Abstract
BackgroundIndonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality.MethodsA qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7–8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation.ResultsThe district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of “sharp downward, blunt upward”; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee’ skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death’s local avoidable factors.ConclusionA productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.
Highlights
Indonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR)
As an integral part of maternal death surveillance and response (MDSR), maternal death reviews (MDR) is of strategic importance for evidence-based policymaking in local contexts to reduce preventable maternal death [4,5,6]
Of 29 informants from four focus group discussions (FGDs), most participants (69%) had 1–3 years of experience participating as a district audit committee member (Table 2)
Summary
The largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The World Health Organization (WHO) launched the maternal death surveillance and response (MDSR) program in 2013 for strengthening the follow-up action of maternal death reviews (MDR) to prevent future preventable maternal deaths [1, 2] This program uses a continuous-action cycle of identification, quantification, Cahyanti et al BMC Pregnancy Childbirth (2021) 21:730 mandatory notification, and review of causes and avoidable factors of maternal death followed by recommended action and monitoring [3, 4]. Through this cyclic process, MDSR mirrors the steps of a typical audit or quality improvement cycle. The number of maternal deaths in Indonesia is still high, and 90% of them are preventable maternal deaths [12,13,14]
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