10.5958/0976-5506.2019.03050.

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Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  1503

Analysis of Risk Factors Maternal Mortality in Sinjai District

Fitriani1, Masni1, M. Nadjib Bustan2, Ummu Salmah1, Stang1, Muh. Syafar3

1Department of Reproduction Health, Faculty of Public Health, Hasanuddin University, 2Department of Statistics
Faculty of Mathematics and Natural Sciences, Makassar State University, 3Departement Promotion Section
Faculty of Public Health, Hasanuddin University.

Abstract
The maternal mortality rate is the number of maternal deaths during pregnancy, labor and childbirth.
Maternal mortality is an important problem because it causes the state to lose a number of productive forces,
increasing child morbidity and mortality. This study aims to determine the risk factors for maternal mortality.
The research used was analytic observational with a case control study design with a sample size of 120
people consisting of 30 case groups and 90 control groups with a ratio of 1: 3, Data analysis used bivariate
analysis with Odds Ratio and multivariate analysis with multiple logistic regression. The results found there
are three variables which are risk factors for maternal mortality, namely late referral (OR = 4,620, 95% CI =
1,513-14,113), history of maternal disease (OR = 3,028, 95% CI = 1,095-8,669), and obstetric complications
(OR = 3,081, 95% CI = 1,161-7,896). While antenatal examination, family planning history, parity and
distance of pregnancy are not risk factors for maternal mortality. Health workers are advised to strengthen
the referral network system, conduct early detection of risk factors and manage obstetric complications.

Keywords: Maternal Mortality, Obstetric Complications, Maternal Disease History Antenatal Examination,
Family Planning History.

