Reducing Maternal Mortality: A Qualitative Study of Health Workers’ Expectation in Urban Area, Indonesia


  • Arlina Dewi Department of Public Health, Master of Hospital Administration, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Sri Sundari Department of Medical Education, School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Nursetiawan Nursetiawan Department of Civil Engineering, Faculty of Engineering, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Supriyatiningsih Supriyatiningsih Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Dianita Sugiyo Department of Public Health Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Dyah Tri Kusuma Dewi Department of Public Health, Master of Hospital Administration, Universitas Muhammadiyah Yogyakarta, Bantul, Indonesia
  • Winda Azmi Meisari Department of Hospital Administration, Faculty of Health Sciences, Universitas Aisyiyah Surakarta, Surakarta, Indonesia



emergency obstetric, health workers, maternal mortality


BACKGROUND: Maternal mortality is a sentinel event used globally to monitor maternal health and the overall quality of reproductive health care. Globally, maternal mortality is mostly due to direct causes; apparently, it is not limited by the setting or geographic region. However, Indonesia has failed to achieve the Millenium Development Goals (MDGs) target for maternal mortality.

AIM: This study aims to explore health workers' and stakeholders' expectations in maternal health services to reduce maternal mortality in urban areas.

METHODS: It is qualitative research through naturalistic, conducted in one of the regencies in Indonesia, the urban area with the highest Maternal Mortality Rate (MMR) in one province by 2019. Data were obtained in the form of information from Focus Group Discussions (FGDs). FGDs were carried out with stakeholders at the Health Service level (n=3), first-level health facilities or public health centres (n=3), and advanced health facilities or hospitals (n=7). Data analysis in this study employed software (Nvivo Release 1.0) to utilise transcripts in coding and categorising.

RESULTS: The expectations that emerged from health workers' perspectives in the field were an integrated system of collaboration between health facilities, affordability of Hospital with Comprehensive Emergency Obstetric Care (CEmOC) in action for maternal-neonatal referral urgency, and the skilled health workers as a golden opportunity.

CONCLUSION: Health workers’ expectations can improve the quality of maternal health services in urban areas, thereby reducing the MMR with a system of collaboration between health facilities, the affordability of maternal-neonatal emergency referral facilities, and the availability of Obstetricians who standby.


Download data is not yet available.


Metrics Loading ...


Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: A systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387(10017):462-74. s0140-6736(15)00838-7 PMid:26584737

World Health Organization. Trends in Maternal Mortality: 1990- 2015: Estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015.

Say L, Chou D, Gemmill A, Tunçalp O, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Health. 2014;2:e323-33. s2214-109x(14)70227-x PMid:25103301

Tort J, Rozenberg P, Traoré M, Fournier P, Dumont A. Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: A cross-sectional epidemiological survey. BMC Pregnancy Childbirth. 2015;15:235. PMid:26423997

Dinas Kesehatan Kabupaten Bantul. Profil Kesehatan Kabupaten Bantul Tahun 2019. Bantul: Dinas Kesehatan Kab; 2019.

UNICEF, editor. Maternal and Newborn Health. New York: UNICEF; 2008.

Reid A, Garrett E. Medical provision and urban-rural differences in maternal mortality in late nineteenth century Scotland. Soc Sci Med. 2018;201:35-43. PMid:29428888

Mersha AG. Male involvement in the maternal health care system: implication towards decreasing the high burden of maternal mortality. BMC Pregnancy Childbirth. 2018;18:493. PMid:30547771

Kodan LR, Verschueren KJ, van Roosmalen J, Kanhai HH, Bloemenkamp KW. Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey. BMC Pregnancy Childbirth. 2017;17:275. PMid:28851302

Beuving J, de Vries G. Doing Qualitative Research the Craft of Naturalistic Inquiry. Amsterdam: Amsterdam University Press; 2014.

Merriam SB, Tisdell EJ. Qualitative Research : A Guide to Design and Implementation. San Francisco: Jossey-Bass A Wiley Brand; 2016.

Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, Calif: Sage Publications; 2002.

Tuckett AG. Part II. Rigour in qualitative research: Complexities and solutions. Nurse Res. 2005;13(1):29-42. PMid:16220839

Flick U. The SAGE Handbook of Qualitative Data Analysis. Singapore: Sage Publications; 2014.

Susan M, Peters PK, Andrew B, Halcomb E. An exemplar of naturalistic inquiry in general practice research. Nurse Res. 2017;24:36-41. PMid:28102791

Thomas E, Magilvy JK. Qualitative rigor or research validity in qualitative research. J Spec Pediatr Nurs. 2011;16(2):151-5. PMid:21439005

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101.

Klode K, Ringer A, Hølge-Hazelton B. Interprofessional and intersectoral collaboration in the care of vulnerable pregnant women: An interpretive study. J Interprof Care. 2020;2020:1-10. PMid:32436756

Raman S, Iljadica A, Gyaneshwar R, Taito R, Fong J. Improving maternal and child health systems in Fiji through a perinatal mortality audit. Int J Gynaecol Obstet. 2015;129(2):165-8. PMid:25636710

Behruzi R, Klam S, Dehertog M, Jimenez V, Hatem M. Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: A case study. BMC Pregnancy Childbirth. 2017;17(1):200. PMid:28651552

Karam M, Brault I, Van Durme T, Macq J. Comparing interprofessional and interorganizational collaboration in healthcare: A systematic review of the qualitative research. Int J Nurs Stud. 2018;79:70-83. PMid:29202313

Pieper PG. The pregnant woman with heart disease: Management of pregnancy and delivery. Neth Heart J. 2012;20(1):33-7. PMid:22068733

Sangaleti C, Schveitzer MC, Peduzzi M, Zoboli EL, Soares AB. Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review. JBI Database Syst Rev Implementation Rep. 2017;15(11):2723-88. PMid:29135752

World Health Organization, ICM, FIGO. Making Pregnancy Safer: The Critical Role of the Skilled Attendant. Switzerland: World Health Organization; 2004.

Bronstein LR. A model for interdisciplinary collaboration. Soc Work. 2003;48(3):297-306. PMid:12899277

Downe S, Finlayson K, Fleming A. Creating a collaborative culture in maternity care. J Midwifery Womens Health. 2010;55(3):250-4. PMid:20434085

Homer C, Brodie P, Sandall J, Leap N. Midwifery Continuity of Care: A Practical Guide. Amsterdam, Netherlands: Elsevier Health Sciences; 2019.

Peterson WE, Medves JM, Davies BL, Graham ID. Multidisciplinary collaborative maternity care in Canada: easier said than done. J Obstet Gynaecol Can. 2007;29(11):880-6. PMid:17977491

Willumsen E. Interprofessional collaboration a matter of differentiation and integration? Theoretical reflections based in the context of Norwegian childcare. J Interprof Care. 2008;22(4):352- 63. PMid:18800277

Kongnyuy E, Hofman J, van den Broek N. Ensuring effective essential obstetric care in resource poor settings. BJOG. 2009;116(Suppl 1):41-7. PMid:19740171

Kongnyuy EJ, Hofman J, Mlava G, Mhango C, van den Broek N. Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi. Matern Child Health J. 2009;13(5):687-94. PMid:18581221

Maru S, Bangura AH, Mehta P, Bista D, Borgatta L, Pande S, et al. Impact of the roll out of comprehensive emergency obstetric care on institutional birth rate in rural Nepal. BMC Pregnancy Childbirth. 2017;17:77.

Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynaecol Obstet. 2005;88(2):181-93. PMid:15694106

Zalvand R, Tajvar M, Pourreza A, Asheghi H. Determinants and causes of maternal mortality in Iran based on ICD-MM: A systematic review. Reprod Health. 2019;16(1):16. PMid:30736803

Chaturvedi S, Randive B, Diwan V, De Costa A. Quality of obstetric referral services in India’s JSY cash transfer programme for institutional births: A study from Madhya Pradesh province. PLoS One. 2014;9(5):e96773. PMid:24810416

Elmusharaf K, Byrne E, AbuAgla A, AbdelRahim A, Manandhar M, Sondorp E. Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis. BMC Pregnancy Childbirth. 2017;17(1):278. PMid:28851308

Banke-Thomas A, Balogun M, Wright O, Ajayi B, Abejirinde IO, et al. Reaching health facilities in situations of emergency: Qualitative study capturing experiences of pregnant women in Africa’s largest megacity. Reprod Health. 2020;17:145.

