Addressing the Growing Burden of Concomitant Illnesses in Pregnancy in Indonesia
Date
2022
Authors
Ryan, Lareesa Marie
Editors
Advisors
Laurence, Caroline
Mahmood, Mohammad Afzal
Mahmood, Mohammad Afzal
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Thesis
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Abstract
Introduction
Maternal mortality persists as a global problem, however low and middle income
countries (LMICs) experience greater rates of mortality. In 2017, it was estimated
that over approximately 94% of maternal deaths worldwide occurred in LMICs.
Significant disparities in maternal mortality ratios (MMRs) exist between countries,
where high income countries (HIC) had an MMR of 11 deaths per 100 000 live births
in 2017. Comparatively, low income, lower-middle income, and upper middle income
countries had average MMRs of 462, 254 and 43 respectively. This is partly due to
health systems in LMICs struggling to provide high maternal quality care, barriers to
access of care, and social determinants of health. To address the issue, the United
Nations (UN) Sustainable Development Goals (SDGs) of 2030 have included an aim
to reduce the global MMR to less than 70.
The decline in maternal mortality in LMICs during the last two decades has mainly
been due to a significant focus on strategies and interventions targeting direct
causes of maternal death, also known as obstetric-related complications, such as
haemorrhage or hypertension, and some indirect causes/non-obstetric
complications, such as HIV/AIDs. However, maternal mortality due to indirect causes
has persisted and is growing. These indirect causes, also known as concomitant
illnesses, include infectious diseases, such as tuberculosis, and noncommunicable
diseases (NCDs), such as diabetes, during pregnancy. Concomitant illnesses in
pregnancy can lead to an increased risk of poor maternal health outcomes if not
appropriately managed. For example, diabetes in pregnancy can lead to
complications such as postpartum haemorrhage, preeclampsia, labour difficulties
and can lead to spontaneous abortion and stillbirth. With the rising burden of NCDs
in reproductive-aged women in LMICs, it is unclear what impact this will have on
pregnancy outcomes under strained health systems.
In Indonesia, the MMR remains high at 177 in 2017. Despite declines in maternal
mortality in Indonesia, maternal care and the health system still face access and quality of care challenges, with some health facilities still lacking the capacity to deal
with direct causes/obstetric-related complications of maternal mortality. This
presents a challenge for Indonesia, a LMIC, which is currently experiencing an
epidemiological transition of high rates of infectious diseases, and a rapid growth of
NCDs among reproductive-aged women. In 2010, concomitant illnesses contributed
to 23% of maternal mortality in Indonesia. However, there is limited research that
examines the extent of the burden of all concomitant illnesses in pregnancy in
Indonesia and how the health system is providing care for this group of women now
and in the future.
In order to reduce the MMR in Indonesia and meet the SDG of MMR of less than 70
by 2030, the focus of evidence and healthcare strategies needs to address maternal
mortality due to obstetric-related complications and concomitant illnesses. Therefore
the aim of this doctoral research was to contribute to the existing body of evidence
on the burden of concomitant illnesses in pregnancy in Indonesia, and how the
health system can be strengthened to provide maternal care for concomitant
illnesses.
To achieve this, the research involved estimating the burden over time of
concomitant illnesses in pregnancy in Indonesia. Subsequently, the research
involved conducting an analysis at a system wide level with healthcare providers and
health service managers to understand how the health system is currently providing
care for concomitant illnesses in pregnancy, and how it can be strengthened. Finally,
the research assessed current processes in the tertiary level of the health system for
an NCD (diabetes mellitus
Methods
This doctoral research is comprised of three studies, which are outlined below:
Study 1: With data limited at a national level in Indonesia, the initial study – an
epidemiology study - focused on understanding the past, current and future burden
of concomitant illnesses in pregnancy by estimating incident cases from 1990 to
2030. Study 2: This study – a health systems analysis - aimed to understand how the
health system is providing care to pregnant women with concomitant illnesses in
Kutai Kartanegara District, East Kalimantan, Indonesia. The study focussed on the
perspectives of key stakeholders including health service managers and health
providers (such as midwives, obstetricians, general practitioners, and specialists)
through a qualitative study involving in-depth interviews.
Study 3: This study aimed to understand what care is provided to pregnant women
with Type 2 diabetes mellitus in tertiary settings in Kutai Kartanegara District, East
Kalimantan, Indonesia. This included examining processes and care patterns by
conducting a medical note review in two hospitals.
Results
Study 1: The results from this study indicated a rising burden of many NCDs in
pregnancy (such as diabetes, stroke and mental health disorders) alongside high
rates of infectious disease (such as sexually transmitted infections, hepatitis, dengue
and tuberculosis) in Indonesia.
Study 2: Challenges identified included knowledge/awareness of concomitant
illnesses among health providers and their competency to diagnosis and manage
these complications in pregnant women, and issues with the referral system. Some
supporting factors recognised included collaboration between health providers and
health services and the availability of screening and diagnostic tools. A range of
improvements were suggested to address current gaps in the health system, and
how it can prepare to deal with the growing burden of concomitant illnesses in
pregnancy. This included, increasing education and training for health providers in
the area of concomitant illnesses in pregnancy and strengthening integration of care.
Study 3: The findings of this study indicated that while consultations with
obstetricians, referrals to internists (diabetes specialists) and hospital based births
are taking place for most women, there are several gaps in the process of care that
need be addressed. Examples include no Antenatal care (ANC) being conducted at
hospital and the full range of recommended examinations/tests not being conducted
in hospital settings. Conclusion
The growth of NCDs and persistent high rates of infectious diseases being
experienced in many LMICs, including Indonesia, has expanded the disease burden
in pregnant women to a greater number of concomitant illnesses in addition to
obstetric-related complications. This thesis has highlighted the need to strengthen
health systems in LMICs to prepare to provide high quality healthcare for all
complications – including obstetric-related complications, infectious diseases and
NCDs – as they work towards reducing maternal mortality and meeting the SDG
target of an MMR of less than 70 by 2030.
Strengths of the research
This thesis has utilised one country (Indonesia) as a case study that is
representative of an LMIC with a high MMR, and undergoing significant changes in
its maternal health landscape. The growth of NCDs in the fourth most populated
country in the world is also anticipated to place extensive strain on its health system.
This has provided an opportunity, using a mixed-methods research design, to
explore in detail the evidence on the growing burden of concomitant illnesses in
pregnancy in Indonesia and how the health system can prepare to deal with this
growing burden from two stand points; from a system-wide perspective and more
closely at the tertiary sector. There is potential for the lessons learnt to be transferred
to other LMICs undergoing similar transitions. Studies 2 and 3 of this doctoral
research were also conducted in collaboration with local researchers and involved
stakeholders of Kutai Kartanegara District and have identified have policy and
practice strategies that are directly applicable to strengthening the local district’s
health system.
Contributions of this thesis to existing body of knowledge
This thesis has contributed to the existing body of evidence on the growing burden of
concomitant illnesses in pregnancy in LMICs, such as Indonesia. In addition, it has
shown the impact the growing burden of concomitant illnesses is having on LMIC
health systems, including Indonesia.
School/Discipline
School of Public Health
Dissertation Note
Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 2023
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