High maternal mortality rate in Indonesia: a challenge to be addressed immediately

¹Department of Midwifery, Politeknik Kesehatan Kementerian Kesehatan, Surabaya, Indonesia, ²Department of Nursing Politeknik Kesehatan Kementerian Kesehatan, Yogjakarta, Indonesia

^&Corresponding author
Suparji Suparji, Department of Midwifery, Politeknik Kesehatan Kementerian Kesehatan, Surabaya, Indonesia

Commentary    

The problem of maternal mortality is a global problem. According to a UN report, the global maternal mortality rate is still high, namely around 287,000 deaths in 2020 [1]. This figure is only a slight decrease from 309,000 deaths in 2016 [1]. Indonesia is a developing country with a high death rate. Globally, Indonesia is ranked 66^th highest out of 183 countries, 12^th highest in Asia, and the third highest in Southeast Asia. The maternal mortality rate in Indonesia is still a serious public health problem. The high maternal mortality rate indicates inequality and injustice in maternal and neonatal health services and hurts the welfare and development of infants and toddlers, both physically, psychologically, and socially [2].

The maternal mortality rate is an indicator of maternal and child health that is important to measure and reduce. The maternal mortality rate shows the number of maternal deaths caused by complications of pregnancy or childbirth per 100,000 live births [3]. The maternal mortality rate is one of the Sustainable Development Goals (SDGs) targets that Indonesia must achieve by 2030, namely 70 per 100,000 live births [4]. The latest data shows that the maternal mortality rate in Indonesia is still far from this target. According to 2020 data, the MMR in Indonesia is 177, which means there are 177 maternal deaths per 100,000 live births [5]. This figure places Indonesia in the third highest ranking in Southeast Asia, after Myanmar (250) and Laos (185) [5]. In the Asian region, Indonesia is ranked 12^th highest, after Afghanistan (638), Pakistan (276), Nepal (239), India (200), Bangladesh (196), Cambodia (160), Timor Leste (142), Philippines (121), Bhutan (120), North Korea (82), and Papua New Guinea (80) (6). Globally, Indonesia is ranked 66^th highest out of 183 countries that have maternal mortality rate data [6].

Factors causing maternal mortality rates in Indonesia can be divided into close determinants, intermediate determinants, and distant determinants. Near determinants are factors that are directly related to the cause of maternal death, such as bleeding, infection, eclampsia, and abortion [5]. Intermediate determinants are factors that influence maternal health status and access to health services, such as nutrition, education, awareness, availability, affordability, and quality of health services [7]. Distant determinants are factors related to social, economic, political, and cultural conditions that influence intermediate determinants, such as poverty, gender inequality, policies, and norms [1,7]. The factors that cause global maternal deaths are that most maternal deaths occur due to complications during pregnancy or the birth process, such as heavy bleeding, infections, unsafe abortions, and conditions such as HIV/AIDS [2]. Other sources state that bleeding is the main factor in maternal mortality in Indonesia, globally, and in Southeast Asia. Infection and hypertension are also important factors causing maternal death. Unsafe abortion is a particular factor contributing to maternal mortality at the global level.

To reduce maternal mortality, comprehensive and integrated efforts are needed that involve all parties, including the government, community, and development partners. These efforts must be aimed at addressing close determinants, intermediate determinants, and distant determinants related to maternal mortality rates. Some of the breakthroughs that can be made include transforming the health system, increasing the coverage and quality of maternal and neonatal health services, improving disease control, increasing universal health service coverage, and increasing public education and awareness about reproductive health [3,8]. The high maternal mortality rate in Indonesia is a challenge that must be addressed immediately. Maternal health is a human right that must be respected, protected, and fulfilled. Maternal health is also the key to achieving sustainable, inclusive, and equitable development. By reducing the maternal mortality rate, we can improve the quality of life for mothers and children in Indonesia.

The reality of maternal mortality rates in the last 3 years in Indonesia: the maternal mortality rate is the number of maternal deaths caused by complications of pregnancy, childbirth, or postpartum per 100,000 live births in one year [8]. The maternal mortality rate is an important indicator of maternal and child health to monitor. The following is data on maternal mortality rates in Indonesia for 2020-2023 (Figure 1) [9]. The incidence of maternal mortality in Indonesia in 2020-2023 as shown in Figure 1 in 2020, the maternal mortality rate in Indonesia was 230 per 100,000 live births, decreasing from 305 per 100,000 live births in 2015 [3]. The reduction in maternal mortality is still far from the target of sustainable development goals (SDGs), namely 70 per 100,000 live births in 2030 [3]. With a decline in MMR of only 1.8% per year, it is estimated that Indonesia will not be able to achieve the SDGs target [3].

