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An Insight Into Maternal Death Caused by Postpartum Hemorrhage in Western Timor, Indonesia

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An Insight Into Maternal Death Caused by Postpartum Hemorrhage in Western Timor, Indonesia Jurnal Keperawatan Indonesia, 2019, 22 (1), 1–10 © JKI 2019 DOI: 10.7454/jki.v22i1.675 pISSN 1410-4490; eISSN 2354-9203 Received July 2018; Accepted March 2019 AN INSIGHT INTO MATERNAL DEATH CAUSED BY POSTPARTUM HEMORRHAGE IN WESTERN TIMOR, INDONESIA Kristiani Desimina Tauho*, Ferry Fredy Karwur Faculty of Health Sciences Universitas Kristen Satya Wacana, Salatiga 50711, Indonesia *E-mail: [email protected] Abstract Maternal deaths in Timor Island, East Nusa Tenggara Province, are one of the contributors to the overall maternal mortality rate (MMR) of Indonesia. The MMR of Western Timor Island was 150/100,000 live births in 2015. The aim of this qualitative study was to explore the perceived causes of maternal death due to postpartum hemorrhage. Data were obtained from family members, traditional birth attendants, and Posyandu cadres, as well as health providers. Using the retrospective method, this study traced six out of nine postpartum hemorrhage cases in the four sub-districts with the highest maternal death rate in 2010. The research findings showed that most childbirth processes were done at home without any help from health workers. Postpartum hemorrhage happened among women ranging from 24-42 years old; five among them had been pregnant more than four times. Medically, five cases were caused by a prolonged third stage of labor due to a retained placenta. Non-medical factors causing postpartum hemorrhage were poor accessibility, lack of communication devices, and lack of infrastructure. Keywords: maternal death, postpartum hemorrhage, Western Timor Abstrak Pengetahuan Tentang Kematian Maternal Karena Perdarahan Postpartum di Timor Barat, Indonesia. Kematian maternal di Pulau Timor, Provinsi Nusa Tenggara Timur, merupakan salah satu penyumbang Angka Kematian Ibu (AKI) di Indonesia. Tahun 2015, AKI di Pulau Timor bagian barat adalah sebesar 150/100.000 kelahiran hidup. Tujuan dari studi kualitatif ini adalah untuk mengeksplorasi persepsi para pihak yang paling mengetahui mengenai penyebab kematian maternal karena perdarahan postpartum. Data diberikan oleh anggota keluarga, dukun bersalin, dan kader Posyandu, serta penyedia layanan. Menggunakan metode retrospektif, penelitian ini menyusur enam dari sembilan kasus perdarahan postpartum yang terjadi di empat kecamatan yang memiliki angka kematian maternal tertinggi pada tahun 2010. Hasil penelitian menunjukkan bahwa sebagian besar prosedur persalinan dilakukan di rumah tanpa bantuan dari tenaga kesehatan. Perdarahan postpartum terjadi di antara wanita dengan rentang umur 24–42 tahun; empat di antara mereka sudah pernah hamil sebanyak lebih dari empat kali. Secara medis, lima kasus disebabkan oleh perpanjangan kala tiga persalinan berhubungan dengan retensi plasenta. Faktor-faktor non medis yang menyebabkan perdarahan posrpartum adalah aksesibilitas yang buruk, ketiadaan piranti komunikasi, dan kurangnya infrastruktur. Kata kunci: kematian ibu, perdarahan postpartum, Timor Barat Introduction live births in 1990 to 126/100,000 live births in 2015 (MMEIG, 2015). However, Indonesia is Maternal death has always been a serious glo- in the fifth rank of maternal death in ASEAN bal problem. Between 1990 and 2015, there countries, mainly caused by complications du- were 13.6 million women who died of obs- ring pregnancy, and mostly during the birthing tetric causes. Most of those deaths happened period (WHO, 2015b). One of the main causes in developing countries (WHO, 2015a). In is hemorrhage, either antepartum or postpar- Indonesia, for the last 25 years, the maternal tum (Kassebaum et al., 2014; Say et al., 2014). death rate has decreased from 446/100,000 A number of research studies have shown that 1 Tauho, et al., An Insight into Maternal Death Caused by Postpartum Hemorrhage in Western Timor, Indonesia JKI, Vol. 22, No. 1, Maret 2019, 1–10 in the regions with a high number of maternal 327.1/100,000 live births (Dinkes Kab. TTS, deaths, the variability of local factors is very 2016). decisively linked to maternal death caused by obstetric hemorrhages, such as chronic illness In 2010, the District Health Center identified before pregnancy, malaria infection or HIV/ six clinical categories of maternal death, which AIDS, and severe anemia during pregnancy are hemorrhage, infection, eclampsia, abortion, (Combs et al., 2012). Regional factors (Calvert complication, and other causes. However, most et al., 2012) and ethnic background are also deaths are d due to hemorrhage. Out of 46 influential (Harvey, et al., 2017). maternal deaths, 36 (or 78.2%) were caused by hemorrhage. It is therefore important to see East Nusa Tenggara Province is one area in what and how local factors in West Timor Indonesia with a very high rate of maternal influence this. The research examined six cases death. MMR in this province is 