Introduction such as Sub-Saharan Africa 179,000, South Asia 69,000,

and Southeast Asia 16,000. The maternal mortality rate
Globally in 2015 around 830 women died every day
in Southeast Asian countries is ranked first by Laos,
and in Indonesia 38 women were due to complications
namely 357 per 100.00 Births, Vietnam 49 per 100,000
during pregnancy or childbirth. Based on the Intercensal
live births, Thailand 26 per 100,000 live births, Brunei
Population Survey (SUPAS 2015) the Maternal
27 per 100,000 live births, Malaysia 24 per 100,000 live
Mortality Rate (MMR) is 305 per 100,000 live births.
births and Singapore have a maternal mortality rate of 7
Total maternal deaths were 14,640, reported 4,999
per 100,000 births.
mothers and those not reported 9,641 maternal deaths.
The agenda for reducing the MMR’s Sustainable The Maternal Mortality Rate in Indonesia still
Development Goals (SDGs) globally by 2030 is 70 per reaches 305 per 100,000 live births, this figure places
100,000 live births and Indonesia targets MMR in 2024 Indonesia as the country with the second highest
to be 232 per 100,000 live births1. mortality rate in Southeast Asia. It is still very far
compared to neighboring Malaysia and Singapore. Based
Nearly 20% of maternal deaths occur before
on data from the South Sulawesi Health Office in 2015
delivery, 82% occur after labor or abortion, 46% occur
the number of maternal deaths was 149 cases, in 2016
within 24 hours of delivery and 69% occur within seven
there were 156 cases and the number of maternal deaths
days after delivery. Most reported maternal deaths occur
in 2017 reached 115 cases. South Sulawesi Province is
in health facilities. The highest maternal mortality sites
included in the top 10 list of provinces contributing to
were 77% in hospitals, 15.6% at home, 4.1% occurred
maternal mortality in Indonesia in 2017. Sinjai District
in trips to hospitals/health facilities, 2.5% in other health
ranks the second highest in MMR in South Sulawesi
facilities and 0.8%2.
province. Based on the health profile of Sinjai district,
The World Health Organization (WHO) in Maternal Mortality Rate in 2016 was 293 (12 cases)
developing countries in some countries have high AKI per 100,000 live births, decreased in 2017. Namely the
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MMR reported 148 (6 cases) per 100,000 KH, the target Data analysis: Data on general characteristics
of the 2017 Strategic Plan is 113 per 100.00 KH. In 2018 of respondents, independent variables and dependent
the MMR was 297 per 100,000 KH (12 cases), the target variables were processed using SPSS. To determine the
of the Strategic Plan 2018 was 113 cases per 100,000 risk factors for maternal mortality in pregnant, childbirth
Births3. and postpartum mothers in Sinjai District, data analysis
was used using univariate analysis, and multivariate
Cases of maternal deaths due to pregnancy, analysis with multiple logistic regression.
childbirth, and childbirth in Sinjai District are generally
caused by bleeding, hypertension, pre-eclampsia, Results
eclampsia, infection, abortion, anemia, nutritional status
and others. Most deaths occur within seven days after Table 1 shows the comparison of the proportion of
saline or the puerperium. Some studies show maternal age between cases and controls, the age category with
mortality is influenced by factors related to maternal the lowest presentation at age> 35 years where the case
factors, reproductive status factors, factors related to group and controls presented the same number (43.3%).
obstetric complications, factors related to health services, Comparing the proportion of education levels between
socio-economic factors and socio-cultural factors. cases and controls, the education level with the lowest
presentation was at the low education level where the
Materials and Method control group was higher (60.0%) than the case group
(50.0%). Comparison of the proportion of employment
Location and Design of Research: This research status between cases and controls, the lowest status of
was conducted in the working area of the Sinjai District work with presentations was for mothers who worked
Health Office. This type of research is observational where the case group was higher (16.7%) than the
analytic with case control design. control group (15.6%).
Population and Samples: The population in Table 1. Distribution of general characteristics of
this study were all pregnant women, maternal and mothers in Sinjai District 2016-2018
postpartum mothers at 13 (thirteen) Puskesmas from
16 (Sixteen) Puskesmas located in the Sinjai District Case Control Total
Variable
Health Office area for the period 2016 to 2018. Samples n % n % n %
were 120 mothers in which groups cases are all maternal Age
deaths (maternal mortality, maternal mortality and 20-35 17 56,7 51 56,7 68 56,7
postpartum maternal mortality) and the control group >35 13 43.3 39 43,3 52 43,3
are all pregnant women and mothers giving birth in Level of
the Puskesmas area where there are cases of maternal education
deaths, with a case sample ratio: control is 1: 3, so Low 15 50,0 54 60,0 69 57,5
Minimum sample amount is 30:90. The withdrawal of High 15 50,0 36 40,0 51 42,5
case and control samples was done by selecting samples Job status
randomly from all mothers who gave birth in the area of Work 5 16,7 14 15,6 19 15,8
Does not work 25 83,3 76 84,4 101 84,2
the Sinjai District Health Office.
30 100,0 90 100,0 120 100,0
Method of collecting data: This study uses
secondary data obtained from the Sinjai District Health Table 2. Shows that variables including risk factors,
Office. Data collected from 13 (thirteen) Puskesmas in which are thought to influence the occurrence of maternal
Sinjai District for 2016 to 2018 are: Balangnipa Health deaths in Sinjai District, show: the results of multiple
Center, Island IX Health Center, Bulupoddo Health logistic regression tests, which are assessed through
Center, Samataring Health Center, Kampala Health significance (Sig.) and “B” coefficients, and Exp (B)
Center, Samaenre Health Center, Aska Health Center, shows that there are three independent variables entered
Mannanti Health Center, Lappadata Health Center, into the test simultaneously, the significance values are
Manimpahoi Health Center, Manipi Community Health described as follows:
Center, Central Lembang and Puskesmas Biji Nangka.
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  1505
Table 2. Multivariate analysis of risk factors for maternal mortality in Sinjai District 2016-2018
Variable B Wald
Late Referral 1,350 7,217
Disease History 1,108 5,133
Obstetrics Complications 1,125 4,454
Referral delay, with B value = 1,350, p = 0,007,
with the risk being assessed through Exp (B) = 4,620,
this value implies that late referrals have a significant
influence (p = 0,007) on the incidence of maternal
mortality with a 4,620 risk times greater than mothers
who are not late to be referred.
Disease history, with a value of B = 1.108, p =
0.023, with the risk being assessed through Exp (B) =
3.028, this value implies that the history of the disease
has a significant influence (p = 0.023) on the incidence of
maternal mortality with a large risk 3,028 times greater
than mothers who did not have a history of disease.
Obstetric complications, with a value of B = 1.125,
p = 0.033, with the risk being assessed through Exp (B)
= 3.081, this value implies that obstetric complications
have a significant influence (p = 0.033) on the incidence
of maternal deaths with a large risk 3,081 times
greater than mothers who did not experience obstetric
complications.
Discussion
In this study showed a significant result that the
delay in referral, provided a risk of 4.620 greater for the
occurrence of maternal deaths. The results of this study