Factors causing maternal mortality rates in Indonesia are still high: one modeling approach that can be used to identify risk factors that influence maternal mortality is the model theory from McCarthy and Maine. This theory discusses three determinants of maternal death, namely distant determinants, intermediate determinants, and close determinants. The conceptual framework of maternal death according to McCarthy and Maine is in Figure 2 [5]. The factors causing the maternal mortality rate in Indonesia to remain high can be divided into three categories, namely close determinants, intermediate determinants, and distant determinants [8,9]. Near determinants are factors that are directly related to the cause of maternal death, such as pre-eclampsia, eclampsia, bleeding, infection, and abortion [7,9]. Intermediate determinants are factors that influence maternal health status and access to health services, such as nutrition, anemia, chronic disease, pregnancy spacing, parity, age, education, economics, culture, and geography [9]. Distant determinants are factors related to health policies, systems, and resources, such as regulations, budget allocation, availability of facilities, personnel, and health equipment, as well as the quality of health services [4,7,9].

The Indonesian government's efforts to reduce maternal mortality: to reduce maternal mortality, there needs to be a comprehensive and collaborative effort from all parties, including the central government, regional governments, communities, and non-governmental organizations. Some efforts that can be made are increasing the coverage and quality of maternal health services, developing an effective referral system, empowering women and families in making health decisions, and carrying out advocacy and outreach about the importance of maternal health [3].

Obstacles faced by Indonesia in reducing maternal mortality: Indonesia's challenges in reducing maternal mortality in the last 3 years are diverse and complex. Some of the main challenges facing Indonesia are: 1) delays in getting quality health services, both before, during, and after giving birth. This is caused by geographical factors, poverty, lack of awareness, limited transportation, and unpreparedness of health facilities [3]; 2) lack of competent health human resources, especially midwives, obstetricians, and anesthetists. In addition, there are still gaps in the distribution and retention of health workers in remote and border areas [1,10]; 3) weak coordination between central, regional, and partner governments in planning, implementing, and monitoring maternal and reproductive health programs. This causes inconsistencies and ineffectiveness in the allocation and use of budgets, resources, and policies [3,10]; 4) low coverage of the Population and Family Planning (KKB) program, especially in areas with low levels of fertility and population growth. This has an impact on the high risk of complications in pregnancy and childbirth, especially for mothers who are young, old, or have many children [9,10].

Indonesia's commitment to reducing maternal mortality is based on the UN's strategy program for the 2030 SDGs target: Indonesia's commitment to reducing maternal mortality is based on the UN strategy program for the 2030 SDGs target: 1) Indonesia and WHO have signed a Country Cooperation Strategy (CCS) for the 2019-2024 period, which is a strategic framework for technical cooperation between the two parties in supporting the achievement of SDGs in Indonesia [3]; 2) Indonesia and WHO also collaborate in Joint External Evaluation (JEE), which is an independent and transparent assessment process of a country's capacity to prevent, detect and respond to health threats, including maternal and child health [3]; 3) Indonesia and WHO also collaborate in Momentum Country Global Leadership (MCGL), which is an initiative supported by USAID to improve the quality and access of maternal and child health services, especially in vulnerable and remote areas [9,10]; 4) apart from that, Indonesia and WHO are also involved in various forums, conferences, and joint activities related to global health issues, including reducing MMR and IMR, such as the International Conference on Population and Development (ICPD), International Conference on Indonesia Family Planning and Reproductive Health (ICIFPRH), and Mother's Day Seminar [6,8,10].

Conclusion     

The conclusion from the commentary article on the problem of maternal mortality in Indonesia in 2020-2023 is that the high maternal mortality rate in Indonesia is a challenge that must be addressed immediately. Maternal health is a human right that must be respected, protected, and fulfilled. Maternal health is also the key to sustainable, inclusive, and equitable development. By reducing the maternal mortality rate, we can improve the quality of life for mothers and children in Indonesia. It is recommended that comprehensive and integrated efforts be made to reduce maternal mortality involving all parties, including the government, community, and development partners. These efforts must be aimed at addressing close determinants, intermediate determinants, and distant determinants related to maternal mortality rates.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Suparji Suparji conceptualized and wrote the original draft; Heru Santoso Wahito Nugroho, Sunarto Sunarto, Agus Sarwo Prayogi revised and edited the paper. All the authors have read and approved the manuscript.

Figures     

Figure 1: maternal mortality rate for 2020-2023 in Indonesia

Figure 2: conceptual framework of maternal death according to McCarthy and Maine (1992)

References