Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors

Abstract

Background Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

Changes in obstetric case fatality and early newborn mortality rates in hospitals after the implementation of the Expanding Maternal and Neonatal Survival program in Indonesia: Results from a health information system

“…Only 29.4% of maternal deaths occurred at the home. Several studies have suggested that poor quality of maternal care at health facilities in Indonesia contributes to high maternal mortality . A study in Papua province suggests poor quality and delays in receiving appropriate care at facilities are the major causes of maternal mortality …”

Assessment of knowledge of evidence‐based maternal and newborn care practices among midwives and nurses in six provinces in Indonesia

“…There is limited information on Indonesian health workers’ knowledge of obstetric and newborn care practices. Mahmood et al . reviewed 30 maternal deaths that occurred in Kutai Kartanegara in East Kalimantan province.…”

The effect of Expanding Maternal and Neonatal Survival interventions on improving the coverage of labor monitoring and complication prevention practices in hospitals in Indonesia: A difference‐in‐difference analysis

“…Behavior change is a complicated endeavor and changing provider behavior related to infection prevention, especially handwashing, can be challenging . Provider behavior, insufficient training, shortages in staffing, and in some cases, limited supplies and resources influence whether care is provided as recommended and may have factored into the observed suboptimal coverage as well as the differences in performance by hospital type …”

“…Ensuring that care provided in these facilities is of sufficient quality to support improvements in maternal and newborn outcomes and reductions in mortality is vital . Improved provider practices to monitor the intrapartum period and prevent complications, as well as facility readiness to prevent and/or manage adverse events, have been the focus of various quality assessment and improvement efforts . The success of EMAS interventions in improving some of these practices in Indonesia through strengthened clinical governance may assist wider efforts in Indonesia to achieve better health for women and their babies.…”