Fertility, morbidity, and mortality in the nineteenth and early twentieth century

It is a great rarity when in a family no children have died. Most families have more children in the grave than in the house. There are many families who have eight to ten children in the graveyard.

One can assume with certainty that three quarters of the children born have died before the age of eight.

(Letter from missionary Nommensen, 5-7-1875, Huta Dame). ⁴

Missionary Nommensen’s description of the havoc caused by a cholera epidemic in 1875 shows that mortality in general, and especially child mortality, was very high at the time. He reported that villages struck by the disease were decimated and some even abandoned. His colleague missionary Johannsen reported that twenty to thirty people died every day in the vicinity of his station on the other side of the Silindung valley, and that parents even committed suicide because they had lost all their children. The 1875 cholera epidemic was probably extremely virulent; but other diseases such as dysentery, typhus, and smallpox epidemics occurred regularly and often raged for months. Local wars and the invasions of the Muslim Padri armies around 1839 and

3 The article by the anthropologist Jane Monnig Atkinson ‘Quizzing the sphinx’ (1999) has inspired the general outline of this chapter. She portrays childbirth as a life-endangering event for women of the Wana, an ethnic minority tribe living in the remote hills of Central Sulawesi, and describes the grief of Wana fathers and mothers over the loss of their children due to bad harvests and disease. It turned out that similar descriptions also exist for the Batak, although not as detailed as the one by Atkinson. In particular, Batak lamentations give insight into the Batak psyche when confronted with the death of a beloved.

4 KIT, Batak instituut, doos 36, C 38, page 9.

the Dutch army in 1878, 1883, and 1889 also affected the health situation negatively, because the villages’ food supplies were often confiscated by the enemy.⁵ Many people had a constant fever, reducing their resistance to disease. Children and adolescents were particularly vulnerable:

besides the diseases cited above, they also succumbed to measles, whooping cough, and chickenpox.⁶ Nommensen, who was very interested in health care and an expert in homeopathic treatment, reported that high mortality was also attributable to the lack of knowledge about appropriate child care and care of the sick. As an example, he mentioned that small children with a high fever, who sweated over their entire body, had cold water poured over them.

Year Epidemics Region

1868 Smallpox Angkola

1869 Smallpox Silindung

1870 Smallpox Lake Toba

1874 Smallpox Silindung

1875 Cholera Silindung, Humbang Plateau, Toba

1876/7 Dysentery and typhus Unspecified

1879/80 Disease affecting the nervous system Unspecified

1883 Smallpox Toba

1889 Smallpox / cholera Toba / Batang Toru Valley

1891 Measles Sipirok

1901 Cholera Silindung

1906 Measles Silindung

1909 Dysentery Silindung

In 1901 the first hospital in the Toba Batak region was founded by the Rhenish Mission (RMG) in Pearaja, Silindung. Its first director, the physician Julius Schreiber, did research between 1900 and 1909 in the valley of Silindung on traditional health care and the conditions causing disease.⁷ His findings are particularly valuable because they describe conditions that were probably common before Western medical services were introduced, keeping in mind that the scope and results of medical assistance by the missionaries before 1900 were limited.

The value of Schreiber’s study lies also in the comparisons made with conditions prevailing in European countries at the time, particularly regarding maternal and child mortality.

Schreiber found that there was nothing amiss with the fertility of Toba Batak women

5 On the effects of the Padri invasion and Dutch military expeditions later in the century, see Chapter 6, page 8 and 30.

Evidence of the value attached to children is the custom prescribed in the area Marbun, that pregnant women were not to be killed during hostilities ([Schröder] 1922:34).

6 KIT, Batak instituut, doss. 36, C 38, page 8. Nommensen described in this letter how he organized the distribution of homeopathic drugs in the region. The care was not without results: according to him, mortality among the Christian population was significantly lower than among the pagan population, which could be proved by the registration of births and deaths. Interesting is Nommensen’s addition that Silindung was still densely populated, because of the influx of immigrants from Toba. For them, he wrote, ‘Silindung [was] on a small scale what New York meant for Europe’. The immigrants had come to Silindung because slavery was already abolished there.

7 The following chapters of Schreiber’s report are used for this section: II. Morbidität, mortalität pp. 526-531; III.

Fruchtbarkeit der Ehe, Geburtsziffer, Kindersterblichkeit pp. 532-537; VI. Kranken-versorgung, ärtzliche Hilfe, Wochenbett- und Kinderpflege (Schreiber 1911:618-631).

