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The Roles of a Ma Blien (a Traditional Midwife)
In Reproductive Health
In The Rural Community
In the Province of Nanggro Aceh Darussalam
A Case Study in Rural Aceh Besar and Pidie
By: T. H. Makmur Mohd. Zein*
Penelitian ini menggunakan metode kualitatif dengan strategi grounded (ground research). Wawancara dilakukan dengan mendalam, berkali-kali, menggunakan analisis induktif. Respondennya Ma Blien, ibu hamil, ibu bersalin yang persalinannya dibantu oleh Ma Blien dan tokoh masyarakat, menggunakan random sampling. Lama penelitian mendekati 12 bulan. Lokasi penelitian 2 desa di Dati II Pidie dan 2 desa di Dati II Aceh Besar.Hasil penelitian menunjukkan, bahwa Ma Blien tetap berperan dalam menolong persalinan di masyarakat desa. Ma Blien ikut terlibat dalam kegiatan ritual adat dan mau mengembangkan dirinya sehingga tetap dipakai oleh masyarakat. Ibu hamil dan ibu bersalin masih tetap percaya dengan Ma Blien untuk membantu proses persalinan. Mereka tetap percaya pada larangan atau pantangan yang berlaku. Proses persalinan adalah krodrat Ilahi, berlangsung secara alamiah, kalau ada kelainan dalam proses persalinan, mereka menganggap karena gangguan setan atau murtad pada orang tua atau gurunya. Ma Blien dapat dimanfaatkan membantu jajaran kesehatan, membantu program kesehatan yang berkaitan dengan Kesehatan Reproduksi.
The study is done in the form of a qualitative grounded strategy (ground research). Interview is done deeply, repeatedly, using inductive analysis. The study is done in two villages in the districts of Pidie and two villages in Aceh Besar. The respondents consist of the Ma Blien, pregnant women, childbirth helped by the Ma Blien, and selected leaders of the society using a simple random sampling procedure. The study took place in 12 months. The results of the study indicates that the Ma Blien still has a role in the process of childbirth in the rural area, in rituals related to pregnancy, and always wants to up grade herself as needed. Pregnant women still trust the Ma Blien to assist the process of giving birth and consistently obey prohibition prescribed by the Ma Blien. The process of childbirth is considered God given. However, if the process is abnormal it is always regarded as caused by satans or due to disobedience of parents or teachers. The Ma Blien can also be used to assist medical services to deliver of health program related to reproductive health.
Keywords: Ma Blein, Childbirth, Reproductive Health
According to Kusyuniati (2002), every minute there is always a mother dying from pregnancy and childbirth. She is generally young and mostly lives in a developing country. Aside from such a death, there are other 100 pregnant women who survive, but they suffer from a certain disease, get handicaps or other physical disorders because of complications during childbirth. It is estimated that there are probably about 585.000 persons annually who lose their live to pregnancy and childbirth, and of those numbers 99% take place in the developing countries, including Indonesia.
* Lecture of public health and medical community department of Medical Faculty Syiah Kuala University, Banda Aceh, Indonesia
According to Wiknyosastro (2002), Chairman of the Indonesian Obstetric and Gynecology Association, as many as 40% childbirths in Indonesia are still handled by traditional birth attendance (Ma Blien). The rests are handled by midwives, general practitioners, or specialists.
