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Komunitas Berbasis pendekatan Penelitian Partisipatif untuk mengeksplorasi persepsi masyarakat terhadap kualitas ibu-bayi baru lahir pelayanan kesehatan di Republik Dominika

Midwifery. Author manuscript; available in PMC 2011 October 1.
Published in final edited form as:
Published online 2010 August 8. doi:  10.1016/j.midw.2010.06.001
PMCID: PMC2946473
A Community-Based Participatory Research approach to explore community perceptions of the quality of maternal-newborn health services in the Dominican Republic
Jennifer Foster, CNM, MPH, Ph.D, Assistant Professor, Rosa Burgos, Program Director, Carmen Tejada, Ramona Cáceres, Asela Altamonte, Lydia Pérez, Frank Mercedes Noboa, Marilyn Felix, Annemarie Heath, Rebecca Carbley, Research Assistants, Fidela Chiang, Research Assistants, and Priscilla Hall, Research Assistants
Small right arrow pointing to:The publisher's final edited version of this article is available at Midwifery
The constraints of limited resources have not diminished the global intention in public health to improve quality healthcare services. The US federal Agency for Healthcare Research and Quality (AHRQ) defines quality health care as “doing the right thing at the right time in the right way for the right person and having the best results possible” (Agency for Healthcare Research and Quality [AHRQ], 2001, p. 4). In areas of the world where both maternal-newborn mortality and morbidity are high, maternal health services that function in this way could significantly reduce the annual 530,000 maternal deaths globally and achieve the World Health Organization’s (WHO) Millennium Development Goals (MDGs) 4 and 5 (World Health Organization [WHO], 2005).
Since the launching of the WHO’s Safe Motherhood Initiative in 1987, considerable resources have been devoted to augmenting the capacity of skilled birth attendants to provide basic obstetric care (WHO, 1997). The reasons for the lack of progress in reducing maternal mortality have been a topic of extensive debate (Shiffman & Smith, 2007). Currently, the WHO ranks maternal and newborn care as a high global priority for patient safety research (WHO, 2009).
The overall literature on quality of care in the developing world is discouraging. Reports from Brazil, Tanzania, Mexico, Kenya, Ecuador, and the Dominican Republic describe care that is inadequate with respect to standards and guidelines, gaps in provider knowledge, overmedicalization of normal pregnancy and poor management of women with complications. Providers have demonstrated disrespectful attitudes towards patients as well as compassion fatigue (Harvey, et al. 2007; Barber, 2006; Barros, et al., 2003; Boller, et al., 2003; Miller, et al., 2003). It is worth noting, however, that there are also reports of achievements in quality of care focused on reduction of disparities and structural efforts to increase skilled birth attendance (Clapham, et al., 2004; Liljestrand & Pathmanathan, 2004).
Additionally, researchers and policy makers have increasingly realized the importance of women’s perceptions of quality care. In an anthropologically based quality of care study, indigenous Mayan women in Guatemala expressed fear and frustration of not being attended to by healthcare personnel, feelings of powerlessness, and an overall lack of trust in staff competence (Berry, 2008). From Nigeria, Fawole et al. (2008) emphasized that client perceptions of quality of care influence their health behaviors, including utilization and compliance with services. Moreover, quality of maternity care in other parts of Africa report examples of disrespectful treatment, as well as inefficient, ineffective, or simply poor medical care (El-Nemer, Downe, & Small, 2006; D’Ambruoso, Abbey, & Hussein, 2005).
In the Making Pregnancy Safer (MPS) initiative, the WHO has noted that access and utilization of quality health services to achieve maternal and newborn health require significant behavioral change on behalf of both consumers and providers of maternal health services. Consumers need to develop capacities to stay healthy, make healthy decisions, and respond to obstetric and neonatal emergencies. They also need increased awareness of their rights, needs and potential problems related to maternal and newborn health (Safdar et al., 2002). Providers need to improve the quality of their services, as well as strengthen the linkages for social support with health systems and their interactions with women, men, families and communities (WHO, 2003). Furthermore, the MPS initiative has emphasized that education processes for individuals, families and communities should be oriented to create knowledge, not deliver it (WHO, 2003, emphasis added).
This article reports on a community-based participatory research (CBPR) study conducted in the Dominican Republic. The Dominican Republic is a Caribbean country that shares its border with Haiti on the island of Hispaniola. There are over 9 million inhabitants and nearly half (45%) live under the national poverty line (CIA, 2009). Although classified as a Middle Income Country in 2010 by the World Bank (World Bank, 2010), income inequalities continue to plague the country, with two-fifths of the GNP going towards the richest 10%, and less than one-fifth going towards the poorest half (CIA, 2009). While 97% of births occur in health facilities, a lack of healthcare quality has been reported (Miller et al., 2003). The maternal mortality ratio (150–160 maternal deaths per 100,000 live births) and the infant mortality rate (22 infant deaths per 1,000 live births) remain higher than one would expect, given the well-developed public health infrastructure and almost universal institutionalized births (PAHO, 2007).
For readers unfamiliar with CBPR, it is an approach that joins community representatives and academically trained researchers in a process of collaborative research that is intended to invoke action or behavioral change. CBPR involves community members in all aspects of the research, from the initial question to data collection, analysis, and dissemination (Minkler & Wallerstein, 2008). The US AHRQ defines CBPR as, “a collaborative approach to research that combines methods of inquiry with community capacity-building strategies to bridge the gap between knowledge produced through research and what is practiced in communities to improve health” (Viswanathan et al., 2004, p. v).
The theoretical framework underlying CBPR is the process of conscientization, articulated by Paulo Freire (2000). As an adult educator of illiterate people, Freire observed that impoverished or marginalized persons who engage in naming and reflecting upon their own social condition become empowered to change it. Given that disparities in the health of mothers and babies are concentrated within the most impoverished and disenfranchised populations, the CBPR approach is relevant to improve participation of communities in improving maternal-newborn health, as well as encouraging their involvement in the health systems designed to serve them.
One critical tenet in CBPR’s efficacy is that the community must formulate the research question (Foster & Stanek, 2007; Mosavel, et al., 2005). This study was one of the outcomes of a continuing international partnership between US midwives (one trained in medical anthropology) and Dominican nurses that was initiated in 2003. Earlier activities of the partnership have been reported elsewhere (Foster, 2009; Foster & Heath, 2007; Foster et al., 2006; Foster et al., 2005). Following an increase in maternal mortality cases within a six month period, the Dominican nurses identified delays in accessing care for complications as a factor contributing to maternal deaths. The research question emerged from this concern: why did women with obstetric complications delay arrival at the hospital until they were in such deteriorated condition(s) that the hospital could do little to help them? There was a perception among the Dominican nurses that women delayed accessing care because they held beliefs and attitudes regarding obstetric care that caused them to delay seeking help.
One objective of the study was to gain a deeper understanding of women’s and men’s beliefs, attitudes and behaviors towards the maternity services in the hospital where women delivered to help understand why women in the Dominican Republic with obstetric complications delay care essential to their survival. CBPR was the methodology selected for this research based on the premise that the maternal healthcare providers, researchers and community members, by working together to jointly understand the community’s experience of maternity care, could then unite to improve it. The mechanism of alliance for change was the research process itself.
Community Based Participatory Research
The Provincial Medical Public Health Director from the Secretariat of Public Health and Social Assistance (SESPAS) suggested 4 neighborhoods that the regional hospital served, for geographic representativeness, high socioeconomic vulnerability, and feasibility for conduct of the study. The study was conducted in Spanish, with English translations done by the PI or bilingual research assistants. A ten- person research team was assembled, including 3 academically trained researchers (2 US nurse-midwives and 1 Dominican nursing professor), two Dominican maternity nurses most interested in research from the partnership hospital, and four community leaders (one from each research neighborhood). Three US student research assistants rotated over the course of the project as well (Table 1).
Table 1
Research Team Members and Education in Research
