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Laurence, Caroline Mahmood, Mohammad Afzal Ryan, Lareesa Marie School of Public Health 2022 https://hdl.handle.net/2440/138203 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. Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 2023 en Concomitant Illnesses; Non-Communicable Diseases, Infectious Diseases, Pregnancy, Maternal Health, Maternal Mortality, Maternal Morbidity, Health Systems; Health Services, Indonesia, Low and Middle Income Countries Addressing the Growing Burden of Concomitant Illnesses in Pregnancy in Indonesia Thesis This electronic version is made publicly available by the University of Adelaide in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. 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