Angerler (2008:41-42) for years until 1891, Schreiber (1911:531) for after 1900.

Table 1: Epidemics in the Batak region (1868-1909)

in Silindung. On the contrary, very few marriages were infertile. A survey he conducted in 91 villages demonstrated that out of 1249 marriages only seven were childless, a mere 0.6%.

This percentage was extremely low: in Europe, infertility of couples ranged between 7–12%. He attributed the low percentage of barren marriages among the Toba Batak to the rare incidence of deformities of the reproductive system among women and the equally rare incidence of venereal diseases.⁸ The fact that childless couples usually divorced after a few of years and remarried with another partner also had a positive effect on the figures.

Schreiber also found that the birth rate was very high: it amounted to 47.7 per 1000 inhabitants, according to the data collected by the Christian congregations in four villages in the valley. This was a significantly higher figure than those known for Germany (36.1:1000), the Netherlands (32.5:1000), and Ireland (23:1000) at the time. The birth rate would have been even higher, wrote Schreiber, if the number of stillborn babies had been taken into account; but their numbers were unknown because they were not registered in the church archive. He also counted the number of children born per woman: many older Toba Batak women had delivered more than ten children during the reproductive period of their life.

Despite the prevailing high fertility and birth rates, however, the population in Silindung had not increased significantly. Schreiber attributed this to the high child-mortality rate and to a relatively high mortality rate among adults as well. To obtain an estimate of the incidence of child mortality, Schreiber conducted a survey among 200 women in the age group 18–50 years who had visited the policlinic attached to the hospital. The survey revealed that of all their children, no less than 42.3% had died: 438 out of a total of 1054 live births. The percentage of deceased children was higher among women who had delivered five children or more, with the highest percentage (71.4%) for the fourteen women who had delivered as many as fourteen children.

To find out more about the causes of child mortality, Schreiber conducted additional small surveys, first in two villages built in a reasonably healthy location on the hillside of the valley, and in a third village in the midst of the rice fields, known for its high incidence of malaria. In the first two villages, significantly fewer children had succumbed (30 out of 89 = 35.9%) than in the latter village (94 out of 212 = 44.3%). That malaria was the worst enemy of small children was also substantiated by the figures on patients who had been treated in the hospital for this disease between 1903 and 1906: of a total of 14,911 cases, 37.5% were children between zero and two years old, and another 56.8% was aged between three and seven.⁹ Malaria was an even more serious problem in Pahae, the valley south of Silindung, of which the southern part was still covered with swamps.¹⁰ It was not in all areas of the Toba Batak region that malaria was the most deadly killer of children. On the Humbang plateau and in other areas where no irrigated rice fields were found, the situation was worse than in Silindung because of more frequent crop failure due to draught. Children often died of lung diseases caused by the hard and vicious winds in the dry season.¹¹ Ida Gräber, a nurse who worked at the hospital in Butar around 1930,

8 The few men he had treated for venereal diseases, mainly gonorrhea, had all been infected outside Tapanuli (Schreiber 1911:529).

9 Malaria was endemic and seasonal in the valley: most new cases were reported in June and July after the harvest when the irrigation systems were left temporarily untended, causing stagnant pools of water, the ideal breeding places for mosquitoes. The beginning of the monsoon in October and November, when the new planting season started, also caused relatively more cases of malaria, for the same reason (Schreiber 1911:537, 608).

10 NA, Col., MvO 773 Controleur Tj.H. Velthuisen, subdistrict Silindung, 1937:116-7.

11 NA, Col., MvO 758 Controleur J.C. Ligtvoet, subdistrict Toba Batak plains (Hoogvlakte van Toba), page 27 (n.y.) page 27; MvO 772 Assistant-resident Bataklanden, M.J. Ruychaver, 1936:160.

estimated that the local child mortality rate was at least 60%!¹² Chickenpox was also very much feared.¹³