The Dominican nurses and nursing professor recruited the community members for the team at the initiation of the study. The inclusion criteria for the community members were: 1) established and verified as a non-politically elected leader in their neighborhood; 2) willingness to commit to the team for the two-year study duration; 3) high school completion; and 4) honesty and reliability. The complete research team attended 40 hours of orientation to the general research process, including an orientation to the study’s specific design. They also attended didactic and practical training in focus groups and interviews.
Orientation included a one-day online research ethics training and certification program in Spanish from Family Health International (Family Health International, 2005). This was particularly challenging and rewarding because none of the community members had ever used a computer before; nonetheless, all successfully passed the certification. The study was approved by the Institutional Review Board of the PI’s university, as well as the Ethics Committee of the partnership hospital.
Adult women (21–49 years of age), adolescent women (15–20 years of age), and adult men (>19 years of age) from four neighborhoods in the third largest city in the Dominican Republic were recruited. Eligible women, approximately 12 adult and 12 adolescent women per neighborhood, who had given birth in the public hospital, were systematically recruited from every third house. Men, approximately 12 per neighborhood, were recruited via snowball sampling if they had experienced the loss of a family member (spouse, daughter, etc.) during childbirth or an infant within a month of childbirth in the public hospital system. This method was used for the men to ensure a sample that included experience with maternal-newborn mortality. High maternal mortality ratios for nations are still relatively rare personal events in communities, and purposive sampling garnered a richer set of experiences in response to the primary research question posed by the Dominican nurses.
Additionally, a cohort of 12 pregnant women (three from each neighborhood) planning to deliver in the public hospital was recruited from the focus groups or community to be prospectively monitored and accompanied to prenatal visits. Participant observations were conducted with 15 women during a total of 44 prenatal visits. Three women did not complete the study and were replaced; one participant had a miscarriage and two women moved away during the pregnancy. Two additional participants were initially recruited for the observation cohort but were replaced because they were in their third trimester and lacked sufficient time for observation. Inclusion criteria were: age 15–49 years of age, registered for prenatal care, and planning to deliver at the public hospital.
A total of 137 participants were recruited, 27 men, 51 adolescent women, and 59 adult women. In addition to the five participants who did not complete the participant observation (described above), two people were removed from the study when it was discovered they were ineligible (a primigravida at a focus group and a women who did not live in the neighborhood) and 16 did not attend their scheduled focus group for a total attrition of 17% (N=23). The mean age for adolescent women was 18 years [range 15–20 years], mean age for adult women was 32 years [range 21–48 years], and mean age for adult men was 37 years [range 19–64 years]. In the participant observation cohort, there were six adolescent women, mean age 16 years [range 15–19 years] and nine adult women, mean age 24 years [range 21–32 years]. The mean highest number of years of education completed for all three groups (adolescent women, adult women and adult men) was 8 years [range 1–17 years], the mean number of people living in the household was 4 [range 1–11], the men were more likely to work (95% vs. 30% and 28% in the adolescent and adult women groups, respectively), and the mean monthly household income (in US dollar equivalents) was $146 USD [range $0–$588] (Table 2). Informed consent was obtained for all eligible, recruited participants.
Table 2
Participant Demographics
Twelve focus groups were conducted, one each in the four neighborhoods for adult women, adolescent women, and adult men. In addition to the focus groups, more in-depth, individual interviews were conducted with 12 focus group women (approximately 3 from each neighborhood) who had described experiences of loss and particular difficulty with maternity health services. These occurred after the focus groups, either immediately or within the week.
Data Collection
Demographics were collected on all participants including age, highest level of education attained, monthly household income, occupation of the participant and his/her spouse, and number of people living within the home. A self-report obstetric history including number and date of pregnancies, birth method, and any complications including infant death was also collected (Table 1 and Table 2).
In each focus group, participants were asked open-ended questions to ascertain their attitudes, beliefs, and behaviors surrounding pregnancy and prenatal and obstetric care received in the public hospital system. The groups were recorded and transcribed by a native Dominican speaker. Audiotapes were listened to and episodically compared to the transcriptions for verification and fidelity purposes.
A parallel arm of the study was the participant observation. Community leaders accompanied the women to prenatal appointments, but remained in the waiting room for anonymity. They documented the length and mode of travel to appointments, wait times (recorded for provider, nurse and occasionally lab visits), prenatal instructions and education witnessed while in the waiting room or reported by the woman, the condition of the physical space, and participants’ observations and comments. After delivery, the research nurses collected participants’ birth accounts of ten of the births.
The research team received 16 hours of didactic and practical training in basic qualitative descriptive analysis of content (Sandelowski, 2000). The practical training involved giving the team transcribed data unrelated to the project to read and make codes. Later, as a whole group, the research team read and coded copies of the de-identified, transcribed text. The Dominican nurses on the team were much more self-confident about the process of making codes than the community leaders, who tended to be silent in the presence of the nurses during this process of analysis. Therefore, the team was separated into sub groups, the nursing team and the community leader team. The nurses and community leader subgroups coded the first section in different rooms and then met together as a whole to discuss their agreement on coding the text. Once the groups had finished coding the first text, the whole research team read through the text together aloud and discussed the codes they had assigned, forming an initial code list with definitions (Table 4). Using this same structure of reading and re-reading text in subgroups, the Dominican research team read and re-read the text, consolidated codes, and discussed and identified central themes, prioritizing those that captured the most significant meaning of the transcribed text. This process did not involve any computerized software, since the community leaders had no experience using computers. The coding and naming of themes from the codes occurred in multiple weekly meetings over four months.
Table 4
Codes with Definitions
The community leaders invited all of the research participants, along with many other members of each neighborhood to a public presentation created and presented by the Dominican nurses and community leaders, with guidance and assistance from the US researchers. Each presentation concluded with the question if the findings accurately represented the experience of the community. This was a planned step in the analytic process to ensure trustworthiness of the data.
Study Limitations
Although the trustworthiness of the data was enhanced by the longstanding collaborative relationship between the US and Dominican nurse researchers (who have observed care in the hospital over the course of more than six years), one must always acknowledge that focus group and interview participants may be influenced by a desire to tell the researchers what they believe researchers expect to hear. Also, while the sampling framework was systematic, no claim is made that the women and adolescent findings presented in this study are representative of the entire population, especially the rural women within the hospital catchment area. Also it is important to remember that the male groups were recruited purposively to explore experiences with maternal or newborn death; thus negative attitudes would be more likely in that group.
There were methodological challenges with the research team, as well as interpretive differences between the community members and the nurses. These differences are crucial to advance what is known about the community’s role in CBPR analysis (Cashman et al., 2008), but this will be reported elsewhere, as it is beyond the scope of this paper.
The team defined beliefs as, “what is true for a person, usually in these texts something not recognized as true by the healthcare system.” Several beliefs surfaced during the interviews regarding food, risk, mood, and sexuality. Although disputed by some as an old wives’ tale, the guanábana (a type of fruit unique to the Caribbean) was generally understood as one to avoid during pregnancy, because as one member of a woman’s focus group said, “They say that it can give you an eclamptic seizure, that it can produce or provoke it.” Other ideas about limiting bathing in pregnancy were mentioned, although many felt this idea was passé.
