The COVID-19 pandemic has made sexual and reproductive health service provision more challenging. Midwife Nur Hidayah, known by her nickname Bidan Aya, does not let the challenges deter her, however. The 36 year-old village midwife from Sidenreng Rappang, South Sulawesi, who has delivered services at her private clinic in Sidenreng Rappang for 11 years, is determined to do her best to serve her patients.  

Bidan Aya continues to develop herself and innovate. The training she participated in as part of UNFPA’s Leaving No One Behind (LNOB) programme helped her respond to challenges that the health crisis has brought.  

Challenges in delivering services during the pandemic 

Bidan Aya admitted that the beginning of the COVID-19 pandemic was tough for her. The lack of knowledge on how to handle COVID-19 led to worries and confusion. In 2020, she assisted a delivery where the patient was later tested COVID-19 positive. ”I wore PPE (personal protective equipment, ed.) when I helped with the delivery, but was still worried,” she recalled. “After that I shut down my practice for three days. My assistant and I underwent self isolation until we received our COVID-19 test results.”

That incident reminded her that her job exposes her and staff risks of COVID-19 transmission. “We cannot just assume that a patient is fine, because someone who looks just fine could be a suspect.”

Despite the fear of COVID-19 infection, Bidan Aya still continues to provide her services under strict terms and conditions. “If a patient does not have any symptoms, I recommend her to just read the KIA, -the mother and child health guidebook, and implement the recommendations,” Bidan aya said. She also encourages pregnant women to observe their own pregnancies and be aware of pregnancy danger signs.

“If they find any concerning signs, I advise them to seek immediate medical attention in our midwifery practice with prior appointment,” she elaborated. Bidan Aya also provides online service using WhatsApp and Instagram platforms where her patients can make appointments and consult with her.

The inspiring and life-changing training 

In August 2021, Bidan Aya enrolled herself in a midwifery training organized by the University of Indonesia’s Faculty of Public Health (FKM UI) and the Indonesian Midwife Association (IBI) with  support from UNFPA and the Government of Japan. The training was part of the LNOB programme, which ensured the continuity and inclusivity of access to sexual and reproductive services for people most impacted by the COVID-19 pandemic.

Bidan Aya did not expect that the training would teach her new knowledge in the ways she had never experienced before. She admitted that the training significantly increased her knowledge on personal protective equipment and infection management.

“The training turned out to be extraordinary… I like joining webinars and training, but this one is different, because really, this training is really good!,” she exclaimed. 

“When I saw the list of the participants, I just realized that the many participants are from all over Indonesia.. Eight training modules, delivered in five days. From module 1 to 8, we learned the basics,” she recalled. “About the pandemic, antenatal care (ANC), services during COVID-19, delivery, contraception, medical waste management, psychosocial support, infection prevention. They’re all very relevant to the current situation and very well delivered by the trainers,” she continued. 

The discussions in break out rooms and WhatsApp groups with other participants soon inspired her to create another innovation. “I created ‘Paman Maco’,” Bidan Aya said. The catchy acronym stands for “Papan Pengumuman Praktik Mandiri Bidan (PMB) Cegah COVID” (“Independent Midwifery Practice’s Announcement Board for Preventing COVID”), a board displaying information on COVID-19 prevention and vaccination for the visitors of her clinic. “This training also allowed me to see how other midwives run their clinics. They look beautiful, so I was inspired to improve mine too,” she said.

She also received constructive inputs for “Kurindu Bumil”, a WhatsApp Group that she initiated and has used to communicate with expecting mothers. Established before the pandemic, Bidan Maya  initially used “Kurindu Bumil”, which in Indonesian literally translates to “I miss pregnant mothers” but actually an abbreviation that stands for “pregnant mothers routine gathering after visiting integrated healthcare center”, to share information on pregnancy classes and ultrasonography (USG) schedules. The platform later grew its function to connect its participants to healthcare providers, including midwives, general practitioners, and obstetricians/gynecologists (OBGYNs). The participants, who have joined the group from when they were pregnant until their babies have grown into 5 year-olds, can ask questions about their health concerns at the platform. The rise of the pandemic has elevated the importance of this online communication platform. Now, more than 300 participants have joined the group. 

