“My parents told me to stay here until the baby was born,” says Diana, not her real name. “I wanted an abortion, but when I found out it was already too late. There was already a heartbeat.”
Beneath her pale yellow pajamas, Diana’s breasts, exceptionally large for her awkward 13-year-old frame, outsize her five-month-old baby bump. Her heart-shaped face has sprinklings of acne and she rarely shows her buck-toothed smile.
Raped by her neighbor last year, she was placed in a women’s shelter in West Jakarta by her family as soon as her pregnancy was discovered in April. To avoid rumors and the social stigma surrounding teenage pregnancy, Diana’s family plans to wait a year or two year before bringing the baby back home to raise it within the family.
Despite her traumatic experience, Diana can be considered one of the lucky few because she has made it to a shelter. While there has been a slight increase in sex education and campaigns to prevent teen pregnancies in recent years, there remains a dire need for reproductive health assistance for unmarried pregnant teens.
Limited Data, Limited Services
“Assistance for teen pregnancies outside of marriage is very poor because society has already declared it to be illegal and forbidden,” says Hadi Supeno, chairman of the Indonesian Commission for Child Protection (KPAI).
There are an estimated 40 million adolescents in Indonesia aged from 10 to 19, according to the Ministry of Health. Recent surveys have pointed to increased sexual activity among young people, although specific and reliable data on teenage sex and pregnancy is hard to come by.
The communication and information technology minister, Tifatul Sembiring, recently publicized a poll supposedly conducted by the KPAI in 2007 involving 4,500 teenagers in 12 cities aged 14-18. Although there are serious doubts over the veracity of the data, Tifatul said the survey showed that 62.7 percent had engaged in sexual intercourse and 21.2 percent of girls had had an abortion.
“The KPAI survey is only an indication of the behavior of our young people,” says Dr. Melania Hidayat, national program officer for reproductive health at the United Nations Population Fund (UNFPA). “Local clinics are the main source for data, and they are very unlikely to have accurate figures.”
Perhaps partly as a result of this lack of data, which could hide the extent of the problem, health services for unmarried teenagers who fall pregnant are very limited. Moreover, what few services are available are not easily accessible due to limited health coverage in rural areas, cultural barriers or lack of supporting government policy.
For instance, in 2003, the Health Ministry began the Adolescent Friendly Health Services approach in community health centers, or puskesmas. The AFHS, an affordable youth-friendly service that stresses confidentiality and sensitivity, provides sexual education information to teenagers. However, it is only available in 26 provinces at 1,611 centers — or about 20 percent of all clinics across the country — most of them in urban areas.
Nongovernmental organizations such as the Indonesian Family Planning Association (PKBI) and the Pelita Ilmu Foundation (YPI), which campaigns against HIV/AIDS, also offer counseling for pregnant teens, although it is not a free service. An hour-long session with a counselor costs about Rp 50,000 ($5.45).
Preferred Option: Abortion
Of the three logical options open to pregnant teens — keeping the child, which involves living with the stigma that comes with it; putting the baby up for adoption; or going through an abortion, which is illegal except in certain circumstances — the last one appears to be the most preferred.
According to a 2009 survey by the National Development Planning Agency (Bappenas), more than two million abortions are performed every year, with 30 percent involving teenagers. But experts say that if illegal abortions were included, that figure would more than double.
“Abortion is illegal, but what else can you do with an unwanted child?” says Dr. Firman Lubis, chairman of the Kusuma Buana Foundation (YKB), an NGO focused on health and community building.
Abortion is legal when the mother’s life is in danger and, as of last year, under the recently passed Health Law, when the mother is a rape victim, such as Diana.
Most groups counseling pregnant teens who wish to have an abortion refer them to places such as the “Raden Saleh Clinics” in Central Jakarta, which is a handful of facilities known for providing abortion services. But because the new Health Law is yet to be fully implemented, clinics such as in Raden Saleh often fall foul of law enforcement authorities.
Even at these clinics, the process of scheduling an abortion requires the pregnant teen to bring her husband as well as proof of marriage. Those who are unmarried are required to bring a copy of their family identity card and a family member.
But having a family member at hand does not provide an environment that encourages a pregnant teen to openly seek help. Shame, fear of reprimand from parents or health staff and the presence of traditional religious and conservative norms make it difficult.
As a result, many teens try their own methods for abortion.
“Their friends will tell them to eat unripe pineapples or jamu [traditional medicine],” says Ninuk Widyantoro, a psychologist and chair of the Women’s Health Foundation (YKP). “They don’t know where to go for an abortion, or else they just can’t afford it.”