The idea that each pregnancy is a time of high risk, fragility and vulnerability was articulated across all neighborhoods, and men felt it was their special responsibility to take care of women, especially when pregnant. For example, one male focus group member said, “I find that all women who are pregnant are very beautiful and one must always protect [her]as much as he can, because it is the period where the woman is the most fragile, and anything can harm her.
Women and adolescents spoke of the need to maintain an even and positive temperament during pregnancy, neither angry nor depressed. The responsibility of women, no coger mala sangre, (Eng. “do not pick up bad blood”) means that pregnant women should maintain a positive affect, or else they could cause their baby to develop a temperament of similar negative emotions.
Women openly discussed their sense of the importance of active sexual activity during pregnancy. For example, a vagina that had been stretched would make for an easier delivery. As one woman stated in the focus group: “We all agree, it is important to have relations (sexual), even the doctors say so, so that you can have a better birth, because [with] having sexual relations more frequently you can have a normal birth [instead of] a Cesarean.
There were also beliefs about routines in the hospital: it was possible that babies could be mixed up and families given the wrong baby; that sedatives were given after surgery to keep women from speaking; and that spontaneous abortions needing dilation and curettage were not spontaneous abortions, but really covert induced abortions (illegal in the Dominican Republic).
There was general agreement across groups that hospital maternity procedures induced fear, specifically vaginal examinations and urinary catheterizations. Beyond fear of specific procedures, there was greater fear and uneasiness expressed that one would be left alone to deliver, either unattended, or attended by someone who did not respect them or made them feel insignificant. (Sp. no me hace caso; Eng. they pay no attention to me). No me hace caso included long waits for services, failure to acknowledge individual’s or family’s history, symptoms, or knowledge, care from students without supervision, a lack of communication, and a system of cuña, or preferential treatment for personal connections, as described below.
In one case a mother felt greatly saddened by the medical decision to perform a Cesarean against her will, since she did not feel she was due to deliver, and reported no abnormal symptoms except spotting. She reported that her infant died a few hours after delivery due to prematurity:
I had a normal pregnancyI went one day to a prenatal visit and the doctor there told the nurse, ”Send her upstairs [labor and delivery area]she is going to give birth.” I said nobut I let myself go along because she was my doctor, she is the one who knowsI never thought they would do surgery; I have always had normal births. The nurse shaved me but I kept saying it wasn’t the right timeI was a little before my eighth month. They sent me for a sonogram andthe baby looked fine. When I gave the sonogram (results) to the doctor, she said, ”This woman needs surgery because she is bleeding,” but I was bleeding from the nurse’s examI didn’t have any centimeters (her cervix was closed)they took me into surgery and did the Cesarean and the baby died a few hours laterhe died from asphyxia. (Adult woman focus group member)
One of the adolescents described elevated blood pressure in her pregnancy that the physicians were monitoring, along with her platelet count. She recounted what she told her physician:
After that, I did not feel the baby move, and I told the doctors, “Look, Doctor, I do not feel the baby,” and they said,
“No, this baby is alright,” and I said,
“‘No, I do not feel it,” as a mother feels her childrenthey did not believe me, they did not want to attend to methe next day, I got some really big fevers, my feet turned purple, my hands, purple; a fever that I was shaking. The next day, the fever left, and I said to the doctor, “Look, Doctor, I feel such and such, in this way,” andhe did not believe me, he severely thought I was playingand they did not want to take me seriously. I have a friend of a nurse who is a friend of my mother [who] spoke with the Director of the hospital, and that way, they did the Cesarean. (Adolescent individual interview)
Attitudes coded as negligence were reported both on the part of consumers and providers of services. A man expressed concern that a pregnant woman he knew who was bleeding refused to seek medical care and died; the team coded this passage as negligence on her part.
Waiting was a common experience; participants reported waiting in the Emergency Department for admittance, for an ultrasound, for laboratory results, for the doctor to arrive at the ambulatory clinic, and long delays before medical staff provided any treatment at all. Prolonged waiting was associated with the fear of being ignored or unattended. Participants described being sent home after a long wait because the doctor had left the clinic or being told nothing was wrong and subsequently having an emergency Cesarean:
Mine was a complicated case, because I was admitted on the 15th of December, and on the 23rd, I didn’t feel the baby movingAnd I would tell the doctor, the baby isn’t moving any morethe days passed and it was the 28th, I had an ultrasound and the baby already was 42 weeks and the doctor said it was still fine; I could have a normal birth. On the 29thI had a fever that I thought I would die, a tremendous fever, and on the 30th they did an emergency Cesarean because of the timethe baby had pooped in my belly. He was born completely dead, and for ten minutes he did not do anything, the umbilical cord was tangled. He was born very ill, but God gave us the victoryand he is well now. (Adolescent focus group member)
Individually, an adolescent confided:
My opinion is that when one arrives [to the hospital] in pain, if one is ready to give birth, that they attend to you right away. Because a friend of mine went three times to the hospital and they said no. That she was not ready to give birth, and she had more and more pain, and when she finally could not stand it anymore, the baby girl was born dead; they let her die. Thank God that did not happen to me, and there are many women that happened to. The best thing would be if one already has 5 centimeters or one is not going to give birth normally, that is, with Cesarean, that they attend her right away, that they attend her well, that they check her.
An adolescent focus group member stated:
I was about 6 months pregnant and when I took my lab results (to the doctor I had very high blood pressure and high blood sugar also. But the girl there (referring to the provider) was a student that they had in the hospital and I told her, “Look at my lab results.” She said it was fine and didn’t give me any medication. Then I went around my eighth month with a headache that would not go away. When I saw the doctor he told me my blood sugar was very high, it was 370 and my blood pressure was extremely highHe said I needed an urgent Cesarean and when they did the Cesarean, the baby was dead because my blood pressure and my blood sugar were too high.
Because of an absence of communication, male family members especially felt ignored and impotent in carrying out their responsibilities to care for their wives and family members who they saw as needing their help:
They don’t give you a lot of attention in the hospital, I was alone, I didn’t have any family that would help me, I didn’t have any experience. The doctors sent me outside, and I am the only family that she has at her side and they sent me outside. (Male focus group member)
Similarly, a male interviewed individually explained:
Well, my wife was pregnantthey told her she was nine months and like, ten days. They sent her for an emergency ultrasound. They admitted her but they did not say why, neither she or I knew whythat was like eight in the morningat three in the afternoon they put the Pitocin injection so she could give birth. When she gave birth the baby was dead, already almost disfiguredat first I was happy when I thought he would be born, but after they told me he was dead, it breaks my heartthey did not give me any explanation.they are brutes, you ask for an explanation and they order you to one side, ‘I am busy, or ‘Go over here’, or ‘go over there, downstairs’… (Individual male interview)
The strategy to circumvent being ignored was to cultivate cuña. Cuña is a social connection between individuals, created by family ties or personal relationship. The way to receive quality care is to have social connections with people who are known in the health care system. As one male focus group member stated, “Here you have cuña, you are friends of the doctor or the nurse in the hospital, well, those people get different treatment. But the person that doesn’t have anyone in there, they get another treatment.
An elder male focus group member commented:
[The situation in the past] is not like today when science is a little more advanced than before. In that time, one went to midwives and one felt more secureI do not know what has happened. There is more intelligence, and science is more advanced, but there is little service, because everyone is free to do whatever they want. I see that every step of the way in the hospital.
Participant Observations
The results of the prenatal visit observations confirmed the spoken accounts, for example demonstrating long wait times and poor communication systems, which were interpreted by the participants as a lack of respect. One of the key themes identified from the data by both community members and nurses was the amount of time necessary for not only appointments and procedures, but also simply waiting. Although observed travel times were relatively brief, averaging 20 minutes, women were required to travel to the outpatient site to request a prenatal appointment. No system exists to make appointments over the phone. Average wait time to see a provider was 95 minutes, and did not vary between an initial prenatal visit and subsequent visits. As described in focus groups, waiting for care at the ambulatory clinic was a common part of the participant experience:
You have to be early for prenatal visits because there is a limited number of tickets, so you have to more or less arrive at 5 o’clock in the morning to be able to get one. But the doctor comes at 8:30. If you get a lower number, you get out earlier; but you will be there about three hoursBecause sometimes it is a little after eight or almost nine when they start. (Comment of participant to research observer)
In 18% of the observed visits (N=44), nurses gave prenatal education presentations (Sp. charlas) while women waited, on topics including care during pregnancy, breastfeeding and infant care, family planning, and HIV prevention. Less than half of the women being observed reported any physician instructions or education, while half received instructions to either take medications or obtain diagnostic testing. Women saw a different physician at each visit.
The research nurses recorded birth stories for ten of the participants. Two women had primary Cesareans, six had repeat Cesareans and two had uncomplicated vaginal deliveries. The participants reported long wait times in the hospital, especially for patients having a scheduled repeat Cesarean. Although some repeat Cesareans are scheduled in advance, none were scheduled in our sample. Women generally were sent to the hospital from the clinic at the 39th or 40th week visit. No anticipatory guidance was given regarding the date of their Cesareans, resulting in the need for last-minute childcare and household arrangements. Typically, women waited 24 hours for surgery upon admittance, but several of our participants waited longer.
Ongoing Community Involvement
Member Checking
Not only to ensure the trustworthiness of the research process but also to exhibit responsibility to the community in CBPR, the team presented their analysis of the most significant themes back to the neighborhoods where the data was collected, before any other dissemination was prepared. Organized by the Dominican team members, these presentations were given at community meetings in each neighborhood with a range of 26 – 76 persons in attendance, and included the research participants as well as other community members.
In each neighborhood, there was unequivocal agreement that these themes did indeed represent their experience, and individual community members eagerly added their own particular examples. Community members wanting to be involved both in the research during its dissemination and in creating solutions to the identified problems left contact information. A joint meeting was held for these volunteers from all four neighborhoods to link with the community research team and each other as the dissemination phase evolved. Following the community presentations, six of the original 15 volunteers felt strongly that they wished to volunteer to continue meeting with the research team to help devise solutions to problems identified in the research. These community health volunteers expressed an interest in accompanying the research team during dissemination of their findings throughout the Dominican public health system. At the time of this writing, they have held over a dozen monthly meetings.
Amidst growing community involvement, how did the health providers perceive the findings? The following excerpt is from the PI’s field notes after the findings were presented to them (January 11, 2010):
The team created a presentation for the hospital nurses and doctors to summarize the research and invite them to join the community volunteers. The key in the dissemination process is to not place blame, but to inform the health providers of the community’s perceptions and to come together to make improvements. At first, the hospital staff was defensive and some denied the claims presented. Yet when the Provincial Director spoke up and exhorted the community volunteers to work with him on examining the hospital budget to advocate for more supplies, the tone of the hospital staff shifted. By the end of the presentation, eight hospital volunteers had signed on to work together with the community volunteers to articulate how they might work together to improve services. It was a fragile beginning, but a new beginning nonetheless.
Most (but not all) of the community’s narratives in this study, as well as the participant observation data, indicate the community’s dissatisfaction with the quality of maternity care, indicating major gaps in the efficacy and the humanity of services. Results from the self-reported participant obstetric histories also indicate that serious newborn complications are common within the maternal health system of the Dominican Republic (Table 3). The findings of this study confirm other reports cited above in the maternity quality literature in the developing world. Reports that only present a litany of complaints only serves to pin blame on health workers who are themselves working long hours under adverse conditions (Foster, 2009; Leinweber & Rowe, 2006).
Table 3
Self-Reported Childbirth Experiences among Study Participants
What this study illustrates in a new way is that both community members and health providers can come to know one another as researchers and team members that subvert historical social relationships of domination and subordination. Nursing and midwifery have described this way of relating as partnership and accompaniment (Jonsdottir, Litchfield, & Pharris, 2004; Hunter, 2002). Nurses and midwives play a significant role in empowering families and communities through community cooperation and support, as well as health promotion (Tlebere, et al., 2007). Research by nurses and midwives about the community’s experience of maternity care can serve to support these providers to fulfill that role.
Anthropologists have long known the transformative power of the ethnographic experience by the mere activity of “being there” with others (Geertz, 1988). Dr. Jim Kim, anthropologist, physician, and former advisor to the WHO, has commented that anthropologists have a long history of providing “moral witness to human suffering.” What is needed now, he argued, is “moral witness to human possibility” (Presentation at the 106th Annual Meeting of the American Anthropological Association, Washington, DC, November 29, 2007).
The research team of community members and health providers came to know each other in new ways by working together on a common mission. As a result of this study, they continue to meet together regularly with hospital and community volunteers to articulate how to implement improvements in the maternity setting. Some of the suggestions from the volunteers included creating a community office in the hospital that persons can go to if they have a complaint about maternal health services. Another suggestion was to invite the doctors or the nurses to talk to the community about what to expect upon entering the Emergency Department or in Labor and Delivery. A third suggestion was to create a movie or drama enacted by a group of involved teenagers about the concerns in the community.
It is crucial that the research team continue their work after the study will end, and this requires support. Mathai has argued that academic institutions and professional and civic organizations all have important roles in the development of health systems that respond to the needs of all mothers and babies in a just and equitable way (Mathai, 2008). To achieve MDGs 4 and 5, communities, providers, academics, and the administrators in the structures that support them need to forge different kinds of relationships with one another. Our CBPR experience in the Dominican Republic indicates that this approach has empowered those involved to collaborate towards a common goal of improving healthcare.
Despite the promising aspects of maternal and newborn care in the Dominican Republic, including focused outreach and education for adolescent prenatal care and near universal hospital-based childbirth rates, many of the antenatal and intrapartum experiences collected in this study illustrate poor quality maternal health services that leave patients and their families feeling impotent, disrespected, and afraid. These attitudes and beliefs may increase the divide between health providers and individuals and communities, and delay women coming for care.
This CBPR study illustrated international collaboration between university researchers, maternity service providers, and community members. While sustained improvements in maternity services in this setting remain unknown, the process of understanding the beliefs and attitudes of the consumers of maternity services by both hospital personnel and community leaders led to a common understanding of the informative value of research. It also reminded all groups of their common mission to promote and protect maternal newborn health.
Supplementary Material
This study was supported by the United States National Institute for Nursing Research 1 R21 NR010201-01A1. Additionally, we would like to acknowledge the cooperation and assistance of Lic. Sor Juana Adames, Dr. Luis Adolfo Dominguez García, Srta. Leonarda Nuñez, Lic. Rafael Alvarez Castillo, Lic. Rosa Maria Nuñez, and Lic. Juan Duran.
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Kebidanan. Penulis naskah; tersedia di PMC 2011 Oktober 1.
Diterbitkan dalam bentuk diedit akhir sebagai:
Kebidanan. 2010 Oktober; 26 (5): 504-511.
Diterbitkan online 2010 Agustus 8. DOI: 10.1016/j.midw.2010.06.001

