title: Assessing quality of care provided by Indonesian village midwives with a confidential enquiry.
abstract: OBJECTIVE
  to conduct a confidential enquiry to assess the quality of care provided by Indonesian village midwives and to identify opportunities for improvement.
  
  
  METHODS
  local health-care practitioners assessed village-based care in obstetric emergencies in 13 cases of maternal death and near-miss from rural villages in West Java. The study focused on clinical quality of care, but also investigated the influence of the health system and social factors. The reviews were based on transcripts of interviews with health-care providers, family and community members involved in the cases. Both favourable and adverse factors were identified in order to recognise positive contributions, where they occurred. At the end of a series of case reviews, recommendations for practice were generated and disseminated.
  
  
  RESULTS
  in the cases reviewed, midwives facilitated referral effectively, reducing delays in reaching health facilities. Midwives' emergency diagnostic skills were accurate but they were less capable in the clinical management of complications. Coverage was poor; in some locations, midwives were responsible for up to five villages. Village midwives were also perceived as unacceptable to women and their families. Families and communities did not prepare for emergencies with finances or transport, partly due to a poorly understood health insurance system. The enquiry had learning effects for those involved.
  
  
  CONCLUSIONS
  village midwives should: receive appropriate support for the management of obstetric emergencies; engage with communities to promote birth preparedness; and work in partnership with formal and informal providers in the community. The enquiry was a diagnostic tool to identify opportunities for improving care. Practitioners had a unique insight into factors that contribute to quality care and how feasible interventions might be made.
authors.affiliation: Immpact, Department of Public Health, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK. l.dambruoso@abdn.ac.uk
authors.forename: Lucia
authors.initials: L
authors.lastname: D'Ambruoso
authors.forename: Endang
authors.initials: E
authors.lastname: Achadi
authors.forename: Asri
authors.initials: A
authors.lastname: Adisasmita
authors.forename: Yulia
authors.initials: Y
authors.lastname: Izati
authors.forename: Krystyna
authors.initials: K
authors.lastname: Makowiecka
authors.forename: Julia
authors.initials: J
authors.lastname: Hussein
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007214:Indonesia; D008429:Maternal Welfare; D008519:Medicine, Traditional; D008880:Midwifery / Q000379:methods*; D024802:Nurse's Role; D009723:Nurse-Patient Relations; D011247:Pregnancy; D011248:Pregnancy Complications / Q000451:nursing* / Q000517:prevention & control; D011295:Prenatal Care / Q000458:organization & administration; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*; D012959:Socioeconomic Factors