are in line with the research of Aeni (2013) that the
delay in referral was proven to be significantly related to
maternal mortality (OR = 10; p value = 0.013, 95% CI =
1.34-74.5). Factors of delay are especially late in making
decisions to refer to and delay in reaching a referral
place related to maternal death. This happens because
the mother’s unwillingness to go to a health facility
immediately and considers the signs of complications
that are common in pregnancy, while other family
members do not know the signs of emergency in obstetric
complications. In general, this occurs in mothers with
parity> 1 because they feel experienced in a previous
pregnancy.
The results of the study were also in line with
Atjo’s4 study, which was one of the causes of maternal
95.0% C.I. for EXP(B)
Df Sig. Exp
Lower Upper
1 0,007 4,620 1,513 14,113
1 0,023 3,028 1,095 8,669
1 0,033 3,081 1,161 7,896
deaths due to the delay in deciding to refer to a hospital,
meaning that the delay from arriving to the hospital until
medical treatment became one of the causes of maternal
and childbirth deaths and numbers maternal mortality
(Maternal Mortality Rate) is the ratio of the number of
maternal deaths to 100,000 live births, this figure is an
important indicator in efforts to achieve better quality
of health services for pregnant and childbirth mothers
in the city of Palu. When viewed from the Odds Ratio
(OR), the delay in medical treatment also has the highest
OR (30,447) compared to the others.
Other infectious diseases that are still the main
problem of public health are Tuberculosis (TB). In
pregnant women. In pregnant women TB can worsen
maternal health and nutritional status, and affect fetal
growth and development and the risk of contracting the
baby3.
Research results in line with the research conducted
by Jayanti, et al5 indicate that there is an influence
between history of history of illness on maternal
mortality. Mothers with a history of illness increased
the risk of maternal death by about 9 times greater than
those of women without a history of disease (OR = 8.9
95% CI; 2.76-28.71).
Godefay et al6 study of risk factors for maternal
mortality in Tigray Ethiopia states that a history of
maternal disease affects maternal mortality where
mothers with a history of disease have a risk of 5.58
times compared to mothers with no history of disease.
In this study obtained the most existing history of
disease data in the case group that is equal to 56.7%. The
types of diseases found include chronic diseases such
as cardiac hypertension asthma and infectious diseases
such as TB, syphilis and nutritional problems, namely
SEZ. Based on data on causes of maternal mortality, it
was found that there were 2 (two) maternal deaths due
to TB disease, 2 maternal deaths due to diagnosed heart
disease and other maternal deaths due to eclampsia
caused by hypertension in the mother before pregnancy.
1506  Indian Journal of Public Health Research & Development, October
November2019,
A history of maternal disease is a disease that has
been suffered by the mother before the last pregnancy
based on the results of an antenatal examination and
the results of laboratory tests. With a mother who has
a history of chronic diseases that can interfere with the
mother’s pregnancy journey or aggravate the problem of
her pregnancy.
The results of this study indicate a significant risk of
a history of maternal disease against maternal mortality.
The history of maternal disease is a disease that has
been suffered by the mother before the last pregnancy
based on the results of an antenatal examination and
the results of laboratory tests. With a mother who has
a history of chronic diseases that can interfere with the
mother’s pregnancy journey or aggravate the problem of
her pregnancy.
The results of this study are in line with Suriani’s7
research, in this study showed that there was a significant
relationship between the history of the disease and the
incidence of maternal mortality. The statistical test
results show that mothers with a history of risky diseases
have 15 times the chance to experience a maternal death
event. This is because the history of the disease during
pregnancy cannot be avoided by pregnant women
because the history occurs before pregnancy and affects
later in pregnancy.
Factors that contribute to maternal mortality are
direct causes of maternal death, namely factors associated
with complications of pregnancy, childbirth, and
childbirth such as bleeding, infection, hypertension in
pregnancy (HDK) preeclampsia/eclampsia, congestion
and abortion. Maternal mortality caused by obstetric
complications In 2017, hypertension was 33.07%,
obstetric bleeding 27.03%, other obstetric complications
12.04%, infections in pregnancy 6.06% and 4.81% due
to other causes3
Obstetric complications such as hypertension in
pregnancy are a major trigger for the occurrence of pre-
eclampsia and eclampsia in pregnant, maternity and
postpartum mothers. As many as 10% of pregnancy
problems in the world are caused by hypertensive
disorders including pregnancies with hypertension and
pre-eclampsia8.
The results of this study indicate that obstetric
complications are significant risk factors for maternal
mortality. This research is in line with the risk factor
research conducted in Gowa South Sulawesi by using
a case control study design by looking at the effect of
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health status consisting of pregnancy complications
stating that women with high risk health status were
found with (OR = 9,750) having 10 times more risk large
maternal mortality compared to mothers who have low
risk health status9.
The yego et al.10 study of risk factors for maternal
mortality in tertiary hospitals in Kenya stated that a
history of complications affected maternal mortality with
a value (OR 9.0, 95% CI 4.2-19.3), in which mothers
with complications such as eclampsia has a risk of dying
as much as 9 times higher than women who do not have
a history of obstetric complications.
Researches found that the main cause of obstetric
bleeding complications was uterine atony, placental
retention, mothers with a history of previous bleeding,
Pre eclampsia, labor induction and macrosomia (large
infants)11,12.
In this study 76.7% of obstetric complications
occurred in the case group. The complications that
occur are as a direct result of pregnancy, and the types
of obstetric complications that occur are anemia,
hypertension, congestion, bleeding Pre eclampsia/
eclampsia, infection, Early Rupture of the membranes
(KPD) and Hyperemesis Gravidarum. Some cases of
complications were detected when the mother performed
an ANC examination but no collaboration was conducted
for laboratory examinations and even some cases were
not referred to for treatment. For example, mothers who
have hypertension are detected by a midwife in the
village but no further treatment is done. Likewise, the
handling is done by referring to the Hospital, but when
the mother goes home, no monitoring is carried out, even
the mother is never visited, so the mother experiences
severe complications.
Conclusions
Based on the results of research and discussion
with reference to the formulation of the problem and
the research hypothesis, conclusions can be drawn,
namely the delay in referral, obstetric history and
complications (Complications of Pregnancy, Childbirth
and Postpartum) are significant risk factors for the
incidence of maternal deaths in Sinjai District.
Ethical Clearance: aken from Faculty of Public
Health, Hasanuddin University committee.
Source of Funding: Self
Conflict of Interest: Nil
 Indian Journal of Public Health Research & Development, October 2019, Vol. 10, No. 10  1507

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