The elephant in the room: an exploratory study of hypertensive disorders of pregnancy (HDP) management in Indonesian primary care settings

Background: Indonesia has the highest maternal mortality rate in South East Asia, that a third of the mortality is
caused by hypertensive disorders of pregnancy (HDP), including preeclampsia and eclampsia. Research suggests that
maternal deaths from HDP are avoidable with appropriate initial management in primary care. However, little is known
regarding the exact way HDP management is conducted in Indonesian primary care. This research aims to explore the
way HDP management is provided, including its barriers and facilitators in Indonesian primary care settings.
Methods: This research applied a practical qualitative methodology using interviews with a topic guide. It is guided by
the implementation science framework of the Medical Research Council (MRC) framework and Practical Robust
Implementation and Sustainability Model (PRISM) to design and evaluate complex healthcare interventions. Primary
care key stakeholders from Yogyakarta province were recruited from May–December 2018. The interviews were
conducted in face-to-face, telephone, and teleconference interviews. Data from the interviews were analysed
thematically using a mix of inductive and deductive approaches.
Results: A total of 24 participants were interviewed, consisting of four general practitioners, five midwives, three
nurses, three obstetricians, a cardiologist, five policymakers and three women with a previous history of HDP. Referrals
are the usual management performed for HDP women in primary care and the primary care providers’ practice is
challenged by three identified themes: (i) providers’ limited confidence to perform HDP management, (ii) fragmented
continuity of care, and (iii) community beliefs. Many participants also desired to have more focused guidance to
improve HDP management in primary care practice.
Conclusion: Even though Indonesian antenatal care and referrals are generally accessible, there are many challenges
and fragmentation of HDP management. The most prominent challenge is the primary care providers’ lack of
confidence in performing the management and the ‘elephant’ of an urgent need of practice guidelines in primary care
that has never been appropriately described in the literature. Further development of an evidence-based primary carefocused
guidance will potentially improve primary care providers’ skills to perform optimal HDP management and
provide appropriate education to their patients.