midwives linguistic equality with herself, Rini constantly referred to them as
dukuns (shamans, traditional healers). For Sasaks in the area of Pelocok, dukuns
are always males.
Mbak is an Indonesian and Javanese title, literally translating as older sister. It is
commonly used among Indonesian speakers to designate respect for a woman
friend. When alone, Rini and I mutually used Mbak for each other.
Sasaks used the word dewa in various ways. Here the usage seemed to draw on
a common understanding that every person is born with a spirit, which stays
with that person until death. It is believed that when a person's spirit is distressed, its problems are physically manifested onto the person.
In July 1995, however, the bidan was able to convince one woman to go to the
hospital to deliver her breach birth but only after that women's husband had
Dying Mothers
275
sought every TBA in the hamlet in vain and Rini had told her that if she didn't
deliver in the hospital, she would die.
23. Even in the United States, studies have shown that when health care representatives are patronizing to impoverished women, miscommunication and distrust
combine with fears of costly and inadequate care to result in irregular use of preand perinatal services (Ginsburg and Rapp 1991:324). For more on the problems
of communication between biomedical personnel on Lombok and rural Sasaks,
see Hay 1998, particularly chapter 8.
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Dying Mothers Maternal Mortality in Rural Indonesia

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On: 06 January 2015, At: 22:00

Medical Anthropology: Cross-Cultural Studies in Health

Dying mothers: Maternal mortality in rural Indonesia

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Medical Anthropology, Vol. 18, pp. 243-279

1999 OPA (Overseas Publishers Association) N.V.

Dying Mothers: Maternal Mortality in

attendants (TBAs); and (6) poorly equipped and staffed biomedical

Dying Mothers 245

MATERNAL MORTALITY IN INDONESIA

24:6 M. Cameron Hay

Dying Mothers 247

prolonged labor, as well as lacerations and uterine ruptures. It is an

248 M. Cameron Hay

MIDWIFERY IN RURAL LOMBOK

Dying Mothers 249

j an (1993:169-197) discusses two ways of training midwives:

In April of 1994, Pelocok was an exceptionally isolated place. The

250 M. Cameron Hay

Dying Mothers 251

252 M. Cameron Hay

Does it happen often that women die in childbirth?

Dying Mothers 253

What is his name?

Sai aran iniqne?

254 M. Cameron Hay

EXPLAINING DEATH, FOREGROUNDING FATE

Fate is an ultimate cause, a force wholly beyond human control.

Dying Mothers 255

appropriate knowledge available to aid a person in living. Usually,

256 M. Cameron Hay

CASE 2: THE DEATH OF INAQ MARNI

Dying Mothers 257

tetokol. Dendeqne iniq,

Here is where you should

So, it's going to come out

Kan genne sugul iye kane

now? (she moves)

Of course in a little bit.

Can you already see the

258 M. Cameron Hay

But it won't be much

Inaq laguq ndeq suwe gene

Kane gene sugul gati, karen

As the jumbled voices continued, Inaq Ju whispered to me "Inaq

The stomach is still having

Inaq, tianne masih polak.

Aduh, iniq ndeqman suwe

Dying Mothers 259

She got pregnant at the

Inaq Min: Why hasn't she given

We've decided against that. Burungne tipatne.

260 M. Cameron Hay

262 M. Cameron Hay

264 M. Cameron Hay

EXPLAINING DEATH, FOREGROUNDING ERRORS

In their conversations and remarks about Inaq Marni, the people of

Dying Mothers 265

266 M. Cameron Hay

DISCUSSION: WHY DID THEY DIE?

[T]here is no final meaning to be found in shocking events such as these. There is

Dying Mothers 267

Explanations and memories are people's interpretations of events,