PMCID: PMC2946473
Copyright pemberitahuan dan Sangkalan
Komunitas Berbasis pendekatan Penelitian Partisipatif untuk mengeksplorasi persepsi masyarakat terhadap kualitas ibu-bayi baru lahir pelayanan kesehatan di Republik Dominika
Jennifer Foster, CNM, MPH, Ph.D, Asisten Profesor, Rosa Burgos, Direktur Program, Carmen Tejada, Ramona Cáceres, Asela Altamonte, Lydia Pérez, Frank Mercedes Noboa, Marilyn Felix, Annemarie Heath, Rebecca Carbley, Riset Asisten, Fidela Chiang , Riset Asisten, dan Priscilla Hall, Asisten Penelitian
Panah kanan kecil yang menunjuk ke: versi terakhir diedit Para penerbit dari artikel ini tersedia di Kebidanan
Penerbit Sangkalan

    * Bagian lain

          o PENDAHULUAN
          o METODE
          o PEMBAHASAN
          o KESIMPULAN
          o Tambahan Bahan
          o Referensi

Kendala sumber daya yang terbatas tidak berkurang niat global dalam kesehatan masyarakat untuk meningkatkan pelayanan kualitas kesehatan. Badan federal AS Kesehatan Penelitian dan Kualitas (AHRQ) mendefinisikan perawatan kesehatan yang berkualitas sebagai "melakukan hal yang benar pada waktu yang tepat dengan cara yang benar untuk orang yang tepat dan memiliki hasil terbaik" (Badan Kesehatan Penelitian dan Kualitas [AHRQ ], 2001, hal 4).. Di wilayah di dunia dimana kedua kematian ibu-bayi baru lahir dan morbiditas yang tinggi, pelayanan kesehatan ibu yang berfungsi dalam cara ini secara signifikan dapat mengurangi 530.000 kematian tahunan ibu secara global dan mencapai Organisasi Kesehatan Dunia (WHO) Tujuan Pembangunan Milenium (MDG) 4 dan 5 (Organisasi Kesehatan Dunia [WHO], 2005).
Sejak peluncuran Initiative Motherhood WHO Aman pada tahun 1987, sumber daya yang cukup telah dibuka untuk menambah kapasitas bidan terampil untuk memberikan perawatan kebidanan dasar (WHO, 1997). Alasan tidak adanya kemajuan dalam mengurangi kematian ibu telah menjadi topik perdebatan yang luas (Shiffman & Smith, 2007). Saat ini, WHO peringkat perawatan ibu dan bayi baru lahir sebagai prioritas global yang tinggi untuk penelitian keselamatan pasien (WHO, 2009).
Literatur keseluruhan pada kualitas perawatan di negara berkembang yang mengecewakan. Laporan dari Brasil, Tanzania, Meksiko, Kenya, Ekuador, dan Republik Dominika menggambarkan perawatan yang tidak memadai terhadap standar dan pedoman, kesenjangan dalam pengetahuan penyedia, overmedicalization kehamilan normal dan manajemen yang buruk dari wanita dengan komplikasi. Penyedia telah menunjukkan sikap tidak hormat terhadap pasien serta kelelahan belas kasih (Harvey et al 2007;. Barber, 2006; Barros, et al, 2003;. Boller, et al, 2003;.. Miller, dkk, 2003). Perlu dicatat, bagaimanapun, bahwa ada juga laporan tentang prestasi dalam kualitas perawatan difokuskan pada pengurangan kesenjangan dan upaya struktural untuk meningkatkan persalinan terampil (Clapham, et al, 2004;. Liljestrand & Pathmanathan, 2004).
Selain itu, peneliti dan pembuat kebijakan semakin menyadari pentingnya persepsi perempuan dari perawatan yang berkualitas. Dalam kualitas berdasarkan studi antropologis perawatan, perempuan adat Maya di Guatemala mengungkapkan ketakutan dan rasa frustrasi karena tidak dirawat oleh petugas kesehatan, perasaan ketidakberdayaan, dan keseluruhan kurangnya kepercayaan kompetensi staf (Berry, 2008). Dari Nigeria, Fawole dkk. (2008) menekankan bahwa klien persepsi kualitas pelayanan mempengaruhi perilaku kesehatan mereka, termasuk pemanfaatan dan kepatuhan dengan layanan. Selain itu, kualitas perawatan bersalin di bagian lain dari contoh laporan Afrika pengobatan tidak sopan, serta perawatan medis yang tidak efisien, tidak efektif, atau hanya miskin (El-Nemer, Downe, & Kecil, 2006; D'Ambruoso, Abbey, & Hussein, 2005).
Dalam inisiatif Making Pregnancy Safer (MPS), WHO telah mencatat bahwa akses dan pemanfaatan layanan kesehatan yang berkualitas untuk mencapai kesehatan ibu dan bayi baru lahir memerlukan perubahan perilaku yang signifikan atas nama kedua konsumen dan penyedia layanan kesehatan ibu. Konsumen perlu mengembangkan kapasitas untuk tetap sehat, membuat keputusan yang sehat, dan menanggapi keadaan darurat obstetri dan neonatal. Mereka juga perlu peningkatan kesadaran akan hak-hak mereka, kebutuhan dan potensi masalah yang berkaitan dengan kesehatan ibu dan bayi baru lahir (Safdar et al., 2002). Penyedia perlu meningkatkan kualitas layanan mereka, serta memperkuat hubungan dukungan sosial dengan sistem kesehatan dan interaksi mereka dengan wanita, pria, keluarga dan masyarakat (WHO, 2003). Selanjutnya, inisiatif MPS telah menekankan bahwa pendidikan proses bagi individu, keluarga dan masyarakat harus berorientasi untuk menciptakan pengetahuan, tidak mengirimkannya (WHO, 2003, penekanan ditambahkan).
Artikel ini dilaporkan studi berbasis masyarakat partisipatif (CBPR) penelitian yang dilakukan di Republik Dominika. Republik Dominika adalah sebuah negara Karibia yang berbagi perbatasan dengan Haiti di pulau Hispaniola. Ada lebih dari 9 juta jiwa dan hampir setengah (45%) hidup di bawah garis kemiskinan nasional (CIA, 2009). Meskipun diklasifikasikan sebagai Negara berpendapatan menengah pada tahun 2010 oleh Bank Dunia (World Bank, 2010), ketidaksetaraan pendapatan terus wabah negeri, dengan dua perlima dari GNP akan menuju 10% terkaya, dan kurang dari seperlima akan menuju semester termiskin (CIA, 2009). Sementara 97% kelahiran terjadi di fasilitas kesehatan, kurangnya kualitas kesehatan telah dilaporkan (Miller et al., 2003). Rasio kematian ibu (150-160 kematian ibu per 100.000 kelahiran hidup) dan angka kematian bayi (kematian bayi 22 per 1.000 kelahiran hidup) tetap lebih tinggi dari satu harapkan, mengingat infrastruktur kesehatan publik yang berkembang dengan baik dan hampir universal dilembagakan kelahiran ( PAHO, 2007).
Untuk pembaca yang tidak terbiasa dengan CBPR, adalah suatu pendekatan yang bergabung perwakilan masyarakat dan peneliti akademis terlatih dalam proses penelitian kolaboratif yang dimaksudkan untuk memohon tindakan atau perubahan perilaku. CBPR melibatkan anggota masyarakat dalam semua aspek penelitian, dari pertanyaan awal untuk pengumpulan data, analisis, dan diseminasi (Minkler & Wallerstein, 2008). Para AHRQ AS mendefinisikan CBPR sebagai, "sebuah pendekatan kolaboratif untuk penelitian yang menggabungkan metode penyelidikan dengan komunitas pengembangan kapasitas strategi untuk menjembatani kesenjangan antara pengetahuan yang dihasilkan melalui penelitian dan apa yang dipraktekkan di masyarakat untuk meningkatkan kesehatan" (Viswanathan et al., 2004 , hal. v).
The CBPR kerangka teori yang mendasari adalah proses penyadaran, diartikulasikan oleh Paulo Freire (2000). Sebagai seorang pendidik dewasa orang buta huruf, Freire mengamati bahwa orang miskin dan terpinggirkan yang terlibat dalam penamaan dan merenungkan kondisi sosial mereka sendiri menjadi diberdayakan untuk mengubahnya. Mengingat bahwa kesenjangan dalam kesehatan ibu dan bayi terkonsentrasi dalam populasi yang paling miskin dan tersingkir, pendekatan CBPR relevan dengan meningkatkan partisipasi masyarakat dalam meningkatkan kesehatan ibu-bayi baru lahir, serta mendorong keterlibatan mereka dalam sistem kesehatan yang dirancang untuk melayani mereka.
Satu prinsip penting dalam keberhasilan CBPR adalah bahwa masyarakat harus merumuskan pertanyaan penelitian (Foster & Stanek, 2007;. Mosavel, dkk, 2005). Penelitian ini adalah salah satu hasil dari kemitraan internasional terus antara bidan AS (satu terlatih dalam bidang antropologi medis) dan perawat Dominika yang dimulai pada 2003. Kegiatan awal kemitraan telah dilaporkan di tempat lain (Foster, 2009; Foster & Heath, 2007; Foster et al, 2006;.. Foster et al, 2005). Menyusul peningkatan kasus kematian ibu dalam jangka waktu enam bulan, para perawat Dominika diidentifikasi keterlambatan dalam mengakses perawatan untuk komplikasi sebagai faktor berkontribusi terhadap kematian ibu. Pertanyaan penelitian muncul dari keprihatinan ini: mengapa wanita yang mengalami komplikasi obstetri menunda kedatangan di rumah sakit sampai mereka memburuk kondisinya seperti (s) bahwa rumah sakit tidak bisa berbuat banyak untuk membantu mereka? Ada persepsi di antara para perawat Dominika bahwa perempuan tertunda mengakses layanan karena mereka memegang keyakinan dan sikap mengenai perawatan obstetri yang menyebabkan mereka untuk menunda mencari bantuan.
Salah satu tujuan penelitian ini adalah untuk mendapatkan pemahaman yang lebih dalam keyakinan perempuan dan laki-laki, sikap dan perilaku terhadap pelayanan maternitas di rumah sakit di mana perempuan disampaikan untuk membantu memahami mengapa perempuan di Republik Dominika dengan hati-hati penundaan komplikasi obstetri penting untuk kelangsungan hidup mereka. CBPR adalah metodologi yang dipilih untuk penelitian ini didasarkan pada premis bahwa penyedia layanan kesehatan ibu, peneliti dan anggota masyarakat, dengan bekerja sama untuk bersama-sama memahami pengalaman masyarakat tentang perawatan bersalin, kemudian bisa bersatu untuk memperbaikinya. Mekanisme aliansi untuk perubahan adalah proses penelitian itu sendiri.

    * Bagian lain

          o PENDAHULUAN
          o METODE
          o PEMBAHASAN
          o KESIMPULAN
          o Tambahan Bahan
          o Referensi

Komunitas Penelitian Partisipatif Berbasis
Medical Kesehatan Provinsi Direktur Umum dari Sekretariat Kesehatan Masyarakat dan Bantuan Sosial (SESPAS) menyarankan 4 lingkungan bahwa rumah sakit daerah dilayani, untuk keterwakilan geografis, kerentanan sosial ekonomi tinggi, dan kelayakan untuk melakukan penelitian. Penelitian dilakukan dalam bahasa Spanyol, dengan terjemahan bahasa Inggris dilakukan oleh asisten peneliti PI atau dua bahasa. Sebuah tim peneliti sepuluh orang berkumpul, termasuk 3 peneliti akademis dilatih (2 AS perawat-bidan dan 1 Dominika profesor keperawatan), dua perawat bersalin Dominika paling tertarik pada penelitian dari rumah sakit kemitraan, dan tokoh masyarakat empat (satu dari setiap lingkungan penelitian ). Tiga asisten mahasiswa riset AS diputar selama proyek juga (Tabel 1).
Tabel 1