In the Province of Nanggro Aceh Darussalam, 50% of childbirths (madeung) were handled by midwives, 42.59% by traditional attendances (Ma Blien), and 7.41% by doctors. Meanwhile, in the city of Banda Aceh in the same year (1999), 73.29 % of childbirths were handled by midwives, 22.40 % by doctors, and 3.31 % by traditional birth attendance (Ma Blien). 4
Atikah and her friends (1997) found that the trust of pregnant women (Mak Madeung) on the traditional birth attendance (Ma Blien) is still high to assist childbirths. The community does not believe on the ability of young village midwife whose approach and attitude toward the community is inappropriate and her communication is not yet smooth. 7
The process of giving birth (madeung) is a ritual (tradition) for most rural communities. The Ma Blien generally has a strong relationship with the village community. She is always involved in the social affairs of the village. The Ma Blien is not often necessarily paid in cash for her services, but one can pay her in kinds. The mother of a pregnant woman usually hands her daughter over to the Ma Blien in a ceremonial event .6
According to Moehammad Hoesin (1970) the local tradition still plays important role during pregnancy, childbirth, and caring. Many ceremonies have to be performed by the family and community for the health and safety of the mother and the baby. The Ma Blien has an important role in such ceremonies.14
Thus, problems of interest to be addressed include questions related to the process of childbirth as performed by the Ma Blien, and the extent of the community believes on the Ma Blien’s skill in attending childbirth. Other questions of interest related to the factors that might have influenced the process of caring pregnancy, and the number of maternal mortality which is still high. However, another important question is the solutions expected from this study.
The study is qualitative in natural using grounded method strategy and inductive analysis. The observation is done in the village of Beuracan, sub district of Meureudu, and Pangwa, sub district of Trienggadeng, both in the district of Pidie, plus the village of Cot Keueng, sub district of Kuta Baro, and Tungkop, sub district of Darussalam, both in the district of Aceh Besar,
There were one Ma Blien, two pregnant women, and two childbirths helped by Ma Blien in each of the two sub districts in Pidie, plus one Ma Blien, two pregnant women and two childbirths helped by Ma Blien in each of the other two sub district in Aceh Besar. In addition one community leader from each village were also selected to be interviewed repeatedly to get an in-depth insight on issues or behaviors related to pregnancy.
The collected information was then classified and categorized accordingly to show interrelationship among them. Such relationships were then tested or compared to the realities in the field. These inter connectedness are expected to form propositions or hypotheses to explain social phenomena.
The study took place for 12 months in 2002, and for several occasions the researcher observed child births helped by the Ma Blien.
Childbirth or Madeung
Madeung means, an individual activity to warm up the body above or close to a fire place to avoid feeling cold. But it also means the time or process of childbirth starting from the flow of liquid, blood and water, the child and the placenta until 40 days later.
When the time comes, the mother of the pregnant women surrenders the daughter to the Ma Blien. It is done in a ceremony and saying: “hukom bak Allah, hukom bak Rasul, hukom bak Ma Blien aneuk kamou pujuok” (in the name of the law from Allah, law from the Prophet, and the law from Ma Blien here with we hand over our daughter to you). Since then the Ma Blien is responsible for the whole process of health care and childbirth of the woman.
The process of handing over takes place before the pregnancy is three months old. The Ma Blien always controls her pregnancy. Usually it is done every month and the Ma Blien decides the age of her pregnancy and the time when she will give birth, “pajan madeung.” The Ma Blien also functions as a godmother, “Mak Suebot”. The living cost of the Ma Blien is the responsibility of the pregnant woman. The cost is generally in kind like rice.
Certain equipment for the madeung must be prepared by the family and some by the Ma Blien. The Ma Blien, first must make ready a thread to tie up the umbilical cord (used to be made of pineapple leaf fiber, now it is any thread bought in the market). Second, teumen (blade of split bamboo to cut umbilical cord) but now it is replaced by a pair of scissors from the Health Center so as the clip for the umbilical cord before it is cut. The family prepares such as turmeric, betel leaf, baby kit and the mother herself. The turmeric is used to cover the navel whenever the umbilical cord is cut. The rich family used gold to replace the turmeric.
After the birth and the mother has been cleaned the Ma Blein chews the betel leaf and the seupah (things usually taken together when chewing betel leaf) and then she spits blow it over the baby’s head or on the crown of the baby’s head. It is done for the baby’s protection from satan, because the seupah is considered to have magical power. The umbilical cord is no longer given kitchen ashes, but alcohol or other solutions from village midwife on the Puskesmas
Madeung usually takes place at the back veranda, “seuramo likot” of the house. Those who are allowed to witness the procession include her mother, mother in law, or her grand mother. Her husband and other relatives should wait at the front veranda, or in corridor connecting the front and back verandah.
