Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Ekawati FM

PROVIDER: S-EPMC8278644 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundHypertensive disorders of pregnancy (HDP) are a significant contributor to the high maternal mortality rate in Indonesia. At the moment, limited guidelines are available to assist primary care providers in managing HDP cases. A previous review of 16 international HDP guidelines has identified opportunities for improving HDP management in Indonesian primary care, but it has not determined the suitability of the recommendations in practice. This study aims to achieve consensus among the experts regarding the recommendations suitability and to develop HDP pathways in Indonesian primary care.MethodsMaternal health experts, including GPs, midwives, nurses, medical specialists and health policy researchers from Indonesia and overseas were recruited for the study. They participated in a consensus development process that applied a mix of quantitative and qualitative questions in three Delphi survey rounds. At the first and second-round survey, the participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP management is appropriate for use in Indonesian primary care settings. The third-round survey presented the drafts of HDP pathways and sought participants' agreement and further suggestions. The participants' agreement scores were calculated with a statement needing a minimum of 70% agreement to be included in the HDP pathways. The participants' responses and suggestions to the free text questions were analysed thematically.ResultsA total of 52 participants were included, with 48, 45 and 37 of them completing the first, second and third round of the survey respectively. Consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. Agreement scores for the statements ranged from 70.8-100.0%, and potential implementation barriers of the pathways were identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants.ConclusionsMost evidence-based management recommendations achieved consensus and were included in the developed HDP management pathways, which can potentially be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the developed HDP pathways in primary care practice.

Project description:PurposeThe Olmsted County hypertensive disorders of pregnancy (HDP) cohort is a population-based retrospective study designed to compare the incidence of HDP on a per-pregnancy and per-woman basis and to identify associations between HDP with ageing-related diseases, as well as accumulation of multimorbidity.ParticipantsUsing the Rochester Epidemiology Project (REP) medical records-linkage system, a cohort was collected consisting of women who gave birth in Olmsted County between 1976 and 1982. After exclusions, a per-pregnancy cohort of 7544 women with 9862 pregnancies between 1976 and 1982 was identified, and their delivery information was manually reviewed. A subset of these women comprised the per-woman cohort of 4322 pregnancies from 1839 women with delivery information available throughout the entirety of their childbearing years, along with decades of follow-up data available for research via the REP.Findings to dateBy constructing both per-pregnancy and per-woman cohorts, we reported a doubling of HDP incidence rates when assessed on a per-woman basis compared with rates observed on a per-pregnancy basis. Moreover, in addition to finding that women with a history of HDP developed specific diseases at higher rates and at early ages, we also discovered that a history of HDP is associated with accelerated ageing, through accumulation of multimorbidity.Future plansIn addition to these outcomes described above, many other potential outcomes of interest for studies of HDP can be ascertained from accessing the electronic health records (EHR) and billing systems available through the REP. These data can include all International Classification of Diseases (ICD)-9 and ICD-10 and Current Procedural Terminology coded diagnoses and procedures, healthcare utilisation, including office visits, hospitalisations and emergency room visits, and full text of the EHR that is available for chart abstraction or for natural language processing of the clinical notes.