Assistance in delivery in the rural parts of the D.I. Jogjakarta and in the greater part of the town of Jogjakarta is given by the “dukun beranak”, native obstetrician. It may be expected that this circumstance will be noticeable in the cause of death in early infancy. The Dukun beranak is an aged women and is acknowledged by the inhabitants of her desa in this function. She gives her assistance during delivery in the following way:
The woman in labour lies on the floor of the house, with straddled legs and the face directed to the door of the house. The door, windows and drawers of the cupboards are opened when the labour pains starts. This happens with the intention that the opening of all the doors, windows and cupboards will facilitate the opening of the cervix uteri. It is one example of the sympathetic magic thinking which is still so vivid in this area of Java.
During the delivery the husband sits near the head of the wife, while the Dukun is sitting beside the woman and waits for the things that will happen. When the child is born she puts the child on a “tampah”. (A tampah is a round tray made of bamboo strips. It has a diameter of 40-50 centimetres).
After the newborn-infant is put on this tampah the dukun waits till the placenta is out. When this has happened the dukun starts cutting the umbilical cord. This ceremony does not take place in the room where the delivery happened, but outside the house. The umbilical cord is put transverse over a “kunir” and draw tighter. (Kunir is the rootstock of curcuma longa). A few centimetres from the skin of the abdomen the umbilical cord is cut with a sharp piece of bamboo, called “welat”. This welat is made by the father. The part of the umbilical cord on the side of the infant is covered with “petukan”. Petukan is a mixture of kunir, limestonepowder, coconutoil and a little bit of salt. After that the petukan is put on the umbilicalstump and covered with a few leafs of sirih.
The abdomen of the infant is washed and wrapped round several times with a broad umbilicus-bandage. After this the care for the infant is finished in the first instance.
Also the placenta is treated with much care. It is washed, wrapped up in the white cotton and burried just in front of the house. The placenta is considered as the “younger brother” of the newborn infant. On the burial-place of the placenta a small oillamp is kept burning for 6-8 days. This oillamp, called “sentir”, is under an earthen pot, the bottom of which was been removed and which is placed upside down over this sentir. When the umbilicus of the infant has dropped off the sentir will be extinguished. A slametan is prepared and all the neighbours and members of the family are invited to this meal, which has a religious signification. It is dedicated to kaki Among and Nini Among, tuteliary spirits of small children.
The results of this popular custom at birth is observed in the children’s ward
In the children’s ward infants with an infection by clostrodium tetani or other pathogenic germs acquired at birth are observed rather frequently.
As we liked to have an idea of the proportion between mothers, who got assistance at delivery from the dukun and those who got it from the qualified midwife we inquired about this of the women who visited the out-patients department of Bethesda-hospital during the period 1956-1957. Only female patients of the Javanese race, aged 30 and older were questioned.
The group of 596 women questioned was divided into two parts according to the place of residence. The first group of women living in the town of Jogjakarta comprised 238 women, the second group of women lived in the rural parts of this region (Sleman and Bantul). The results of this inquiry are collected in table VIII-6.
These women, who were already more or less medical-minded because they came for medical examination to the out-patients department, yet preferred the assistance of the dukun at childbirth. A striking difference appeared to exist between the women of the urban and those of the rural parts of this region.
The women living in the rural parts were nearly exclusively assisted by the dukun at childbirth. Only the wives of the officials and of non-resident-persons, who lived in the village but worked in the town as a driver, merchant, or labourer in batik- and leather-industry, were exceptions. Even of the women living in the town of Jogjakarta 63% preferred the assistance of the dukun to that of the midwife. From these data appears that the qualified midwife has conquered only a few small enclaves of the dukun’s “territory”. The assistance of the dukun is still highly appreciated by the greater part of the population of the D.I. Jogjakarta.
During the period July 1, 1954 – July 1, 1958 a total of 95 infants (49 boys and 46 girls) with tetanus of the newborn were admitted in the Bethesda children’s ward and the University’s children’s ward. It is true that the greater part of these infants were delivered with the assistance of the dukun, but 9 out of these 95 infants were delivered with the assistance of a qualified midwife. The greater part, viz. 61% of these patients lived in the town of jogjakarta, while the other came from the rural parts.
Table VIII – 6.
Results of an inquiry among female patients of the Bethesda out-patient clinic concerning the type of assistance during delivery.
The diagnosis was as a rule not difficult, because at the moment of admission all the specific symptoms were presents. Sardonic grin, trismus, convulsions with or without cyanosis, and fever often made diagnosis possible at first sight. Sometimes the differential diagnosis with intracranial hemorrhage complicated by convulsions gave some difficulties.
The mothers took their newborn-infants with tetanus to the hospital because the infants had not been able to drink for one or two days.
The treatment given to these patients was: 1,000-2,000 units of antitoxin, daily for 2-4 days, and phenobarbital. Phenobarbital was given the first time by injection and further via the nasal tube. The daily dose was 180-240 milligrams. When the convulsions diminished, the dose of phenobarbital was lessened. Penicillin 50,000 – 200,000 units daily in one single injection. When it was necessary oxygen and artificial respiration were give.
The mortality among these infants suffering from tetanus was 78.7%. The greater part died within 24 hours after admission, 36 patients died within the first 24 hours and 34 patients on the 2nd to 7th day after admission. Only a few patients died after a longer period than seven days. This mortality is very high, but when compared with other figures in the literature about this subject we find the same level of mortality.
Low Sieuw Gek, singapore, 1946 – 1951 mentioned a mortality of 61.6% among 67 cases. Poesponegoro, Djakarta, 1947-1957 mentioned a mortality of 77.3% among 578 cases. Lily Cramer, Bandung, 1950, mentioned a mortality of 61.6% but among only 13 cases.
In all these series of patients suffering from tetanus of the newborn the treatment was nearly the same. The patients died mostly during a long and serious attack often accompanied by high fever (41.5°C).
Prognosis appeared to be connected with the weight of the child at the moment of admission and also with the time passed since incubation period.
The figures concerning the prognosis are collected in table VIII – 7.
Table VIII – 7.
Relation between incubation period and mortality and between bodyweight at admission and mortality of the patients suffering from tetanus of the newborn.
A bodyweight of less than 3,000 grams at the moment of admission appeared to be connected with a mortality of 88.7%, while a bodyweight of 3,000 grams and above was connected with a mortality of 40.9%.
There was also a relation between the length of the duration period and mortality among these patients Infection very probably took place just after birth. An incubation period of less than 8 days was connected with a mortality of 90%, while an incubation period of 8 days and longer was connected with a mortality of 50%.
Among the infants who survived we twice observed the occurrence of a scoliose. This complication was established on the X-ray photographs. The opportunity to control these two patients after discharge from hospital appeared impossible.