Tropical Medicine and International Health

volume 8 no 9 pp 847852 september 2003

Influence of socio-economic background and antenatal care

programmes on maternal mortality in Surabaya, Indonesia
N. Taguchi1,2, M. Kawabata1, M. Maekawa3, T. Maruo2, Aditiawarman4 and L. Dewata4

1 International Center for Medical Research, Kobe University School of Medicine, Kobe, Japan
2 Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
3 Department of Hygiene, Kobe University Graduate School of Medicine, Kobe, Japan
4 Department of Obstetrics and Gynecology, Dr Soetomo Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia

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) 5.029.2], unemployment (OR 4.4, 95%
CI 1.713.8), unavailability of toilet facilities (OR 2.9, 95% CI 1.07.7), <4 antenatal visits
(OR 2.5, 95% CI 1.15.5) and initial visit to antenatal care facilities after the fourth month of
pregnancy (OR 3.0, 95% CI 1.37.0). 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.

keywords maternal mortality, socio-economic background, antenatal care, family planning, Surabaya

Improved family planning services can help in reducing

Introduction
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 ante-
natal 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).
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 inter-
vention is limited in reducing maternal mortality leads us
to propose that vulnerable women with low socio-econo-
mic 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,

2003 Blackwell Publishing Ltd 847

Tropical Medicine and International Health volume 8 no 9 pp 847852 september 2003

N. Taguchi et al. Socio-economic background, antenatal care programmes and maternal mortality

compliance to antenatal care or use of family planning for O

th
high maternal mortality in Indonesia. e
ca r in Unknown
12 us dir 3.1%
.4 es ec
% t
Materials and methods Tub
ercu
Eclampsia
Study population 3.1%losis 35.0%

Surabaya is the capital city of the province of East Java in Cardiac

Indonesia. Most of the residents of Surabaya are Javanese dysfunction
9.3%
and Muslim. In 1999, the estimated population in Sura-
baya was 2 864 105; the crude birth rate was 17.8 per Other direct
1000 population; the total fertility rate was 1.8; the causes
2.1%
proportion of deliveries assisted by a skilled attendant was s
uteru
90%; the proportion of women receiving antenatal care u p t ured
R 5.2 %
was 89% and of those getting postnatal care was 107%
sis Hemorrhage
(Kantor Department Kesehatan Kotamadya Surabaya sep
p e ral 20.6%
2000). In 1994, the MMR was 325 per 100 000 live births r %
Pue 9.3
(Surabaya Municipal Health Services 1995).
Dr Soetomo Hospital is a teaching hospital of the Figure 1 Cause of maternal deaths (n 97).
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 for 38 cases. In 59 maternal deaths, the mean age
labour rooms in the department of obstetrics and one in the was 28.4 5.6 years and the mean gravidity was
Emergency Unit, built with assistance from the Japanese 2.2 1.2.
government. In the Emergency Unit there are seven Matching for age and gravidity, 372 controls were
obstetricians, four midwives and several anaesthesiologists drawn from 5697 women admitted to the same hospital as
and paediatricians on duty round the clock. the cases, from January to December 1999. Maternal age
At Dr Soetomo Hospital, there were 97 maternal deaths and gravidity have been shown to be risk factors for
from January 1996 to December 1999. The mean age of maternal mortality (for example, younger than 20 or older
the women was 27.8 5.6 years and the mean gravidity than 34 years and first pregnancy or more than four
was 2.3 1.4. Autopsies were not performed because of pregnancies) (Walsh et al. 1993). After that, 177 women
cultural reasons. The leading causes of maternal deaths are were selected from the group of 372 women by systematic
shown in Figure 1. Eclampsia (35.0%) and haemorrhage random sampling. Table 1 shows the clinical characteris-
(20.6%) were most common in this hospital. Most of the tics of the cases and the controls.
deaths occurred in women who had been transferred from Pre-coded questionnaires were designed and adminis-
other facilities (79.4%, 77 of 97 maternal deaths). Of all tered to measure socio-economic background, quality of
the deaths, 15.5% (15 of 97) were antenatal, 2.1% (two of antenatal care and use of family planning. Indicators of
97) were during labour or delivery, 79.4% (77 of 97) were socio-economic status included the following: living
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, Table 1 Clinical profiles of the study population
vacuum extraction or destruction of the fetus), whereas
25.6% (21 of 82) were operative abdominal deliveries (i.e. Case Control
(n 59) (n 177)
Caesarean section or hysterectomy). Duration of hospital-
ization was from 20 min to 28 days. Of those who died, Age in years (mean SD) 28.4 5.6 29.3 5.0
44.3% died within 2 days after admission. Gravidity (mean SD) 2.2 1.2 2.1 1.2
Maternal transfer 74.6% (44) 21.5% (38)
Delivery at Dr Soetomo Hospital* 65.3% (32) 87.6% (155)
Data collection Caesarean section rate* 22.4% (11) 5.1% (9)
Not receiving antenatal care 5.1% (3) 0% (0)
There were 59 maternal deaths that were considered cases,
although information on socio-economic background, SD, standard deviation.
antenatal care and family planning was insufficient * Excluding 10 deaths, who had died before delivery.

