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

Abstract

BackgroundThe delays in receiving adequate emergency maternal care described by Thaddeus and Maine twenty years ago are still occurring, as exemplified in this study of cases of maternal deaths in a subdistrict in rural eastern Indonesia.MethodsAn ethnographic design was conducted, recruiting eleven families who reported on cases of maternal deaths in one sub-district of Indonesia, as well as assessing the geographical and cultural context of the villages. Traditional birth attendants and village leaders provided information to the research team which was thematically and contextually analysed.ResultsTwo stages to the first and second delays have been differentiated in this study. First, delays in the decision to seek care comprised time taken to recognise (if at all) that an emergency situation existed, followed by time taken to reach a decision to request care. The decision to request care resided variously with the family or cadre. Second, delays in reaching care comprised time taken to deliver the request for help and then time for help to arrive. A phone was not available to request care in many cases and so the request was delivered by walking or motorbike. In two cases where the decision to seek care and the delivery of the request happened in a timely way, help was delayed because the midwife and ambulance respectively were unavailable.ConclusionsThis study, although a small sample, confirmed that either a single delay or a sequence of delays can prove fatal. Delays were determined by both social and geographic factors, any of which alone could be limiting. Initiatives to improve maternal health outcomes need to address multiple factors: increased awareness of equitable access to maternal health care, village preparedness for emergency response, improved access to telecommunications and geographic access.

Gambaran Pelaksanaan Jaringan Sosial Dalam Upaya Pencegahan Dan Penanganan Kegawatdaruratan Kehamilan Dan Persalinan Di Desa Karang Bajo, Kabupaten Lombok Utara

“…Tiga kondisi keterlambatan penanganan kegawat daruratan yang sering ditemukan dalam kasus kematian ibu melahirkan adalah keterlambatan dalam pengambilan keputusan sebelum persalinan, keterlambatan dalam mencapai tempat persalinan serta keterlambatan dalam mendapatkan penanganan yang memadai (Ayanian, Markel and Ph, 2016). Beberapa penelitian di Indonesia, menunjukkan bahwa keterlambatan saat persalinan terjadi akibat sulitnya kondisi geografis, terbatasnya ekonomi masyarakat, serta masih tingginya peran dukun dalam proses kehamilan dan persalinan sebagai salah satu aspek sosial budaya yang masih dipertahankan hingga saat ini (Titaley et al, 2010;Birdsall and Hill, 2011;Belton, Myers and Ngana, 2014). Salah satu hambatan dalam mempercepat penurunan AKI di daerah juga terkait dengan kurangnya interaksi ibu hamil dengan lingkungan keluarga dan masyarakat yang lebih luas.…”

Assessing the effect of the Expanding Maternal and Neonatal Survival program on improving stabilization and referral for maternal and newborn complications in Indonesia

“…Nevertheless, an assessment in five regions in Indonesia found that 41.9% of maternal deaths occurred at public hospitals and that Eastern Indonesia and Sulawesi provinces reported the second highest maternal mortality rates and lower levels of service coverage, compared with Java and Bali . Persistent high maternal morbidity and mortality are likely linked to the lack of health workers’ capacity to provide high‐quality care, potentially due to insufficient training, limited experience in managing complications, inadequate infrastructure in which care is provided, and geography . Accordingly, efforts have been focused on improving timely access to care, including effective management of complications during labor at community health facilities ( puskesmas ), and, if necessary, timely and effective referral to a hospital for specialist care…”

“…Previous studies in Indonesia identified transport as a major barrier to efficient referral; emergency transport was often unavailable and private transport was unreliable and incurred costs. One study identified patients’ and providers’ uncertainty about where to seek emergency care, which resulted in patients traveling to several hospitals before receiving treatment, as a source of delay within an ineffective referral system . A reluctance to admit poorer women covered by social health insurance was also found to be the case in some facilities .…”

“…One study identified patients' and providers' uncertainty about where to seek emergency care, which resulted in patients traveling to several hospitals before receiving treatment, as a source of delay within an ineffective referral system. 12 A reluctance to admit poorer women covered by social health insurance was also found to be the case in some facilities. 13,24 Other barriers include a lack of proper documentation for health insurance registration, the distance to health facilities, shortage of qualified health workers, overcrowded health facilities, and suboptimal health facility accreditation.…”

“…11 Persistent high maternal morbidity and mortality are likely linked to the lack of health workers' capacity to provide high-quality care, potentially due to insufficient training, limited experience in managing complications, inadequate infrastructure in which care is provided, and geography. 7,9,12,13 Accordingly, efforts have been focused on improving timely access to care, 14,15 including effective management of complications during labor at community health facilities (puskesmas), and, if necessary, timely and effective referral to a hospital for specialist care. 16 A well-functioning referral system should act as an early warning system for comprehensive emergency obstetric and newborn care (CEmONC) facilities; ideally, ensuring that the necessary staff, supplies, and equipment are fully prepared to provide emergency obstetric and newborn care 24 hours a day, 7 days a week.…”