Quality of antenatal care and maternal mortality: a mixed-methods study in Purwakarta District, Indonesia.

BACKGROUND

Maternal health plays a key role in fostering a healthy and high-quality generation within a nation. One indicator of a nation's health status is the maternal and infant mortality rates. Maternal and infant deaths can be prevented through high-quality antenatal care (ANC). In Indonesia, integrated ANC programs have been implemented; however, the number of visits alone is insufficient, and the quality of care is a critical determinant of maternal outcomes. This study aimed to assess the role of antenatal care quality in reducing maternal mortality and to explore underlying factors influencing care quality.

METHODS

A mixed-methods study using an explanatory sequential design was conducted in a district in West Java, Indonesia. The quantitative method used a case-control design with 90 participants (24 maternal deaths and 66 controls), and analyses were conducted using chi-square tests and logistic regression. The qualitative method involved in-depth interviews with 13 informants to provide contextual explanations for the quantitative findings.

RESULTS

High-quality ANC was significantly associated with reduced maternal mortality (p < 0.001; OR = 0.10; 95% CI: 0.001-0.158). Pregnancy complications were strongly associated with maternal mortality (p < 0.001; OR = 145.8; 95% CI: 8.71-251.78). Management was also associated with maternal mortality in the bivariate analysis (p < 0.001; OR = 7.692; 95% CI: 2.360-25.074) but was not significant after multivariate adjustment. Qualitative findings indicated that ANC quality was influenced by healthcare provider competence, facility availability, the effectiveness of the referral system, maternal health programs, and maternal education and family support.

CONCLUSION

Improving ANC quality and strengthening the referral system should be prioritized to support efforts to reduce preventable maternal mortality. A comprehensive evaluation within the Maternal and Perinatal Death Surveillance and Response (MPDSR) system is needed to identify root causes and ensure appropriate follow-up.