Authors Aditiawarman and L. Dewata, Department of Obstetrics and Gynecology, Dr Soetomo Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia. Dr Nao Taguchi (corresponding author) and M. Kawabata, International Center for Medical Research, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650–0017, Japan. Fax: 81-78-382-5715. E-mail: email@example.com M. Maekawa, Department of Hygiene, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650–0017, Japan. T. Maruo, Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
Summary Objective To determine the risk factors, such as socio-economic background, quality of antenatal care and availability of family planning, responsible for high maternal mortality in Surabaya, Indonesia.
Methods The study used a case-control design. Descriptive, bivariate and multivariate analyses were carried out, comparing 59 maternal deaths and 177 women survivors in the referral hospital, from 1996 to 1999.
Results The risk factors for maternal mortality were: living outside of Surabaya [odds ratio (OR) = 11.7, 95% confidence interval (CI) = 5.0–29.2], unemployment (OR = 4.4, 95% CI = 1.7–13.8), unavailability of toilet facilities (OR = 2.9, 95% CI = 1.0–7.7), <4 antenatal visits (OR = 2.5, 95% CI = 1.1–5.5) and initial visit to antenatal care facilities after the fourth month of pregnancy (OR = 3.0, 95% CI = 1.3–7.0). There was no significant association between maternal mortality and the availability of family planning.
Conclusion Low socio-economic background and the availability of antenatal care have a significant influence on maternal mortality in Surabaya, Indonesia.
According to the World Health Organization (WHO 1999), 493 000 women worldwide died in 1998 from complications of pregnancy and delivery. Of these 99% of the deaths occurred in developing countries. Maternal mortality in these countries is 18 times higher than in the developed countries (WHO 1998). Lack of available maternal health services in developing countries, a result of social and economic conditions, contributes significantly to maternal mortality (Thaddeus & Main 1994; Jafarey & Korejo 1995; Fikree et al. 1997).
Antenatal care and family planning appears to be indispensable for the prevention of maternal deaths. The introduction of home-based antenatal risk screening in East Java (Indonesia) resulted in a reduction of maternal mortality (Rochjanti 1997). In South Africa, there is a difference in the maternal mortality ratio (MMR) between patients receiving antenatal care in tertiary hospitals (29.8 per 100 000 live births) and patients not receiving antenatal care in those facilities (304.7 per 100 000 live births) or not receiving antenatal care at all (348.5 per 100 000 live births) (Daponte et al. 2000).
Improved family planning services can help in reducing MMR. This can be achieved by educating couples on how to avoid unwanted pregnancy, delaying childbearing and ensuring safer spacing between births (Walsh et al. 1993). A population-based case-control study in China reported that women who do not use family planning have twice the risk of maternal mortality as the women who do (Ni & Rossignol 1994).
Indonesia has the highest MMR (450 per 100 000 live births) among developing countries in south-east Asia, despite the high rate of pregnant women who receive antenatal care and use family planning (Ministry of Health, Republic of Indonesia 2000). The fact that clinical intervention is limited in reducing maternal mortality leads us to propose that vulnerable women with low socio-economic backgrounds suffer serious illness from pregnancy and childbirth because they have no access to health services. However, very little has been done to evaluate the risk factors for maternal mortality associated with low socio-economic status and poor compliance to antenatal care or family planning technology in Indonesia. We designed this case-control study with multivariate analyses to determine the risk factors related to socio-economic background, compliance to antenatal care or use of family planning for high maternal mortality in Indonesia.
Materials and methods
Surabaya is the capital city of the province of East Java in Indonesia. Most of the residents of Surabaya are Javanese and Muslim. In 1999, the estimated population in Surabaya was 2 864 105; the crude birth rate was 17.8 per 1000 population; the total fertility rate was 1.8; the proportion of deliveries assisted by a skilled attendant was 90%; the proportion of women receiving antenatal care was 89% and of those getting postnatal care was 107% (Kantor Department Kesehatan Kotamadya Surabaya 2000). In 1994, the MMR was 325 per 100 000 live births (Surabaya Municipal Health Services 1995).