169/100,000 of maternal death caused by hemorrhage. live births. In Western Timor, the MMR is 150/100,000 live births (Dinkes NTT, 2015). Method This number is higher than the national rate, which is 126/100,000 live births (WHO, This qualitative research was conducted in four 2015b). The main cause of maternal death in sub-districts in TTS: Fatumnasi, Amanuban this province is obstetric hemorrhage (Dinkes Timur, Amanatun Selatan, and Oenino to ex- NTT, 2013). plore the perceived causes of maternal death due to postpartum hemorrhage. The other cau- Various efforts have been made by the govern- ses during pregnancy, such as maternal nutri- ment to reduce maternal death in East Nusa tion and prior illnesses, were not examined. Tenggara, such as the Safe Motherhood Pro- Permission to conduct research was provided gram, which has been going for about 26 years by the TTS District Government (Kesbang- (AbouZahr, 2003), the National Declaration of polinmas 18 02/464/VII/ TTS/, 2011). Gathe- Millennium Development Goals (Lundine, ring of data was permitted in the Health Com- Hadikusumah, & Sudrajat, 2013), and the im- munity Center (Puskesmas) as the working plementation of Revolusi KIA (Mother-Child’s area, which includes Fatumnasi, Oe Ekam, and Health Revolution). KIA Revolution was regu- Oinlasi dan Oenino. The research participants lated in the Governor’s Regulation no. 42 in signed an informed consent form before data 2009. The regulation states that it is recom- gathering began. mended that every woman gives birth in an adequate health facility (Dinkes NTT, 2009) Selecting the cases was done purposively ba- and that the role of women in mothers’ health sed on the reports of the District Health Servi- should be institutionalized through the Pos- ce Office about the number of maternal deaths yandu organization. However, the maternal a year ago. The total cases were 46; 36 of mortality level remains high. Therefore, the these were caused by hemorrhage among 32 significant question is to determine the local sub-districts. There were four sub-districts factors that have caused a high level of ma- with the highest maternal death, in which nine ternal death by hemorrhage in East Nusa cases were due to hemorrhage; six of those Tenggara, especially in Timor. cases were selected. This research was conducted in South Central Data gathering was done from July to August Timor District (Kabupaten Timor Tengah 2011 through an in-depth interview with the Selatan or TTS), East Nusa Tenggara. With a closest family member/s who had accompa- population of 459,310 people, its MMR is nied the woman before her death, the traditional 2 Tauho, et al., An Insight into Maternal Death Caused by Postpartum Hemorrhage in Western Timor, Indonesia JKI, Vol. 22, No. 1, Maret 2019, 1–10 birth attendant (TBA), the Posyandu cadre, the the baby’s birth. For one and a half hours doctor, and the midwife, with a total of 15 (from 9.30 am to 11 am), Mrs. MS had kept participants. The participants in each case we- pushing to deliver the placenta while the fa- re different based on the data saturation. Only mily members were unable to help. At 11 am, one health worker was interviewed in each the TBA, who is the closest neighbor, and also sub-district. The secondary data were taken the TBA in that area, came to visit because she from the woman’s medical record in the Pus- heard the baby’s crying. The TBA narrated kesmas. Most of the data are concerned with that when she arrived, Mrs. MS’s condition the mother’s biodata, the reason for death, and was no longer good (she made a comparison the mother’s health history. with another childbirth she helped before). She ran to the Puskesmas, which is about one Data analysis using the qualitative-verification kilometer away, and called the doctor. strategy was applied by inductively analyzing the data. Content analysis was done based on At around 12 noon, the doctor and nurses verbatim in-depth interviews. Firstly, the data arrived in an ambulance. They tried to install were coded and classified into categories. an intravenous (IV) catheter, but the doctor Units of meaning and identified category were assessed that Mrs. MS’s venous vessels were analyzed and were determined to establish not palpable; all of the vessels collapsed and relationships and to find out the meaning and the blood pressure also could not be measured. purpose of the communication’s content. The The doctor then decided to bring her to the result of the analyses was then described. Puskesmas. The baby was put on her stomach, and they lifted her into the ambulance. Results According to the doctor, their clothes were full of blood at the time. The doctor estimated that Mrs. MS’s case (34 years old, Fatumnasi). “the blood volume reached two to three liters.” Mrs. MS lived with her husband, a builder, in the capital city of the province during her preg- At 12.30 pm, Mrs. MS arrived at the Puskes- nancy and never did antenatal care in Puskes- mas and was attended to by the health work- mas. When she was about to deliver, she and ers.
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