Table 4 Quotes for each theme
Theme | Subthemes | Quotes |
|---|---|---|
Empowerment | Well-designed intervention | “The pathways are easy, not that difficult and they focus on preeclampsia” (GP 1, Interview1) “Your toolkits are helpful, the checklist I think is the most important toolkit, the module is good to improve our knowledge” (Midwife 2, FG 8) “The toolkits are really good. The information listed in the mugs and stickers is easy to understand and I used those for my Whatsapp status” (Patient 5, Interview 13) “The pathways are very clear and succinct compared to the routine ANC form, that is more detailed. The ANC form has many coloumns to fill, and we got confused at the end as the conclusion is meaningless, only whether the patient has an infection or not, and no further follow up” (Interview 1, GP) |
Empowerment | “We have been warned for referring many women and we have massive ‘red lines’ from the JKN system, but I am thankful that we now have this guidance for aspirin prescription and to monitor their conditions. We feel that we are helped” (Midwife 5, FG 4) | |
Hierarchy | Between nurses, midwives and GPs | “We could not prescribe medicines because it is not our responsibility. If there are any pregnancy complications, it should be the midwives who can follow up and do the standard operating procedures (SOP)” (Nurse 1, FG 10) |
Between GPs and patients | “I think all patients are so obedient to our advice. I found that the patients are often defying doctors like Gods. So the doctors are everything and they are so obedient” “I agree, that when we give the prescription, they also agree to take it. No further questions” (GP 2 and 4, FG 2) (notes: However, these quotes contradict with results of our observations that some patients seem afraid with their doctors) | |
Between GPs and specialists | “I prefer to consult (the obstetrician) first. I am afraid if I will get audited for making a mistake. Then I would be asked about this and that. But often, the hospital advice is also very little. A specialist stopped our aspirin prescription last week. He only prescribed a few tablets and provided no further advice for our patients (and the GPs could not discuss the patient management)” (GP 1, FG 3) Aspirin should be given under 16 weeks to prevent preeclampsia and indeed, it is preventive management that I think should be conducted more aggressively because of our high maternal mortality rate. Overdiagnosis is also good. For example, we recommend that women who have doubtful (dipstick) proteinuria to be seen as a positive result. (Therefore,) Primary care should also upgrade their knowledge regarding the patients’ condition and (including preeclampsia prevention) in the community. For example, how is the community consumption level for calcium and iron” (Interview 5, Obstetrician 2) “The risk factors screening is good, GPs can perform screening and refer high-risk patients to us, then us (obstetricians) can do further tests and start Aspirin if necessary” (Interview 3, Obstetrician) | |
Between primary care providers and local health office | “Currently, we are under the maternal emergency policy and we are closely monitored for pregnancy complication management. This policy somehow makes us scared and paranoid if we are get audited if the patients do not see the specialist in the first place. Therefore, we liked to refer women with complications to the hospital” (GP 1, FG 3) | |
Clinical resource | “We now still have the reagents so that I am able just to check SGOT SGPT and it is free for the patients, but later we might have limited reagents and we should consider that too” (GP 1, FG 9) “if we have to provide aspirin for nine months of the pregnancy, then we have to also order that from the local health office” (GP1, FG 7) | |
Direction | Uniformity | “I think further research to scale-up the implementation of the pathways will be good. First, it (the pathway) is beneficial in this Puskesmas. if that is also applied in other Puskesmas, that will be better so that we are in one rhyme with them” (Midwife 2, FG 8) |
Conformity with current medical record system | “We don’t really use the diagnosis of transient or masked hypertension, I know there are some conditions like that, but if we enter them in the medical record system, they don’t appear as a clinical diagnosis” (Interview 5, Obstetrician) | |
Supporting policy | “We do not have a legal umbrella (policy from the local health officer) yet. Even though we have seen patients with preeclampsia also patients with moderate and high-risk factors and we give aspirin anyway. Alternatively, we need to have a backup from the obstetrician organisation in the province or at the district level first. I think they are very open (for any suggestion) because our maternal mortality rate is high” (GP 1, Interview 1) | |
Champions involvement | “I think later for your further study, you need to involve consultations with obstetrician consultant or organisation. This case (HDP management) in primary care is under the obstetricians organisation responsibility. Usually, the highest resistance is within the obstetrician organisation. If any women died from preeclampsia in primary care, those will also be audited by obstetricians” (Interview 5, Obstetrician) | |
More training and education tools | “Nurse 1: I would suggest more posters and training provided to the clinic or maybe the big one so that pregnant women can easily read it Nurse 2: Something like dangerous signs for preeclampsia to increase awareness for the patients”. (Nurse 1 and 2, FG 10) |