Tabel 1
Tim Peneliti Anggota dan Pendidikan dalam Penelitian
Para perawat dan keperawatan Dominika profesor merekrut anggota masyarakat untuk tim di inisiasi penelitian. Kriteria inklusi untuk anggota masyarakat adalah: 1) didirikan dan diverifikasi sebagai pemimpin non-politik terpilih di lingkungan mereka, 2) kesediaan untuk berkomitmen tim selama masa studi dua tahun, 3) sekolah tinggi selesai, dan 4) kejujuran dan kehandalan. Tim peneliti lengkap dihadiri 40 jam berorientasi pada proses penelitian umum, termasuk orientasi ke desain khusus penelitian ini. Mereka juga mengikuti pelatihan didaktik dan praktis dalam kelompok fokus dan wawancara.
Orientasi termasuk satu hari pelatihan etika riset online dan program sertifikasi di Spanyol dari Family Health International (Family Health International, 2005). Ini khususnya menantang dan bermanfaat karena tidak ada anggota masyarakat yang pernah menggunakan komputer sebelumnya, tetap saja, semua berhasil lulus sertifikasi. Studi ini disetujui oleh Institutional Review Board dari universitas PI, serta Komite Etika rumah sakit kemitraan.
Wanita dewasa (21-49 tahun), perempuan remaja (15-20 tahun), dan laki-laki dewasa (> 19 tahun) dari empat lingkungan di kota terbesar ketiga di Republik Dominika direkrut. Wanita usia subur, sekitar 12 dewasa dan 12 wanita remaja per lingkungan, yang telah melahirkan di rumah sakit umum, secara sistematis direkrut dari setiap rumah ketiga. Pria, sekitar 12 setiap lingkungan, direkrut melalui snowball sampling apakah mereka pernah mengalami kehilangan anggota keluarga (pasangan, anak, dll) saat melahirkan atau bayi dalam waktu satu bulan melahirkan dalam sistem rumah sakit umum. Metode ini digunakan untuk laki-laki untuk memastikan sampel yang meliputi pengalaman dengan ibu-bayi baru lahir kematian. Rasio kematian ibu yang tinggi bagi negara masih acara pribadi relatif jarang terjadi di masyarakat, dan purposive sampling mengumpulkan satu set lebih kaya pengalaman dalam menanggapi pertanyaan penelitian utama yang ditimbulkan oleh perawat Dominika.
Selain itu, sekelompok 12 wanita hamil (tiga dari setiap kawasan sekitar) berencana untuk melahirkan di rumah sakit umum direkrut dari kelompok fokus atau komunitas yang akan dipantau secara prospektif dan disertai dengan kunjungan prenatal. Pengamatan Peserta dilakukan dengan 15 wanita selama total 44 kunjungan prenatal. Tiga wanita tidak menyelesaikan studi dan digantikan; satu peserta wanita telah keguguran dan dua pindah selama kehamilan. Dua peserta tambahan pada awalnya direkrut untuk kohort pengamatan tetapi digantikan karena mereka di trimester ketiga mereka dan tidak memiliki cukup waktu untuk observasi. Kriteria inklusi adalah: usia 15-49 tahun, terdaftar untuk perawatan sebelum melahirkan, dan berencana untuk melahirkan di rumah sakit umum.
Sebanyak 137 peserta direkrut, 27 pria, 51 wanita remaja, dan 59 wanita dewasa. Selain lima peserta yang tidak menyelesaikan observasi partisipan (dijelaskan di atas), dua orang dikeluarkan dari penelitian ketika ditemukan mereka tidak memenuhi syarat (a primigravida pada kelompok fokus dan wanita yang tidak tinggal di lingkungan itu) dan 16 tidak menghadiri kelompok fokus dijadwalkan mereka untuk gesekan total 17% (N = 23). Usia rata-rata untuk wanita remaja berusia 18 tahun [kisaran 15-20 tahun], usia rata-rata untuk wanita dewasa adalah 32 tahun [kisaran 21-48 tahun], dan usia rata untuk pria dewasa adalah 37 tahun [kisaran 19-64 tahun]. Dalam kohort observasi partisipan, ada enam perempuan remaja, usia rata-rata 16 tahun [kisaran 15-19 tahun] dan sembilan wanita dewasa, usia rata-rata 24 tahun [kisaran 21-32 tahun]. Jumlah tertinggi rata-rata tahun pendidikan selesai untuk ketiga kelompok (perempuan remaja, wanita dewasa dan pria dewasa) berusia 8 tahun [kisaran 1-17 tahun], rata-rata jumlah orang yang hidup dalam rumah tangga adalah 4 [kisaran 1-11 ], para pria lebih mungkin untuk bekerja (95% vs 30% dan 28% pada kelompok wanita remaja dan dewasa, masing-masing), dan pendapatan rumah tangga rata-rata bulanan (setara dolar AS) adalah $ 146 USD [kisaran $ 0 - $ 588 ] (Tabel 2). Informed consent diperoleh untuk semua, peserta yang memenuhi syarat direkrut.
Tabel 2

Tabel 2
Peserta Demografi
Dua belas kelompok fokus dilakukan, masing-masing di empat lingkungan untuk wanita dewasa, wanita remaja, dan pria dewasa. Selain kelompok fokus, lebih mendalam, wawancara individual dilakukan dengan 12 wanita kelompok terarah (sekitar 3 dari setiap kawasan sekitar) yang menggambarkan pengalaman kesulitan dan kerugian tertentu dengan pelayanan kesehatan bersalin. Ini terjadi setelah kelompok fokus, baik segera atau dalam waktu seminggu.
Pengumpulan Data
Demografi dikumpulkan pada semua peserta termasuk usia, tingkat pendidikan tertinggi yang ditamatkan, pendapatan rumah tangga bulanan, pendudukan peserta dan suami / istri, dan jumlah orang yang hidup dalam rumah. Sebuah laporan diri obstetri sejarah termasuk nomor dan tanggal kehamilan, metode kelahiran, dan setiap komplikasi termasuk kematian bayi juga dikumpulkan (Tabel 1 dan Tabel 2).
Dalam setiap kelompok fokus, peserta diminta pertanyaan terbuka untuk memastikan sikap, keyakinan, dan perilaku seputar kehamilan dan perawatan prenatal dan obstetri diterima dalam sistem rumah sakit umum. Kelompok-kelompok direkam dan ditranskrip oleh seorang pembicara Dominika asli. Kaset audio yang mendengarkan dan episodik dibandingkan dengan transkripsi untuk keperluan verifikasi dan kesetiaan.
Sebuah lengan paralel penelitian ini adalah observasi partisipatif. Tokoh masyarakat disertai para wanita untuk janji sebelum melahirkan, tetapi tetap di ruang tunggu untuk anonimitas. Mereka mendokumentasikan panjang dan cara perjalanan ke janji, menunggu waktu (dicatat untuk penyedia, perawat dan sesekali kunjungan laboratorium), instruksi pendidikan prenatal dan menyaksikan saat di ruang tunggu atau dilaporkan oleh wanita, kondisi ruang fisik, dan peserta 'pengamatan dan komentar. Setelah melahirkan, perawat penelitian dikumpulkan kelahiran peserta rekening sepuluh kelahiran.
Tim peneliti menerima 16 jam pelatihan didaktik dan praktis dalam analisis deskriptif kualitatif dasar dari konten (Sandelowski, 2000). Pelatihan praktis terlibat memberikan tim data ditranskripsi tidak terkait dengan proyek untuk membaca dan membuat kode. Kemudian, sebagai kelompok keseluruhan, tim peneliti membaca dan kode salinan teks, de-diidentifikasi ditranskrip. Para perawat Dominika dalam tim jauh lebih percaya diri tentang proses pembuatan kode dari tokoh masyarakat, yang cenderung untuk diam di hadapan para perawat selama proses analisis. Oleh karena itu, tim ini dipisahkan menjadi sub kelompok, tim keperawatan dan tim pemimpin masyarakat. Para perawat dan subkelompok tokoh masyarakat dikodekan bagian pertama di ruangan yang berbeda dan kemudian bertemu bersama-sama secara keseluruhan untuk membahas kesepakatan mereka pada pengkodean teks. Setelah kelompok selesai coding teks pertama, tim peneliti membaca seluruh teks bersama-sama keras dan dibahas kode mereka ditugaskan, membentuk sebuah daftar kode awal dengan definisi (Tabel 4). Dengan menggunakan struktur yang sama membaca dan membaca ulang teks dalam sub kelompok, tim peneliti Dominika membaca dan membaca kembali teks, kode konsolidasi, dan tema sentral yang dibahas dan mengidentifikasi, memprioritaskan mereka yang menangkap makna yang paling signifikan dari teks ditranskrip. Proses ini tidak melibatkan perangkat lunak komputerisasi, karena pemimpin masyarakat tidak memiliki pengalaman menggunakan komputer. Pengkodean dan penamaan tema dari kode terjadi di beberapa pertemuan mingguan selama empat bulan.
Tabel 4

