Maternal mortality and severe morbidity in rural Indonesia Part 1: The community perspective

INTRODUCTION: Based on the premises that maternal health in developing countries is socially constructed and that valid insights into this phenomenon can be gained from local knowledge, we developed a participatory, community-based review of maternal mortality and severe morbidity in rural Indonesia. OBJECTIVES: The study aimed to demonstrate the utility of the ‘community-perspective’ as a valid source of information for health planning. The objectives were to engage with community groups to conduct critical assessments of quality of, and access to, care in obstetric emergencies, and to develop recommendations for local health planning. METHODS: Four independent village-based groups conducted a series of structured assessments of cases of maternal death and disability. Key care processes were identified through qualitative analysis of the discussion narratives. RESULTS: In the cases reviewed, the health insurance scheme, designed to protect poor families from the catastrophic costs of care, was widely used but often negatively affected access to good quality care. The schemes were seen to be inadequately socialised, inequitably distributed, complex, bureaucratic and led to multiple delays and discriminatory care in time-limited emergencies. The schemes were also reportedly used by families not officially classified as poor, but likely to find care unaffordable. Other problems included poor birth preparedness, the lack of midwives in villages, and shortages in emergency transport. A series of recommendations were generated for health insurance reform, more complete resourcing of village health workers, and continued investments in community health infrastructure. CONCLUSIONS: The reviewers conferred rich and vivid data that allowed for a detailed analysis of the complex relationships between individual providers and women as they interacted in the health system. The reviews suggested that the social and structural determination of maternal health a may be a useful point of departure for health planning and reform. Community-based participatory research can provide useful information for the social organisation of care.