Please use this identifier to cite or link to this item: http://hdl.handle.net/2440/123743
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Type: Journal article
Title: Root-cause analysis of persistently high maternal mortality in a rural district of Indonesia: role of clinical care quality and health services organizational factors
Author: Mahmood, M.
Ismi Mufidah
Steven Scroggs
Amna Rehana Siddiqui
Hafsa Raheel
Koentijo Wibdarminto
Bernardus Dirgantoro
Jorien Vercruyssen
Hayfaa A Wahabi
Citation: BioMed Research International, 2018; 2018:3673265-1-3673265-11
Publisher: Hindawi Publishing Corporation
Issue Date: 2018
ISSN: 2314-6133
2314-6141
Statement of
Responsibility: 
Mohammad Afzal Mahmood, Ismi Mufidah, Steven Scroggs, Amna Rehana Siddiqui, Hafsa Raheel, Koentijo Wibdarminto, Bernardus Dirgantoro, Jorien Vercruyssen, and Hayfaa A. Wahabi
Abstract: Background. Despite 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. Method. Thirty 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. Findings. The 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. Conclusion. There 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.
Keywords: Humans; Maternal Mortality; Obstetrics; Pregnancy; Parturition; Adolescent; Adult; Rural Population; Hospitals; Maternal Health Services; Rural Health Services; Health Services Accessibility; Quality of Health Care; Indonesia; Female; Young Adult
Description: Published 22 February 2018
Rights: Copyright © 2018 Mohammad Afzal Mahmood et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
RMID: 0030083307
DOI: 10.1155/2018/3673265
Appears in Collections:Public Health publications

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