In Study 1, assessing QOC, the panellists quickly established that village midwives were not available in the emergencies. Other midwives present in villages, or nearby, who were available by virtue of circumstance or chance, typically attended. Attending midwives made many important contributions: diagnosing conditions, stabilising women, convincing families of the need for referral, and facilitating admissions to facilities. Some clinical management competencies were found to be substandard, however.
In Study 1, strong preferences for TBAs were also identified among women and families, as was poor knowledge of social health insurance (SHI). Otherwise, communities were not collectively prepared for emergencies, but actively participated in mobilising resources when they occurred. In facilities, shortages in blood supplies for transfusions were common, and blood, others medications, and care, were often unavailable. As a result, tertiary care was often sought in more than one location (83
In three of the cases selected for Study 1, the woman had not made contact with care in the acute situation. These cases were excluded from the enquiry because the panellists felt that there was no care to assess. The excluded cases were all deaths that had occurred in the home, with TBA assistance, and all from postpartum haemorrhage.
Although the decision to exclude these cases was not challenged (so as not to compromise panellists’ ownership over the process), it highlighted a potential for the systematic exclusion of certain (more severe) circumstances and events from QA enquiries. And (assuming QA influences health service organisation and delivery), the potential for resulting services to become inadvertently configured to maintain the exclusion of particular groups, by failing to account for and address their needs.
As a result, and based on the findings suggestive of the determining effects of events that occur outside facilities, access to care was considered in its own right in Study 2.
In Study 2, over 70% of respondents reported delays in seeking, reaching and/or receiving care. When unexpected complications occurred, families were often unprepared, TBAs were usually called, and midwives were generally unavailable. The financial costs of care were identified as highly influential. Most families had serious concerns about the costs of midwifery and hospital care. Since most were also uninsured and uninformed about SHI, arranging it in the acute situation was often complicated and time-consuming. In addition, transport was often unavailable and unaffordable. Where they were used, ambulances were reportedly unstaffed and ill-equipped.
Serious barriers to access were also identified inside facilities. Difficulties related to the admissions of women with SHI, partially arranged SHI, or no insurance, and no ability to pay were frequently recounted. Facilities were also reported as inadequately staffed and equipped, and shortages of crucial supplies such as blood products were again apparent. Many families had to embark on additional journeys (and pay associated costs) to locate and purchase medications and/or blood. Several second referrals that incurred further delays were also reported. Referral was less favourably reported in Study 2; midwives were described as poorly equipped, and several did not accompany women to hospitals (84
In terms of CODs, Study 2 revealed that pregnancy-related sepsis accounted for 28% of the deaths (associated conditions included genital tract sepsis and indirect infectious causes, e.g. typhoid). Haemorrhage and malaria accounted for 3 and 8%, respectively. Small proportions were attributed to pregnancy-induced hypertension (4%), unsafe abortion (2%), and obstructed labour (2%). The apparent burden of infectious disease (of obstetric and non-obstetric origin) including HIV, malaria, TB, and pregnancy-related sepsis was considerable, accounting for over 40% of the deaths.
Infectious causes can have long durations of onset, potentially requiring several presentations for care, incurring direct and indirect costs for women and families several times over. If serious and multiple barriers to access exist, then these may be encountered several times over for the treatment of infectious diseases. Haemorrhage, by contrast, has a rapid onset and can be fatal without prompt treatment (85
). Timely diagnosis and treatment of the main CODs depends upon available services, albeit in different ways, underscoring the necessity of a functioning referral system to ensure access to life-saving care.
In Study 2, the extended interviews also yielded information on culturally-derived systems of explanation, causation and behaviour. Some respondents described delivery complications in terms of curses or supernatural forces, and most attributed the deaths to fate, destiny or God's will. Examination of these perspectives revealed a simultaneous recognition of the failures of the health system among family members, coupled with fatalism and passivity regarding the deaths. This may have been a consequence of families’ inability to question systems of authority, and/or due to feelings of powerlessness in the face of multiple barriers to access (86
). Otherwise, the theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld (87
The narratives gained in Study 2 offered complementary insights into care and outcomes, and revealed marked differences between the explanatory frameworks of service users and providers. This suggested that broader empirical frameworks, examining the socio-economic and cultural landscapes in which healthcare is situated and sought from a range of stakeholder perspectives could potentially provide more robust interpretations of complex health problems. This informed the development of a participatory, community-based review of care in obstetric emergencies in the third and final study, in which service users and providers collectively assessed care. The three cases excluded from Study 1 were also included in Study 3.
A repeated and persistent theme in the community assessments (Study 3) related to ‘poor care for poor people’, and, in particular, problems with SHI. Here, SHI was often viewed as instrumental in constraining access to quality care. Problems included bureaucratic and complex administration, inequitable and incomplete distribution, and a pervasive lack of knowledge regarding SHI entitlements and how to use it in an emergency. Study 3 also revealed that women using SHI in facilities were explicitly discriminated against, often refused entry and/or treated with hostility and contempt. As a result, several women discharged themselves from hospital early, or before treatment was complete, to avoid the poor QOC, as well as spiralling costs (88
The participatory approach yielded rich and explicit assessments, and multi-level explanations of care and outcomes, relating individual perceptions and behaviours to broader contextual features. For example, the preferences for TBAs previously identified were attributed to factors related to tradition, availability and cost, which when combined, resulted in the ‘dominance’ of TBAs as the first choice of delivery provider. Study 3 also revealed that TBAs and midwives fail to collaborate due to their having competitive roles in the market for MCH care in villages, and that hospitals discriminate against poor women in critical conditions due to the resource implications of providing care.
Theoretical frameworks of CPH conceive of a continuum of passive to active participation, and in terms of approaches that foster agency versus responsibility. Analysis of the discussion narratives according to these frameworks helped to document key features of the process: that participation was complex and dynamic, and changed considerably over the course of the study (89
). Study 3 also suggested that CPH configured to foster agency (political resourcing) may provide a means to enable individual responsibility.
Studies 1–3 yielded a range of critical perspectives that triangulated, at times converging (validating) the findings. At other times divergent views served to provide a more complete picture of the phenomena under investigation. In general, despite state provisions for delivery services, care in obstetric emergencies was seen to be predominately available on a fee-for-service basis. In a context of poor and uninsured patients, this led to difficult decisions for women, families and providers in medical emergencies, balancing the costs of care against the likelihood of a positive outcome. The multitude of delays incurred added a further constraint whereby, as the woman's condition deteriorated, higher levels of care that were more expensive were required further intensifying the cost/payment issues. Where they could be made, payments often secured only sub-optimal, and in some cases downright discriminatory care.