Maternal healthcare has received significant emphasis in the last two decades globally, and system-wide changes have contributed to improvements in pregnancy outcomes and reduction in maternal mortality [
Indonesia’s maternal mortality is still very high. In 2012, MMR was reported as 359/100,000 live births [
This persistent high maternal mortality despite significant access to the care necessitated a detailed analysis to identify root causes. Considering that maternal deaths occur mainly at the time of labour and delivery and in the postpartum period, the decrease in maternal mortality depends to quite an extent on a well-performing health system [
We conducted an in-depth analysis of root causes to maternal deaths in district Kutai Kartanegara of East Kalimantan province, to define relevant interventions to improve outcomes. With recommendation and approval by the provincial and district authorities, a team comprising the district health authority, district hospital, and collaborating public health and maternal health academics and researchers set out to identify the root causes of this persistently high MMR.
Healthcare services in Indonesia are decentralized to the district level, with District’s Department of Health responsible for planning, service delivery, and management of primary care services and frontline hospitals. While the frontline secondary care hospitals with basic services are funded and managed by the District Department of Health, the main tertiary specialist hospitals have independent management outside of the District Department of Health, with associated challenges in defining and implementing integrated care between primary care and tertiary care hospital in the district. Mainly the district government provides funding, through its own revenues, for the district services. However, some funds are provided by the central government for subsidized care to poor and as special grants such as for the development of new hospital or extension of services. The provincial department of health provides some financial assistance and technical support for services such as emergency obstetrics care.
The research was conducted for the period from July 2014 to June 2015 in a rural district, Kutai Kartanegara, in East Kalimantan province of about 650,000 people. While topography and access to transport make it difficult for about 100,000 people who live in remote areas to reach hospitals in the city, more than 500,000 people live no more than four hours from the well-equipped district hospital. The district had 32 well-staffed health centres, 179 subhealth centres, 103 doctors, 445 midwives, and 522 nurses. The District Department of Health manages two frontline hospitals placed in the rural areas, about two hours from the capital city of the district. The district’s tertiary hospital is located in the capital city and has a well-equipped and well-staffed obstetrics department. Antenatal care, intrapartum care, and postnatal care in primary care are provided by midwives in both public and private sectors in the district. A majority of the women receive ANC, PNC, and labour and delivery care from private midwives in their neighborhoods/villages and from midwives and doctors at the local government healthcare centre.
The district borders with the East Kalimantan province capital city has a tertiary teaching hospital, another large metropolitan city which also has many hospitals and a teaching hospital, and two other districts. Some of the residents of the district who live in the border areas visit these neighboring cities and district for primary care and hospital-based care and for which the district has funding arrangement with the neighboring districts.
In 2013, there were 203,340 women of reproductive age in the district. During that year, out of the 13,688 deliveries in the district, 12,601 were conducted by skilled birth attendants. Despite the high rate of access to ANC and despite 92% being delivered by skilled midwives or at the hospitals, MMR was about 230/100,000 live births. Majority of deaths, 73%, occurred at the hospitals.
The cases of maternal death in this study were identified through the Indonesian maternal death notification system. Maternal deaths in the hospitals and health centres are reported to the District Department of Health. All deaths of women of reproductive age are investigated by Maternal Health Team at the District Department of Health to confirm if it is a maternal death. Similarly, all deaths in the communities are investigated by the local government health centres with government midwives visiting the family to confirm whether a death is a maternal death. Additionally, the District Department of Health Maternal Health Team receives from the health centres reports of all deaths of woman in reproductive age, investigates, and then conducts verbal autopsies as required by the Indonesian Health System.
For this study, a comprehensive maternal deaths review framework was developed by incorporating safe motherhood concepts
A questionnaire in the local language was used to conduct verbal autopsy interview with the family members. This detailed structured questionnaire included 104 questions covering information on general health, pregnancy history, use of antenatal and intrapartum care services for the index pregnancy, and a detailed narrative about the terminal event and healthcare received during the terminal event. Additionally, using algorithms information was collected to define if the woman had suffered from preeclampsia, hemorrhage, sepsis, or other complications. The interview with the family took about two hours to complete.