For Bidan Aya, innovation in sexual and reproductive health services is important to make sure that there is no pregnant woman and young person left behind in access to health services. "If you don't innovate, it means you are stuck in place, there is no progress. (We should innovate) to support Puskesmas (local community health centers, ed.) programs, for example, in motivating pregnant women to routinely take iron supplements,” she provided an illustration. “Pregnant women used to not take iron supplements regularly. In 2018-2019 there were 12 bleeding cases, 2 maternal deaths, and 5 low birth weight babies (LBW). Consuming iron supplements can reduce bleeding rates, miscarriages, LBW, and maternal deaths," she continued.

Turning inspiration into action

Further, the respectful midwifery principles taught in the training led Bidan Aya to reflect on the ways she treated her patients. “Before this training, sometimes I felt  irritated when patients came in the middle of the night, when I was exhausted,” she recalled. “I have learned that I was not supposed to behave that way to the community members, and especially my patients. The training taught me ways to regulate my emotions… I hope I can have more patience now,” she said.

Bidan Aya admitted that being a midwife in a village means being ready to serve as a healthcare provider, a friend, a counselor, public health promoter. “Aside from those intense duties, we still have a family to take care of, and now, COVID.” Thankfully, the training also reminded her to take care of herself. “After the training on mental health and selfcare, I took a vacation with my husband and gave my assistant 2-day leave.” 

From the training, she also learned  about  gender-based violence (GBV) and harmful practices. The module made Bidan Aya realize that the female genital  mutilation (FGM) and child marriage practices that are still common in her area are actually harmful to women and girls. 

“There are a lot of adolescent pregnancies here. In 2018, there were 15 teenagers who got pregnant, five of which happened out of wedlock... Some of them were only 13 years old, and had to have a cesarean section because their pelvis was still small,” she recalled. "A child dropping out of school can be seen as a signal that they are ready for marriage. For example, if you don't go to junior or senior high school, it means you are waiting to be proposed," Bidan Aya provided context to the child marriage prevalance in her village.

"Female circumcision is also common… I discussed what happened here with the trainers and other participants during the training, and they agreed that we need to end FGM because it’s harmful,” she continued.

That realization drove her to reach out to adolescents and further initiated a reproductive health network for educating girls named after a famous martial art comic book character, “Wiro Sableng 212”. The name stands for “education center for adolescent girls to prevent pregnancy at a young age through reproductive health education and stunting prevention”. She uses the number “2+1+2” to refer to five essential things for adolescent reproductive health in her village: 1) weighting and physical examination, 2) contraceptive pills to delay pregnancies among married adolescents, 3) education for grandparents who raise adolescents, 4) literacy for adolescents (reproductive health books), and 5) control card for anemia among adolescents.

“I have identified 58 young girls who were already out of school, and started to educate them on reproductive health to prevent sexual violence and child marriage,” Bidan Aya explained. “I hope it will turn out well and help them to think of other options for their future, and to shift their focus from seeing marriage as the only option available to them,” she affirmed. 

With local Puskesmas cadres, she also rolls out a monthly health examination for young people. “I also coordinated with the Women’s Empowerment and Child Protection District Office to discuss female circumcision. It is part of our tradition, but we will try to change it, slowly.” 

The journey goes on

As innovative and hardworking as she has been, Bidan Aya still encounters significant challenges. “From those eight modules, the hardest one to implement is the prevention of sexual violence and child marriage.” She has attempted to prevent child marriage cases in her village, but failed as institutions gave the permission for the marriages despite her testimony about the children’s unfitness for marriage. 

“If only we could implement all eight modules of the training, then it would be possible for us to reach zero maternal and neonatal death… but it is impossible for me to do everything on my own,” she said. “But I am not giving up. I will continue my service and innovation,” she concluded optimistically.

Asri Wijayanti, (Former) Communications and Knowledge Management Officer, 

LNOB Programme

Ria Ulina, Sexual and Reproductive Health in Emergency Officer

UNFPA Indonesia