The process of birth begins when the mother lays down on a mat following certain symptom such as, the flow of phlegm, blood and fetal membrane. The Ma Blien reads her secret mantra in a very low tone, and then she blows toward the patient. This is a symbol that will give the patient the strength and blow out evil spirit from the body.
People regard that giving birth is a natural process. But, if there is an obstacle in the process it is assumed to be caused by satan or evil spirit. In such an event the Ma Blien will use her very secret magic. She will recite or read the seuleusoh pray over a glass of water. The Ma Blien lets the patient drink the water. If the Ma Blien fails to spell the problems the family must find a religious leader in the village or in the neighboring village. The next step is that her husband and her mother must be called. The Ma Blien will ask the patient to apologize from her husband and her mother-in-law. After granting forgiveness, the mother-in-law blows on her forehead seven times with a certain reading while saying,” bek trep that saket gata, jak laju u lua, lage badee teureubang” (do not hold up too long, came out like the hurricane blows). The Ma Blien generally does not understand difficulties in childbirth, like a prolonged labor. She takes them as all Satan’s work.
Normally when a baby is born the first to appear is the head, but it may also be the buttock or feet. Such a birth is called lahee jaheuk (up side down). Some believe that a child of this kind may become a bone fracture healer or able to cure broken bone. It is said that his saliva can cure sprained joints.
A newly born baby is placed in siteuok thoo (a dry areca nut leaf), while waiting for the placenta come out. The baby umbilical cord is cut and the baby is washed with warm water. The cutting of the umbilical cord is usually done over turmeric or gold, depend on the prosperity of the family. The yellow color (turmeric or gold) is a symbol of glory and greatness. Before cutting the umbilical cord it is clipped on both sides. The tweezers usually supplied by the Community Health Center. All the Ma Blien can do this procedure since they got some training from midwives at the Health Center. The umbilical cord is now cut using a pair of scissors, not using split bamboo. Then the tip of the umbilical cord is bandaged with a clean bandage using alcohol which they can buy in stores or from the Health Center. In the past they used to apply kitchen ashes. Refrain from using kitchen ashes plus clean work has decreased the tetanus rate among the children under five years old. In addition, the awareness among the pregnant women to have ant tetanus injection during their pregnancy has helped decrease the tetanus among the neonatal. But, although it has followed a modern way of childbirth there are still babies who get the betel nut and other ingredients spit blow by the Ma Blien or the grand mother over the whole body of the baby. It is aimed to protect the baby from evil things as the betel plus all other ingredients have a super natural power.
When the baby is given new clothing she/he is handed to her/his father to call to prayer. If the baby is a boy, the father will call azan (call the time to prayer) and if it is a girl, the father will only iqomat (call to immediately begin to prayer). But, this obligation can be also done by a religious leader so that the child will behave accordingly in the future and obey Allah (the God). However, this also means that the first sound the baby hears is the call to be pious.
After the placenta comes out the mother is bathed. All blood spots are cleaned using warm water and soap. Finally she is bathed with citreous fragrant water to protect her from evil spirit and to get rid of bad odor from childbirth.
When the placenta comes out it is cleaned by the Ma Blien, dried and given some salt, lime, and kitchen ashes, then wrapped in cloth, put into clay pot, and then buried. Sometime it is dried first over the fire place. The placenta of a girl is buried under the ladder or the front step of the house and for the boy under the caves of roof. It means that a girl should stay in the house, while the boy goes away but still remember to come back home. For as long as seven nights a panyeut cilet (oil lamp made of earthenware) must by lighted to prevent the placenta from thieves or evil spirits to take it away. The placenta should not be buried very deep or very shallow. If it is very deep, the next time the mother gives birth she might face difficulty.
People believe that there is a strong relationship between the baby and the placenta. If the placenta is not well cleaned or well taken care, the baby will often get stomach aches and may die of it. But, actually it may have nothing to with the placenta. It is common that the baby get stomach ache if the baby is too early to feed with hard food like banana which may cause the ileum folded.