Interviews were conducted with those public and private sector midwives who provided ANC to these 30 women and/or provided care during the terminal events. These interviews were conducted using a questionnaire with questions about general health, risk factors, care provided, and terminal event. The review of deaths at the hospitals included interviews with the staff and review of medical records, including investigations, complications, medication and referrals, timeliness, workloads, and availability of staff, equipment, and products. Information, including ANC received and medication in the Pink Book [pregnant women-held medical record book], was also collected.
Three doctors and three midwives were trained to collect verbal autopsy data. All interviews were conducted by these native language speaking doctors and midwives in Bahasa Indonesia. Six pilot interviews were conducted and minor adjustments to the questionnaires were made. With assistance by the research team, the hospital management constituted a Death Audit Committee. For those who died at the district hospital or another facility in the district, interviews were conducted with the family members, primary care midwife/traditional birth attendant, and the hospital staff. For those who died at home or on the way, interviews were conducted with the family members and primary care providers in addition to reviewing the medical records where available. The district hospital Death Audit Committee included a hospital director, district midwifery services coordinator, an obstetrician, a hospital midwife, and a public health specialist. Medical information contained in the hospital records was collected, and interviews were conducted with the staff.
Interviews were conducted with 30 families. 39 interviews were conducted with ANC providers, as in some cases there were more than one healthcare provider that provided ANC. For those 12 women who died at the district hospital, the hospital Death Audit Committee conducted death audits and the research team reviewed the hospital records in addition to the information provided by ANC providers and family members as well as the information available in the Pink Book (women-held record of health and healthcare during the pregnancy). For those who did not access the district hospital services, the information provided by ANC providers, family members, and the Pink books was reviewed to identify the immediate and root causes.
The data, including detailed terminal event narrative, for the 30 deaths was entered into Excel sheets. The researchers had access to detailed medical records as well. The root-cause analysis focused on organizational and management factors, team environment, individual staff knowledge, skills and practices, and patient characteristics [
Based on this data, six case studies were developed and shared with the staff for their observations about what could have been the reasons to ineffective management. A clinically trained health system specialist researcher, two obstetricians, health services managers, and another researcher reviewed the data to identify the contributory factors as defined by Farquhar et al. [
During the 12-month research period, 2014-2015, there were 30 deaths and 14,952 births in the district, with MMR of 200/100,000.
For the 12 deaths that occurred at the government hospitals within the district detailed medical notes were available. For the 10 women who died at the government hospitals outside of the district or at a private hospital, medical records were not available.
Table
Maternal characteristics of women who died.
