Quality of maternal health care in Indonesia


  • Hanifatur Rosyidah Universitas Islam Sultan Agung
  • Korrie De Koning Royal Tropical Institute
  • Hermen Ormel Royal Tropical Institute


Abstract views 3142 times


Quality of care, Quality assurance, Midwives, Maternal health, Indonesia,


Maternal Mortality Ratio (MMR) in Indonesia remains high, 190 per 100,000 live births in 2013. World Bank emphasizes that 60% of maternal death is contributed by poor quality of care. Lack of attitude, competence and compliance of midwives were found in Indonesia, which indicate poor quality of maternal health care. The objective of this study is to analyze factors influencing the quality of maternal health care in Indonesia. The literatures from 2004-2014 were selected and reviewed. The latest framework of 2014 on quality maternal health care by Renfrew et al. was used as a guide. The quality of maternal health care in Indonesia is influenced by lack of midwives’ competence, inadequate supervision and monitoring, lack of drugs and equipment supply, lack of community involvement in health services. In order to address the gaps in quality of maternal health care in Indonesia, six effective interventions are proposed; namely: maternal health audit and feedback, cultural competence, education, educational outreach visit, optimizing the role of lay health workers, group prenatal care and ensure adequate supply of drugs and equipment. The interventions needs to be carried out through a collaborative approach, policy change, pilot study and strengthen activities in implementation level.


Agus, Y & Horiuchi, S 2012, ‘Factors influencing the use of antenatal care in rural West Sumatra, Indonesia’, BMC Pregnancy and Childbirth, vol. 12, no. 9, doi:10.1186/1471-2393-12-9.

Agus, Y, Horiuchi, S & Porter SE 2012, ‘Rural Indonesia women’s traditional beliefs about antenatal care’, BMC Research Notes, no. 5, pp. 589, http://www.biomedcentral.com/1756-0500/5/589.

Alazri, M, Heywood, P, Neal, RD & Leese, B 2007, ‘Continuity of Care: Literature review and implications’, Sultan Qaboos Univ Med J, vol. 7, no. 3, pp. 197–206.

Amiri, A & Gerdtham, Ulf-G 2013, ‘Impact of Maternal and Child Health on Economic Growth: New Evidence Based Granger Causality and DEA Analysis’, The Partnership for Maternal, Newborn & Child Health (PMNCH), viewed 11 May 2014, http://www.who.int/pmnch/knowledge/topics/201303_mnch_impact_on_economic_growth/en/

Anderson FWJ, Morton, SU, Naik, S & Gebrian B 2007, ‘Maternal Mortality and the Consequences on Infant and Child Survival in Rural Haiti’, Matern Child Health J, vol. 11, pp. 395–401.

Audo, MO, Ferguson, A & Njoroge, PK 2005, ‘Quality of health care and its effects in the utilisation of maternal and child health services in Kenya’, East African medical journal, vol. 82, no. 11, pp. 547-553.

Broek, van den, NR & Falconer, AD 2011, ‘Maternal mortality and Millennium Development Goal 5’, British Medical Bulletin, vol. 99, pp. 25–38.

Carolan, M & Hodnett, E 2007, ‘‘With woman’philosophy: examining the evidence, answering the questions’, Nursing inquiry, vol. 14, no. 2, pp. 140-152.

D'Ambruoso, L, Achadi, E, Adisasmita, A, Izati, Y, Makowiecka, K & Hussein J 2009, ‘Assessing quality of care provided by Indonesian village midwives with a confidential enquiry’, Midwifery, vol. 25, no. 5, pp. 528-539, doi: 10.1016/j.midw.2007.08.008.

D'Ambruoso, L, Byass, P & Qomariyah, SN 2010 ‘'Maybe it was her fate and maybe she ran out of blood': final caregivers' perspectives on access to care in obstetric emergencies in rural Indonesia’, J Biosoc Sci., vol. 42, no. 2, pp. 213-241, doi: 10.1017/S0021932009990496.

de Graft-Johnson, J, Kerber, K, Tinker, A, Otchere, S, Narayanan, I, Shoo, R, Oluwole, D & Lawn, J 2006, ‘Continuum of care’, in PMNCH, Opportunities for Africa’s Newborns, World Health Organization (WHO), Geneva, pp. 23-36..

