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‘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
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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

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