Yaya Y, Eide KT, Norheim OF, Lindtjørn B. Maternal and neonatal mortality in south-west Ethiopia: estimates and socio-economic inequality. PLoS One. 2014;9(4):e96294. PMid:24787694

Jahn A, Debrouwere V. Referral in Pregnancy and Childbirth: Concepts and Strategies. Safe Motherhood Strategies: A Review of the Evidence. Studies in Health Services Organisation and Policy. 2001;17:225-42.

Nyamtema AS, de Jong AB, Urassa DP, van Roosmalen J. Using audit to enhance quality of maternity care in resource limited countries: Lessons learnt from rural Tanzania. BMC Pregnancy Childbirth. 2011;11:94. PMid:22088168

Lindtjørn B, Mitiku D, Zidda Z, Yaya Y. Reducing maternal deaths in Ethiopia: Results of an intervention programme in Southwest Ethiopia. PLoS One. 2017;12(1):e0169304. PMid:28046036

World Health Organization. Monitoring Emergency Obstetric Care: A Handbook. Geneva: World Health Organization; 2009.

Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019;7(8):e1074-87. PMid:31303295

Bamgboye EA, Adebiyi AO, Fatiregun AA. Assessment of emergency obstetric care services in Ibadan-Ibarapa Health Zone, Oyo State, Nigeria. Afr J Reprod Health. 2016;20(1):88- 97. PMid:29553181

Murray SF, Davies S, Phiri RK, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan. 2001;16(4):353-61. PMid:11739360

Bale JR, Stoll BJ, Lucas AO. Improving Birth Outcomes: Meeting the Challenge in the Developing World. United States: National Academies Press; 2003.

World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization; 2016. Available from: http://www. health/anc-positive-pregnancy-experience/en. [Last accessed on 2020 Apr 20].

Alshami M, Almutairi S, Househ M. The implementation experience of an electronic referral system in Saudi Arabia: A case study. Stud Health Technol Inform. 2014;202:138-41. PMid:25000035

Nadkarni D, Minocha A, Harpaldas H, Kim G, Gopaluni A, Gravelyn S. Predicting resource-dependent maternal health outcomes at a referral hospital in Zanzibar using patient trajectories and mathematical modeling. PLoS One. 2019;14(3):e0212753. PMid:30835755

Owusu-Sarpong A, Boamah KA, Baiden F. Associated factors and quality of care received among maternal deaths at a regional hospital in Ghana: Maternal death audit review. Afr J Reprod Health. 2017;21(2):49-54. PMid:29624939

Adusi-Poku Y, Antwil E, Osei-Kwakye K, Tetteh C, Detoh EK, Antwi P. Quality of care: A review of maternal deaths in a regional hospital in Ghana. Afr J Reprod Health. 2015;19(3):68-76. PMid:26897915

Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy MH. Burden of morbidities and the unmet need for health care in rural neonates--a prospective observational study in Gadchiroli, India. Indian Pediatr. 2001;38(9):952-65. PMid:11568371

Anand S, Bärnighausen T. Human resources and health outcomes: Cross-country econometric study. Lancet. 2004;364(9445):1603-9. s0140-6736(04)17313-3 PMid:15519630

Sharan M, Ahmed S, Ghebrehiwet M, Rogo K. The quality of the maternal health system in Eritrea. Int J Gynaecol Obstet. 2011;115(3):244-50. PMid:21945424




How to Cite

Dewi A, Sundari S, Nursetiawan N, Supriyatiningsih S, Sugiyo D, Dewi DTK, Meisari WA. Reducing Maternal Mortality: A Qualitative Study of Health Workers’ Expectation in Urban Area, Indonesia. Open Access Maced J Med Sci [Internet]. 2021 Mar. 1 [cited 2021 May 9];9(T4):18-26. Available from: