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A protocol study of participatory action research: Midwife empowerment in improving the quality of maternal referral in Indonesia

  • Nurmala Dewi Ria Lestari ,
  • Ova Emilia ,
  • Detty Siti Nurdianti ,
  • Retna Siwi Padmawati ,


Background: The maternal referral system is still a health problem, especially in Indonesia’s remote areas. That system is related to the maternal referral system regarding referral decision-making. At the same time, in deciding to refer anyone other than the husband, it must involve parents, shaman/confidant, then the hamlet head. If the patient still does not want to be referred, it must involve the village head, even the sub-district head. Besides, the referral facility's distance also takes a very long time, around 2 hours to travel; therefore, many mothers/babies die while traveling to the referral place. Health professionals, especially midwives, are responsible for explaining to patients and families because average midwives do not give detailed explanations, starting from the anamnesis, examination results, and actions done before and in the referral process.

Method: The research design utilized the Participatory Action Research (PAR) approach, consisting of four stages: problem identification, planning, action, and evaluation. Qualitative data is obtained through in-depth interviews and FGD (Focus Group Discussion) to determine existing problems and programs that are not yet running. Contradictary, quantitative data were obtained from the intervention and control groups. Qualitative data analysis used content analysis, while quantitative data used Wilcoxon sign-rank and rank-sum.

Result: This study aimed to determine the quality of midwives towards maternal referrals, to design a module for midwife empowerment programs, to implement a model design, and to evaluate the results of implementing a midwife empowerment model for maternal referrals so that midwives have guidelines and improve midwife skills so that pregnant women are given explanations by midwives, in order to facilitate the referral process.

Conclusion: The PAR approach is one of the potential ways to determine the midwife’s quality, improving the maternal referral system, especially for the remote area in Indonesia.


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How to Cite

Lestari, N. D. R., Emilia, O., Nurdianti, D. S., & Padmawati, R. S. (2023). A protocol study of participatory action research: Midwife empowerment in improving the quality of maternal referral in Indonesia. Bali Medical Journal, 12(3), 2957–2962.




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Nurmala Dewi Ria Lestari
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Ova Emilia
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Detty Siti Nurdianti
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Retna Siwi Padmawati
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