PLANNING THE FAMILY INDONESIAN STYLE: Adapting Creative and Innovative Ways to Face the Challenges

Like other Southeast Asian countries, Indonesia is no stranger to myths surrounding family planning and childbearing. Most common of which is the false belief that “more children means more wealth.”

Indonesia, an archipelagic nation in Southeast Asia -- made up of 5 major islands and 17,000 smaller ones -- is known to be the 4th most populous country in the world with a total population estimated at 253.6 million as of July 2014. More than half of that lives in the island of Java making it the most populous island in the planet. Accounting for 143 million of the country’s inhabitants, it is easily the most densely populated place on earth. Central Java, the focus of the ensuing case studies has a population of close to 33 million people and Indonesia’s Central Statistics Agency (BPS) predicts the province’s total population will reach 36 million by 2025.

Despite contraceptive prevalence rate noted at over 60 percent of the population since the introduction of family planning in the early 70s Indonesia continues to defy population growth projections and predictions. Experts predicted population growth to reach around 254 million by 2020 and a staggering 288 million by 2050. The population of Indonesia as of 2014 has already reached over 253 million with no signs of slowing. This calls for more vigilant, aggressive and imaginative strategies to tackle the issue.

The Innovative Women of Nuansa Mandiri

In Indonesia’s Central Java administrative capital of Semarang, 38-year old homemaker Tri Kristianingsih puts on a protective helmet and hops on her motorcycle with a bag full of reproductive health literature along with boxes of condoms and birth control pills. She and Wiwiek, a friend and colleague with blood pressure monitor in hand, are off to the traditional open market, as is their usual daily practice, to lend and collect money to the local merchants and at the same time use the opportunity to enlighten people on the merits of family planning.

These two Indonesian women are not your typical public health workers. They both belong to a small-scale community micro-finance cooperative called Nuansa Mandiri consisting of women -- mostly traditional housewives – who organized themselves with the end goal of empowering women not just financially but also with knowledge and life skills that will equip them to be independent and productive members of society. Nuansa Mandiri literally translates to “Degree of Independence”.

Tri Kristiangningsih more popularly known by her nickname Bu Nining is the head of the aforementioned women’s co-op that provides an informal alternative to savings and loans facilities outside the banking institution. She animatedly recounts how she and her fellow members were inspired by a particular visit in 2008 from the Indonesia Planned Parenthood Association (IPPA) of Central Java (an affiliate of the International Planned Parenthood Federation locally known as BPKB) whose community outreach staff provided her cooperative with a training seminar on the concepts of Cash Flow and Family Planning.

“It made me realize that for a woman to be productive and at the same time be an effective wife and mother, her health is of the utmost importance,” said Ibu Nining. Since a significant part of women’s health is reproductive health, this inspired her team to take initiative and grab the opportunity to impart the knowledge they have acquired on public and reproductive health and disseminate these information to the growing public they interact with regularly.

“Since we are adaptors and practitioners of planned-parenthood methods and are out there almost everyday, we have the advantage to reach out and be agents of change for the betterment of the future and welfare of families. So why not also be motivators and encourage the practice of family planning, ” she says.

The informal “ice-breaking” approach usually starts with casually asking if anyone is interested in getting their blood pressure reading taken. Within minutes both the women and menfolk line up for their turns and this is when the opportunity to chat them up presents itself. Consequently brochures, pills and condoms change hands in between discussing topics of small loans for start-up capitals and saving money. Interestingly, this approach is helpful to lessen the awkwardness of discussing sensitive and oftentimes culturally taboo topics relating to sex and reproductive health.

“We start off with friends and close family relations,” says 39-year old member Sundari, a housewife and mother of 2, who has been on the pill for years. She adds that the cooperative not only provides a venue for social interaction and exchange of knowledge but also gives the added value of acquiring new skills and practicing them -- such as handicraft making -- and earn extra money to augment the family income.