After the process of childbirth, the Ma Blien visits the mother to bathe and massage her abdomen every day so that it will soon be clean. She can manipulate the next pregnancy that it will happen in about two years time later. Beside the mother, she also bathes the baby for as long as the umbilical cord falls off. For the next 40 days the husband may not sleep on the same bed as the wife as it is a part of the traditional taboo.
On the seventh day after the childbirth, when her health is improving the mother will start madeung. She will lay down on an iron bed and live coals are put under the bed. The purpose is to dry her up so that her connective tissues become tightened and strong including her vaginal muscles to make the husband loves to stay home.
The process of madeung may take 15 days, but some take 20 or 30, to 40 days depending on the mother’s choice. While on the madeung her diet is arranged strictly. She can only eat one handful of rice, drink a little water, and dried small anchovy. But, it reduces production of breast milk. However, those processes are no longer practiced due to modernization influences.
Madeung is now replaced by teet batee (heating stone). A round stone as a big punch taken from the river is heated on live coals. It is then covered with a piece of cloth and placed it on the lower abdomen. Then the stone is wrapped again with an abdominal sash around the hip. The purpose is to relieve the uterus and vaginal muscles. It is believed to be able regulate the blood circulation and prevent the mother from pregnancy. The length of time for the teet batee depends on the mother’s physical strength and choice. However, it is recommended for 40 days, but some do it 2 weeks, 20 days, even some for 30 or 40 days. While practicing this, the mother may not eat much, may not drink much, and every day, she must drink turmeric juice and certain herbs. Following the teet batee, the mother should drink boiled herbs of 44 kinds to clean up the uterus, regulate blood circulation and to prevent from pregnancy.
In the past the community did not know jamu bersalin (medical the herbs for childbirth), but now it is already made by industry and has been used widely. There are two well-known herbal medicines “Nyonya Meneer” and “Ayam Jago”. This has put aside the herbs made by the Ma Blien from herbs and bark of certain trees.
The Ma Blien (The Traditonal Birth Attendance)
The role of the Ma Blien beside her main function is also to become the mak ubat that is to mix traditional herb medicine, made of many different leaves or tree skins to cure a sick child and the mother in addition to herbs for childbirth. Another function is to help infertile woman to conceive. The Ma Blien usually massages the lower stomach for 3 to 5 days following the last day of her menstruation. The infertile woman is encouraged to take traditional medicine she prepares. The Ma Blien also gives ajimat (amulet) to protect the woman from evil spirits.
The Ma Blien also functions as a Teungku Imum Inong (woman religions teacher). It means she is involved in teaching of reading the Qur’an for children. She helps a bride in a wedding ceremony. She peu mano dara baro (bathes the bride), paints nails and palms. It is also common that she cleanses a dead woman. She is also involved in warding off misfortune. Because of so many roles the Ma Blien plays, she therefore becomes a very central or prominent figure in the village. The Ma Blien is sometimes called the midwife, Nyak Wa, or Mak Tuha. But these names are in reference to her job and age. As the Teungku Imum Inong (teacher of Qur’an reading), she plays an important role in basic education of ethics for the younger generation. She teaches ethics, morality and introduces norms and values in the community.
The relationship between the Ma Blien and the patient she helps is very close. It is visible in the event taking place in the home of one of her patients. The patient will feel incomplete or anxious if the Ma Blien is not present. If the Ma Blien can not present herself, the food or other things should be taken to her house first before the party should start. It is just the same if one wants to harvest fruits, some of the first harvested should be taken to her house first. On the first day of Eid, or on the Haj celebration day, the woman whom the Ma Blien has helped in childbirth should drop by the Ma Blein house first before she goes on to her parents’ house.
But the Ma Blien is always ready to welcome her “grand children” the babies she helps deliver. Each child is given peucicap, something to taste, either sweet or salty or a little money as if is given a little gift as a symbol that the child will find it easy getting a job.
The Ma Blien inherits her knowledge from her mother or grandmother. She then follows a senior Ma Blien to take an apprenticeship. Generally the Ma Blien is over 40 years of age.