Duley, L, Gülmezoglu, AM, Henderson-Smart, DJ & Chou, D 2010, ‘Magnesium sulphate and other anticonvulsants for women with pre-eclampsia’, doi: 10.1002/14651858.CD000025.pub2.

ElHameed, HSA, Mohammed, AI & Hameed, LTAE 2012, ‘Effect of Nutritional Educational Guideline among Pregnant Women with Iron Deficiency Anemia at Rural Areas in Kalyobia Governorate’, Life Sci J, vol. 9, no. 2, pp. 1212-1217.

Fahdhy, M & Chongsuvivatwong, V 2005, ‘Evaluation of World Health Organization partograph implementation by midwives for maternity home birth in Medan, Indonesia’, Midwifery, vol. 21, no. 4, pp. 301–310.

Finlayson, K & Downe, S 2013, ‘Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies’, PLoS medicine, vol. 10, no. 1, e1001373.

Global Health Workforce Alliance (GHWA) 2013, ‘Indonesia Case Study’ in GHWA, Mid-level health workers for delivery of essential health services: A global systematic review and country experiences, Global Health Workforce Alliance.

Graham, WJ & Varghese, B 2012, ‘Quality, quality, quality: gaps in the continuum of care’, The Lancet, vol. 379, issue 9811, pp. e5-e6.

Groene, O & Jorgensen, SJ 2005, ‘Health promotion in hospitals—a strategy to improve quality in health care’, The European Journal of Public Health, vol. 15, no. 1, pp. 6-8.

Hennessy, D, Hicks, C & Koesno, H 2006, ‘The training and development needs of midwives in Indonesia: paper 2 of 3’, Human Resources for Health, vol. 4, no. 9, doi:10.1186/1478-4491-4-9.

Ho, JJ, Pattanittum, P, Japaraj, RP, Turner, T, Swadpanich, U & Crowther, CA 2010, ‘Influence of training in the use and generation of evidence on episiotomy practice and perineal trauma’, International Journal of Gynecology & Obstetrics, vol. 111, no. 1, pp. 13–18, doi:10.1016/j.ijgo.2010.04.035.

ICM 2011, Global Standards for Midwifery Regulation, viewed 21 July 2014, http://www.internationalmidwives.org/what-we-do/global-standards-competencies-and-tools.html

ICM 2013a, Symposium: Addressing Challenges of Midwifery Care, News 27 May 2013, viewed 30 July 2014, http://www.internationalmidwives.org/news/?nid=65.

ICM 2013b, Essential competencies for basic midwifery practice 2010 Revised 2013, viewed 27 July 2014, <http://www.internationalmidwives.org/what-we-do/education-coredocuments/essential-competencies-basic-midwifery-practice/>

Inayati, DA, Scherbaum, V, Purwestri, RC, Hormann, E, Wirawan, NN, Suryantan, J, Hartono, S, Bloem, MA, Pangaribuan, RV, Biesalski, HK,

Iyengar, K, Yadav, R & Sen, S 2012, ‘Consequences of Maternal Complications in Women’s Lives in the First Postpartum Year: A Prospective Cohort Study’, J Health Popul Nutr, vol. 30, no. 2, pp. 226-240.

Izumi, S, Baggs, JG & Knafl, KA 2010, ‘Quality nursing care for hospitalized patients with advanced illness: Concept development’, Research in nursing & health, vol. 33, no. 4, pp. 299-315.

Kim, SS, Kaplowitz, S & Johnston, MV 2004, ‘The effects of physician empathy on patient satisfaction and compliance’, Evaluation & the health professions, vol. 27, no. 3, pp. 237-251.

Lavender, T & Chapple, J 2004, ‘An exploration of midwives’ views of the current system of maternity care in England’, Midwifery, vol. 20, no. 4, pp. 324-334.

Lincetto, O, Mothebesoane-Anoh, S, Gomez, P & Munjanja, S 2006, ‘Antenatal Care’, in PMNCH, Opportunities for Africa’s Newborns, World Health Organization (WHO), Geneva, pp. 51-62.

Makowiecka, K, Achadi, E, Izati, Y & Ronsmans C 2008, ‘Midwifery provision in two districts in Indonesia: how well are rural areas served?’, Health Policy Plan, vol. 23, no. 1, pp. 67-75, doi:10.1093/heapol/czm036.

