Hostname: page-component-586b7cd67f-l7hp2 Total loading time: 0 Render date: 2024-11-23T07:33:06.594Z Has data issue: false hasContentIssue false
  • English
  • Français

‘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

Published online by Cambridge University Press:  17 December 2009

LUCIA D'AMBRUOSO ,
PETER BYASS  and
SITI NURUL QOMARIYAH
LUCIA D'AMBRUOSO
Affiliation:
Immpact, Population Health Section, University of Aberdeen, UK
PETER BYASS
Affiliation:
Immpact, Population Health Section, University of Aberdeen, UK Umeå Centre for Global Health Research, Epidemiology and Public Health Sciences, Umeå University, Sweden
SITI NURUL QOMARIYAH
Affiliation:
Immpact, Center for Family Welfare, Faculty of Public Health, University of Indonesia, Indonesia
Get access Rights & Permissions [Opens in a new window]

Summary

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.

Type
Research Article
Information
Journal of Biosocial Science , Volume 42 , Issue 2 , March 2010 , pp. 213 - 241
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

ACCESS (2009) ACCESS Program: Access to Clinical and Community Maternal, Neonatal and Women's Health Services. US Agency for International Development, Baltimore (available at: http://www.accesstohealth.org/program/overview.htm).Google Scholar
Achadi, E., Scott, S., Pambudi, E. S., Makowiecka, K., Marshall, T., Adisasmita, A., Deviany, P. E. & Ronsmans, C. (2007) Midwifery provision and uptake of maternity care in Indonesia. Tropical Medicine & International Health 12, 1490–1497.Google Scholar
Aday, L. A. & Andersen, R. (1974) A framework for the study of access to medical care. Health Services Research 9, 208–220.Google Scholar
Adisasmita, A., Deviany, P. E., Nandiaty, F., Stanton, C. & Ronsmans, C. (2008) Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy and Childbirth 8, 10 (available at: http://www.biomedcentral.com/1471-2393/8/10/abstract).Google Scholar
Andersen, R. & Newman, J. F. (1973) Societal and individual determinants of medical care utilization in the United States. The Milbank Memorial Fund Quarterly Health and Society 51, 95–124.Google Scholar
Andersen, R. M. (1995) Revisiting the behavioural model and access to medical care: does it matter? Journal of Health and Social Behavior 36, 1–10.Google Scholar
Averting Maternal Death and Disability Program (AMDD) (2009) Averting Maternal Death and Disability Program. Columbia University, New York (available at: http://www.amddprogram.org/).Google Scholar
Badan Pusat Statistik-Statistics Indonesia (BPS) & ORC Marco (2003) Indonesia Demographic and Health Survey 2002–2003. Calverton, MD (available at: http://www.measuredhs.com/pubs/pub_details.cfm?ID=439&ctry_id=17&SrchTp=psummary#dfiles)Google Scholar
Baiden, F., Bawah, A., Biai, S., Binka, F., Boerma, T., Byass, P. et al. (2007) Setting international standards for verbal autopsy. Bulletin of the World Health Organization 85, 570.Google Scholar
Bailey, P. E., Szaszdi, J. A. & Glover, L. (2002) Obstetric complications: does training traditional birth attendants make a difference? Pan American Journal of Public Health 11, 15–23.Google Scholar
Barber, G. (2003) ‘To tell or not to tell’: ethics and secrecy in anthropology and childbearing in rural Malawi. In Caplan, P. (ed.) The Ethics of Anthropology: Debates and Dilemmas. Routledge, London and New York, pp. 133–154.Google Scholar
Barnes-Josiah, D., Myntti, C. & Augustin, A. (1998) The “three delays” as a framework for examining maternal mortality in Haiti. Social Science & Medicine 46, 981–993.Google Scholar
Bartlett, L. A., Jamieson, D. J., Kahn, T., Sultana, M., Wilson, H. G. & Duerr, A. (2002) Maternal mortality among Afghan refugees in Pakistan, 1999–2000. Lancet 359, 643–649.Google Scholar
Bartlett, L. A., Mawji, S., Whitehead, S., Crouse, C., Dalil, S., Ionete, D. & Salama, P. (2005) Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002. Lancet 365, 864–870.Google Scholar
