Maternal mortality and severe morbidity in rural Indonesia Part 2: Implementation of a community audit

INTRODUCTION: In the absence of unifying conceptual frameworks, there have been calls to identify and share practical experiences of community participation in health (CPH) to document the contexts and dynamics of participatory practice. OBJECTIVES: This article describes the process of a community-based review of care in obstetric emergencies from rural Indonesia. METHODS: Four village-based groups were convened to review a series of cases of maternal death and disability and to develop recommendations for health planning. Narrative analysis of the reviewers’ discussions was employed to describe and explain whether and how participation occurred. RESULTS: Participation was complex, dynamic and evolved over the course of the study. Although blame and defensiveness characterised the early discussions, over time the reviewers became less condemning of individuals and more so of systems and services, situating individual behaviours within wider health and social systems. Participants also increasingly shared personal experiences, generating rich and explicit reviews of care. Eliciting this information was contingent on skilful facilitation, assuring anonymity and instilling a ‘permission to criticise’ among participants. Sufficient time was also required to convey the necessary principles and reassurances. Despite evidence of learning outcomes, implementation and evaluation of the recommendations were not possible so sustainability and empowerment were likely to be limited. CONCLUSIONS: Despite its potential and relevance, the adoption of meaningful CPH activities may be threatened by wider socio-economic and political conditions, as well as by prevailing evidence hierarchies. We recommend policy and research to establish a firmer foundation for this progressive, yet obscured, public health concept.