MOH-RI & Maternal and Child Health Integrated Program-USAID 2012, Petunjuk Kerja Pelayanan Antenatal Terpadu, Persalinan and Paska Persalinan Terpadu, Ministry of Health – Republic of Indonesia, Jakarta.

MOH-RI 2007, Pedoman Pelayanan Antenatal – Antenatal Care Guideline, Ministry of Health – Republic of Indonesia, Jakarta.

MOH-RI 2012a, Indonesia Health Profile 2011, Center for Data and Information, Ministry of Health Republic Indonesia, Jakarta.

MOH-RI 2012b, Integrated Antenatal Care Guideline (Pedoman Pelayanan Antenatal Terpadu), Edisi kedua, Dirjen Bina Gizi and KIA, Ministry of Health – Republic of Indonesia, Jakarta.

MOH-RI 2013b, Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan: Pedoman Bagi Tenaga Kesehatan, Ministry of Health – Republic of Indonesia, Jakarta.

Moore, ER, Anderson, GC, Bergman, N & Dowswell, T 2012, ‘Early skin-to-skin contact for mothers and their healthy newborn infants’, Cochrane Database Systematic Reviews, issue 5, Art. No. CD003519. DOI: 10.1002/14651858.CD003519.pub3.

MSH & USAID 2006, Clinic Supervisor’s Manual, Management Sciences for Health, Cambridge.

Nasir, S, Ahmed, R, Kurniasari, M, Limato R, De Koning, K, Tulloch, O & Syafruddin D 2014, Context analysis: Close-to-community maternal health providers in South West Sumba and Cianjur, Indonesia, REACHOUT Consortium.

Nuraini, E & Parker, E 2005, ‘Improving knowledge of antenatal care (ANC) among pregnant women: a field trial in central Java, Indonesia’, Asia Pac J Public Health, vol. 17, no.1, pp. 3-8.

Raven, JH, Tolhurst, RJ, Tang, S & van den Broek, N 2012, ‘What is quality in maternal and neonatal health care?’, Midwifery, vol. 28, no. 5, pp. e676-e683.

Renfrew, MJ, McFadden, A, Bastos, AH, Campbell, J, Channon, AA, Cheung, NF, Silva, DRAD, Downe, S, Kennedy, HP, Malata, A, McCormick, F, Wick, L & Declercq E 2014, ‘Midwifery and quality care: findings from a new evidence informed framework for maternal and newborn care’, Lancet, viewed 24 June 2014, http://dx.doi.org/10.1016/S0140-6736(14)60789-3.

Romano, AM & Lothian, JA 2008, ‘Promoting, protecting, and supporting normal birth: A look at the evidence’, Journal of Obstetric, Gynecologic, & Neonatal Nursing, vol. 37, issue 1, pp. 94-105.

Rosen, IM, Krueger, MV, Carney, LM & Graham, JA 2008, ‘Prenatal Breastfeeding Education and Breastfeeding Outcomes’, American Journal of Maternal Child Nursing, vol. 33, no. 5, pp. 315-319, doi: 10.1097/01.NMC.0000334900.22215.ec

Saimi 2006, ‘Faktor-Faktor yang mempengaruhi pemanfaatan pelayanan persalinan gratis di puskesmas Kabupaten Lombok Tengah Provinsi Nusa Tenggara Barat’, Medical Faculty, University of Gadjah Mada, Yogyakarta.

Sartore, A, De Seta, F, Maso, G, Pregazzi, R, Grimaldi, E & Guaschino, S 2004, ‘The Effects of Mediolateral Episiotomy on Pelvic Floor Function After Vaginal Delivery’, Obstetrics & Gynecology, vol. 103, no. 4, pp. 669-673, doi: 10.1097/01.AOG.0000119223.04441.c9.

Shankar, A, Sebayang, S, Guarenti, L, Utomo, B, Islam, M, Fauveau, V & Jalal, F 2008, ‘The village-based midwife programme in Indonesia’, Lancet, vol. 371.

Shrestha, R 2007, ‘The Village Midwife Program and the Reduction in Infant Mortality in Indonesia’, paper prepared for the 2007 Meeting of the Population Association of America, New York, 29–31 March 2007.

Sobhy, SI & Mohame, NA 2004, ‘The effect of early initiation of breast feeding on the amount of vaginal blood loss during the fourth stage of labor’, J Egypt Public Health Assoc., vol. 79, no. 1-2, pp. 1-12.

