Maternal characteristics and clinical diagnoses influence obstetrical outcomes in Indonesia

Determinant Factors for High-Risk Pregnancy among Minangkabau Ethnicity in Indonesia

BACKGROUND: High-risk pregnancy cause multifactorial. The lack of investment in better and more accessible hospital care for women and newborns in Indonesia may be partly to blame for the country's disproportionately high rates of high-risk pregnancy, maternal, and perinatal death. AIM: The aim of this study was to determine determinant factors for high-risk pregnancy among minangkabau ethnicity in Indonesia. Method: The authors conducted a case control study. Data were gathered  in Healthcare Facilities Padang, Indonesia from December 2019-December 2020. The number of subjects in this research were 64 cases group (women with high-risk pregnancy) and 128 control group (normal pregnancy) matching by sex and region. The sampling technique in this research was proportional random sampling. Data were gathered from medical records and primary data collection with survey data. Bivariate and multivariate analysis were investigated using Chi-square and Logistic binary regression test. The data were analyzed using STATA version 14.2. Result: There were associations between mother's educational level, women's empowerment, head of the family educational level, chronic diseases, history of childbirth, maternal age and parity with high-risk pregnancy. Multivariate analysis found that the highest Odds ratio (OR) for the occurrence of high-risk pregnancy were history of childbirth (OR = 8.26, 95% CI 3.32-20.52), and mother's level of education (OR = 5.67, 95% CI 2.64-12.15). Conclusion: This analysis confirmed the history of childbirth and the mother’s level of education for high-risk pregnancy among Minangkabau ethnicity in Indonesia. The findings of risk factors for a high-risk pregnancy can be determined through early detection and useful predictors so that women can detect high-risk pregnancy themselves.

A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to?

BACKGROUND

Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes.

AIMS

To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region.

MATERIALS AND METHODS

A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators.

RESULTS

The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective.

CONCLUSIONS

Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.

Severe maternal morbidity in the Asia Pacific: a systematic review and meta-analysis

BACKGROUND

Monitoring rates of severe maternal morbidity (such as eclampsia and uterine rupture) is useful to assess the quality of obstetric care, particularly in low and lower-middle-income countries (LMICs).

METHODS

We undertook a systematic review characterising the proportion and causes of severe maternal morbidity in the Asia Pacific region. We searched Medline, Embase, Cochrane CENTRAL library and the World Health Organization Western Pacific Index database for studies in the Asia-Pacific reporting maternal morbidity/near miss using a predefined search strategy. We included cohort, case-control and cross-sectional studies published in English before September 2020. A meta-analysis was performed calculating the overall proportion of near miss events by sub-region, country, near miss definition, economic status, setting and cause using a random-effects model.

FINDINGS

We identified 26,232 articles, screened 24,306 and retrieved 454 full text articles. Of these, 197 studies spanning 27 countries were included. 13 countries in the region were not represented. There were 30,183,608 pregnancies and 100,011 near misses included. The total proportion of near miss events was 4•4 (95% CI 4•3-4•5) per 1000 total births. The greatest proportion of near misses were found in the Western Pacific region (around Papua New Guinea) at 11•8 per 1000 births (95% CI 6•6-17•1; I² 96.05%). Low-income countries displayed the greatest proportion of near misses (13•4, 95% CI 6•0-20•7), followed by lower-middle income countries (11•1; 95% CI 10•4 - 11•9). High-income countries had the lowest proportion (2•2, 95% CI 2•1-2•3). Postpartum haemorrhage was the most common near miss event (5•9, 95% CI 4•5-7•2), followed by eclampsia (2•7, 95% CI 2•4 - 2•9).

INTERPRETATION

There is a high burden of severe maternal morbidity in the Asia-Pacific. LMICs are disproportionately affected. Most of the common causes are preventable. This provides an opportunity to implement targeted interventions which could have major clinical impact.

Regional disparities in postnatal care among mothers aged 15-49 years old: An analysis of the Indonesian Demographic and Health Survey 2017

