Is Healthcare Staffing Related to Maternal Health Outcomes?

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Illustration by Dinkes Kuburaya

Maternal death is the second-highest death among women of reproductive age with nearly eight hundred women dying every day due to various causes. Maternal morbidity is experienced by around twenty million women around the world, causing death and disability without proper prevention or care. Considering the magnitude of this problem, continuous improvement in maternal healthcare receives major attention from global stakeholders. Sustainable Development Goals (The Sustainable Development Goals/SDGs) set a target to reduce the maternal mortality ratio to 70 deaths per 100,000 live births in 2030.

Despite the declining trend in maternal mortality (MMR), Indonesia is a developing country with a high number of maternal deaths. Based on government reports, the Maternal Mortality Rate (MMR) has decreased from 390 per 100,000 live births in 1991 to 305 per 100,000 live births in 2015. This achievement is in line with the increasing proportion of competent health personnel.

The availability of competent health workers in assisting births in health service facilities is a major strategy in Indonesia to prevent delays in maternal emergencies. Based on the 2012 Indonesian Demographic and Health Survey, more than 80% of maternal deaths occur in hospitals. It shows that women with obstetric complications may not arrive on time at the hospital or may receive inadequate care while in the hospital. The Government of Indonesia stated that delays in making decisions to seek health services, late referrals to health facilities, and inadequate emergency obstetric care due to constraints in infrastructure and human resources are among factors that contribute to maternal mortality.

Healthcare staff level is a significant component of health system. To improve maternal healthcare, the right staff is highly recommended by policymakers from international and national institutions. Previous review studies reported that shortages of health workers and imbalance distribution occur in various public health facilities in Indonesia. Therefore, we conducted an observational study using retrospective data from an electronic database of hospital administration aims to understand the maternal staffing and outcomes in several referral public hospitals in Java region.

Data of 8,396 deliveries with live births and 522 birth attendants were collected from six referral hospitals in Java, Indonesia chosen based on the similarity in structural characteristics, type A hospital. We included all data with live births (single and multiple births). Data on failed and incomplete delivery were excluded from data analysis.

This research used data on nursing staff including S1 nurses and diploma nurses, while midwifery staff consists of S1 midwives and diploma midwives. The staffing level variable was presented as an aggregate at the maternity unit level. Variables in maternal outcomes showing obstetric patients categorized as follows: 1) death: women died in hospital due to obstetric causes; 2) near-miss: women who almost died within 42 days after the pregnancy ends; 3) survive: women who lived when she is discharged from the hospital. In addition to variables related to staffing and maternal outcomes, we also include other variables that represent the characteristics of obstetric patients.

Staffing level is an important component in providing quality care. The results showed that the average level of nursing, obstetrics, and gynecology in this study was sufficient at the referral facility. However, the maternal mortality ratio and severe maternal morbidity ratio are still quite high which indicates that other factors may have an influential contribution. Most of the underlying causes of maternal mortality and near-death events in this study included puerperal complications, pregnancy complications, other complications (including intrapartum bleeding and preterm labor), other maternal care related to the fetus and amniotic cavity and possible labor problems, and hypertension. According to WHO, most causes of maternal death can be prevented through effective interventions, including antenatal care, intranatal care, and postnatal care. This intervention aims to ensure that every pregnant woman is physically and mentally healthy during pregnancy and gives birth to a healthy baby. Effective maternal healthcare services require adequate and competent health personnel. In Indonesia, staffing in maternity units is determined based on hospital classification. Type A and Type B referral hospitals are recommended to have one nurse or one midwife per patient. This regulation implies that at the secondary or tertiary referral level each patient must be attended by a nurse or midwife on all shifts.

Author: Ferry Efendi, S.Kep., Ns., M.Sc., Ph.D.

Details of this research available at:

http://www.indianjournals.com/ijor.aspx?target=ijor:ijphrd&volume=10&issue=7&article=121   Makhfudli, Ferry Efendi, Anna Kurniati, Retnayu Pradanie, Susy Katikana Sebayang. 2019. ‘What are the Staffing Levels and Maternal Outcomes? A Descriptive Study in Referral Hospitals in Java, Indonesia’. Indian Journal of Public Health Research & Development. doi: 10.5958/0976-5506.2019.01644.9

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