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

Figures & data

Table 1. Empirical studies and research questions

Study	Perspective from which care examined	Research questions
1. A confidential enquiry into maternal mortality and severe morbidity	Healthcare providers	• What factors affect the quality of care provided in obstetric emergencies in rural areas?• How do these factors exert an influence over quality of care?• How can routine assessments of quality of care be elicited from the perspectives of healthcare providers?
2. An extended verbal autopsy to investigate maternal deaths	Final caregivers	• What are the medical and non-medical circumstances and events that contribute to access to care in obstetric emergencies in rural areas?• How do these factors influence access to care in obstetric emergencies?• How can medical and social causes and contributory factors be investigated using a routine health surveillance method that utilises the perspectives of final caregivers?
3. A community-based review of maternal mortality and severe morbidity	Women of reproductive age and community members (families, village officials, TBAs and midwives)	• What are the individual, familial, social, cultural, health systems and healthcare factors that determine access to, and quality of, care in obstetric emergencies in rural areas?• How do these factors influence access to, and quality of, care in obstetric emergencies?• How can investigations of quality of, and access to, care in obstetric emergencies be meaningfully elicited from the perspectives of women of reproductive age and community members?

Table 2. A combined inductive/deductive framework analysis approach [adapted, (81)]

Stage	Description
1. Immersion and organisation	An initial organisation of data according to pre-determined (deductive) categories, as well as to preliminary emergent (inductive) themes
2. Development of coding frameworks	The development of thematic, or coding frameworks that resulted from Stage 1
3. Application of coding frameworks	The thematic frameworks applied to data to code or index. This is done iteratively, until no new themes emerge (‘thematic saturation’)
4. Preparation of thematic summary grids	Preparation of thematic summaries, whereby grids of dominant and recurrent themes prepared with related themes and sub-themes in columns and respondents (or groups of respondents) as rows. This allows large volumes of narrative data to be distilled, and for the identification of patterns within and between narratives
5. Interpretation	Interpretation involves establishing associations between themes to construct sequentially descriptive and explanatory accounts of the phenomena of interest. Additional, relevant theoretical frameworks can be applied at this stage

Table 3. Recommendations for policy

Human resources	• Increased numbers of village midwives are urgently needed Village midwives should receive training for obstetric complications, supportive legal and regulatory frameworks, and supervision Village midwives should be resourced for referral, with village transport networks and village ambulances• Village midwives should receive incentives to accept and treat poor patients• Village midwives should work with TBAs to locate pregnant women in villages and to ensure that they receive adequate ANC and make birth plans• CHWs should be resourced and supported to connect poorer women with delivery care services
Community-based care	• Partnerships between TBAs and midwives may help to connect poor, rural, and disadvantaged women with MCH care• Given the tensions between midwives and TBAs, partnerships could be brokered by CHWs and villages authorities• Incorporating the contributions of families and communities into service delivery may foster more inclusive, responsive and culturally appropriate healthcare
Facility-based care	• Public hospitals must not be able to refuse entry to women who are unable to pay for care in advance. Incentives for accepting and treating poor patients may be a mechanism to achieve this• Public hospitals should be more fully resourced, with equipment and supplies (blood products in particular)
Financial access	• SHI needs to be extended to cover larger numbers of people living in, or vulnerable to, poverty• SHI should be more effectively socialised and simplified• SHI entitlements should be extended to include indirect costs of care seeking and provision such as transport and medical supplies• Women without insurance should be accepted and treated in facilities
Health systems	• Health systems to make explicit recognition of the potential for unintended effects of decentralised, market based, provision of life-saving delivery care services to exclude those without the ability to pay• Health systems strengthening to develop accountability-oriented systems providing essential delivery care on the basis of need

Fig. 1.  A conceptual model of quality of care (83). The model posits that QOC is an event that occurs when service users (represented by left innermost circles) and providers (right innermost circles) interact. Determining this interaction are broader factors related to the sociocultural and health systems environment (examples are provided in the left and right outer circles, respectively). These factors individually and collectively determine the uptake of services. QOC occurs when services and utilized, and outcomes result. Outcomes, QOC and uptake also operate through feedback mechanisms to their determinants.

Fig. 2.  A conceptual model of access to care (62, 86). Elements of the eligibility to access concept (62) were applied to the thematic analysis of the narratives gained in Study 2. The analysis revealed a hierarchical arrangement of the relevance of the dimensions of access, whereby the organisation of health systems dictates service provision, and provider and service user behaviours, i.e. the locus of control over eligibility for access to care, lies within the macro-level operating conditions of the health system. A reciprocal effect was also identified whereby the behaviours and attitudes of service users’ feedback into the operating conditions, maintaining the social norms that shape exclusion from access.

Pope C, Mays N. Qualitative research in health care. Blackwell Publishing. Oxford, 2006

 Google Scholar

D'Ambruoso L, Achadi E, Adisasmita A, Izati Y, Makowiecka K, Hussein J. Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. Midwifery. 2009; 25: 528–39. 10.3402/gha.v5i0.17989.

 Google Scholar

Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, et al.. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006; 6: 35. Available from: http://www.biomedcentral.com/1471-2288/6/35[cited 12 July 2012].10.3402/gha.v5i0.17989.

 PubMedGoogle Scholar

D'Ambruoso L, Byass P, Qomariyah SN. Maybe it was her fate and maybe she ran out of blood’: final caregivers’ perspectives on access to care in obstetric emergencies rural Indonesia. J Biosoc Sci. 2010b; 42: 213–41. 10.3402/gha.v5i0.17989.

 PubMed Web of Science ®Google Scholar