Contextual Blindness: Indonesian Cesarean Section Research Trapped in Narrow Perspectives [Letter]

Dear editor

We appreciate the opportunity to comment on the article “Development of an Efficient and Effective Clinical Pathway for Cesarean Section in West Sumatra (Indonesia)” by Aladin, Taifur, Aljunid, and Ocviyanti.¹ While the study provides valuable insights into cesarean section (CS) services in West Sumatra. This study makes a significant contribution by developing an integrated clinical pathway for effective and efficient caesarean section, based on a comprehensive analysis of costs and procedures in various hospitals in West Sumatra, so that it can be a reference for hospitals in improving service quality while controlling costs.

However, there are several critical points warrant further discussion and investigation. First, geographical limitations; the study’s focus on 11 hospitals in West Sumatra, while informative, limits its generalizability to the broader Indonesian context. Second, public and private hospital analysis; a notable omission in the current study is the lack of in-depth comparative analysis between public and private hospitals. Third, policy and financing framework; the study’s primary focus on service recipients, while valuable, overlooks critical aspects of health service financing policies and programs. Fourth, sociocultural factors and patient behavior; the authors have not addressed a crucial phenomenon observed in Indonesia (the tendency of lower-income individuals to seek CS services in private hospitals despite financial constraints, often driven by perceptions of superior care.² This behavior, coupled with the prevalent stigma surrounding public hospitals, merits in-depth exploration.³ Lastly, comprehensive healthcare system evaluation.

Therefore, we strongly recommend expanding future research to encompass a wider geographical area, including diverse regions across Indonesia. This would provide a more comprehensive understanding of CS service efficiency and effectiveness nationwide. Furthermore, given the significant differences in funding structures, operational models, and patient demographics between these two sectors, a more nuanced exploration of their respective efficiencies and service qualities is crucial. We suggest conducting a thorough comparative analysis in future studies to elucidate these differences and their implications for CS service delivery. Then, a more comprehensive examination of the National Health Insurance (JKN/BPJS) system’s impact on CS services, including accessibility, quality, and financial implications, would significantly enhance our understanding of the broader healthcare landscape. We recommend integrating policy analysis into future research to provide a more holistic view of CS service delivery in Indonesia. The future studies can incorporate a qualitative research methodology to uncover the sociocultural factors, perceptions, and decision-making processes influencing patient choices in CS services. Besides, to truly understand the efficiency and effectiveness of CS services, it is imperative to evaluate the entire healthcare system’s performance. This includes assessing referral systems, emergency obstetric care networks, and the integration of primary and tertiary care in managing CS cases.⁴ We recommend broadening the scope of future studies to encompass these systemic aspects. While the current study provides a foundation for understanding CS services in West Sumatra, addressing these critical points in future research will significantly enhance our comprehension of CS service delivery in Indonesia. Such comprehensive studies are essential for informing evidence-based policies and improving maternal healthcare outcomes across the nation. These suggestions incorporated into future research endeavors in this crucial area of public health.