Dr Soetomo Hospital is a teaching hospital of the Faculty of Medicine at Airlangga University and is one of the main referral hospitals in Surabaya. In 1997, there were 6366 deliveries in Dr Soetomo Hospital. There are two labour rooms in the department of obstetrics and one in the Emergency Unit, built with assistance from the Japanese government. In the Emergency Unit there are seven obstetricians, four midwives and several anaesthesiologists and paediatricians on duty round the clock.
At Dr Soetomo Hospital, there were 97 maternal deaths from January 1996 to December 1999. The mean age of the women was 27.8 ± 5.6 years and the mean gravidity was 2.3 ± 1.4. Autopsies were not performed because of cultural reasons. The leading causes of maternal deaths are shown in Figure 1. Eclampsia (35.0%) and haemorrhage (20.6%) were most common in this hospital. Most of the deaths occurred in women who had been transferred from other facilities (79.4%, 77 of 97 maternal deaths). Of all the deaths, 15.5% (15 of 97) were antenatal, 2.1% (two of 97) were during labour or delivery, 79.4% (77 of 97) were postnatal and 3.1% (three of 97) were unclear. Of 82 deliveries, 39% (32 of 82) were normal and 28.0% (23 of 82) were operative vaginal deliveries (i.e. forceps, vacuum extraction or destruction of the fetus), whereas 25.6% (21 of 82) were operative abdominal deliveries (i.e. Caesarean section or hysterectomy). Duration of hospitalization was from 20 min to 28 days. Of those who died, 44.3% died within 2 days after admission.
There were 59 maternal deaths that were considered cases, although information on socio-economic background, antenatal care and family planning was insufficient for 38 cases. In 59 maternal deaths, the mean age was 28.4 ± 5.6 years and the mean gravidity was 2.2 ± 1.2.
Matching for age and gravidity, 372 controls were drawn from 5697 women admitted to the same hospital as the cases, from January to December 1999. Maternal age and gravidity have been shown to be risk factors for maternal mortality (for example, younger than 20 or older than 34 years and first pregnancy or more than four pregnancies) (Walsh et al. 1993). After that, 177 women were selected from the group of 372 women by systematic random sampling. Table 1 shows the clinical characteristics of the cases and the controls.
Table 1. Clinical profiles of the study population
Case (n = 59)
Control (n = 177)
SD, standard deviation.
* Excluding 10 deaths, who had died before delivery.
Age in years (mean ± SD)
28.4 ± 5.6
29.3 ± 5.0
Gravidity (mean ± SD)
2.2 ± 1.2
2.1 ± 1.2
Delivery at Dr Soetomo Hospital*
Caesarean section rate*
Not receiving antenatal care
Pre-coded questionnaires were designed and administered to measure socio-economic background, quality of antenatal care and use of family planning. Indicators of socio-economic status included the following: living conditions, distance and travel time to the hospital, women's educational attainment, employment status, possession of an automobile and electrical appliances (TV sets, washing machine and refrigerator) and availability of clean water and toilet facilities. For antenatal care, indicators were: frequency of antenatal visits, initial visit to antenatal care facilities, facility of antenatal care, type of antenatal care provider and referral from other facilities. For family planning, indicators were: interval between deliveries, age at the time of first delivery and method of contraception. The questionnaire was translated into Indonesian and administered to the patient or family by the midwife. Researchers, including the authors, collected and confirmed the data from medical records. If medical records were insufficient to complete the questionnaires, researchers conducted a personal interview with the patients or their families. Informed consent was obtained from each of the participants. Ethical clearance was granted by the Ethical Review Committee, Faculty of Medicine, Airlangga University, Dr Soetomo Provincial Hospital.
All variables were compared between cases and controls, using measures of central tendency such as mean, median, mode and standard deviation (SD) with paired t-test and chi-squared test. Statistical significance was accepted at P < 0.05. Bivariate analyses between indicators (independent variables) and maternal mortality (dependent variable) were carried out by chi-squared test. Unadjusted OR and 95% CI were estimated. Significant risk factors (P < 0.05) identified by bivariate analysis were entered into the multiple logistic regression models to predict the risk factors for maternal death and to control for potential confounders. Adjusted OR and 95% CI were estimated. Statistical analysis package JMP version 4 (SAS Institute, NC, USA) was used.
