Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia

Sep 12, 2026

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Despite widespread antenatal care coverage and skilled birth attendance in Indonesia, maternal mortality remains high at an estimated 177 per 100,000 live births. This study performs an in-depth analysis of health service organizational and quality-of-care factors linked to deaths of 30 women admitted to a major referral hospital in East Java. Poor protocol implementation, weak information flow, delays in emergency response, and delays in managing deteriorating patients were key contributors, with referral pyramids further limiting effective care. Training and monitoring for protocol adherence and local capacity building are emphasized.

LanguageEnglish

CategoryGeneral

FormatPDF

Pages13

Reading Time5 min

AccessFree to download

Introduction

Maternal mortality context in Indonesia

Methods and analysis focus

Organizational factors and quality of care

Key contributing factors

Protocol implementation

Information flow and emergency delays

Management delays for deteriorating patients

Referral and system-level contributors

Pyramidal referral impact

Recommendations

Training, monitoring, and local capacity building

PLOS ONE OPEN ACCESS Citation: Mahmood MA, Hendarto H, Laksana MAC, Damayanti HE, Suhargono MH, Pranadyan R, et al. (2021) Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia. PLoS ONE 16(2): e0247911 . [https://doi.org/10.1371/journal.pone.0247911](https://doi.org/10.1371/journal.pone.0247911) [Editor:](Editor: Emily A. Hurley)[ Emily A. Hurley](Editor: Emily A. Hurley), [Children](Children)’[s Mercy](s Mercy) Hospitalsand Clinics Department of Pathology and Laboratory Medicine, UNITED STATES Received: April 5, 2020 Accepted: February 16, 2021 Published: February 26, 2021 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: [https://doi.org/10.1371/journal.pone.024791](https://doi.org/10.1371/journal.pone.024791)1 Copyright: © 2021 Mahmood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data cannot be uploaded as additional files and cannot be sent to a public repository considering ethical restriction as RESEARCH ARTICLE Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia Mohammad Afzal Mahmood1,2 *, Hendy Hendarto3,4, Muhammad Ardian Cahya Laksana3,4, Hanifa Erlin Damayanti3,4, Mohammad Hud Suhargono5, Rizki Pranadyan3,4, Kohar Hari Santoso6, Kartika Sri Redjeki7, Baksono Winard3,4, Budi Prasetyo3,4, Jorien Vercruyssen8, John Robert Moss1, Peng Bi1, Syarifah Masitah9, Warsiti4, Aldilia Wyasti Pratama10, Erni Rosita Dewi10, Charity Hartika Listiyani10, Ismi Mufidah11 1 School of Public Health, University of Adelaide, Adelaide, SA, Australia, 2 Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia, 3 Faculty of Medicine, Department of Obstetrics and Gynaecology, Universitas Airlangga, Soetomo Teaching Hospital, Surabaya, Indonesia, 4 Soetomo Teaching Hospital, Surabaya, East Java, Indonesia, 5 Bangil General Hospital, Pasuruan District, Jawa Timur, Indonesia, 6 Department of Health, Jawa Timur, Surabaya, Indonesia, 7 Department of Health, Surabaya, Indonesia, 8 Obstetrics Department, Antwerp University Hospital, Edegem, Belgium, 9 Wahab Syaharani Hospital, Samarinda, Indonesia, 10 Faculty of Medicine, School of Midwifery, Universitas Airlangga, Surabaya, Indonesia, 11 Department of Health, Kutai Kartanegara, Kalimantan Timur, Indonesia * [afzal.mahmood@adelaide.edu.au](afzal.mahmood@adelaide.edu.au) Abstract Despite most Indonesian women now receiving antenatal care on the nationally recommended four occasions and being delivered by skilled birth attendants, the nation’s maternal mortality ratio (MMR) is estimated as 177 per 100,000 live births. Recent research in a rural district of Indonesia has indicated that poor service quality due to organizational and personnel factors is now a major determinant of this high MMR. The present research is an indepth analysis of possible health service organizational and quality of care related causes of death among 30 women admitted to a peak referral hospital in a major Indonesian city. Despite their condition being complex or deteriorating, most of these women arrived at the hospital in a state where it was feasible to prevent death with good quality care. Poor application of protocols, poor information flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating patients were the main contributing factors to these deaths. Pyramidal referrals also contributed, as many women were initially referred to hospitals where their conditio

FAQs

What does the study examine regarding maternal deaths in East Java?

It examines organizational and quality-of-care related causes of death among women admitted to a major referral hospital in East Java.

What were the main factors contributing to these deaths?

Key contributors included poor application of protocols, inadequate information flow from frontline hospitals, delays in emergency care, and delays in managing deteriorating patients.

How could maternal outcomes potentially be improved according to the findings?

The study highlights training and monitoring for rigorous protocol application, including forward planning for deterioration, alongside building local capacity to assess and address local organizational and resource-related delays.

Sep 12, 2026

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