Characteristics | Deaths in hospital ( | Deaths in community ( | Total |
---|---|---|---|
| |||
16–22 years | 4 | 3 | 7 (23.3) |
23–29 years | 5 | 1 | 6 (20.0) |
30–35 years | 7 | 2 | 9 (30.0) |
>35 years | 6 | 2 | 8 (26.7) |
| |||
None | 0 | 1 | 1 (3,3) |
Primary | 12 | 4 | 16 (53) |
Secondary | 4 | 1 | 5 (16.6) |
>Secondary | 6 | 2 | 8 (26.6) |
| |||
Housewife | 20 | 6 | 26 (86) |
Working in private/govt. | 2 | 2 | 4 (13) |
| |||
None | 1 | 5 | 6 (20) |
District govt. Insurance | 17 | 3 | 20 (66.6) |
Employer/other | 4 | 0 | 4 (13) |
| |||
10–20 minutes | 9 | 5 | 14 (46) |
>20–45 minutes | 5 | 2 | 7 (23) |
>45–180 minutes | 8 | 1 | 9 (30) |
| |||
None | 1 | 5 | 6 (20) |
Motor-Bike | 18 | 3 | 21 (70) |
Small Boat | 0 | 1 | 1 (3.3) |
Motor-bike & a small boat | 2 | 3 | 5 (16.6) |
| |||
Good | 12 | 4 | 16 (53) |
High BP/High cholesterol | 3 | 2 | 5 (16.6) |
Shortness of breath | 4 | 1 | 5 (16.6) |
Past or suspected TB | 2 | 1 | 3 (10) |
Other | 1 | 0 | 1 (3.3) |
| |||
None | 3 | 3 | 6 (20) |
Received 1-2 TT | 15 | 5 | 20 (66.6) |
Missing | 4 | 0 | 4 (13) |
| |||
None | 3 | 1 | 4 (13) |
TBA, at home | 3 | 3 | 6 (20) |
Midwife, at home | 4 | 2 | 6 (20) |
Midwife, at clinic | 4 | 1 | 5 (16.6) |
Health center | 2 | 0 | 2 (6.6) |
Hospital | 3 | 0 | 3 (10) |
Missing | 3 | 1 | 4 (13) |
Four maternal deaths were during pregnancy and five during labour and 21 women died in the postnatal period, of which 11 died within one day of the delivery, seven deaths occurred within 4–10 days after delivery, and three died more than ten days after the delivery. Fifteen women were delivered by Caesarian Sections (CS).
For the 20 direct maternal deaths, eclampsia/preeclampsia was the immediate cause of death for 45% of the deaths. The other causes included hemorrhage, pulmonary embolism CS complications obstructed labour, and complications of anesthesia (Table
Immediate causes of deaths.
Characteristics | Total (%) | Deaths in Hospital | Deaths in Community (Home, health centre, on-the-way to health centre or hospital) |
---|---|---|---|
Direct maternal deaths | 20 (67) | 17 | 3 |
APH-PPH | 3 | 3 | 0 |
Preeclampsia/eclampsia | 9 | 7 | 2 |
Obstructed labour | 2 | 2 | 0 |
Pulmonary embolism | 2 | 1 | 1 |
Anaesthesia related | 2 | 2 | 0 |
C-section complications | 2 | 2 | 0 |
Indirect maternal death | 3 (10) | 2 | 1 |
Unspecified | 7 (23) | 3 | 4 |
Many women suffered from at least one risk factor. Three women had CS in previous delivery. Four out of 30 were reported to have hypertension prior to the pregnancy or hypercholesterolemia. One woman was pregnant with twin pregnancy. Other risks were grand multiparity in seven women, advanced maternal age in eight women past or suspected tuberculosis in three women, and malaria in one woman (Table
Maternal obstetric profile of women who died.
Characteristic | Death in the hospital | Death in the community | Total |
---|---|---|---|
| |||
0-1 | 6 | 3 | 9 (30) |
2–4 | 12 | 3 | 14 (46) |
≥5 | 1 | 0 | 1 (3.3) |
Missing | 4 | 2 | 6 (20) |
| |||
3 months | 1 | 0 | 1 (3.3) |
7 months | 0 | 1 | 1 (3.3) |
8 months | 4 | 1 | 5 (16) |
9 months | 13 | 6 | 19 (63) |
Missing | 4 | 0 | 4 (13) |
| |||
No visit | 1 | 2 | 3 (10) |
One visit | 1 | 0 | 1 (3.3) |
Two visits | 1 | 2 | 3 (10) |
Three visits | 1 | 2 | 3 (10) |
Four and above | 16 | 2 | 18 (59.3) |
Missing | 2 | 0 | 2 (6.6) |
| |||
Previous CS | 3 | 0 | 3 (10) |
Previous stillbirth | 1 | 1 | 2 (7) |
Previous abortion | 1 | 1 | 2 (7) |
Previous miscarriage | 0 | 0 | 0 (0) |
Previous postpartum hemorrhage | 1 | 0 | 1 (3.3) |
| |||
Traditional birth attendant | 7 (23) | ||
Trained midwife | 13 (43) | ||
Midwife at the health centre | 3 (10) | ||
Government Hospital | 2 (7) | ||
Private Hospital | 0 (0) | ||
Private midwife clinic | 0 (0) | ||
Family member | 1 (3.3) | ||
Missing | 4 (13) |
Contributing factors were noted in each of the 30 deaths. Table
Root-cause analysis example: factors contributing to a death due to hemorrhage cause of death: hemorrhagic shock.
Questions & Reasons | How to address the contributing factors |
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| Improve rosters and policies for timely availability of specialists, development of midwifery risk assessment teams at ER |
| |
| Refresher training for better assessment of risks, management of risks hypertension, diabetes, and effective course of action for complications such as obstructed labour |
| |
| Develop, implement and monitor protocols for follow ups to assess if the referral was taken. Provide primary care workers, particular those midwives who are providing labour and delivery care in private sector, information about what services are available in which of the facilities |
| |
| Train primary care staff for risk assessment and for communicating the risk. Protocols for early assessment (first trimester) and subsequent categorization into high, intermediate and low risk, with each category having a plan of where to deliver. The plan should be included in the Pink Book |
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| Retrain midwives, with a focus on best practice protocols, referrals, communication skills, assessment and management of risks with case studies based on situation in the district |
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| Primary care services in this district must include family planning, actively supporting woman offering them a selection of methods. Improved health education as part of centre based and home based ANC provision |
Factors contributing to maternal death.
Contributing factors | Total deaths | Immediate cause of maternal death | Unsure if the factor played a role | ||
---|---|---|---|---|---|
Direct | Indirect | Unknown | |||
30 | 20 | 3 | 7 | ||
| |||||
| | ||||
Poor organization/management (both in primary and tertiary care) | 9 | 7 | 1 | 0 | 5 |
Lack of policy/protocol/guidelines | 13 | 12 | 1 | 0 | 2 |
Inadequate staff | 4 | 4 | 0 | 0 | 1 |
Inadequate access to senior clinical staff | 13 | 9 | 2 | 2 | 2 |
Failure/delay in emergency response | 15 | 11 | 1 | 3 | 2 |
Delay in procedures | 11 | 8 | 0 | 3 | 4 |
Poor system/process for sharing information (between primary and tertiary care) | 7 | 4 | 1 | 3 | 4 |
Delay in Access to Test Results | 2 | 1 | 1 | 0 | 4 |
| |||||
| | ||||
Knowledge and skills lacking | 24 | 15 | 3 | 6 | 4 |
Delay in emergency response | 14 | 9 | 1 | 4 | 2 |
Poor communication | 9 | 6 | 2 | 1 | 3 |
Failure to seek supervision/help | 13 | 7 | 2 | 4 | 3 |
Failure to follow best practice (hospital for 13 women, primary care for 12) | 25 | 18 | 3 | 4 | 3 |
Lack of recognition of seriousness | 20 | 13 | 2 | 5 | 4 |
| |||||
| | ||||
Malfunction/failure | 1 | 1 | 0 | 0 | 1 |
Supplies (blood, FFP, drugs, etc.) out of stock, unavailable on premises | 7 | 6 | 0 | 1 | 0 |
| |||||
| | ||||
Geography as contributory factor | 14 | 9 | 1 | 4 | 1 |
| |||||
| | ||||
Lack of recognition of seriousness | 16 | 9 | 2 | 5 | 1 |
Not Eligible for free care/financial difficulty | 5 | 3 | 1 | 1 | 0 |
Adapted from Farquhar et al. 2011 and Madzimbamuto et al. 2014.
