ArticleBioMed research international2018
Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.
Article in BioMed research international, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 18 papers, 3 of them syntheses that pooled it.
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Who cites it
18 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- Trends and causes of maternal mortality in Indonesia: a systematic review.BMC pregnancy and childbirth · 2024Pooled it
- The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis.BMC pregnancy and childbirth · 2021Pooled it
- How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review.Medical principles and practice : international journal of the Kuwait University, Health Science Centre · 2020Pooled it
- Community Participation, Mediation and Advocacy to Harness the Developmental Benefits of Relocation of New Capital of Indonesia for Local Communities: Action Research Linking Community and Government Perspectives.Health promotion journal of Australia : official journal of Australian Association of Health Promotion Professionals · 2025Article
- Development and testing of mobile phone text messages for improving maternal and newborn care practice in Jimma Zone, Ethiopia: a user-centered design approach.Pilot and feasibility studies · 2025Article
- Challenges of health workers in primary health facilities in implementing obstetric emergency referrals to save women from death in Indonesia: A qualitative study.Belitung nursing journal · 2024Article
- Obstetrics care in Indonesia: Determinants of maternal mortality and stillbirth rates.PloS one · 2024Article
- Men's determinant factors on antenatal care involvement and childbirth place preference in Indonesia: An analysis of the 2012 Indonesia Demographic and Health Survey (IDHS).Journal of public health research · 2023Article
- Causes for Medical Errors in Obstetrics and Gynaecology.Healthcare (Basel, Switzerland) · 2023Review
- Verbal autopsy analysis of maternal mortality in Bong County, Liberia: a retrospective mixed methods study.BMJ open quality · 2023Article
- Study Factors Involved in Maternal Deaths Attributed to COVID-19 in a Disadvantaged Area in Southeast of Iran.Journal of family & reproductive health · 2022Article
- Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level.PloS one · 2022Article
- "Sharp downward, blunt upward": district maternal death audits' challenges to formulate evidence-based recommendations in Indonesia - a qualitative study.BMC pregnancy and childbirth · 2021Article
- Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia.PloS one · 2021Article
- A protocol study of participatory action research: integrated care pathway for pregnant women with heart disease in Indonesia.BMC health services research · 2020Article
- Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis.Journal of global health · 2020Article
- Maternal health improvement through root cause analysis of severe maternal morbidity (maternal near miss) in Isfahan, Iran.Journal of education and health promotion · 2020Article
- The Effect of Massage Therapy Using Frangipani Aromatherapy Oil to Reduce the Childbirth Pain Intensity.International journal of therapeutic massage & bodywork · 2019Article
Corrections and comments
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Authors and funding
9 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundDespite 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.
methodThirty 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.
findingsThe 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.
conclusionThere 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.
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