‘Maybe It Was Her Fate and Maybe She Ran Out of Blood’: Final Caregivers' Perspectives on Access to Care in Obstetric Emergencies in Rural Indonesia

Abstract

Maternal mortality persists in low-income settings despite preventability with skilled birth attendance and emergency obstetric care. Poor access limits the effectiveness of life-saving interventions and is typical of maternal health care in low-income settings. This paper examines access to care in obstetric emergencies from the perspectives of service users, using established and contemporary theoretical frameworks of access and a routine health surveillance method. The implications for health planning are also considered. The final caregivers of 104 women who died during pregnancy or childbirth were interviewed in two rural districts in Indonesia using an adapted verbal autopsy. Qualitative analysis revealed social and economic barriers to access and barriers that arose from the health system itself. Health insurance for the poor was highly problematic. For providers, incomplete reimbursements, and low public pay, acted as disincentives to treat the poor. For users, the schemes were poorly socialized and understood, complicated to use and led to lower quality care. Services, staff, transport, equipment and supplies were also generally unavailable or unaffordable. The multiple barriers to access conferred a cumulative disadvantage that culminated in exclusion. This was reflected in expressions of powerlessness and fatalism regarding the deaths. The analysis suggests that conceiving of access as a structurally determined, complex and dynamic process, and as a reciprocally maintained phenomenon of disadvantaged groups, may provide useful explanatory concepts for health planning. Health planning from this perspective may help to avoid perpetuating exclusion on social and economic grounds, by health systems and services, and help foster a sense of control at the micro-level, among peoples' feelings and behaviours regarding their health. Verbal autopsy surveys provide an opportunity to routinely collect information on the exclusory mechanisms of health systems, important information for equitable health planning.

Maternal deaths in eastern Indonesia: 20 years and still walking: an ethnographic study

“…D’Ambruoso et al [17] work on access to maternal health services in Java resonates strongly with this study. These authors take a health planning stance across the health system where as our focus is on village level interventions.…”

Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature

“…Twelve of the 16 studies provided glimpses into some of the other reasons families may not be seeking prompt attention. These included perceived low quality of care at the facility [6,9,17,21], attributing illness to spiritual and other non-medical causes [6,8,18,19], thinking that the baby would die anyway or was too sick to travel [12,14], thinking that the baby was not sick enough to seek care [14], not having a family member to accompany the woman to the facility [12,20], and needing husband’s permission to seek care [8]. Specific examples of how such barriers influence care include that in Bangladesh, 18% of mothers said they did not bring the baby for care because they thought it would die anyway [18].…”

“…Of the 16 articles examined in this review, four included a qualitative component in addition to the quantitative data [6,8,17,19], and only one focused solely on qualitative results [9]. Existing social autopsy tools include an open-ended qualitative portion, yet these data are rarely included in published manuscripts.…”

Enhancing the quality of life for palliative care cancer patients in Indonesia through family caregivers: a pilot study of basic skills training

“…These include unavailability and unaffordability of services, as well as lack of adequate staff, transportation, and equipment [2]. Many patients in Indonesia tend to postpone cancer treatment because of their lack of knowledge on treatment options, insufficient financial resources, the side effects of treatment, and the paternalistic approach of health professionals [3].…”