Ma Blien is a health provider without a formal education to serve in the process of childbirth. She learns the skill from her grandmother or her mother or from her teacher or from an apprenticeship. They always want to improve their knowledge on health and childbirth, to win the trust of society. In the profession the Ma Blien competes with the village midwife who has a formal education in their profession. The Ma Blien is roles in the community may strengthen her status in the rural community.
People believe that pregnancy and childbirth are given by ALLAH and it is natural. If the baby cannot be born naturally it is considered the work of evil spirit or Satan. Or it might be due to the child bearing mother has broken some rules of during pregnancy or has disobeyed her parents during the course or has committed some sinful things. If it is disturbed by evil spirit or satan, it can be relieved by praying or reading certain verses from the Qur’an by the Ma Blien or a religious leader. If the child bearing mother breaks the rules or forgets the parents’ advice she must seek the mercy of the parents for such misconducts.
The process of pregnancy and childbearing are taken as natural phenomena, which have a great meaning for life, since they are related to a high risk of death. Facing such a life threatening event some certain rituals are usually performed to relief some psychological burdens of pregnant woman and to support her spirit and confidence while waiting for the birth of her child. Such rituals include mee boh kayee, mee bu meunileum, manoo tujouh buleun, etc. The movement of the expectant mother is generally limited also only to certain places on certain times. She is not expected to take certain food and she is encouraged to carry a certain amulet with her during her pregnancy.
Other traditional behaviors she must watch include not sitting on top of the ladder of the house, not to hit other or kill other living creatures (cat, dog, snake, etc). She must not be against her parents’ advice to avoid problems in childbirth. Religiously she may not leave any of her required prayers which are considered good to reposition the baby in the womb, to do as many Sunnah prayers as possible, read the Al-Qur’an as often as possible. Iqamah is performed on the birth of baby girl, and azan in the baby boy.
Since this community still sees that pregnancy and childbirth are life threatening events, generally the expectant mothers faithfully observe the do’s and the don’ts.
1. Pregnant women and childbirths in the rural areas still need the services of the Ma Blien to control pregnancies and to help women in childbirth.
2. Child bearing mothers have a lack of knowledge of the health of pregnant women, childbirth, caring of babies, nutrition of pregnant mothers as well as caring of mothers, and nutrition of under five years children.
3. The Ma Blien gets her knowledge to help childbirth from her mother or grandmother, and from her experience in assisting a senior Ma Blein. But her knowledge is limited in cases of a normal delivery. If there is an abnormal case she tends to relate the case to the evil spirit, or because she is always against her parents, or she breaks the customs.
4. The knowledge of the Ma Blien is lacking on reproductive health and she knows very little about abortion and infertility.
5. The Ma Blien has some special important status among the rural community besides helping the childbirth since she is also involved in marriage procession and in teaching Qur’an and the like.
6. The knowledge of Acehnese rural community on health is considerably sufficient. They hold strongly on to the tradition in relation to prohibition for pregnant women and during childbirth which have some disadvantages in health care as well as their.
1. It is important to improve the Ma Blien’s knowledge about health especially the health of reproduction and nutrition. These kinds of training should be done by well trained health providers.
2. All Ma Blien should be re-registered and trained continuously, and supplied with parturient medical kits.
3. The trained Ma Blien can become effective extended hand of health organizations to do the following tasks.
3.1 Helping normal childbirth
3.2 Registering the number of childbirth, number of mother and baby mortalities
3.3 Providing information about nutrition for the pregnant, the process of childbirth, caring including giving colostrums to the baby, and giving immunizations for the baby under five years old.
3.4 Cooperating with the village health posts for increasing health and safe motherhood
The result of the study is the result at limited and public seminar which sponsored by the Development Center of Regional Studies of Syiah Kuala University guided by Prof. Bahren T. Sugihen. All of the content is under responsibility of the author. The author would like to give a compliment to thinking contribution from every member at Prof. Bahrein T. Sugihen seminar as a Director of the Center for Regional Studies of Syiah Kuala University.
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