In all 30 deaths personnel factor played a role. The analysis revealed that inadequate knowledge and skills of staff, both in primary care and in hospitals, and failure to follow best practice were the major factors contributing to these deaths. Inadequate knowledge and skills and failure to follow best practices were evident in all three indirect deaths and played a role in 75% of direct deaths as well. The organizational and management factors were noted for 28 (93%). Delay in provision of care, both due to organizational factors such as poor transfer practices from one to the other facility and due to staff failing to recognize the need for urgency, is another major contributing factor. Barriers at family/personal level in 16 (53%) deaths and the distance as a contributing factor also played a role towards 14 deaths (46%). The health services environment and technology factors played a role in 8 of 30 deaths, with unavailability of or delay in procuring blood or blood products in time contributing to 7 of these 8 deaths.
The root-cause analysis in this study provided a comprehensive understanding about how organizational, provider, patient, and community factors affected quality of care. Our study that combined many data collection tools including verbal autopsy and audits, which is an effective measure to identify quality of care factors [
Ineffective communication by staff led to poor understanding about which complications could be managed at which of the facilities and when to seek care. The deaths occurring at homes and on the way to a health facility most were due to preeclampsia and hemorrhage, long known causes of MM, for which health providers at first level could be trained and should have been able to assess warning signs and educate women and families about the associated dangers. A major cause of death was eclampsia; hence, midwives, health centre staff, and hospital staff needs to be retrained using protocols about assessment and management of hypertension, facilitating effective referral, defining a delivery plans and follow-ups at home during pregnancy and postnatal periods.
Majority of the women engaged with the formal healthcare services adequately. However, the poor quality of care received by these women is a major concern. In Kutai Kartanegara during the year this research was conducted, 86% deliveries were conducted by skilled birth attendants and 80% women received ANC from skilled healthcare providers (midwives, doctors, and obstetricians) at least 4 times during the pregnancy. Another study that used verbal autopsies to determine factors contributing to maternal mortality reported women having adequate access to care but with quality of care as a major concern [
In our research setting, the causes of poor quality of healthcare reside in poor organizational capacity and healthcare provider knowledge and practices. Lack of equipment and supplies, such as blood and blood products, deficiency of vital laboratory investigations, and shortage of specialist staff, are major contributory factors. The hospital staff and the Death Audit Committee’s observations highlighted the need for improved timeliness and effective care by addressing the shortage of specialists, particularly anesthetists. Similarly, the reviews by hospital staff alerted to the immediate need for timely and improved availability of appropriately crossed matched blood and blood products. Another recommendation based on the Death Audit Committee and hospital staff’s observations is to promote a team approach involving multiple specialists for managing complex cases through coordinated assessment and interventions.
Although the data generated by this research does not directly inform about ineffective use of the time of specialists, discussions with the hospital staff and management alerted to unnecessary referrals to specialists and that there is a subtle pressure on specialists to generate resources by providing care to many patients. There is a need to review hospital administration policies and practices that could potentially lead to ineffective use of human resources. A shortage of specialists to be available onsite, particularly during the night shifts, was a major concern. In one case, the unavailability of anesthetist led to less qualified anesthetist nurse to provide anesthesia, the quality of which was questionable and contributed to death. In at least three cases the condition of women deteriorated during the night and the specialist intervention and procedures could only be arranged by the next morning. Another organizational factor was inadequate triage facilities. Poor decision-making by specialists occurs as they may not be able to provide sufficient time and attention to assess risk. The research has identified association between hospital physician workload and length of stay, as an indicator of quality of care [
The factors undermining quality of healthcare are present in primary care as well. The inadequate quality of care and inconsistent approach to manage the risks such as preeclampsia in primary care have been noted previously as a major factor in maternal mortality [
Another major contributing factor to the delays in receiving care at the optimum time is the strict hierarchy of referral from the health centre to the district hospital, where some time operative intervention is not feasible, then again to a tertiary hospital. Precious valuable time is usually wasted which results in delays in receiving treatment and leaves the mother in a condition where her life in unsalvageable especially with the limited resources of the tertiary health setting in Indonesia.
