Maternal mortality and severe morbidity in rural Indonesia Part 2: Implementation of a community audit

Introduction: In the absence of unifying conceptual and operational frameworks, there have been calls to share practical experiences of community participation in health (CPH) to document the contexts and dynamics of participatory practice. Objectives: This article describes the implementation of a participatory community-based audit of care in obstetric emergencies that was conducted in rural Indonesia. Methods: Four village-based groups were convened to review a series of cases of maternal death and disability and to develop recommendations for health planning. Thematic narrative analysis of the discussion transcripts was employed to describe how participation occurred. Results: Participation was complex and dynamic and evolved over the course of the study. Although blame and defensiveness characterized the early discussions, over time, participants became less condemning of individuals and more so of systems and services, situating individual behaviors within the wider health system context. Participants also increasingly shared personal experiences, generating rich and explicit assessments of care. Eliciting this information was contingent on skillful facilitation, assuring anonymity, and instilling "permission to criticize" among the participants. Sufficient time was also required to convey the necessary principles and reassurances. Despite evidence the process had resulted in women and community members being more prepared, informed, and responsive toward obstetric emergencies in villages, the short-term nature of the study meant that implementation and evaluation of the recommendations were not possible. Without a sustained and ongoing approach, the potential for impact, sustainability and empowerment were limited. Conclusions: The study demonstrates that when carefully implemented, CPH can yield rich explanatory accounts of adverse health events, providing unique information for health planning. We recommend the method for routine district health planning, configured as a continuous process characterized by autonomy, authority, and self-reliance, and involving those excluded by health and social systems. Despite its potential and relevance, authentic CPH may be threatened by wider socio-economic and political conditions, as well as by prevailing evidence hierarchies that exist in public health research. We recommend policy and research to establish a firmer foundation for this progressive, yet obscured, public health concept.