Bebbington, A., Dharmawan, L., Fahmi, E. & Guggenheim, S. (2006) Local capacity, village governance, and the political economy of rural development in Indonesia. World Development 34, 1958–1976.Google Scholar
Beegle, K., Frankenberg, E. & Thomas, D. (2001) Bargaining power within couples and use of prenatal and delivery care in Indonesia. Studies in Family Planning 32, 130–146.Google Scholar
Béhague, D. P., Kanhonou, L. G., Filippi, V., Lègonou, S. & Ronsmans, C. (2008) Pierre Bourdieu and transformative agency: a study of how patients in Benin negotiate blame and accountability in the context of severe obstetric events. Sociology of Health and Illness 30, 489–510.Google Scholar
Berman, P. A., Gwatkin, D. R. & Burger, S. E. (1987) Community-based health workers: head start or false start towards health for all? Social Science & Medicine 25, 443–459.Google Scholar
Berry, N. S. (2008) Who's judging the quality of care? Indigenous Maya and the problem of “not being attended”. Medical Anthropology: Cross-Cultural Studies in Health and Illness 27, 164–189.Google Scholar
Byass, P. (2007) Who needs cause-of-death data? PloS Medicine 4, e333 (available at: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040333).Google Scholar
Byass, P., D'Ambruoso, L., Ouédraogo, M. & Qomariyah, S. N. (2009) Assessing the repeatability of verbal autopsy for determining cause of death in Burkina Faso and Indonesia. Population Health Metrics 7, 6 (available at: http://www.pophealthmetrics.com/content/7/1/6).Google Scholar
Campbell, O. M. & Graham, W. J. (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368, 1284–1299.Google Scholar
Cham, M., Sundby, J. & Vangen, S. (2005) Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care. Reproductive Health 2, 3 (available at: http://www.reproductive-health-journal.com/content/2/1/3).Google Scholar
D'Ambruoso, L., Byass, P. & Qomariyah, S. N. (2008) Can the right to health inform public health planning in developing counties? A case study for maternal healthcare from Indonesia. Global Health Action 1 (available at: http://journals.sfu.ca/coaction/index.php/gha/article/view/1828).Google Scholar
D'Ambruoso, L., Byass, P., Qomariyah, S. N. & Ouedraogo, M. (2009) A lost cause? Investigating social and medical causes of maternal death with verbal autopsy: a method and implications for health planning. Paper presented at: Loss in Childbearing in Sub-Saharan Africa and South Asia Workshop, Department of Social and Political Studies, University of Edinburgh, Edinburgh.Google Scholar
Davis-Floyd, R. (2003) Home-birth emergencies in the US and Mexico: the trouble with transport. Social Science & Medicine 56, 1911–1931.Google Scholar
De Kok, B. C. & Widdicombe, S. (2008) ‘I really tried’: Management of normative issues in accounts of responses to infertility. Social Science & Medicine 67, 1083–1093.Google Scholar
Dixon-Woods, M., Cavers, D., Agarwal, S., Annandale, E., Arthur, A., Harvey, J. et al. (2006) Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Medical Research Methodology 6, 35 (available at: http://www.biomedcentral.com/1471-2288/6/35).Google Scholar
Eden, J. (1998) Measuring access to care through population-based surveys: where are we now? Health Services Research 33, 685–708.Google Scholar
Ensor, T. & Cooper, S. (2004) Overcoming barriers to health service access: influencing the demand side. Health Policy and Planning 19, 69–79.Google Scholar
Ensor, T., Nadjib, M., Quayyum, Z. & Megraini, A. (2008) Public funding for community-based skilled delivery care in Indonesia: to what extent are the poor benefiting? European Journal of Health Economics. DOI: 10.1007/s10198-007-0094-x.Google Scholar
Family Care International (FCI) (2009) The Skilled Care Initiative. Family Care International, New York (available at: http://familycareintl.org/en/issues/35).Google Scholar