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Tropical Medicine and International Health
N. Taguchi et al. Socio-economic background, antenatal care programmes and maternal mortality
conditions, distance and travel time to the hospital,
womens educational attainment, employment status,
possession of an automobile and electrical appliances
(TV sets, washing machine and refrigerator) and avail-
ability 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 ques-
tionnaires, 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.
Statistical analyses
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 (indepen-
dent variables) and maternal mortality (dependent vari-
able) 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.
Results
Socio-economic factors
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
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volume 8 no 9 pp 847852 september 2003
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.
Family planning
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.
Multivariate analysis
Bivariate analysis was carried out between maternal
mortality and the risk factors of socio-economic back-
ground, 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.
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N. Taguchi et al. Socio-economic background, antenatal care programmes and maternal mortality

Table 2 Bivariate and Multivariate

Risk factors Case Control Unadjusted OR Adjusted OR 95% CI analysis; unadjusted odds ratio (OR) and
adjusted OR for socio-economic, antenatal
Race
care and family plannning factors and 95%
Other 4 14 0.8
confidence interval (CI) of cases and
Javanese 55 163 1.0
controls
Religion
Other 3 13 0.8
Islam 56 164 1.0
Living area
Out of Surabaya 28 14 10.5** 11.7** 5.029.2
Within Surabaya 31 163 1.0
Travel time to the hospital
Over 30 min 10 39 0.7
Within 30 min 49 138 1.0
Educational attainment of patient
Up to primary school 26 39 2.8* 1.5 0.63.4
Over primary school 33 138 1.0
Employment of patient
Unemployed 53 119 4.3** 4.4* 1.713.8
Employed 6 58 1.0
Availability of automobile
No 57 163 2.5
Yes 2 14 1.0
Availability of clean water
No 9 30 0.9
Yes 50 147 1.0
Availability of toilet facility
No 15 18 3.0* 2.9* 1.07.7
Yes 44 159 1.0
Frequency of antenatal care
03 times 27 36 3.3** 2.5* 1.15.5
4 times 32 141 1.0
Initial visit to antenatal care facilities
After 4 month of pregnancy 46 87 3.7** 3.0* 1.37.0
13 month of pregnancy 13 90 1.0
Antenatal care facilities
No doctor 39 99 1.5
With doctor 20 78 1.0
Birth interval
<2 years 12 20 2.6
2 years 26 94 1.0
Age at first delivery
<18 years old 8 13 2.0
18 years 51 164 1.0

* P < 0.05.
** P < 0.001.
Excluding primigravida: 21 women in cases, 63 women in controls.

Significant risk factors found in the bivariate analysis 95% CI 5.029.2), unemployment (not earning income)
were entered into the multiple logistic regression models (OR 4.4, 95% CI 1.713.8), unavailability of toilet
(Table 2). Significant risk factors used in the multivariate facilities (OR 2.9, 95% CI 1.07.7), <4 antenatal
analysis were: living outside of Surabaya (OR 11.7, visits (OR 2.5, 95% CI 1.15.5) and initial visit to

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Tropical Medicine and International Health
N. Taguchi et al. Socio-economic background, antenatal care programmes and maternal mortality
antenatal facilities after the fourth month of pregnancy
(OR 3.0, 95% CI 1.37.0). The level of education
achieved was not considered as a risk factor in the
multivariate analysis.
Discussion
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 facil-
ities are indicators of womens 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 utiliza-
tion of medical services increases with the level of
2003 Blackwell Publishing Ltd
volume 8 no 9 pp 847852 september 2003
education (Thaddeus & Main 1994). However, no
investigation has provided evidence suggesting that
maternal mortality is directly associated with womens
education (Walsh et al. 1993). Further study is needed to
show if there is an association between maternal deaths
and womens 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 (613%) (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
Childrens 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
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N. Taguchi et al. Socio-economic background, antenatal care programmes and maternal mortality

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 signifi-
cantly influence the results because there were no differ-
ences 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.
Acknowledgements
This study was conducted in collaboration with the
International Center for Medical Research, Kobe Univer-
sity 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 Gyn-
ecology, Kobe University Graduate School of Medicine.
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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 6500017, Japan. Fax: 81-78-382-5715. E-mail: nao925@mpd.biglobe.ne.jp
M. Maekawa, Department of Hygiene, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku,
Kobe 6500017, 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.

852 2003 Blackwell Publishing Ltd