Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

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Abstract

Objectives

Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

Design

With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

Setting

In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

Participants

Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

Primary and secondary outcome measures

The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

Results

Overall, mothers’/families’ consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

Conclusions

The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

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Most cited references 20

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Universal health coverage in Indonesia: concept, progress, and challenges

Rina Agustina, Teguh Dartanto, Ratna Sitompul … (2018)

Indonesia is a rapidly growing middle-income country with 262 million inhabitants from more than 300 ethnic and 730 language groups spread over 17 744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20 900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 livebirths to 23 per 1000, and the total fertility rate decreased from 5·61 to 2·11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 livebirths, and minimal change in neonatal mortality. The centralised one size fits all approach did not address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. Decentralisation of governance to 354 districts in 2001, and currently 514 districts, further increased health system heterogeneity and exacerbated equity gaps. The novel UHC system introduced in 2014 focused on accommodating diversity with flexible and adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. With early success, challenges have emerged, such as the so-called missing-middle group, a term used to designate the smaller number of people who have enrolled in UHC in wealth quintiles Q2-Q3 than in other quintiles, and the low UHC coverage of children from birth to age 4 years. Moreover, high costs for non-communicable diseases warrant new features for prevention and promotion of healthy lifestyles, and investment in a robust integrated digital health-information system for front-line health workers is crucial for impact and sustainability. This Review describes the innovative UHC initiative of Indonesia along with the future roadmap required to meet sustainable development goals by 2030.

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What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective

Alex Filby, Fran McConville, Anayda Portela (2016)

Background Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider’s perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care. Methods and Findings A systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care. Conclusions Significant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

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Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program

Jonathan Spector, Priya Agrawal, Bhala Kodkany … (2012)

Background Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. Methods and Findings A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes. Conclusions Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2019

Publication date (Electronic): 8 December 2019

Volume: 9

Issue: 12

Electronic Location Identifier: e031484

Affiliations

[1 ] Universitas Syiah Kuala , Banda Aceh, Aceh, Indonesia

[2 ] departmentCentre for Modern Indian Studies , University of Goettingen , Göttingen, Germany

[3 ] Centre for Evaluation and Development , Mannheim, Germany

[4 ] departmentDepartment of Economics , University of Mannheim , Mannheim, Baden-Württemberg, Germany

[5 ] Deutsches Institut für Entwicklungspolitik , Bonn, Nordrhein-Westfalen, Germany

[6 ] Leibniz University Hanover , Hannover, Niedersachsen, Germany

Author notes

[Correspondence to ] Dr Ida Monfared; ida.gohardoustmonfared@ 123456uni-goettingen.de

Author information

Ida Monfared http://orcid.org/0000-0001-6990-2350

Sebastian Vollmer http://orcid.org/0000-0002-7863-0462

Article

Publisher ID: bmjopen-2019-031484

DOI: 10.1136/bmjopen-2019-031484

PMC ID: 6924809

PubMed ID: 31818837

SO-VID: 3f826fd8-bc35-4d06-b536-ff006bde2783

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 06 May 2019

Date revision received : 23 October 2019

Date accepted : 12 November 2019

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100001663, Volkswagen Foundation;

Funded by: FundRef http://dx.doi.org/10.13039/501100001659, Deutsche Forschungsgemeinschaft;

Funded by: Experts4Asia;

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ScienceOpen disciplines: Medicine

Keywords: referral system,neonatal health,maternal health,aceh,indonesia

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ScienceOpen disciplines: Medicine

Keywords: referral system, neonatal health, maternal health, aceh, indonesia

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Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

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Abstract

Objectives

Design

Setting

Participants

Primary and secondary outcome measures

Results

Conclusions

Related collections

Indonesia family life and health survey

Most cited references 20

Universal health coverage in Indonesia: concept, progress, and challenges

What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective

Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program

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Cited by 9

Most referenced authors 301