ABSTRACT
Despite most Indonesian women now receiving antenatal care on the nationally recommended four occasions and being delivered by skilled birth attendants, the nation's maternal mortality ratio (MMR) is estimated as 177 per 100,000 live births. Recent research in a rural district of Indonesia has indicated that poor service quality due to organizational and personnel factors is now a major determinant of this high MMR. The present research is an in-depth analysis of possible health service organizational and quality of care related causes of death among 30 women admitted to a peak referral hospital in a major Indonesian city. Despite their condition being complex or deteriorating, most of these women arrived at the hospital in a state where it was feasible to prevent death with good quality care. Poor application of protocols, poor information flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating patients were the main contributing factors to these deaths. Pyramidal referrals also contributed, as many women were initially referred to hospitals where their condition could not be effectively managed. While generic quality improvement measures, particularly training and monitoring for rigorous application of clinical protocols (including forward planning for deteriorating patients) will help improve the situation, the districts and hospitals need to develop capacity to assess their local situation. Unless local organisational factors, staff knowledge and skill, blood and blood product availability, and local reasons for delays in providing care are identified, it may not be possible to effectively reduce the adverse pregnancy outcomes.
Subject(s)
Eclampsia/mortality , Postpartum Hemorrhage/mortality , Pre-Eclampsia/mortality , Pregnancy Complications, Infectious/mortality , Prenatal Care/organization & administration , Quality of Health Care , Cities , Eclampsia/epidemiology , Female , Health Knowledge, Attitudes, Practice , Health Personnel/psychology , Health Services Accessibility/organization & administration , Humans , Indonesia , Maternal Mortality , Postpartum Hemorrhage/epidemiology , Pre-Eclampsia/epidemiology , Pregnancy , Pregnancy Complications, Infectious/epidemiology , Referral and Consultation , Risk Factors , Time-to-TreatmentABSTRACT
OBJECTIVE: To determine the factors contributing to hospital-based maternal deaths in Indonesia, given most women deliver with skilled birth attendants and in health facilities. METHODS: A retrospective review of case records examined quality of care issues related to maternal mortality in hospital settings. The review abstracted information from blinded medical records of 90 women who died in 11 hospitals from January to June 2014. Specialists from the Indonesian Society of Obstetrics and Gynecology reviewed abstracted records to determine causes of death and identify contextual factors for these deaths. RESULTS: Seventy-five of the 90 maternal deaths (83%) reviewed were due to direct obstetric causes. Severe pre-eclampsia and eclampsia combined were the leading direct cause of death (42%). Human resource/health worker factors were more frequently identified than supply, facility, or infrastructure factors. Ninety percent of maternal deaths were classified as preventable. CONCLUSION: The review exercise yielded useful information on factors contributing to preventable maternal mortality in hospitals in Indonesia. Results helped focus quality improvement efforts and increased awareness of the value of routine, in-depth facility-based maternal death reviews.