Background: In Indonesia, maternal mortality remains high, significantly 61.59% occur in the postnatal period. Postnatal care (PNC) provision is a critical intervention between six hours and 42 days after childbirth and is the primary strategy to reduce maternal mortality rates. However, underutilisation of PNC in Indonesia still remains high, and limited studies have shown the regional disparities of PNC in Indonesia. Methods: This study aims to explore the gaps between regions in PNC service for mothers who have had live births during the last five years in Indonesia. This study was a secondary data analysis study using the Indonesian Demographic and Health Survey (IDHS) in 2017. A total of 13,901 mothers aged 15-49 years having had live births within five years were included. Chi-squared test and binary logistic regression were performed to determine regional disparities in PNC. Results: Results indicated that the prevalence of PNC service utilisation among mothers aged 15-49 years was 70.94%. However, regional gaps in the utilisation of PNC service were indicated. Mothers in the Central of Indonesia have used PNC services 2.54 times compared to mothers in the Eastern of Indonesia (OR = 2.54; 95% CI = 1.77-3.65, p<0.001). Apart from the region, other variables have a positive relationship with PNC service, including wealth quintile, accessibility health facilities, age of children, childbirth order, mother's education, maternal occupation, spouse's age, and spouse's education. Conclusion: The results suggest the need for national policy focuses on service equality, accessible, and reliable implementation to improve postnatal care utilisation among mothers to achieve the maximum results for the Indonesian Universal Health Coverage plan.

Regional disparities in postnatal care among mothers aged 15-49 years old: An analysis of the Indonesian Demographic and Health Survey 2017

Background: In Indonesia, maternal mortality remains high, significantly 61.59% occur in the postnatal period. Postnatal care (PNC) provision is a critical intervention between six hours and 42 days after childbirth and is the primary strategy to reduce maternal mortality rates. However, underutilisation of PNC in Indonesia still remains high, and limited studies have shown the regional disparities of PNC in Indonesia. Methods: This study aims to explore the gaps between regions in PNC service for mothers who have had live births during the last five years in Indonesia. This study was a secondary data analysis study using the Indonesian Demographic and Health Survey (IDHS) in 2017. A total of 13,901 mothers aged 15-49 years having had live births within five years were included. Chi-squared test and binary logistic regression were performed to determine regional disparities in PNC. Results: Results indicated that the prevalence of PNC service utilisation among mothers aged 15-49 years was 70.94%. However, regional gaps in the utilisation of PNC service were indicated. Mothers in the Central of Indonesia have used PNC services 2.54 times compared to mothers in the Eastern of Indonesia (OR = 2.54; 95% CI = 1.77-3.65, p<0.001). Apart from the region, other variables have a positive relationship with PNC service, including wealth quintile, accessibility health facilities, age of children, childbirth order, mother's education, maternal occupation, spouse's age, and spouse's education. Conclusion: The results suggest the need for national policy focuses on service equality, accessible, and reliable implementation to improve postnatal care utilisation among mothers to achieve the maximum results for the Indonesian Universal Health Coverage plan.

Surviving mothers and lost babies - burden of stillbirths and neonatal deaths among women with maternal near miss in eastern Ethiopia: a prospective cohort study

Background

Although maternal near miss (MNM) is often considered a ‘great save’ because the woman survived life-threatening complications, these complications may have resulted in loss of a child or severe neonatal morbidity. The objective of this study was to assess proportion of perinatal mortality (stillbirths and early neonatal deaths) in a cohort of women with MNM in eastern Ethiopia. In addition, we compared perinatal outcomes among women who fulfilled the World Health Organization (WHO) and the sub-Saharan African (SSA) MNM criteria.

Methods

In a prospective cohort design, women with potentially life-threatening conditions (PLTC) (severe postpartum hemorrhage, severe pre-(eclampsia), sepsis/severe systemic infection, and ruptured uterus) were identified every day from January 1st, 2016, to April 30th, 2017, and followed until discharge in the two main hospitals in Harar, Ethiopia. Maternal and perinatal outcomes were collected using both sets of criteria. Numbers and proportions of stillbirths and early neonatal deaths were computed and compared.

Results

Of 1054 women admitted with PTLC during the study period, 594 women fulfilled any of the MNM criteria. After excluding near misses related to abortion, ectopic pregnancy or among undelivered women, 465 women were included, in whom 149 (32%) perinatal deaths occurred: 132 (88.6%) stillbirths and 17 (11.4%) early neonatal deaths. In absolute numbers, the SSA criteria picked up more perinatal deaths compared to the WHO criteria, but the proportion of perinatal deaths was lower in SSA group compared to the WHO (149/465, 32% vs 62/100, 62%). Perinatal mortality was more likely among near misses with antepartum hemorrhage (adjusted odds ratio (aOR) = 4.81; 95% CI = 1.76-13.20), grand multiparous women (aOR = 4.31; 95% confidence interval CI = 1.23-15.25), and women fulfilling any of the WHO near miss criteria (aOR = 4.89; 95% CI = 2.17-10.99).