Fawcus, S., Mbizvo, M., Lindmark, G. & Nystrom, L. (1996) A community-based investigation of avoidable factors for maternal mortality in Zimbabwe. Studies in Family Planning 27, 319–327.Google Scholar
Filippi, V., Brugha, R., Browne, E., Gohou, V., Bacci, A., de Brouwere, V. et al. (2004) Obstetric audit in resource-poor settings: lessons from a multi-country project auditing ‘near miss’ obstetrical emergencies. Health Policy and Planning 19, 57–66.Google Scholar
Filippi, V., Richard, F., Lange, I. & Ouattara, F. (2009) Identifying barriers from home to the appropriate hospital through near-miss audits in developing countries. Best Practice & Research: Clinical Obstetrics & Gynaecology 23, 389–400.Google Scholar
Filippi, V., Ronsmans, C., Campbell, O. M., Graham, W. J., Mills, A., Borghi, J. et al. (2006) Maternal health in poor countries: the broader context and a call for action. Lancet 368, 1535–1541.CrossRefGoogle Scholar
Fottrrel, E., Byass, P., Ouedraogo, T. W., Tamini, C., Gbangou, A., Sombie, I. et al. (2007) Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies. Population Health Metrics 5 (available at: http://www.pophealthmetrics.com/content/5/1/1).Google Scholar
Freedman, L. (2005) Achieving the MDGs: health systems as core social institutions. Development 48, 19–24.Google Scholar
Friend, T. (2003) Indonesia Destinies. Harvard University Press, United States.Google Scholar
Gilson, L. (2003) Trust and the development of health care as a social institution. Social Science & Medicine 56, 1453–1468.Google Scholar
Gold, M. (1998) Beyond coverage and supply: measuring access to healthcare in today's market. Health Services Research 33, 625–652.Google Scholar
Hatt, L., Stanton, C., Makowiecka, K., Adisasmita, A., Achadi, E. & Ronsmans, C. (2007) Did the strategy of skilled attendance at birth reach the poor in Indonesia? Bulletin of the World Health Organization 85, 774–782 (available at http://www.who.int/bulletin/volumes/85/10/06.033472/en/index.html).Google Scholar
Iskandar, M. B., Utomo, B., Hull, T., Dharmaputra, N. G. & Anwar, Y. (1996) Unravelling the Mysteries of Maternal Death in West Java: Re-examining the Witnesses. University of Indonesia, Jakarta.Google Scholar
Izati, Y., Pambudi, E. & D'Ambruoso, L. (2005) A Descriptive Analysis of Dho and Bps Data on Coverage and Profile of Midwifery Services in Serang and Pandeglang Districts. University of Indonesia, Jakarta.Google Scholar
Khan, K. S., Wojdyla, D., Say, L., Gulmezoglu, A. M. & Van Look, P. F. (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 367, 1066–1074.Google Scholar
Kilpatrick, S. J., Crabtree, K. E., Kemp, A. & Geller, S. (2002) Preventability of maternal deaths: comparison between Zambian and American referral hospitals. Obstetrics & Gynecology 100, 321–326.Google Scholar
Killewo, J., Anwar, I., Bashir, I., Yunus, M. & Chakraborty, J. (2006) Perceived delay in healthcare-seeking for episodes of serious illness and its implications for safe motherhood interventions in rural Bangladesh. Journal of Health Population and Nutrition 24, 403–412 (available at: http://www.icddrb.org:8080/images/jhpn24_4_Perceived-Delay.pdf).Google ScholarPubMed
Kristiansen, S. & Santoso, P. (2006) Surviving decentralisation? Impacts of regional autonomy on health service provision in Indonesia. Health Policy 77, 247–259.CrossRefGoogle ScholarPubMed
Lambert, H. & McKevitt, C. (2002) Anthropology in health research: from qualitative methods to multidisciplinarity. British Medical Journal 325, 210–213.Google Scholar
Leimena, S. L. (1989) Posyandu: a community based vehicle to improve child survival and development. Asia Pacific Journal of Public Health 3, 264–267.Google Scholar
McCaw-Binns, A. (2005) Safe motherhood in Jamaica: from slavery to self-determination. Paediatric and Perinatal Epidemiology 19, 254–261.Google Scholar
McCaw-Binns, A., Standard-Goldson, A., Ashley, D., Walker, G. & MacGillivray, I. (2001) Access to care and maternal mortality in Jamaican hospitals: 1993–1995. International Journal of Epidemiology 30, 796–801.Google Scholar