Firman estimates that unsafe abortions account for about 15 percent of Indonesia’s maternal mortality rate — one of the highest in Asia, with 228 mothers dying for every 100,000 births.
Overlooked Option: Adoption
There is, of course, the adoption option, which would require pregnant teenagers to go through the full pregnancy cycle — nine difficult months that would be hard to hide from their family, friends and curious neighbors, unless she finds a shelter to stay in.
In Diana’s case, she found her shelter, which doubles as an orphanage, through word of mouth. Though the shelter has assisted more than 80 pregnant women in the last nine years, only a handful were unmarried teens, according to Yohana, an administrator at the shelter.
The reason, Yohana says, is that many teenagers are unaware such shelters exist.
“I didn’t know that there were other options,” says Cita, not her real name. “I only know of orphanages but not shelters for pregnant women who want to give up their babies. My only options were either to abort or keep the baby.”
Cita, who comes from a devoutly Muslim family, was unmarried and in her early 20s when she became pregnant. She was finishing her university thesis at the time and was planning to continue with her master’s degree overseas. After a failed attempt to abort the fetus using oral medication, she decided to keep the baby.
Another reason for the lack of awareness about the shelters is because there are not many around.
Such shelters are expensive to run, says Inne Silviane, executive director for the PKBI. “They’re expensive because from pregnancy until birth, we have to feed the mothers and provide them with good nutrition,” she says.
To support a teen through a full term of pregnancy, including checkups, daily meals and birthing, can cost a shelter up to Rp 17 million.
Perhaps the core of this problem is the social stigma attached to unwanted teen pregnancies.
The AFHS program for puskesmas, for instance, is underutilized. AFHS health centers log less than three visits per day, according to a 2009 study conducted by the Peduli Perempuan (Care for Women) network that consists of NGOs dealing with gender, sexuality and reproductive health in rural areas.
At the YPI’s youth clinic in South Jakarta, a family member must accompany teens seeking counseling. “They need someone who can support them, because their condition is very unstable,” said Usep Solehudin, a YPI program manager. But he admits very few pregnant teens approach the YPI.
Counseling before and after abortion is often required by clinics. But as long as society is reluctant to approach sex education openly, let alone teen pregnancy, counseling will not help, according to the KPAI’s Hadi.
“Families are still confused, running scared and ashamed. They feel disgraced,” he says. “Pregnant teens attending schools are taken out. Those teens are going through physical changes in puberty, while also experiencing alienation from their community and schools. So it’s a big burden.”
Ida Wulan, assistant deputy for women’s health at the State Ministry for Women’s Empowerment and Child Protection, says parents are often reluctant to talk to their children about sex, leading to further isolation for teenagers. “If asked by their children, parents will just say it’s taboo,” she says.
For young people to open up about their problems, confidentiality from health service providers is essential, says Julie Rostina, a reproductive health consultant at the Peduli Perempuan network. “Confidentiality is needed so the client can talk openly and allow health service providers to make the proper diagnosis and take the right action,” she says.
Focus on Prevention
Most organizations such as the PKBI focus more on prevention than assistance. “We still help those who are already pregnant,” says the PKBI’s Inne, although making it clear that the PKBI mainly counsels married couples who experience unintended or unwanted pregnancies.
Inne says dealing with unmarried teens involves strict conditions imposed by the government, particularly requiring parents to attend the counseling sessions.
The PKBI is allowed to provide abortions by trained medical staff, but only within 10 weeks of conception and with parental consent.
“Unmarried teenagers who become pregnant in Indonesia face a very bleak situation,” says the KPAI’s Hadi. “The mind-set here is that it’s something contemptible, that the teens don’t deserve assistance. They’re outside the system.”
While the 1992 Health Law makes no references to adolescent health, the new Health Law, issued in October 2009, includes a chapter on adolescent health, stipulating the government’s obligation to ensure young people are able to obtain education, information and services on adolescent health.
But experts such as Hadi are skeptical that the law will ever be fully implemented at the operational level. “The new law is good for education and information,” but lacks service terms, he says.
The government, Hadi goes on, will not stir controversy by offending religious and conservative groups.
According to Wahyu Hartomo, assistant to the deputy director for child protection at the women’s empowerment ministry, the government aims to strengthen family values.
“We’re holding on to our religious values, so pregnant teens have to go to an illegal doctor or dukun [shaman],” he says. “The government doesn’t provide assistance.”
With or without reinforcement from the government, the reluctance to be open about sex education persists. And parents are not the only ones guilty of it. Diana, who considers her pregnancy an accident, says: “I don’t think it’s important for kids my age to know about sex, because it’s not appropriate for them.”