Relating the construction and maintenance of maternal ill-health in rural Indonesia

Abstract

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

• maternal mortality
• maternal morbidity
• audit
• quality of care
• access to care
• Indonesia
• decentralisation
• health systems

Acknowledgements

This paper was developed within the Umea° Centre for Global Health Research, with support from FAS, the Swedish Council for Working Life and Social Research (grant no. 2006-1512). The research was funded as part of the Initiative for Maternal Mortality Programme Assessment (Immpact), supported by the Bill & Melinda Gates Foundation, UK Department for International Development, European Commission and USAID, and coordinated by the University of Aberdeen, Scotland. The views expressed herein are solely those of the author. The author would like to acknowledge PhD supervisors, Dr. Julia Hussein and Dr. Alice Kiger, University of Aberdeen, UK, Prof. Peter Byass, University of Umea, Sweden and Dr. Anna Coates, Gender Equality and Women's Empowerment Section, Social Development Division United Nations ESCAP, Thailand. At the University of Indonesia, acknowledgement is made to Prof. Anhari Achadi, Dr. Endang Achadi, Dr. Asri Adisasmita, Trisari Anggondowati, Poppy Deviany, Kamaluddin Latief, Dr. Mardiati Nadjib, Fitri Nandiaty, Eko Pambudi, Meidy Prameswari, Tetty Rachmawati, Dr. Dyah Suslam, Prof. Budi Utomo, Widyaningsih and Nathya S. Yahya. Special thanks go to Yulia Izati, Dr. Siti Nurul Qomariyah, and Dr. Evi Martha at the University of Indonesia and Krystyna Makowiecka at the London School of Hygiene and Tropical Medicine who made significant contributions to the fieldwork and analysis. Thanks to Dr. Lukman H.L. at the Ministry of Health in Jakarta, to Dr. Sri Nurhayati, Serang District Health Office, to the staff at Pandeglang District Health Office and Kramat Watu and Ciruas Puskesmas, Serang, who provided invaluable support, advice and practical assistance. Thanks to Study 1 panellists Dr. M.J.N. Mamahit, Tangerang Hospital, Tangerang, Dr. M. Baharuddin Budi Kemulyaan Hospital, Jakarta, Dr. Didi Danukusumo, Fatmawati Hospital, Jakarta, Dr. Eddy Harianto, Cipto Mangunkusumo Hospital, Dr. A. Sastrowardoyo, Fatmawati Hospital, Jakarta, Dr. A. Sulistomo, Facility of Medicine, University of Indonesia (Hospital OBGYN Specialist Practitioner Panel), Dr. T. Lestaria, Tangerang District Health Office, Dr. Meis, Balaraja Puskesmas, Tangerang, Dr. Yully, Curug Puskesmas, Tangerang, Bidan Henalusti, Balaraja Puskesmas, Tangerang, Bidan A. Mulyani, Balaraja Puskesmas, Tangerang, Bidan Nasih S., Tangerang District Health Office, Bidan N. Hanum, Teluknaga Puskesmas, Tangerang (Community Midwife Practitioner Panel) for their inputs, commitment, and for championing the method. Special thanks also go to the data collectors, Lupthi Tri Utari, Sri Rahmi, Kray S. Asa and Agus Khomeini (Study 2), and Indah Ayu Permata Sary, Dendi Hendarsyah and Reny Setiawaty (Study 3) for their hard work, enthusiasm and insights into the perspectives of study participants. Finally, sincere thanks go to the study participants for their time, hospitality, good humour and for sharing personal information about relatives and patients.

Notes

^†Basic EmOC facilities provide administration of parenteral antibiotics, oxytocic drugs and anticonvulsants, manual removal of placenta, removal of retained products and assisted vaginal delivery. Comprehensive EmOC facilities perform all basic EmOC signal functions as well as surgery (Caesarean section) and blood transfusion (27)