A protocol study of participatory action research: integrated care pathway for pregnant women with heart disease in Indonesia

Abstract

Background Heart diseases are increasingly identified as an important indirect cause of maternal mortality in several cities in Indonesia. The management of pregnancy with heart diseases requires a multidisciplinary approach, and interprofessional collaboration practice (IPCP) is critical to improving the quality of patient care. To enable the effective implementation of IPCP, integrated care pathways (ICPs) are needed to define the roles and responsibilities of the health professionals involved. This study aims to examine the obstacles and enabling factors of IPCP, to develop and use ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. Methods A participatory action study consisting of four stages (diagnostic, planning, implementation, and evaluation) will take approximately 2 years after consensus of ICPs are made. The primary data collection process will employ consensus, observations, focus group discussions, and in-depth interviews throughout the four stages, while secondary data from referral documents and medical records will be collected mainly during the diagnostic and evaluation stages. The findings are being analysed and will then be used to develop an ICPs through consensus building at the planning stage to be applied in the implementation stage. Finally, the implementation outcome, including acceptability, adoption, appropriateness, and feasibility of IPCP, will be assessed in the evaluation stage. All qualitative data will be analysed thematically by two coders using NVIVO 12 software. Discussion This research aims to assess the needs of IPCP, develop and use the ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. Findings from this study will be used for health service planning and policy making to strengthen practice of IPCP during the referral process. As a result, pregnant women with heart disease will have better access to high-quality services at every health care facility to reduce maternal mortality. Trial registration Retrospectively registered in the ISRCTN registry with study ID ISRCTN82300061 on Feb 6, 2019.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level

“…However, integration between primary care and hospital settings remains sub-optimal for the screening, diagnosis, referral and management of pregnant women with concomitant illnesses. Inappropriate referrals and inadequate integration of care are known contributing factors to poor pregnancy outcomes in Indonesia, including for concomitant illnesses [18,19,22]. Integration of care between maternal healthcare and other health services is an important factor that needs to be addressed given the complexity of the management of concomitant illnesses in pregnancy, and the magnitude of health providers involved in service delivery along the continuum of care from pre-conception, ANC, intrapartum care and postnatal care in Indonesia [18].…”

“…Inappropriate referrals and inadequate integration of care are known contributing factors to poor pregnancy outcomes in Indonesia, including for concomitant illnesses [18,19,22]. Integration of care between maternal healthcare and other health services is an important factor that needs to be addressed given the complexity of the management of concomitant illnesses in pregnancy, and the magnitude of health providers involved in service delivery along the continuum of care from pre-conception, ANC, intrapartum care and postnatal care in Indonesia [18]. One suggested solution to strengthen integration of care by participants included development of specialised referral protocols.…”

“…One suggested solution to strengthen integration of care by participants included development of specialised referral protocols. In respect to specialised referral protocols, Yulianti and colleagues [18] is seeking to develop integrated care practice guidelines specifically for heart disease in pregnancy to strengthen integration of care and referrals from primary to tertiary care facilities in Semarang, East Java. Further studies at the district levels are needed to facilitate effective implementation of new referral protocols and practice guidelines for concomitant illnesses that are contextually appropriate.…”

“…haemorrhage, preeclampsia), due to factors such as lack of competency of health providers to diagnose and manage complications, poor quality of care, and ineffective referrals [13]. Concomitant illnesses in pregnancy present another layer of complexity for the Indonesian health system, where they may require different or additional approaches to care such as integrated care with multiple health providers throughout pregnancy, and access to specialist care [18]. However, these services are not always accessible, or health facilities or health workers may not have the competency to address such complex diseases in pregnancy [18][19][20].…”

“…Concomitant illnesses in pregnancy present another layer of complexity for the Indonesian health system, where they may require different or additional approaches to care such as integrated care with multiple health providers throughout pregnancy, and access to specialist care [18]. However, these services are not always accessible, or health facilities or health workers may not have the competency to address such complex diseases in pregnancy [18][19][20]. Therefore, there is a need to understand how the health system in Indonesia needs to improve to prepare to deal with the growing "double burden" of disease.…”