Other reasons for the high child mortality rate were traditional practices regarding post-partum care of mother and child, lack of hygiene, inappropriate nutrition, and inappropriate care of sick infants and small children. Schreiber was quite adamant about Toba Batak child care: he considered it entirely inadequate and misguided. For example, it was usual to leave a newborn lying on the mat where his mother had given birth without any protection against the cold until after the placenta had come out, which sometimes took hours. The umbilical cord was cut with a sharp bamboo knife, which easily led to infection, because the navel was not disinfected afterwards nor cleaned in the following days. Although Schreiber praised the Batak mothers for their prolonged breastfeeding practice¹⁴, he rejected their habit of feeding their babies masticated rice shortly after birth, because this could cause fatal gastrointestinal disorders. Other practices he frowned upon because of their pernicious effect were the habit of mothers taking their children with them wherever they went thus exposing the child to various health hazards, and the practice of bathing children with a high fever in cold water, a habit also mentioned by Nommensen (see above) and other missionaries who were shocked by it.¹⁵

Child mortality was also related to maternal mortality. It was customary to let the baby die if the mother had succumbed in childbirth.¹⁶ The Batak rationale behind this practice was that the soul (tondi) of the mother had rejected the child or was not strong enough to protect it, and therefore it would have no chance to survive. Whether a child would reach the age when it could walk was also attributed to the willingness of the mother’s tondi to nurture and protect the soul of her child.¹⁷ The care of babies who had lost their mother in childbirth was one of the first tasks that the missionary sisters—appalled by the Batak treatment of motherless infants—took upon themselves in the last decade of the nineteenth century.

On maternal mortality Schreiber had difficulty to obtain accurate data, because women who experienced serious complications during delivery were rarely brought to the hospital.

In the period 1901–1909 he assisted a mere hundred and six women, of whom thirteen died (12.3%), because they were already so weakened that he had been incapable of saving their lives.¹⁸ The overall maternal mortality rate was probably much lower than that, but according to his estimate still amounted to 8.1 per 1000 births, which was a much higher figure than that

12 Gräber, Ida, ’Schwesternarbeit in Butar auf Sumatra’, Der Meisters Ruf: 80-2. The nurse Gräber also described the problems of two women in childbirth, one she could help, the other not, and the newly erected, very simple hospital in Butar.

13 Ypes (1932:185) mentioned a ritual practiced in Pangururan on the island of Samosir to ward off diseases, in particular the chickenpox for children.

14 However, he was also a physician of his time, being of the opinion that breastfeeding whenever a child asked for it could not remain without negative consequences.

15 Similar observations were made earlier by Nommensen (KIT, Batak instituut, doss 36, C 38, page 9), Ruhut [tr.

Meerwaldt] 1905:120; Bruch 1912:5-6. Even Junghuhn as early as 1847 (1847:57) had already been struck by the infant- and childcare, which he found wanting.

16 In 1875, the court of rajas in Lumut (sub-district Batang Taro), led by the local Controller, convicted a man because he had buried a baby who was still alive after the mother had died (Strafzaken 1875).

17 Asselt 1906:204; Warneck 1909:11, 54. An abortion was likewise attributed to the rejection of the child by the tondi of the mother. Similarly, the tondi of women who died during pregnancy or in childbirth were believed to reject their responsibility of motherhood (Niessen 1985:123)

18 This is a current problem in remote areas in Indonesia up to this day. An obstetrician I know well felt extremely frustrated a few years ago while working in the general hospital in the poorest districts (kabupaten) of Bali, Karangasem, because he had not always been able to save the lives of women from remote villages who arrived at the hospital in a life-threatening condition, and was blamed for their death by their relatives.

found in several European countries.¹⁹ The main cause, he suspected, was not puerperal fever, but excessive bleeding, as more than half of the women who had succumbed in childbirth had died within 24 hours after the delivery. Most deliveries took place under the care of female relatives, who would call a woman with a reputation of being more knowledgeable (sibaso) when something seemed amiss. According to Schreiber, these women often did more harm than good.

Perhaps Schreiber’s estimated figure for maternal mortality was even too optimistic.

Women also died weeks or months after a delivery as the result of uterine infections or because of exhaustion due to insufficient nutrition, the constant nursing of babies, and heavy work in the fields. Physical weakness due to frequent pregnancy also made them more prone to succumb if an epidemic broke out or because of a particularly vicious malarial season. Atkinson (1999:178) adds yet another cause of maternal death: the grief over a lost baby or child. Johannsen’s report on the suicide of parents after they had lost their children in the cholera epidemic of 1875 shows that psychological stress could indeed be a ‘fatal’ factor. In sum it is safe assume that the Toba Batak in the pre- and early colonial period, and probably for long after that, had every reason to be worried that their children would not survive them and that the mother might die in childbirth.