McCullock-Melnyk, K. A. (1988) Barriers: a critical review of recent literature. Nursing Research 37, 196–201.Google Scholar
McCullock-Melnyk, K. A. (1990) Barriers to care: operationalizing the variable. Nursing Research 39, 108–112.Google Scholar
Makowiecka, K., Achadi, E., Izati, Y. & Ronsmans, C. (2008) Midwifery provision in two districts in Indonesia: how well are rural areas served? Health Policy and Planning 23, 67–75.Google Scholar
Manandhar, D. S., Osrin, D., Shrestha, B. P., Mesko, N., Morrison, J., Tumbahangphe, K. M. et al. (2004) Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 364, 970–979.Google Scholar
Mavalankar, D. V. & Rosenfield, A. (2005) Maternal mortality in resource-poor settings: policy barriers to care. American Journal of Public Health 95, 200–203.Google Scholar
Mbaruku, G., van Roosmalen, J., Kimondo, I., Bilango, F. & Bergström, S. (2009) Perinatal audit using the 3-delays model in western Tanzania. International Journal of Gynecology & Obstetrics 106, 85–88.Google Scholar
Millman, M. (ed.) (1993) Access to Health Care in America. Institute of Medicine (IOM), Washington DC.Google Scholar
Okonofua, F. E., Abejide, A. & Makanjuola, R. A. (1992) Maternal mortality in Ile-Ife, Nigeria: a study of risk factors. Studies in Family Planning 23, 319–324.Google Scholar
Otis, K. E. & Brett, J. A. (2008) Barriers to hospital births: why do many Bolivian women give birth at home? Revista Panamericana de Salud Pública 24, 46–53.Google Scholar
Pattinson, R. C. & Hall, M. (2003) Near misses: a useful adjunct to maternal death enquiries. British Medical Bulletin 67, 231–243.Google Scholar
Penchansky, R. & Thomas, J. W. (1981) The concept of access: definition and relationship to consumer satisfaction. Medical Care 19, 127–140.Google Scholar
Popay, J., Escorel, S. H. M. , Johnston, H., Mathieson, J., Rispel, L. & On behalf of the WHO Social Exclusion Knowledge Network (2008) Understanding and Tackling Social Exclusion: Final Report to the WHO Commission on Social Determinants of Health From the Social Exclusion Knowledge Network. World Health Organization, Geneva (available at: http://www.who.int/entity/social_determinants/knowledge_networks/final_reports/sekn_final%20report_042008.pdf).Google Scholar
Rappaport, J. (1995) Empowerment meets narrative: listening to stories and creating settings. American Journal of Community Psychology 23, 795–807.Google Scholar
Richard, F., Ouédraogo, C., Zongo, V., Ouattara, F., Zongo, S., Gruénais, M. E. et al. (2008a) The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso. British Journal of Obstetrics and Gynaecology 116, 38–44.Google Scholar
Richard, F., Witter, S. & De Brouwere, V. (2008b) Reducing financial barriers to obstetric care in low-income countries. Studies in Health Service Organisation and Policy 24.Google Scholar
Ricketts, T. C. & Goldsmith, L. J. (2005) Access in health services research: the battle of the frameworks. Nursing Outlook 53, 274–280.Google Scholar
Riessman, C. K. (1974) The use of health services by the poor. Social Policy 5, 41–49.Google Scholar
Riessman, C. K. (1984) The use of health services by the poor: are there any promising models? Social Policy 14, 30–40.Google Scholar
Ronsmans, C., Endang, A., Gunawan, S., Zazri, A., McDermott, J., Koblinsky, M. & Marshall, T. (2001) Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia. Tropical Medicine and International Health 6, 799–810.Google Scholar
Ronsmans, C. & Graham, W. J. (2006) Maternal mortality: who, when, where, and why. Lancet 368, 1189–1200.Google Scholar
Ronsmans, C., Scott, S., Adisasmita, A., Deviany, P. & Nandiaty, F. (2008) Estimation of population-based incidence of pregnancy-related illness and mortality (PRIAM) in two districts in West Java, Indonesia. British Journal of Obstetrics and Gynaecology 116, 82–90.Google Scholar
