Siti Nurul Qomariyah

Professional assistance during birth and maternal mortality in two Indonesian districts

OBJECTIVE To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia. METHODS We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios. FINDINGS The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen. CONCLUSION Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesias maternal mortality ratio.

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

New modelled estimates of maternal mortality

This letter comments on the estimated maternal mortality (MMRs) presented by Margaret Hogan and colleagues specifically those in Peru. It finds a discrepancy in the MMRs for Peru in comparison to the National Statistics Institute. It concludes that although analysts may draw on the same sources of data across countries the methods with which these data are collected varies widely within countries and the high uncertainty intervals for MMR reflect the need to strengthen the capacities of national and local information systems to obtain robust data.

A practical approach to identifying maternal deaths missed from routine hospital reports: lessons from Indonesia

Background: Accurate estimates of the number of maternal deaths in both the community and facility are important, in order to allocate adequate resources to address such. On the other hand, current studies show that routine methods of identifying maternal deaths in facilities underestimate the number by more than one-half. Objective: To assess the utility of a new approach to identifying maternal deaths in hospitals. Method: Deaths of women of reproductive age were retrospectively identified from registers in two district hospitals in Indonesia over a 24-month period. Based on information retrieved, deaths were classified as ‘maternal’ or ‘non-maternal’ where possible. For deaths that remained unclassified, a detailed case note review was undertaken and the extracted data were used to facilitate classification. Results: One hundred and fifty-five maternal deaths were identified, mainly from the register review. Only 67 maternal deaths were recorded in the hospitals’ routine reports over the same period. This underestimation of maternal deaths was partly due to the incomplete coverage of the routine reporting system; however, even in the wards where routine reports were made, the study identified twice as many deaths. Conclusion: The RAPID method is a practical method that provides a more complete estimate of hospital maternal mortality than routine reporting systems.

Maternal mortality, birth with a health professional and distance to obstetric care in Indonesia and Bangladesh.

To examine the relationship between distance to a health facility, consulting a health professional and maternal mortality.

Can the right to health inform public health planning in developing countries? A case study for maternal healthcare from Indonesia.

Background: Maternal mortality remains unacceptably high in developing countries despite international advocacy, health and development targets, and simple, affordable and effective interventions. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged. Objective: We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal health care. Our objective is to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective. Design: Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceaseds relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death. Results: In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent, reflecting her exclusion from access to healthcare. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld. Conclusion: There are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning.