Introduction: Based on the premises that maternal ill health and social disadvantage are inextricably linked and that local knowledge can provide important insights into this phenomenon, we developed a community-based audit of maternal mortality and severe morbidity in a rural Indonesian district. Aims & objectives: The study aimed to demonstrate the "community perspective" as a valid source of information for health planning. The objectives were to engage communities in critical assessments of access to care and quality of care in obstetric emergencies and to generate recommendations for reform. Methods: Four independent groups of women and other individuals typically involved in obstetric emergencies in villages participated in assessments of cases of maternal death and severe disability. Key care processes and determining mechanisms were identified through framework analysis of the discussion narratives. Results: One repeated and persistent theme related to how social health insurance (SHI) failed to mediate financial barriers to access and quality. Despite being designed to protect poor individuals from the catastrophic costs of care, SHI was frequently seen to be instrumental in constraining access to quality services. The scheme was inadequately socialized, inequitably distributed, complex and bureaucratic, and led to delays and discriminatory care in the time-limited emergencies. In addition, people not officially classified as poor, but for whom emergency delivery care may have remained unaffordable, reportedly used SHI. Other problems identified included poor birth preparedness, a lack of midwives in villages, and shortages in emergency transportation. Recommendations for health insurance reform, improved resources for village health workers, and investments in community public health infrastructure were developed and disseminated. Conclusions: In this setting, access to good quality care is constrained by inadequate district health resources and commodified care provision. Health system reform to promote universal access to essential delivery care services may be an effective means to improve outcomes among rural women. The community perspective yielded rich and vivid insights into the complex interactions between care users and providers in emergencies. Routine community evaluation can inform contextually relevant implementation solutions that promote the equitable provision of emergency delivery care.
|Number of pages||21|
|Publication status||Published - 5 Sep 2013|