Most cases were Javanese (93.2%) and Muslim (94.9%). There was no significant difference in race and religion between the cases and the controls. The proportion of women living outside of Surabaya was 47.5% for the cases and 7.9% for the controls. This was statistically significant. The mean distance from their residence to Dr Soetomo Hospital was longer for the cases than for the controls (cases: 12.9 ± 14.2 km, controls: 6.5 ± 6.8 km; P < 0.001). However, there was no significant difference in the mean time of travel between the cases and the controls (cases: 32.1 ± 5.0 min, controls: 36.2 ± 2.9 min). The proportion of women who attended primary school was 44.1% in the cases and 22.0% in the controls (P < 0.001). There were no significant differences found for possession of electrical appliances.
Features of antenatal visits
The mean number of visits (±SD) to antenatal care facilities was 4.6 ± 0.4 in the cases and 7.1 ± 0.2 in the controls. This difference was significant. In the cases, 22.0% of women had visited an antenatal care facility by the third month of pregnancy and 45.8% had visited in their fourth month of pregnancy. However for the controls, 50.8% of women had visited a facility by their third month of pregnancy.
For the cases, the percentage who visited the private clinics of midwives was 37.3%, the percentage who visited health centers attended by doctors and midwives was 20.3% and the percentage who visited maternity homes attended by midwives was 13.6%. For the controls, corresponding percentages were 19.8%, 26.6% and 12.4%, respectively. There was no significant difference in types of care providers and health facilities between the two groups.
The age at first pregnancy in the cases was not significantly younger than in the controls (mean ± SD; cases: 22.0 ± 0.7 years, controls: 24.1 ± 0.4 years). The mean interval (± SD) between deliveries was not significantly different between the two groups (cases: 5.0 ± 3.4 years, controls: 5.4 ± 3.2 years). The methods used for contraception could not be analyzed, as information was insufficient for the cases.
Bivariate analysis was carried out between maternal mortality and the risk factors of socio-economic background, features of antenatal care and use of family planning (Table 2). The following were regarded as risk factors: living outside of Surabaya, no education past primary school, unemployment and unavailability of toilet facilities. As for features of antenatal care, <4 antenatal visits and an initial visit to antenatal facilities after the fourth month of pregnancy were considered risk factors for maternal mortality. No significant relationship between family planning and maternal mortality was noted.
Table 2. Bivariate and Multivariate analysis; unadjusted odds ratio (OR) and adjusted OR for socio-economic, antenatal care and family plannning factors and 95% confidence interval (CI) of cases and controls
* P < 0.05.
** P < 0.001.
† Excluding primigravida: 21 women in cases, 63 women in controls.
Out of Surabaya
Travel time to the hospital
Over 30 min
Within 30 min
Educational attainment of patient
Up to primary school
Over primary school
Employment of patient
Availability of automobile
Availability of clean water
Availability of toilet facility
Frequency of antenatal care
Initial visit to antenatal care facilities
After 4 month of pregnancy
1–3 month of pregnancy
Antenatal care facilities
Age at first delivery
<18 years old
Significant risk factors found in the bivariate analysis were entered into the multiple logistic regression models (Table 2). Significant risk factors used in the multivariate analysis were: living outside of Surabaya (OR = 11.7, 95% CI = 5.0–29.2), unemployment (not earning income) (OR = 4.4, 95% CI = 1.7–13.8), unavailability of toilet facilities (OR = 2.9, 95% CI = 1.0–7.7), <4 antenatal visits (OR = 2.5, 95% CI = 1.1–5.5) and initial visit to antenatal facilities after the fourth month of pregnancy (OR = 3.0, 95% CI = 1.3–7.0). The level of education achieved was not considered as a risk factor in the multivariate analysis.
This study shows that low socio-economic factors, such as living in a rural area, unemployment, poor hygiene and unavailability of antenatal care, have an influence on the high maternal mortality in Surabaya, Indonesia. Despite paved roads and the availability of an ambulance, which shortened the travel time to the hospital from rural areas, women living outside of Surabaya city had the highest risk of maternal mortality (OR = 11.7). It is clear that the severity and urgency of perinatal problems are the most important risks for maternal death, because of the increased frequency of operative deliveries and maternal transfers. The high rate of Caesarean section associated with maternal deaths suggests that those patients were in serious condition upon arrival and Caesarean section was indicated. The risk of bleeding and infection might be increased by operative procedures as well. Further evidence of the seriousness of the conditions among the cases is that 44.3% of the patients died within 2 days after admission. Most of the maternal deaths could have been prevented if inadequate conditions had been recognized early and if women had had access to basic medical care early in their pregnancies. In rural areas, lack of medical facilities and scarce information on safe delivery seems to discourage women from using health services. Pregnancy and delivery are often recognized by many to be a normal and natural event in traditional villages. Therefore, less attention is given to issues relating to pregnancy (Thaddeus & Main 1994). Health education on pregnancy and delivery, and improvement of basic medical care are needed to help women utilize health services, especially in rural areas where sources of information are limited.
