Challenging the status quo: results of an acceptability and feasibility study of hypertensive disorders of pregnancy (HDP) management pathways in Indonesian primary care

Ekawati F.M., Emilia O., Gunn J., Licqurish S., Lau P.

Department of Family and Community Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of General Practice, University of Melbourne, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, Universitas Gadjah Mada/Sardjito Hospital, Yogyakarta, Indonesia; School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia; Department of General Practice, Western Sydney UniversityNSW, Australia


Background: Hypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in Indonesia. Focused HDP management pathways for Indonesian primary care practice have been developed from a consensus development process. However, the acceptability and feasibility of the pathways in practice have not been explored. This study reports on the implementation process of the pathways to determine their acceptability and feasibility in Indonesian practice. Methods: The pathways were implemented in three public primary care clinics (Puskesmas) in Yogyakarta province for a month, guided by implementation science frameworks of Medical Research Council (MRC) and the Practical Robust Implementation and Sustainability Model (PRISM). The participating providers (general practitioners (GPs), midwives, and nurses) were asked to use recommendations in the pathways for a month. The pathway implementation evaluations were then conducted using clinical audits and a triangulation of observations, focus groups (FGs), and interviews with all of the participants. Clinical audit data were analysed descriptively, and qualitative data were analysed using a mix of the inductive-deductive approach of thematic analysis. Results: A total of 50 primary care providers, four obstetricians, a maternal division officer in the local health office and 61 patients agreed to participate, and 48 of the recruited participants participated in evaluation FGs or interviews. All of the providers in the Puskesmas attempted to apply recommendations from the pathways to various degrees, mainly adopting preeclampsia risk factor screenings and HDP monitoring. The participants expressed that the recommendations empowered their practice when it came to HDP management. However, their practices were challenged by professional boundaries and hierarchical barriers among health care professionals, limited clinical resources, and regulations from the local health office. Suggestions for future scale-up studies were also mentioned, such as involving champion obstetricians and providing more patient education toolkits. Conclusion: The HDP management pathways are acceptable and feasible in Indonesian primary care. A further scale-up study is desired and can be initiated with investigations to minimise the implementation challenges and enhance the pathways’ value in primary care practice. © 2021, The Author(s).

Acceptability; Barriers; Feasibility; Hypertensive disorders of pregnancy; Implementation; Indonesia; LMICs; Management; Preeclampsia; Primary care


BMC Pregnancy and Childbirth

Publisher: BioMed Central Ltd

Volume 21, Issue 1, Art No 507, Page – , Page Count

Journal Link:

doi: 10.1186/s12884-021-03970-8

Issn: 14712393

Type: All Open Access, Gold, Green


Say, L., Chou, D., Global causes of maternal death: a WHO systematic analysis (2014) Lancet Glob Health, 2 (6), pp. e323-e333; Brown, M.A., Magee, L.A., The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice (2018) Pregnancy Hypertens, 13, pp. 291-310; (2018) Maternal Mortality Key Facts: WHO, ,; (2016) Indonesian Health Profiles: Data and Information (Data dan Informasi tahun 2015 Profil Kesehatan Indonesia), ,, Indonesian Ministry of Health Health Do, Jakarta; Firoz, T., Harshad, S., Pre-eclampsia in low and middle income countries (2011) Best Pract Res Clin Obstetr Gynaecol, 25 (4), pp. 537-548; Ekawati, F.M., Licqurish, S., Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol (2019) Reprod Health, 16 (1), p. 12; (2012) Referral Manual for Pregnancy, Labor, Delivery and Newborn Care, according to the Technical Procedure of Jampersal and Situation at Kulonprogo District Kulon Progo Yogyakarta, ,; (2013) Kementerian Kesehatan Republik Indonesia, ,, Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan; Yuli, M., Utarini, A., Maternal care quality in near miss and maternal mortality in an academic public tertiary hospital in Yogyakarta, Indonesia: a retrospective cohort study (2017) BMC Pregnancy Childbirth, 17, p. 149; Baharuddin, M., Amelia, D., Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia (2019) Int J Gynecol Obstetr, 144 (S1), pp. 59-64; Ekawati, F.M., Emilia, O., Opportunities for improving hypertensive disorders of pregnancy (HDP) management in primary care settings: A review of international published guidelines in the context of pregnancy care in Indonesia (2020) Pregnancy Hypertension, 19, pp. 195-204; Ekawati, F.M., Licqurish, S., Management of hypertensive disorders of pregnancy (HDP) in Indonesian primary care settings: the views of stakeholders (2019) Austr J Prim Health, 25 (3), pp. XIV. , Abstracts of the AAAPC Annual Research Conference, Adelaide 2019; Widyaningsih, V., Khotijah, Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia (2017) Glob Health Action, 10 (1), p. 1339534; Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2017 tentang izin dan penyelenggaraan praktik bidan (Regulation of the Minister of Health of the Republic of Indonesia Number 28 of 2017 concerning licensing and implementation of midwifery practices) (2017) Ministry of Health Republic Indonesia, ,; Craig, P., Dieppe, P., Developing and evaluating complex interventions: the new Medical Research Council guidance (2013) Int J Nurs Stud, 50 (5), pp. 587-592; Feldstein, A.C., Glasgow, R.E., A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice (2008) Joint Commission J Qual Patient Safety, 34 (4), pp. 228-243; Maternal death surveillance guideline (Pedoman surveilans kematian ibu) (2016) Ministry of Health Republic Indonesia, ,; (2017) Dinas Kesehatan Propinsi Yogyakarta (Yogyakarta Local Health Office), 2017. ,, Profil Kesehatan Provinsi di Yogyakarta Tahun; Tren data kematian dan penyebab kematian ibu 2016–2019 (2020) Jakarta; (2014) The Ministry of Health Regulation number 28 year 2014 about the implementation guideline of Indonesian universal health coverage, ,, Jakarta; Agustina, R., Teguh, D., Universal health coverage in Indonesia: Concept, progress, and challenges (2018) Lancet, (18), pp. 31647-31647. ,; Ekawati, F.M., Licqurish, S., Hypertensive disorders of pregnancy (HDP) management pathways: results of a Delphi survey to contextualise international recommendations for Indonesian primary care settings (2021) BMC Pregnancy Childbirth, 21 (1), p. 269; Pournassehmurphy, H., (2010) Short Message System for Mobile Devices, , Google Patents; Acton, J.K., (2020) Brian Whatsapp, ,, Available from; (2005) Participant Observation as a Data Collection Method, 6 (2). ,;; (2019),, Nvivo (Software) version 12.2.0 (3262); Ogrinc, G., Mooney, S.E., The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration (2008) Qual Safety Health Care, 17, p. i13; Douglas, S.P., Samuel, C.C., Collaborative and iterative translation: An alternative approach to back translation (2007) J Int Market, 15 (1), pp. 30-43; Leimena, S.L., Posyandu: a community based vehicle to improve child survival and development (1989) Asia-Pacific J Publ Health, 3 (4), pp. 264-267; Lau, R., Stevenson, F., Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews (2016) Implement Sci, 11 (1), p. 40; Claramita, M., Riskiyana, R., Interprofessional communication in a socio-hierarchical culture: development of the TRI-O guide (2019) J Multidiscip Healthc, 12, pp. 191-204; Claramita, M., Susilo, A.P., Improving communication skills in the Southeast Asian health care context (2014) Perspect Med Educ, 3 (6), pp. 474-479; Santesso, N., Tugwell, P., Knowledge translation in developing countries (2006) J Continuing Educ Health Prof, 26 (1), pp. 87-96; Baradaran-Seyed, Z., Nedjat, S., Barriers of clinical practice guidelines development and implementation in developing countries: a case study in Iran (2013) Int J Prev Med, 4 (3), p. 340. , PID: 23626892; Dewi, W.N., Evans, D., Person-centred care in the I ndonesian health-care system (2014) Int J Nurs Pract, 20 (6), pp. 616-622; Stokes, T., Shaw, E.J., Barriers and enablers to guideline implementation strategies to improve obstetric care practice in low- and middle-income countries: a systematic review of qualitative evidence (2016) Implement Sci, 11 (1), p. 144; Ekawati, F.M., (2015) Patients’ Experience of Using Primary Care in the Context of Indonesian Universal Health Coverage Implementation: An Interpretative Phenomenological Analysis; Ekawati, F.M., Claramita, M., The Indonesian general practitioners’ perspectives on formal postgraduate training in primary care (2018) Asia Pacific Fam Med, 17 (1), p. 10; Istiono, W., Claramita, M., Physician’s self-perceived abilities at primary care settings in Indonesia (2015) J Fam Med Prim Care, 4 (4), pp. 551-558; Ekawati, F.M., Claramita, M., Patients’ experience of using primary care services in the context of Indonesian universal health coverage reforms (2017) Asia Pacific Fam Med, 16, p. 4; Ekawati, F.M., Lau, P., Short communication: What if there is no reliable and appropriate medication for pregnancy hypertension available in Indonesian primary care? (2020) Pregnancy Hypertens, 21, pp. 68-69; Squires, J.E., Sullivan, K., Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews (2014) Implement Sci, 9 (1). , (,):,.,; Wensing, M., Glidewell, L., (2004) Effectiveness and efficiency of guideline dissemination and implementation strategies; Grol, R., Grimshaw, J., From best evidence to best practice: effective implementation of change in patients’ care (2003) Lancet, 362 (9391), pp. 1225-1230. , (,):.,; Hamilton, A.B., Finley, E.P., Qualitative methods in implementation research: An introduction (2019) Psych Res, p. 463; Breen, R.L., A practical guide to focus-group research (2006) J Geography Higher Educ, 30 (3), pp. 463-475; Willcox, M.L., Price, J., Scott, S., Death audits and reviews for reducing maternal (2020) Perinatal and Child Mortality. Cochrane Database Syst Rev, 3 (3). ,; (2013) Maternal death surveillance and response: technical guidance information for action to prevent maternal death; Kislov, R., Walshe, K., Managing boundaries in primary care service improvement: a developmental approach to communities of practice (2012) Implement Sci, 7 (1), p. 97; Bate, P., Chapter 13 – Designing an effective approach to cultural change (1996) Strategies for Cultural Change, pp. 212-234. , Bate P, Oxford, Butterworth-Heinemann

Indexed by Scopus

Leave a Comment