The success of Bu Nining’s group as “motivators” spread to surrounding neighborhoods and with the support of IPPA, developed outreach programs extending to other communities in Semarang. This innovation and resourcefulness earned her a much-coveted accolade among Indonesian women called the Indihome Woman Awards in the Woman Preneur Category for 2014. Sponsored by the national telecommunications company Telkom, this honor is bestowed on women with creative initiatives that bring prestige and contributes to the advancement of Indonesian women.

A basic requisite to winning this award is for the candidate to be effective in her role as wife and mother while actively using digital technology to promote and achieve both her social and business goals for a minimum of 2 years via various forms of social media, writing blogs and maintaining a website -- tools Bu Nining efficiently employs both for her microfinance and family planning campaign activities.

The “Supportive” Men of Priyo Utomo

Meanwhile, in the highlands of Central Java approximately 5 hours drive from Semarang City lies the rural Regency of Wonosobo where the population mainly depends on agriculture for their source of livelihood. This municipality boasts of a high and successful rate of adaptation to various forms of family planning contraceptive methods both among men and women. In fact, in 2013 the mayor of Wonosobo was given public recognition by the country’s president for actively campaigning and advocating the government’s Family Planning programs.

Years ago a support group of vasectomy acceptors was initially formed by IPPA called Priyo Utomo (in the local Javanese language, Priyo means “men” and Utomo means “the best”), of which Wonosobo has 16 chapters. Over the years it gained the reputation as the most successful and effective group in the practice and adaptation of family planning methods and eventually became part of the government’s nationwide planned parenthood program.

In particular, the village of Bogoran in the sub-district of Sapuran claims to have the highest number of vasectomy cases amongst the 15 districts of Wonosobo. This farming and livestock community claims that almost 40 percent of the vasectomy cases in Wonosobo for 2014 alone are from their village and the number of cases is significantly on the rise each year.

The success of the movement is largely attributed to encouraging testimonies by acceptors turned motivators who go about campaigning in neighboring sub-districts. According to community outreach officers in the area, respected members of society, such as religious leaders, government officials or prominent figures taking the role of “motivators” are more likely to influence the decision of other men in the community to undergo vasectomy. “The information is passed on mostly through word-of-mouth,” says BKKPN Wonosobo head Djunaedi.

37-year old Muhadin, for instance, is a respected Islamic clergy in the village of Bogoran. He finally opted for non-surgical vasectomy after feeling reassured that it is not against his beliefs to do so. His wife was pregnant with their 5th child despite having tried various forms of contraceptive methods after the birth of their 2nd child. “After our second child was born, I tried using condoms and my wife was on the pill and sometimes also used contraceptive injections. But obviously it was not foolproof as we had 3 more unwanted pregnancies after that,” says Muhadin. He is now confident that deciding to undergo vasectomy will prevent another unplanned pregnancy, a very important choice that spelled peace of mind for both him and his wife.

“In the beginning, myths about men losing their sexual virility and becoming physically weak after undergoing vasectomy was one of the major concerns of the men in our society,” says vasectomy acceptor Sudiyono. “That was proven to be untrue. On the contrary, now that disturbing thoughts of unwanted pregnancies is least likely to happen, our sex life is much better,” he adds.

Remarkably, when the members of Priyo Utomo in Bogoran Village were asked individually what convinced them to submit to the procedure despite initial misgivings and uncertainties, the most prevalent response was concern for the health and welfare of their wives, who were mostly on hormone-based contraceptives.

A thoughtful and considerate husband, Nahadi could not bear watching his wife go through the discomforts of having to be on the pill, “I love my wife and it saddened me to see her always feeling sick and unhappy because she is carrying the burden of having to be on contraceptives. Once the local health worker and community outreach officer explained to me what it entailed, I decided to undergo a vasectomy procedure a few months ago.”

