Mortalidad materna y morbilidad severa en Indonesia rural. Parte II. Implementación de auditorías comunitarias / Maternal mortality and severe morbidity in rural Indonesia Part 2: Implementation of a community audit

Lucia D’Ambruoso, Yulia Izati, Evi Martha, Alice Kiger, Anna Coates

Resumen


Introducción: en ausencia de marcos conceptuales u operativos unificados, se han hecho llamamientos para compartir experiencias prácticas de participación comunitaria en salud (pcs) para documentar el contexto y la dinámica de la práctica participativa.

Objetivos: en este artículo se describe la implementación de un enfoque participativo basado en la comunidad de auditoría de la atención en emergencias obstétricas que se llevó a cabo en zonas rurales de indonesia.

Métodos: cuatro grupos provenientes de distintas aldeas se reunieron para revisar una serie de casos de muerte materna y discapacidad
Para formular recomendaciones para la planificación sanitaria. El análisis narrativo temático de las transcripciones de las discusiones fue empleado para describir la participación en lo ocurrido.

Resultados: la participación fue compleja y dinámica y evolucionó a lo largo del estudio. Aunque la culpa y la actitud defensiva caracteriza las primeras discusiones, con el tiempo, los participantes condenan menos a las personas y más a los sistemas y servicios, situando las conductas individuales en el contexto del sistema de salud en general. Los participantes también compartieron cada vez más sus experiencias personales, generando evaluaciones ricas y explícitas sobre la atención. La obtención de esta información estuvo supeditada a la facilitación hábil, asegurando el anonimato e “inculcando” entre los participantes el permiso para criticar. Tiempo suficiente también estaba obligada a transmitir los principios necesarios y consuelos. A pesar de la evidencia, el proceso ha dado lugar a que las mujeres y los miembros de la comunidad estén más preparados e informados y sean sensibles a las emergencias obstétricas en los pueblos. La naturaleza de corto plazo del estudio significó que la aplicación y evaluación de las recomendaciones no fueron posibles. Sin un enfoque sostenido y permanente, el potencial para el impacto, la prevalencia y la autonomía fue limitado.

Conclusiones: el estudio demuestra que si es cuidadosamente implementado, la participación comunitaria en la salud (PCS) puede rendir cuentas ricas y explicativas de los eventos adversos a la salud, proporcionando información irremplazable para la planificación sanitaria. Recomendamos el uso rutinario del método para la planificación distrital de la salud, configurado como un proceso continuo caracterizado por la autonomía, autoridad, independencia y la participación de los excluidos por los sistemas de salud y seguridad social. A pesar de su potencial y relevancia, la pcs auténtica puede verse amenazada por las condiciones socio-económicas y políticas de su contexto, así como por la evidencia de jerarquías existentes dentro de la investigación en salud pública. Recomendamos la implementación de políticas y más investigación para establecer una base más firme para definir precisamente este concepto de salud pública, progresista aunque opaco.

Palabras clave: salud materna, participación comunitaria en salud, indonesia.

Abstract

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.

Keywords: Maternal Health; Community Participation In Health; Indonesia.

Abstract

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.

Keywords: maternal health; community participation in health; indonesia.

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