It is important to note that social determinants, including factors such as social exclusion, gender equity, education, and employment play a major role towards health [
Millennium Development Goal 2015 MMR target was 102 per 100.000 live births. The national average MMR is reported from under 200 [
Recommendations to address the contributing factors.
Contributing factors | Recommendations |
---|---|
Failure to follow best practice protocols | District Health Department should institute a system of closer supervision & support, with maternal health team having sufficient number of midwife-supervisors working closely with the health centre and private midwives |
| |
Inability to manage deterioration | In hospitals, provide CME, and where possible place trainers on-site, retrain staff using standard courses particularly for preeclampsia and postpartum hemorrhage and effective use of early warning system. In primary care retrain staff for improved skills particularly for BP measurement and management |
| |
Poorly resourced facilities | Strengthen midwifery at the sub-district hospitals. Review staffing needs and retrain staff at the centres particularly those that are two or more hours from the district hospital |
| |
Missing essential service, such as blood products | Support the hospital management for decision to initiate or relocate services on premises |
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Ineffective communication | Conduct focused training for midwifery supervisors and heads of primary care centres, to communicate and develop delivery plans with the women, document sufficient details of the condition, and effectively use hotline with calls to hospitals before and during transfer of women |
| |
Unintegrated care and poor referrals | Develop protocols for early assessment and subsequent categorization into high, intermediate and low risk, with each category having a clear plan of where to deliver. Train staff using these protocols including information about capability of each of the district hospitals in terms of what services are available. Additionally, there is a need to train staff and emphasize on assessment of risks posed by concomitant illnesses with reference to the locally prevalent diseases such as TB, malaria and dengue, and provision of comprehensive and integrated care through a team approach. |
| |
Ineffective family planning services | Reemphasize a strong focus on family planning as part of maternal health care services in both primary care and at the hospital. Retrain staff to provide care to women with unmet need and potential unplanned pregnancies with a particular focus on multipara and age beyond 30 |
| |
Many women suffering from hypertensive conditions | Investigate eating & nutritional practices (e.g. salt intake) |
The research was approved by the Human Research Ethics Committee, University of Adelaide, approval number H-2014-035.
Mohammad Afzal Mahmood and Ismi Mufidah are co-first authors.
The authors declare that there are no conflicts of interest.
Mohammad Afzal Mahmood, Steven Scroggs, Ismi Mufidah, Koentijo Wibdarminto, and Bernardus Dirgantoro contributed to conceptualization. Mohammad Afzal Mahmood, Steven Scroggs, Ismi Mufidah, Hayfaa A. Wahabi, Amna Rehana Siddiqui, and Hafsa Raheel drafted survey instruments. Mohammad Afzal Mahmood, Steven Scroggs, Hayfaa A. Wahabi, and Amna Rehana Siddiqui did the literature search. Mohammad Afzal Mahmood, Ismi Mufidah, Koentijo Wibdarminto, and Bernardus Dirgantoro reviewed data collection tools, trained staff, and piloted the study. Mohammad Afzal Mahmood, Steven Scroggs, Ismi Mufidah, Hayfaa A. Wahabi, Amna Rehana Siddiqui, Hafsa Raheel, Koentijo Wibdarminto, and Jorien Vercruyssen contributed to data analysis and interpretations. Mohammad Afzal Mahmood and Ismi Mufidah drafted the manuscript and all authors reviewed and commented on drafts.
The authors are highly thankful to the families and other survey respondents, Dr. Martina Yulianti, Sri Lindawati, Meidiantati, District Hospital and Department of Health staff, Dr. Rini Retno Sukesi, Head Provincial Department of Health, and Meliana Oswald, Syarifah Masitah, and Rochmad Koesbiantoro. Thanks are due to Ms. Endang, Ms. Betty, Ms. Ulfa, Dr. Ronny, Dr. Adam, and Dr. Aulia who collected data. The research was conducted using the District Department of Health resources, with no outside funding.