Prasetyo, a 54-year old farmer from the same group underwent vasectomy in 1999 after the birth of his 3rd child. “It is the best form of contraception as it is the safest health-wise,” he said.

The most significant answer common to all the respondents was, as expected, economic considerations. “We are mostly small farmers in this area. Having 2 children is enough because more children mean more expenses. Otherwise, we won’t be able to support them and give them a better future,” says 33-year old Tuyono, who is a father of 2. The average number of children per family in the village of Bogoran is 2.5.

The Bogoran chapter of Priyo Utomo meets regularly not only to provide moral support to each other in various aspects of daily life but also to educate and train its members to become effective motivators to promote vasectomy to potential candidates.

Dispelling the myths surrounding vasectomy and the knowledge that non-surgical vasectomy is a reversible procedure with a high percentage of success is critical information in the campaign among the menfolk.

The Indonesian Challenge

However, reproductive health is not only about fertility concerns and sexually related diseases. It is also about quality of life and improving the welfare of the family as a whole. To this end, both IPPA Indonesia and the government family planning board BKKPN are hard at work trying to address not only planned parenthood and the problems of unwanted pregnancies but also related issues such as the harmful traditional practice of child marriages, which poses a direct and serious threat to all concerned.

“A case in point is the common practice in some rural areas of marrying off girls at an early age or just after reaching the age of menarche. This should be seriously addressed by the national government for it is key to solving the problem of early marriages, which in turn contributes to all sorts of ensuing social problems particularly reproductive health, rights and the stability of the institutions of marriage and family,” says IPPA Central Java executive director Elisabet S.A. Widiastuti.

In Indonesia, statistics show that more than 40 percent of the girls marry between the ages of 15 and 19, a trend the Indonesian authorities claims they are attempting to curb with plans of amending the regulation governing legal age for marriage. However, early marriages are still widespread in rural areas, leading to more likely cases of infant and maternal mortality due to underdeveloped female reproductive systems incapable of providing a healthy environment to the growing fetus. And in Indonesia, teenage pregnancy accounts for almost 2 percent for age range 15-19 and below 15 years of age.

The 1974 Marriage Law of Indonesia currently still in place sets the minimum legal age for marriage at 19 for males and 16 for females. “But it is possible and legal for girls to marry before the age of 16 if the religious court or a government officer provides legal dispensation. This practice is clearly in violation of the UN Convention on the Rights of the Child (CRC),” adds Elisabet. CRC defines child marriage as the marriage of those under 18 and before this outdated law is amended, it will be impossible to curtail the practice of child marriages.

On the whole, the statistics on Indonesia is still disconcerting and not to be easily ignored. The National Population and Family Planning Board predict that the percentage of Indonesians within the productive age group will be relatively high in 2025-2035. Meanwhile, the United Nations projections of Indonesia’s absolute population is expected to exceed 250 million inhabitants in the year 2015 (this psychological threshold was already surpassed in mid-2014 by over 3 million), will exceed 270 million by 2025, 285 million by 2035 and an alarming 290 million by 2045. Only after 2050 is Indonesia's population expected to decline.

As Indonesia is faced with the task of controlling population growth, creative and innovative strategies such as those practiced by collectives like Nuansa Mandiri and Priyo Utomo prove to be essential, inspiring and much more effective.

Both the government and concerned non-government institutions should spearhead similar initiatives that take into consideration Indonesia’s cultural context. And where such existing efforts are already in place, it is absolutely vital to encourage, support and even cultivate them by possibly socializing, adopting and duplicating such schemes on a wider scale.

In addition to addressing public and reproductive health issues at the policy level, the government must gear up to face bigger challenges ahead and start by informing the public of health rights. Focus on practical concerns must be prioritized through improved public health services including ensuring access to medical and health facilities, availability of medical supplies and the quality of trained medical and health practitioners providing proper medical attention to the country’s population.

*The writer is a Jakarta-based documentary filmmaker and producer with a degree in Sociology from the University of the Philippines