Women with low socio-economic status are often ignored, even if they need medical support. Employment, educational attainment and availability of sanitary facilities are indicators of women's socio-economic status. In the present study, unemployed women had 4.4 times higher risk for maternal death than women who were employed. The financial independence of women may have an effect on their decision-making power and on use of health services (The Prevention of Maternal Mortality Network 1992). Otherwise, there was no significant difference in the risk of maternal mortality between women educated through primary school and women educated beyond. Most studies have argued that utilization of medical services increases with the level of education (Thaddeus & Main 1994). However, no investigation has provided evidence suggesting that maternal mortality is directly associated with women's education (Walsh et al. 1993). Further study is needed to show if there is an association between maternal deaths and women's education.
It is interesting that the unavailability of toilet facilities appeared to increase the risk of maternal mortality (OR = 2.9), whereas there was no association between the unavailability of clean water and maternal mortality. This implies that health benefits would be maximized only when households have safe water and sanitation services.
In 1994, The Technical Working Group on Antenatal Care of the WHO recommended a minimum of four antenatal visits, with the initial visit by the end of the fourth month (16 weeks), in order to treat complications (WHO 1994). Our results revealed that the greatest risk factors for maternal mortality are <4 antenatal visits (OR = 2.5) and the initiation of antenatal care after the fourth month of pregnancy (OR = 3.0), which support the WHO recommendations. Since 1989, major interventions by the government of Indonesia to decrease maternal mortality have included the training and placement of village midwives and the standardization of antenatal services (WHO 1992). As a result of these efforts, the proportion of pregnant women who visited antenatal care facilities more than four times increased from 34.4% in 1986 to 71.2% in 1998 (Ministry of Health, Republic of Indonesia 2000). However, it was pointed out in the study in West Java that 69.2% of women who had known complications delivered at home and that the referral rate was quite low (6–13%) (Alisjahbana et al. 1995). Improvement of referral systems and feedback to antenatal care providers on outcomes will be required to improve the quality of antenatal care.
Successful family planning programmes in Indonesia achieved a contraceptive prevalence rate of 57% and a total fertility rate of 2.5% in 1999 (The United Nations Children's Fund 2000). The Indonesian government has advocated the importance of family planning through mass media. Community health care workers have also played a role. These contributions may have influenced the results that showed that age at first delivery and interval between deliveries had no significant effect on mortality.
We collected data on maternal death for 4 years, because it is a rare event and the sample size from 1 year would have been too small to evaluate the risk. On the other hand, it is difficult to follow survival data for women in this hospital for 4 years. The long survey period may have biased the results because of the dramatic changes in the Indonesian health system and the economy during that time. Moreover, there were many unresolved issues relating to maternal deaths in this study regarding antenatal care and family planning. The result was the exclusion of 38 maternal deaths from a total of 97. However, these exclusions probably did not significantly influence the results because there were no differences in clinical profiles between cases and all maternal deaths. Further research is needed to focus on not only medical causes, but also on the social context of maternal mortality. Interventions that target women of low socio-economic status and that increased access to antenatal care may be effective in decreasing maternal mortality in Surabaya, Indonesia.
This study was conducted in collaboration with the International Center for Medical Research, Kobe University School of Medicine and the Faculty of Medicine, Airlangga University. We are grateful to the staff of Dr Soetomo Hospital for their efforts. Contributions to this study were also made by Dr Marsianto, Prof. Soegeng Soegijanto; Surabaya Municipal Health Department Office; Tropical Disease Center, Airlangga University; Prof. I. Kamae, Health Informatics and Sciences, Kobe University Graduate School of Medicine; Dr M. Mizutori and Dr S. Nakago, Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine.