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

Authors

Mohammad Afzal Mahmood, University of Adelaide, Adelaide, SA, Australia
Ismi Mufidah, Kutai Kartanegara District Department of Health, East Kalimantan, Indonesia
Steven Scroggs, Women's and Children's Hospital, Adelaide, SA, Australia
Amna Rehana Siddiqui, Aga Khan UniversityFollow
Hafsa Raheel, King Saud University, Riyadh, Saudi Arabia
Koentijo Wibdarminto, Kutai Kartanegara District Department of Health, East Kalimantan, Indonesia
Bernardus Dirgantoro, Parikesit Hospital, Kutai Kartanegara, East Kalimantan, Indonesia
Jorien Vercruyssen, Flinders Medical Centre, Bedford Park, SA, Australia
Hayfaa A. Wahabi, King Saud University, Riyadh, Saudi Arabia

Document Type

Article

Department

Community Health Sciences

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.

Comments

volume, issue are not provided by the author/publisher

Publication (Name of Journal)

BioMed Research International

Recommended Citation

Mahmood, M. A., Mufidah, I., Scroggs, S., Siddiqui, A. R., Raheel, H., Wibdarminto, K., Dirgantoro, B., Vercruyssen, J., Wahabi, H. A. (2018). Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors. BioMed Research International, 1-11.
Available at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/657

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This work is licensed under a Creative Commons Attribution 3.0 License.