Care in obstetric emergencies : quality of care, access to care and participation in health in rural Indonesia

Study Setting: Two rural Indonesian districts served by the national midwife-in-the-village programme. Methods: Three critical incident audits of maternal mortality and severe morbidity: confidential enquiry, a verbal autopsy survey, and a participatory community-based review. Results: A range of inter-related factors contributed to poor quality and access. When delivery complications occurred, many women and families were un-informed, un-prepared, found care unavailable, unaffordable, and relied on traditional providers. Social health insurance was poorly promoted, inequitably distributed, complex, bureaucratic, and often led to lower quality care. Public midwives were scarce in remote areas and lacked incentives to provide care to the poor. Emergency transport was often unavailable and private transport incurred further expense. In facilities, there was reluctance to admit poor women, and ill-equipped, under-staffed wards for those accepted. Referrals between hospitals were also common. Examining adverse events from user and provider perspectives yielded multi-level causal explanations. These were used to develop a conceptual model relating structural arrangements (such as decentralisation, commodified care and reductions in public funding) to constrained service provision and adverse health consequences. Conclusions and recommendations: A policy shift towards healthcare as a public good may provide a route to reduce available maternal ill-health. Engaging with those who require and provide critical care in routine assessments can inform more robust health planning, and promote inclusion and participation in health.EThOS - Electronic Theses Online ServiceGBUnited Kingdo