Tabel 4
Kode dengan Definisi
Para tokoh masyarakat diundang semua peserta penelitian, bersama dengan anggota lain dari masing-masing lingkungan untuk presentasi publik dibuat dan disajikan oleh perawat Dominika dan tokoh masyarakat, dengan panduan dan bantuan dari para peneliti AS. Setiap presentasi diakhiri dengan pertanyaan apakah temuan secara akurat mewakili pengalaman masyarakat. Ini merupakan langkah yang direncanakan dalam proses analitik untuk memastikan kepercayaan data.
Studi Keterbatasan
Meskipun kepercayaan dari data itu ditingkatkan oleh hubungan kolaboratif lama antara AS dan peneliti perawat Dominika (yang telah mengamati perawatan di rumah sakit selama lebih dari enam tahun), salah satu harus selalu mengakui bahwa kelompok terfokus dan wawancara peserta mungkin dipengaruhi oleh keinginan untuk memberitahu peneliti apa yang mereka yakini peneliti berharap untuk mendengar. Selain itu, sementara kerangka sampling sistematis, tidak ada klaim yang dibuat bahwa perempuan dan remaja temuan yang disajikan dalam penelitian ini adalah wakil dari seluruh penduduk, terutama perempuan pedesaan dalam wilayah tangkapan rumah sakit. Juga penting untuk diingat bahwa kelompok laki-laki direkrut secara purposif untuk mengeksplorasi pengalaman dengan kematian ibu atau bayi baru lahir, sehingga sikap negatif akan lebih mungkin dalam kelompok itu.
Ada tantangan metodologis dengan tim penelitian, serta perbedaan penafsiran antara anggota masyarakat dan para perawat. Perbedaan ini sangat penting untuk memajukan apa yang diketahui tentang peran masyarakat dalam CBPR analisis (Cashman et al, 2008.), Tapi ini akan dilaporkan di tempat lain, karena berada di luar cakupan tulisan ini.
Tim didefinisikan sebagai keyakinan, "apa yang benar bagi seseorang, biasanya sesuatu dalam teks tidak diakui sebagai benar oleh sistem kesehatan." Beberapa keyakinan muncul selama wawancara mengenai makanan, risiko, mood, dan seksualitas. Meskipun dibantah oleh sebagian orang sebagai cerita lama ', yang Guanabana (sejenis buah yang unik ke Karibia) secara umum dipahami sebagai salah satu yang harus dihindari selama kehamilan, karena sebagai salah satu anggota kelompok fokus wanita berkata, "Mereka mengatakan bahwa itu bisa memberikan kejang eklampsia, yang dapat menghasilkan atau mendorongnya "ide lainnya tentang membatasi mandi pada kehamilan. disebutkan, meskipun banyak orang merasa ide ini ketinggalan jaman.
Gagasan bahwa setiap kehamilan merupakan masa berisiko tinggi, kerapuhan dan kerentanan telah disosialisasikan di semua lingkungan, dan laki-laki merasa bertanggung jawab khusus mereka untuk mengurus perempuan, terutama saat hamil. Sebagai contoh, salah satu fokus anggota kelompok laki-laki berkata, "Saya menemukan bahwa semua wanita yang sedang hamil sangat indah dan satu harus selalu melindungi [nya] sebanyak yang ia bisa, karena itu adalah masa di mana wanita adalah yang paling rapuh, dan apa pun bisa membahayakan dirinya. "
Wanita dan remaja berbicara tentang perlunya untuk menjaga temperamen bahkan dan positif selama kehamilan, tidak marah atau tertekan. Tanggung jawab perempuan, tidak ada coger mala sangre, (Eng. "jangan mengambil darah buruk") berarti bahwa wanita hamil harus menjaga pengaruh yang positif, atau mereka dapat menyebabkan bayi mereka untuk mengembangkan temperamen emosi negatif yang serupa.
Wanita secara terbuka mendiskusikan rasa pentingnya aktivitas seksual aktif selama kehamilan. Sebagai contoh, sebuah vagina yang telah direntangkan akan membuat untuk pengiriman lebih mudah. Sebagai salah satu wanita lain dalam kelompok fokus: "Kita semua setuju, penting untuk memiliki hubungan (seksual), bahkan dokter mengatakan demikian, sehingga Anda dapat memiliki kelahiran yang lebih baik, karena [dengan] melakukan hubungan seksual lebih sering Anda dapat memiliki persalinan normal [bukan] Caesar seorang. "
Ada juga keyakinan tentang rutinitas di rumah sakit: ada kemungkinan bahwa bayi bisa dicampur dan keluarga diberi bayi yang salah, bahwa obat penenang diberikan setelah operasi untuk mencegah perempuan dari berbicara, dan bahwa aborsi spontan membutuhkan dilatasi dan kuretase tidak aborsi spontan , tapi aborsi diinduksi benar-benar rahasia (ilegal di Republik Dominika).
Ada kesepakatan umum di seluruh kelompok bahwa rumah sakit bersalin prosedur diinduksi takut, pemeriksaan khusus vagina dan catheterizations kemih. Selain takut prosedur tertentu, ada ketakutan yang lebih besar dan kegelisahan menyatakan bahwa akan ditinggalkan sendirian untuk menyampaikan, baik tanpa pengawasan, atau dihadiri oleh seseorang yang tidak menghormati mereka atau membuat mereka merasa tidak berarti. (Sp. tidak saya HACE CaSO;. Eng mereka tidak memperhatikan saya). Tidak ada saya HACE CaSO termasuk lama menunggu untuk layanan, gagal untuk mengakui sejarah individu atau keluarga, gejala, atau pengetahuan, perawatan dari siswa tanpa pengawasan, kurangnya komunikasi, dan sistem Cuna, atau perlakuan istimewa untuk koneksi pribadi, seperti dijelaskan di bawah .
Dalam satu kasus seorang ibu merasa sangat sedih dengan keputusan medis untuk melakukan operasi caesar terhadap keinginannya, karena dia tidak merasa dia adalah karena menyampaikan, dan melaporkan tidak ada gejala abnormal kecuali bercak. Dia melaporkan bahwa bayinya meninggal beberapa jam setelah melahirkan karena prematuritas:

    Saya memiliki kehamilan normal ... saya pergi satu hari untuk kunjungan prenatal dan dokter di sana mengatakan kepada perawat, aku bilang tidak "Kirim ke lantai atas [tenaga kerja dan daerah pengiriman] ... dia akan melahirkan." ... Tapi aku membiarkan diriku pergi bersama karena dia dokter saya, dia adalah orang yang tahu ... Saya tidak pernah berpikir mereka akan melakukan operasi, saya selalu memiliki kelahiran normal. Perawat dicukur saya tapi saya terus berkata itu bukan waktu yang tepat ... Saya sedikit sebelum bulan kedelapan saya. Mereka mengirim saya untuk sonogram dan ... bayi tampak baik-baik. Ketika saya memberikan sonogram (hasil) ke dokter, katanya, "Wanita ini perlu dioperasi karena dia adalah pendarahan," tapi aku berdarah dari ujian perawat ... Saya tidak memiliki cm (leher rahim ditutup) ... mereka membawa saya ke ruang operasi dan tidak dengan sesar dan bayi meninggal beberapa jam kemudian ... dia meninggal karena asfiksia. (Dewasa wanita anggota kelompok fokus)

Salah satu remaja dijelaskan tekanan darah tinggi dalam kehamilannya bahwa dokter adalah pemantauan, bersama dengan jumlah butir darah ibu. Dia menceritakan apa yang dia mengatakan kepada dokternya:

    Setelah itu, saya tidak merasakan gerakan bayi, dan saya mengatakan kepada dokter, "Begini, Dokter, saya tidak merasa bayi," dan mereka berkata,

    "Tidak, bayi ini baik-baik saja," dan saya berkata,

    "'Tidak, saya tidak merasakannya," sebagai seorang ibu merasa anak-anaknya ... mereka tidak percaya saya, mereka tidak mau memperhatikan saya ... pada hari berikutnya, aku punya beberapa demam yang sangat besar, kaki saya berubah ungu, saya tangan, ungu, demam yang saya gemetar. Hari berikutnya, demam itu pergi, dan aku bilang ke dokter, "Begini, Dokter, saya merasa ini dan itu, dengan cara ini," dan ... dia tidak percaya saya, dia sangat pikir saya bermain ... dan mereka tidak ingin mengambil saya serius. Saya punya teman dari seorang perawat yang adalah teman dari ibu saya [yang] berbicara dengan Direktur rumah sakit, dan cara itu, mereka melakukan sesar tersebut. (Wawancara individu Remaja)

Sikap dikodekan sebagai kelalaian dilaporkan baik di pihak konsumen dan penyedia jasa. Seorang pria menyatakan keprihatinan bahwa seorang wanita hamil yang dikenalnya yang berdarah menolak untuk mencari perawatan medis dan meninggal; tim kode ayat ini sebagai kelalaian di pihaknya.
Menunggu adalah pengalaman umum, peserta melaporkan menunggu di bagian gawat darurat untuk masuk, untuk USG, untuk hasil laboratorium, bagi dokter untuk tiba di klinik rawat jalan, dan penundaan yang lama sebelum staf medis yang diberikan perlakuan sama sekali. Menunggu lama dikaitkan dengan rasa takut akan diabaikan atau tanpa pengawasan. Peserta dijelaskan dibawa pulang setelah menunggu lama karena dokter telah meninggalkan klinik atau diberitahu tidak ada yang salah dan kemudian memiliki sesar darurat:

    Tambang adalah kasus rumit, karena saya mengaku pada tanggal 15 Desember, dan pada tanggal 23, saya tidak merasa bayi bergerak ... Dan aku akan memberitahu dokter, bayi tersebut tidak bergerak lagi ... hari-hari berlalu dan itu 28, aku harus USG dan bayi sudah adalah 42 minggu dan dokter mengatakan masih baik-baik saja, saya bisa memiliki kelahiran normal. Pada tanggal 29 ... aku punya demam yang saya pikir saya akan mati, demam luar biasa, dan pada tanggal 30 mereka melakukan sebuah sesar darurat karena waktu ... bayi itu pup di perut saya. Ia lahir benar-benar mati, dan selama sepuluh menit ia tidak melakukan apapun, tali pusat yang kusut. Ia lahir sangat sakit, tetapi Allah memberi kami kemenangan ... dan dia baik sekarang. (Fokus anggota kelompok Remaja)

Secara individu, seorang remaja bercerita:

    Pendapat saya adalah bahwa ketika seseorang datang [ke rumah sakit] kesakitan, jika ada yang siap untuk melahirkan, bahwa mereka hadir untuk Anda segera. Karena seorang teman saya pergi tiga kali ke rumah sakit dan mereka bilang tidak. Bahwa ia belum siap untuk melahirkan, dan dia memiliki rasa sakit lebih dan lebih, dan ketika dia akhirnya tidak tahan lagi, gadis bayi lahir mati, mereka membiarkan dia mati. Syukurlah itu tidak terjadi kepada saya, dan ada banyak wanita yang terjadi. Hal terbaik adalah jika salah satu sudah memiliki 5 sentimeter atau salah satu tidak akan melahirkan secara normal, yaitu, dengan Bedah Caesar, bahwa mereka menghadiri sekarang juga, bahwa mereka hadir dengan baik, bahwa mereka memeriksa dia.

Seorang anggota kelompok fokus remaja menyatakan:

    Saya sekitar 6 bulan hamil dan ketika saya mengambil hasil laboratorium saya (ke dokter saya memiliki tekanan darah yang sangat tinggi dan gula darah yang tinggi juga. Tapi gadis ada (mengacu pada penyedia) menjadi mahasiswa bahwa mereka harus di rumah sakit dan saya berkata, "Lihatlah hasil lab saya." Dia mengatakan baik-baik saja dan tidak memberi saya obat apa pun Lalu aku pergi sekitar bulan kedelapan saya dengan sakit kepala yang tidak akan pergi.. Ketika saya melihat dokter dia bilang saya gula darah sangat tinggi, itu adalah 370 dan tekanan darah saya sangat tinggi ... Dia bilang aku butuh sesar mendesak dan ketika mereka melakukan sesar, bayi itu sudah mati karena tekanan darah saya dan gula darah saya terlalu tinggi.

Karena tidak adanya komunikasi, anggota keluarga laki-laki terutama merasa diabaikan dan tidak berdaya dalam melaksanakan tanggung jawab mereka untuk merawat istri dan anggota keluarga yang mereka lihat sebagai membutuhkan bantuan mereka:

    Mereka tidak memberikan banyak perhatian di rumah sakit, saya sendirian, saya tidak punya keluarga yang akan membantu saya, saya tidak punya pengalaman. Para dokter mengirim saya di luar, dan saya satu-satunya keluarga yang dia di sampingnya dan mereka mengirim saya luar. (Fokus anggota kelompok Male)

Demikian pula, laki-laki diwawancarai secara individu menjelaskan:

    Nah, istri saya hamil ... mereka mengatakan bahwa ia berumur sembilan bulan dan seperti, sepuluh hari. Mereka mengirim dia untuk USG darurat. Mereka mengakui, tapi mereka tidak mengatakan mengapa, baik dia atau aku tahu mengapa ... yang seperti delapan pagi ... jam tiga sore mereka menempatkan injeksi Pitocin sehingga ia bisa melahirkan. Ketika ia melahirkan bayi itu sudah mati, sudah hampir rusak ... pada awalnya saya senang ketika saya pikir dia akan lahir, tapi setelah mereka mengatakan kepada saya dia sudah mati, itu menghancurkan hati saya ... mereka tidak memberikan penjelasan apa pun .... mereka adalah biadab, Anda meminta penjelasan dan mereka memesan Anda ke satu sisi, 'aku sibuk, atau' Pergi ke sini ', atau' pergi ke sana, lantai bawah '... (wawancara individu laki-laki)

Strategi untuk menghindari diabaikan adalah untuk menumbuhkan Cuna. Cuna adalah koneksi sosial antara individu, yang diciptakan oleh ikatan keluarga atau hubungan pribadi. Cara untuk menerima perawatan yang berkualitas adalah harus memiliki hubungan sosial dengan orang yang dikenal dalam sistem perawatan kesehatan. Sebagai salah satu fokus anggota kelompok laki-laki menyatakan, "Di sini Anda memiliki Cuna, kamu adalah temannya dari dokter atau perawat di rumah sakit, baik, orang-orang mendapatkan perlakuan yang berbeda. Tapi orang yang tidak memiliki siapa pun di sana, mereka mendapatkan pengobatan lain. "
Seorang pria tua fokus anggota kelompok berkomentar:

    [Situasi di masa lalu] tidak seperti hari ini ketika ilmu adalah sedikit lebih maju dari sebelumnya. Pada waktu itu, satu pergi ke bidan dan satu merasa lebih aman ... Saya tidak tahu apa yang terjadi. Ada kecerdasan lebih, dan ilmu pengetahuan lebih maju, tapi ada sedikit layanan, karena setiap orang bebas untuk melakukan apapun yang mereka inginkan. Saya melihat bahwa setiap langkah dari jalan di rumah sakit.

Peserta Pengamatan
Hasil pengamatan kunjungan prenatal mengkonfirmasi account yang diucapkan, misalnya menunjukkan waktu menunggu lama dan sistem komunikasi yang buruk, yang ditafsirkan oleh para peserta sebagai kurangnya rasa hormat. Salah satu tema utama yang diidentifikasi dari data oleh anggota masyarakat dan perawat adalah jumlah waktu yang diperlukan untuk tidak hanya janji dan prosedur, tetapi juga hanya menunggu. Meskipun waktu perjalanan yang diamati relatif singkat, rata-rata 20 menit, wanita diharuskan untuk melakukan perjalanan ke situs rawat jalan untuk meminta janji prenatal. Tidak ada sistem ada untuk membuat janji melalui telepon. Rata-rata waktu tunggu untuk melihat penyedia adalah 95 menit, dan tidak bervariasi antara penambahan kunjungan prenatal awal dan kunjungan berikutnya. Seperti dijelaskan dalam kelompok fokus, menunggu perawatan di klinik rawat jalan adalah bagian umum dari pengalaman peserta:

    Anda harus awal untuk kunjungan prenatal karena ada sejumlah tiket, jadi anda harus lebih atau kurang sampai pada pukul 5 pagi hari untuk bisa mendapatkan satu. Namun dokter datang pada pukul 8:30. Jika Anda mendapatkan angka yang lebih rendah, Anda keluar sebelumnya, tetapi Anda akan berada di sana sekitar tiga jam ... Karena kadang-kadang itu adalah sedikit setelah delapan atau hampir sembilan ketika mereka mulai. (Komentar dari peserta untuk pengamat penelitian)

Dalam 18% dari kunjungan yang diamati (N = 44), perawat memberikan presentasi pendidikan prenatal (sp. charlas) sementara wanita menunggu, pada topik termasuk perawatan selama perawatan kehamilan, menyusui dan bayi, keluarga berencana, dan pencegahan HIV. Kurang dari setengah perempuan yang diamati melaporkan instruksi setiap dokter atau pendidikan, sementara setengah instruksi yang diterima baik untuk mengambil obat atau mendapatkan tes diagnostik.

Anggota Pemeriksaan


    * Bagian lain

          o PENDAHULUAN
          o METODE
          o PEMBAHASAN
          o KESIMPULAN
          o Referensi


Tabel 3

Tabel 3

    * Bagian lain

          o PENDAHULUAN
          o METODE
          o PEMBAHASAN
          o KESIMPULAN
          o Referensi


Tambahan Bahan


Ucapan Terima Kasih

Catatan kaki
Ini adalah file PDF dari sebuah naskah diedit yang telah diterima untuk publikasi. Sebagai layanan kepada pelanggan kami kami menyediakan versi awal naskah. Naskah akan menjalani copyediting, typesetting, dan penelaahan atas bukti yang dihasilkan sebelum diterbitkan dalam bentuk akhirnya citable nya. Harap dicatat bahwa selama kesalahan proses produksi dapat ditemukan yang dapat mempengaruhi isi, dan semua penolakan hukum yang berlaku untuk berhubungan jurnal.

    * Bagian lain

          o PENDAHULUAN
          o METODE
          o PEMBAHASAN
          o KESIMPULAN
          o Referensi


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