Stanton, C, Armbruster, D, Knight, R, Ariawan, I, Gbangbade, S, Getachew, A, Portillo, JA, Jarquin, D, Marin, F, Mfinanga, S, Vallecillo, J, Johnson, H & David, S 2009, ‘Use of active management of the third stage of labour in seven developing countries’, Bulletin of the World Health Organization, vol. 87, pp. 207-215. doi: 10.2471/BLT.08.052597.

Statistics Indonesia (BPS), National Population and Family Planning Board (BKKBN), Ministry of Health & ICF International 2013, Indonesia Demographic and Health Survey 2012, BPS, BKKBN, MOH, and ICF International, Jakarta.

Titaley, CR, Hunter, CL, Dibley, MJ & Heywood, P 2010a, ‘Why don’t some women attend antenatal and postnatal care services?: a qualitative study of community members’ perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia’, BMC Pregnancy and Childbirth, vol. 10, no. 61.

Titaley, CR, Hunter, CL, Dibley, MJ & Heywood, P 2010b, ‘Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia’, BMC Pregnancy and Childbirth, vol. 10, no. 43, doi:10.1186/1471-2393-10-43.

Truong, M, Paradies, Y, & Priest, N 2014, ‘Interventions to improve cultural competency in healthcare: a systematic review of reviews’, BMC health services research, vol. 14, issue 99, DOI: 10.1186/1472-6963-14-99.

UNFPA, Midwives, viewed 14 July 2014, <http://www.unfpa.org/public/mothers/pid/4384#moms>.

Utomo, AJ 2014, ‘Marrying Up? Trends in Age and Education Gaps Among Married Couples in Indonesia’, Journal of Family Issues, doi: 10.1177/0192513X14538023.

Van den Broek, NR & Graham, WJ 2009, ‘Quality of care for maternal and newborn health: the neglected agenda’, BJOG: An International Journal of Obstetrics & Gynaecology, vol. 116, no. s1, pp. 18-21.

Webster, PC 2012, ‘Indonesia makes maternal health a national priority’, The Lancet, vol. 380, issue 9858, pp. 1981-1982.

White, Patrice & Levin, L 2006, The Potential of Private Sector Midwives in Reaching Millennium Development Goals, Bethesda, MD: Private Sector Partnerships-One project, Abt Associates Inc.

WHO 2006, Quality of care: a process for making strategic choices in health system, World Health Organization, Geneva.

WHO 2008, WHO country cooperation strategy 2007-2011: Indonesia’, WHO Country Office for Indonesia.

WHO 2011, PMNCH Fact Sheet: Maternal mortality, World Health Organization, viewed 11 May 2014, http://www.who.int/pmnch/media/press_materials/fs/fs_mdg5_maternalmortality/en/

WHO 2013, A Handbook for Building Skills: Counselling for maternal and newborn health care, World Health Organization, Geneva.

WHO 2014, Trends in Maternal Mortality 1990-2013: Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division, WHO, Geneva.

Widyawati, W, Jans, S, Bor, H, Siswishanto, R, van Dillen, J & Lagro-Janssen, AL 2014, ‘A randomised controlled trial on the Four Pillars Approach in managing pregnant women with anaemia in Yogyakarta-Indonesia: a study protocol’, BMC Pregnancy Childbirth, vol. 14, no. 1, pp. 163, doi: 10.1186/1471-2393-14-163.

World Bank 2010, "...and then she died": Indonesia Maternal Health Assessment, No 2837, World Bank Other Operational Studies, The World Bank, viewed 14 July 2014, <http://EconPapers.repec.org/RePEc:wbk:wboper:2837>.

Yamin, AE, Boulanger, VM, Falb, KL, Shuma, J & Leaning, J 2013, ‘Costs of Inaction on Maternal Mortality: Qualitative Evidence of the Impacts of Maternal Deaths on Living Children in Tanzania’, PloS one, vol. 8, issue 8, e71674, DOI: 10.1371/journal.pone.0071674.




How to Cite

Rosyidah, H., Koning, K. D., & Ormel, H. (2019). Quality of maternal health care in Indonesia. Journal of Health Technology Assessment in Midwifery, 2(1), 10–22. https://doi.org/10.31101/jhtam.924