Ronsmans, C., Scott, S., Qomariyah, S. N., Achadi, E., Braunholtz, D., Marshall, T. et al. (2009) Professional assistance during birth and maternal mortality in two Indonesian districts. Bulletin of the World Health Organization 87, 416–423.Google Scholar
Shankar, A., Sebayang, S., Guarenti, L., Utomo, B., Islam, M., Fauveau, V. & Jalal, F. (2008) The village-based midwife programme in Indonesia. Lancet 371, 1226–1229.Google Scholar
Sibley, L. & Armbruster, D. (1997) Obstetric first aid in the community – partners in safe motherhood a strategy for reducing maternal mortality. Journal of Nurse-Midwifery 42, 117–121.Google Scholar
South Africa Every Death Counts Writing Group. (2008) Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 371, 1294–1304.Google Scholar
Sparrow, R. (2008) Targeting the poor in times of crisis: the Indonesian health card. Health Policy and Planning 23, 188–199.Google Scholar
Starrs, A. (1997) The Safe Motherhood Action Agenda: Priorities for the Next Decade. Family Care International, New York (available at: http://www.familycareintl.org/en/resources/publications/51).Google Scholar
Sword, W. (1999) A socio-ecological approach to understanding barriers to prenatal care for women of low income. Journal of Advanced Nursing 29, 1170–1177.Google Scholar
Thaddeus, S. & Maine, D. (1994) Too far to walk: maternal mortality in context. Social Science & Medicine 38, 1091–1110.CrossRefGoogle Scholar
Utomo, B. (2005) Challenges in addressing safe motherhood issues in Indonesia. In United Nations Economic and Social Commission for Asia and the Pacific: Health and Mortality in the Asian and Pacific Region. Asian Population Studies Series, vol. 163, pp. 109–125 (available at: http://www.unescap.org/esid/psis/population/popseries/apss163/apss163.pdf#page=116).Google Scholar
Wall, L. L. (1998) Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Studies in Family Planning 29, 341–359.Google Scholar
Weiss, J. E. & Greenlick, M. R. (1970) Determinants of medical care utilization: the effect of social class and distance on contacts with the medical care system. Medical Care 8, 456–462.Google Scholar
White, K., Small, M., Frederic, R., Joseph, G., Bateau, R. & Kershaw, T. (2006) Health seeking behaviour among pregnant women in rural Haiti. Health Care for Women International 27, 822–838.Google Scholar
World Bank (2006) Making the New Indonesia Work for the Poor. World Bank, Jakarta/Washington (available at: http://siteresources.worldbank.org/INTINDONESIA/Resources/Publication/280016-1152870963030/2753486-1165385030085/Overview_standalone_en.pdf,).Google Scholar
World Health Organization (2004) Beyond the Numbers: Reviewing Maternal Deaths and Complications to make Pregnancy Safer. WHO, Geneva. (available at http://www.who.int/making_pregnancy_safer/documents/9241591838/en/index.html).Google Scholar
World Health Organization (2007) Verbal Autopsy Standards: Ascertaining and Attributing Causes of Death. WHO, Geneva (available at: http://www.who.int/whosis/mort/verbalautopsystandards/en/).Google Scholar
World Health Organization & UNICEF (1996) Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF. WHO/FRH/MSM/96.11, Geneva (available at: http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.11.pdf,).Google Scholar
World Health Organization, UNICEF & UNFPA (2001) Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF, UNFPA. WHO/RHR/01.9, Geneva (available at: http://www.who.int/reproductive-health/publications/rhr_01_9_maternal_mortality_1995/index.html).Google Scholar
World Health Organization, UNICEF & UNFPA (2004) Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. WHO, Geneva (available at: http://www.who.int/reproductive-health/publications/maternal_mortality_2000/index.html).Google Scholar
World Health Organization, UNICEF, UNFPA & World Bank (2007) Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF and UNFPA. Geneva (available at: http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html).Google Scholar