Indonesia has one of the highest rates of maternal mortality in Southeast Asia. Community participation has been known to reduce maternal mortality in some areas in Indonesia. However, in Aceh Province, the prevalence remains higher than the general Indonesian maternal mortality rate. The aim of this research was to gain an understanding of pregnancy and childbirth experiences from multiple perspectives, in relation to the use of maternal health services in Aceh, Indonesia. The conceptual framework was based on the importance of community engagement in improving maternal health. A qualitative study design with a grounded theory approach was utilised. This approach was chosen in order to gain an understanding of the social processes and ways in which experiences of pregnancy and childbirth are related to maternal death incidents. The process inherent in the method enabled the emergence of important theoretical concepts. A theoretical sampling strategy was employed. The data collection used multiple methods that involved a series of in-depth interviews, observations and focus group discussions with women, family members, a village leader and health professionals. The sample size was determined by data saturation (19 women, 15 family members, 7 health professionals, 3 kaders, 4 student midwives and 1 village leader participated). Ethical approval was gained and the research setting was in the two villages of Aceh Besar District, Aceh Province, Indonesia. Data were coded and analysed by following a constant comparison process. The emergent core category, entitled “maternal death: the elephant in the room” explains the views of the community about maternal death incidents in the research setting. The research findings highlighted that despite the maternal mortality rate still being high in the region, maternal death was not focused upon, as a problem within the community. The research findings revealed that maternal mortality was a hidden problem within the community, and was related to inadequate maternity practices in the village. The core category “maternal death: the elephant in the room” was found to consist of four interrelated categories. The categories of the value of midwifery in the community, desicion-making of maternity care, social control of the childbearing and distancing of maternal deaths; explain maternity practices in the community. Understanding of social processes related to maternal health can assist in informing strategies to improve the quality of maternal healthcare in Aceh Indonesia.

This research examined intersectoral relationships and community participation in policy processes across the mental health and housing sectors. The focus was on the development of suitable housing options for people with a psychiatric disability. The study period covered five years of mental health system reform in South Australia (2000-2005). The research found a shortage of housing and support options for people with psychiatric disability and lack of significant strategic policy coordination or ongoing cross-sectoral programmes. The problems faced by people in gaining access to housing and disability support services and the ways in which families provide housing or support in the absence of public services are documented. This case study used qualitative research methods which were triangulated across four stages: 1) a thematic analysis of national and state policies in the health, housing and disability sectors; 2) participant observation of NGO activity, a thematic analysis of NGO documents, and interviews and focus groups with NGOs; 3) interviews and focus groups with consumer and carer representatives and a thematic analysis of the minutes from state-level groups; 4) interviews with professionals from the health, housing and disability sectors The housing situation for people with psychiatric disability was explained in terms of a number of key issues in the policy environment; „X The overarching neo-liberal policy context synonymous with a decline in public housing resources and increasing tension between NGOs service provider and advocacy roles. „X The political nature of the local mental health policy context and lack of political commitment to ongoing resources. Broad community stigma reflected in the media and government, affecting ongoing political commitment to mental health and housing and the introduction and progress of housing ¡¥projects¡¦. „X The slow development of peak NGO and consumer organisations and alliances in South Australia which affected access to policy networks and contributed to the dominance of professional interests within policy processes. „X The separation of health, housing and disability policy and networks within and across levels of government. This was associated with bilateral agreements (between Australian and state governments) tied to resources within departments, the programme objectives and the goals of bureaucrats. „X The separation of policy networks by sector was also connected to the dominance of bio-medical discourses and interventions and associated professional interests in the health policy sector. Medical discourses on health and disability and ¡¥consumerist¡¦ discourses on participation also led to social determinants of health such as housing being overlooked within policy processes. „X Governance reform at a state level contributed to organisational instability within departments, causing some problems for cross-sectoral initiatives and protocols. Kingdon¡¦s (2003) multiple streams analysis of policy helped to explain what missed or reached political agendas within each policy sector of the case study. Kingdon predicts that the unity of policy networks is important for the realization of policy solutions, and the lack of unity in policy sectors was an obstacle to policy agendas on housing for people with a psychiatric disability. However, the way in which problems were being represented (Bacchi 1999) was also important to understanding this policy environment. For example, a medical discourse on disability (Fulcher 1989) tied to the health sector led to a narrow focus on clinical mental health services. Similarly, neo-liberal discourse (Dean 1999) supported private housing solutions and resources or NGOs advocating ¡¥within sectors¡¦ for the types of services they already provided or wished to provide. The case study suggested strategies for ¡¥policy change¡¦ need to address a number of factors across service delivery, policy and political realms. Firstly, better recognition is warranted of the difficulty experienced by many people with psychiatric disability in achieving stable housing, and the need for indicators on housing access and stability for this group. Secondly, processes to address stigma (particularly that perpetuated in the media) will be instrumental for policy change and political commitment. Thirdly, ongoing cross sectoral advocacy and alliances require development at both a national and state level and support by a political culture which encourages advocacy. Developing processes for working across sectors such as policy learning forums involving both experts and community groups could counter problems arising from professional culture and territories that were documented in this study. Finally, the cross-sectoral development of policy, programmes and accountability mechanisms and the stability of policy networks will be important to ensuring stable housing for people with psychiatric disability.