Conclusion

WHO MNM criteria pick up fewer perinatal deaths, although perinatal mortality occurred in a larger proportion of women fulfilling the WHO MNM criteria compared to the SSA MNM criteria. As women with MNM have increased risk of perinatal deaths (in both definitions), a holistic care addressing the needs of the mother and baby should be considered in management of women with MNM.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Outcomes by birth setting and caregiver for low risk women in Indonesia: a systematic literature review

BACKGROUND

Care for women during pregnancy, labour, birth and the postpartum period is essential to reducing maternal and neonatal mortality and morbidity, however the ideal place and organisation of care provision has not been established. The World Health Organization recommends a two-tier maternity care system involving first-level care in community facilities, with backup obstetric hospital care. However, evidence from high-income countries is increasingly showing benefits for low risk women birthing outside of hospital with skilled birth assistance and access to backup care, including lower rates of intervention. Indonesia is a lower middle-income country with a network of village based midwives who attend births at homes, clinics and hospitals, and has reduced mortality rates in recent decades while maintaining largely low rates of intervention. However, the country has not met its neonatal or maternal mortality reduction goals, and it is unclear whether greater improvements could be made if all women birthed in hospital. BODY: This paper reviewed the literature on birth outcomes by place of birth and/or caregiver for women considering their risk of complications in Indonesia. A systematic literature search of Pubmed, CINAHL, CENTRAL, Web of Science, Popline, WHOLIS and clinical trials registers in 2016 and updated in 2018 resulted in screening 2211 studies after removing duplicates. Twenty four studies were found to present outcomes by place of birth or caregiver and were included. The studies were varied in their findings with respect of the outcomes for women birthing at home and in hospital, with and without skilled care. The quality of most studies was rated as poor or moderate using the Effective Public Health Practice Project Quality Assessment Tool. Only one study gave an overall assessment of the risk status of the women included, making it impossible to draw conclusions about outcomes for low risk women specifically; other studies adjusted for various individual risk factors.

CONCLUSION

From the studies in this review, it is impossible to assess the outcomes for low risk women birthing with health professionals within and outside of Indonesian hospitals. This finding is supported by reviews from other countries with developing maternity systems. Better evidence and information is needed before determinations can be made about whether attended birth outside of hospitals is a safe option for low risk women outside of high income countries.

Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia

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.

Women who have not utilized health Service for Delivery in Nigeria: who are they and where do they live?

BACKGROUND

Health facility delivery has been described as one of the major contributors to improved maternal and child health outcomes. In sub-Saharan Africa where 66% of the global maternal mortality occurred, only 56% of all births take place in health facility. This study examined the individual and contextual predictors of non-use of health service for delivery in Nigeria where less than 40% births occur in health facility.

METHODS

Data from 2013 Nigeria Demographic and Health Survey (DHS) involving 20,192 women who had delivery within 5 years of the survey were used in the study. Multilevel multivariable logistics regression models which had the structure of non-use of health service for delivery defined at individual, community and state levels were applied in the analysis. Spatial analysis was also used to capture the locations where the phenomenon is prevalent in the country.

RESULTS

About 62% of the women did not utilize health service during delivery. More than three-quarter of those with no education and 92% of those who did not attend antenatal clinic during pregnancy never utilized health service for delivery. The odds of non-use of health service during delivery increased for women who had no education, from poor households, aged 25-34 years, unmarried, never attended antenatal clinic, experienced difficulty getting to health facility and lived in the most socioeconomically disadvantaged communities and states.

CONCLUSIONS

This study has demonstrated that non-utilization of health service for delivery is influenced by individual, community and state level factors, with substantial proportions of women not utilizing such service residing in the northern region of Nigeria. Each level should be adequately considered in the design of the appropriate interventions.

Maternal socio-demographic factors associated with low parity and grand multiparity in Nigeria

Parity may be categorized as low parity (one or two births), multiparity (three or four births), and grand multiparity (five or more births). In Nigeria, studies have examined factors associated with parity among women. However, these studies have focused on the associated factors of grand multiparity with near exclusion of associated factors of low parity. This study addressed this knowledge gap by examining maternal socio-demographic factors associated with both low parity and grand multiparity in Nigeria. The study analyzed secondary data from 2013 Nigeria Demographic and Health Survey (NDHS). The weighted sample size was 25,852 women. With the use of Stata (version 14), analyses were performed at three levels. Multinomial logistic regression was applied at the multivariate level. Results showed that many of the studied maternal characteristics were significantly associated with either low parity or grand multiparity. Results further showed that while late age at first marriage, improved education, never experiencing child mortality, and polygyny increased the likelihood of low parity, improved education, polygyny, never experiencing child mortality, late age at first marriage, and higher household wealth reduced the likelihood of grand multiparity. These factors should be given prominence in population and women-centered programs in the country.

Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia

Background: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem.

Objective: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity.

Methods: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762).

Results: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia.

Conclusion: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.

'I wanted to enjoy our marriage first… but I got pregnant right away': a qualitative study of family planning understandings and decisions of women in urban Yogyakarta, Indonesia

BACKGROUND

Despite several decades of investment into family planning and maternal health systems strengthening, Indonesia's maternal mortality ratio remains among the highest in Southeast Asia. Among postpartum women unmet need for family planning is greater than at any other time, thus there is great potential to improve the reproductive health outcomes of Indonesian women through enhanced postpartum family planning access. This article explores the socially embedded nature of family planning choices in the Indonesian context, drawing on the experiences of a sample of urban dwelling and predominantly middle class women.

METHODS

This was an ethnographic study which explored the reproductive experiences of women residing in Yogyakarta City, and Sleman and Bantul regencies. Fieldwork was undertaken over 18 months from September 2014 to March 2016. This article draws on 31 in-depth interviews (IDIs) conducted with 20 women aged 21 to 38 years who had given birth less than two years prior.

RESULTS

Though there was great variance across women's reproductive trajectories, the majority had limited understandings of family planning, especially in relation to contraception. Societal norms pertaining to women's fertility and reproduction underpinned women's desires to become pregnant soon after marriage. Normative ideals concerning family size and the composition of families underpinned women's desires for a maximum of two to three children, with at least one child of each sex. Negotiations concerning timing of pregnancies and family size occurred within spousal relationships. The majority of women were using some form of fertility control to prevent or space pregnancies, with method choice decisions often informed by family members, friends and family planning providers. Quality of care among family planning providers was often lacking, perpetuating misinformation, and women's choices were not always respected.

CONCLUSIONS

Our analysis reveals the socially embedded nature of women's postpartum family planning understandings and choices, and the ways in which social and relational factors sometimes constrain and at other times support women's reproductive agency. We identify key areas for health sector reform to enhance women's understandings of postpartum family planning and improve family planning quality of care.

Maternal and neonatal services in Ethiopia: measuring and improving quality

Problem

Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress.

Approach

We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services.

Local setting

Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals.

Relevant changes

Significant improvements in quality of intrapartum care were detected from baseline (June–July 2015) to follow-up (February–March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001).

Lessons learnt

The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.

Maternal characteristics and obstetrical complications impact neonatal outcomes in Indonesia: a prospective study

BACKGROUND

We investigated associations between maternal characteristics, access to care, and obstetrical complications including near miss status on admission or during hospitalization on perinatal outcomes among Indonesian singletons.

METHODS

We prospectively collected data on inborn singletons at two hospitals in East Java. Data included socio-demographics, reproductive, obstetric and neonatal variables. Reduced multivariable models were constructed. Outcomes of interest included low and very low birthweight (LBW/VLBW), asphyxia and death.

RESULTS

Referral from a care facility was associated with a reduced risk of LBW and VLBW [AOR = 0.28, 95% CI = 0.11-0.69, AOR = 0.18, 95% CI = 0.04-0.75, respectively], stillbirth [AOR = 0.41, 95% CI = 0.18-0.95], and neonatal death [AOR = 0.2, 95% CI = 0.05-0.81]. Mothers age <20 years increased the risk of VLBW [AOR = 6.39, 95% CI = 1.82-22.35] and neonatal death [AOR = 4.10, 95% CI = 1.29-13.02]. Malpresentation on admission increased the risk of asphyxia [AOR = 4.65, 95% CI = 2.23-9.70], stillbirth [AOR = 3.96, 95% CI = 1.41-11.15], and perinatal death [AOR = 3.89 95% CI = 1.42-10.64], as did poor prenatal care (PNC) [AOR = 11.67, 95%CI = 2.71-16.62]. Near-miss on admission increased the risk of neonatal [AOR = 11.67, 95% CI = 2.08-65.65] and perinatal death [AOR = 13.08 95% CI = 3.77-45.37].

CONCLUSIONS

Mothers in labor should be encouraged to seek care early and taught to identify early danger signs. Adequate PNC significantly reduced perinatal deaths. Improved hospital management of malpresentation may significantly reduce perinatal morbidity and mortality. The importance of hospital-based prospective studies helps evaluate specific areas of need in training of obstetrical care providers.