Rural and Remote Health rrh.org.

au
James Cook University ISSN 1445-6354

ORIGINAL RESEARCH
-

AUTHORS

Vitri Widyaningsih1 MD, Lecturer *

Khotijah Khotijah2 MPH, Lecturer

CORRESPONDENCE
*Dr Vitri Widyaningsih vitri_w@staff.uns.ac.id

AFFILIATIONS
1 Department of Public Health and Preventive Medicine, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir Sutami 36A Surakarta,
Indonesia

2 Occupational Health and Safety Program, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir Sutami 36A Surakarta, Indonesia

PUBLISHED
10 October 2018 Volume 18 Issue 4

HISTORY
RECEIVED: 11 October 2017

REVISED: 1 March 2018

ACCEPTED: 15 June 2018

CITATION
Widyaningsih V, Khotijah K.  The patterns of self-reported maternal complications in Indonesia: are there rural–urban differences? Rural
and Remote Health 2018; 18: 4609. https://doi.org/10.22605/RRH4609

Except where otherwise noted, this work is licensed under a Creative Commons Attribution 4.0 International Licence
ABSTRACT:
Introduction:  Specific and targeted intervention is needed to rural areas had a higher prevalence of bleeding and infection, but
reduce the relatively high maternal mortality and morbidity in a significantly lower prevalence of pregnancy rupture of
Indonesia. The apparent rural–urban disparities might require membrane. Nulliparity was a dominant factor for self-reported
different intervention strategies. Therefore, this study aims to maternal morbidity. Younger urban, but not rural, women
assess patterns and sociodemographic determinants of self- represented a higher proportion of maternal morbidity. In urban
reported maternal morbidity in rural and urban areas. areas, women with social disadvantage represented a higher
Methods:  Data from the Indonesian Demographic and Health proportion of morbidity. However, in rural areas, a higher
Survey 2012 were analyzed. In this cross-sectional survey, maternal prevalence of maternal morbidity was seen in women of higher
morbidity status and sociodemographic factors were obtained socioeconomic status. These rural–urban disparities might be
through questionnaire-based interviews. Women who completed partially caused by differences in knowledge of maternal
the maternal morbidity questionnaire were included in the morbidities and sociodemographic status between rural and urban
analyses (n=12 679). Descriptive statistics were used to assess women.
differences in proportion; mixed-effects regression was used to Conclusions:  This study found similar patterns of pregnancy
evaluate the association between sociodemographic factors and morbidity, but slight differences in labor morbidity patterns.
maternal morbidity. Specific interventions for major maternal complications within rural
Results:  Approximately 53.3% of women reported experiencing or urban areas are important. There were also differences in the
pregnancy and/or labor complications, with a lower proportion in proportion of self-reported maternal complications by
rural areas (51.3%) than in urban areas (55.1%). The patterns of sociodemographic factors, which might be caused by differences
pregnancy morbidities were similar for rural and urban women. in reporting. Intervention to improve knowledge and awareness of
The highest proportion of pregnancy morbidity was classified as maternal complication is needed, specifically for socially
‘other’, followed by ‘bleeding’. There were slight differences in the disadvantaged women and women living in rural areas.
type of labor morbidities. Compared to urban women, women in

Keywords:
Indonesia, labor complications, maternal morbidity, pregnancy complications, rural–urban disparities, sociodemographics.

FULL ARTICLE:
Introduction maternal complications by rural/urban area and the corresponding
sociodemographic factors. This study aims to describe the patterns
In addition to the need to reduce maternal deaths1, addressing the of maternal complications and the association with
relatively high prevalence of maternal morbidity (which covers the sociodemographic characteristics in urban and rural settings, to
period of pregnancy, delivery, and six weeks postpartum)2 is a provide a more specific recommendation for more effective
challenge for Indonesia. Previous studies have reported slower community-based intervention in Indonesia and countries with
improvement in achieving Millennium Development Goals in similar settings.
maternal health3,4, and an increasing self-reported maternal
morbidity in Indonesia2,5. Indonesia is one of 10 countries that Methods
contributes almost 60% of maternal deaths worldwide6 and
therefore maternal mortality has been the focus of many health This study used data from the Indonesia Demographic and Health
programs in Indonesia. These programs include the launching of Survey (IDHS) 20122. IDHS was a nationally representative cross-
Alert Husband and Alert Village programs7-9. With the increasing sectional survey using multistage sampling design. The present

burden of maternal morbidity, the focus should extend beyond study analysed data from women who gave birth in the previous
reducing maternal deaths to include improvement of overall health 5 years and completed the pregnancy and labor complications
and quality of life of Indonesian women10,11. questions (n=12 679). There was relatively little missing data on
knowledge of danger signs during the maternal period
Indonesia is one of the world’s biggest archipelagos, with more (n=7, 0.06%) and WHO standard antenatal care (ANC)
than 260 million people living in 34 provinces12. Geographical (n=472, 3.7%). The present study only included data on self-
barriers are a major challenge to distribution of healthcare access reported maternal complications in the most recent pregnancy and
and dissemination of public health programs13-15. The significant childbirth. In the IDHS, the pregnancy complications questions
differences in rural and urban areas beyond socioeconomic status included the topics of prematurity, bleeding, fever or infection,
compound the problem of ensuring equal access to healthcare16. convulsion and/or other morbidities during the most recent
Therefore, understanding the pattern of maternal morbidity in pregnancy. Meanwhile, prolonged labor, bleeding, fever or foul
terms of geographical area is essential to design effective and vaginal discharge, convulsions, premature rupture of membrane
specific community and hospital-based intervention. To date, there (PROM) and/or other morbidities were included in the labor
are limited data for Indonesia on the patterns of different types of complications questions. In this study, maternal morbidity status
was derived from a combination of pregnancy and/or labor Ethics approval
complications data10. Only the morbidities during pregnancy and
labor were included in the analyses, because of a data limitation This study was approved by the health research ethics committee

for postpartum morbidity in IDHS. at the Faculty of Medicine, Universitas Sebelas Maret (783/IX
/HREC/2016).
All statistical analyses were conducted in Statistical Analysis System
v9.4 (SAS Institute; http://www.sas.com) and were weighted to take Results

account the IDHS sampling scheme. Chi-squared tests were used Data were analyzed for 12 679 women (weighted n=12926), with
to assess the differences in the patterns of maternal morbidity by 47.2% living in rural and 52.8% in urban areas of Indonesia. There
different sociodemographic characteristics. Multilevel mixed- were significant differences between rural and urban areas in all
effects logistic regressions were conducted to evaluate the the sociodemographic characteristics assessed in this
relationship between various sociodemographic variables with study. Women in rural areas were relatively young and had higher
maternal morbidity. The individual-level variables included age, parity. Additionally, women from rural areas had lower family
parity, family wealth, maternal education, knowledge of maternal wealth and lived in the less developed region in Indonesia
complications, and WHO standard ANC of four visits during (Table 1). There were significant differences in knowledge of
pregnancy. Region was used as the community-level variable. The danger signs during the maternal period. Only 25.2% of women in
region was classified into three categories based on development: rural areas knew about any danger signs during the maternal
Java-Bali, more developed other islands and less developed other period compared to 34.8% of women in urban areas. Women in
islands2,10. rural areas had significantly lower insurance membership (31.9%)
than women in urban areas (42.1%).

Table 1:  Sociodemographic characteristics of women in rural and urban areas of Indonesia

Pattern of self-reported maternal morbidity types complications during their most recent pregnancy or
childbirth. Women in rural areas reported significantly fewer
Table 2 shows the self-reported prevalence of maternal
maternal complications (51.3%) than women in urban areas
complication types during pregnancy and labor in IDHS 2012. (55.1%). Similarly, self-reported pregnancy and labor morbidities
Overall, 53.3% of women reported pregnancy and/or labor were lower in rural areas than in urban areas (Table 2).
The patterns of pregnancy morbidities were similar for rural and urban areas, the highest proportion was for prolonged labor,
urban women. The highest proportion of pregnancy morbidity was followed by the PROM, bleeding and infection categories. In rural
the category of complications classified as ‘other’, followed by areas, prolonged labor and PROM were followed by the infection
‘bleeding’. However, women in urban areas had a significantly and bleeding categories. Compared to urban women, women in
higher prevalence of bleeding compared to women in rural areas. rural areas reported a higher proportion of bleeding and infection,
There were no significant differences between rural and urban for but a significantly lower proportion of PROM and other
the remaining pregnancy complications: prematurity, fever, complications (Table 2). There were no significant differences in the
convulsions and ‘other’ (Table 2). proportion of self-reported prolonged labor and convulsions
among women in urban and rural areas.
There were slight differences in the types of labor morbidities. In

Table 2:  Self-reported morbidity types for rural and urban women in Indonesia during most recent birth

Sociodemographic pattern of self-reported maternal areas, a higher proportion of morbidity was reported in women of
complications high family wealth. However, in mixed-effects regression, only
parity showed significant association with self-reported
The proportion and association of maternal complications by complications in the maternal period. Compared to primiparous
sociodemographic characteristics were also analyzed (Table 3). women, multiparous women were less likely to report maternal
Overall, there were significant differences in the proportion of
complications (adjusted odds ratio 0.8, 95% confidence interval
maternal morbidity by sociodemographic factor. There was a 0.7–0.9). In contrast, there were no significant differences in the
higher proportion of self-reported morbidity in women who were proportion of self-reported complications by family wealth in
younger, primiparous, knew about danger signs in pregnancy,
urban areas. Furthermore, although insignificant, a higher
were of higher family wealth and living in Java-Bali (Table 3). In proportion of morbidities in urban areas was observed where
multivariate regression, only two factors were significantly social disadvantage was high. For urban areas, significant
associated with self-reported morbidity: parity and knowledge of differences in proportion of morbidity by age, parity and region
maternal complications. were found (Table 3). In multivariate regression, only parity and
Table 3 shows differences in the sociodemographic pattern of knowledge of danger signs during the maternal period were

maternal complications when stratified by area. For rural areas, significantly associated with self-reported morbidity. Multiparous
significant differences in self-reported maternal morbidity were women were less likely to report maternal complications (adjusted
observed by parity, family wealth and region (p<0.05). In rural odds ratio 0.7, 95% confidence interval 0.6–0.8) than primiparous
women.
Table 3:  Weighted proportion and multilevel logistics regression of maternal morbidity for rural and urban women in Indonesia
during most recent pregnancy in maternal period

Discussion in rural areas compared to urban areas. These factors might

influence the self-reporting of maternal morbidity and the rural–
Pattern of self-reported maternal morbidity types urban disparities observed in this study.
This study showed differences in the proportion of maternal
The results also showed similarities between Indonesian rural and
morbidities between rural and urban areas. Previous studies urban areas in the types of self-reported pregnancy morbidities.
looking at different health outcomes also reported differences However, there were slight differences in labor complication types.
between rural and urban areas in Indonesia17,18 and other low– The differences in patterns of maternal morbidities might require
middle income countries19-22. All of these previous studies different intervention approaches. With the relatively low
reported a preferable condition in urban areas compared to rural knowledge of danger signs during the maternal period, increasing
areas. In contrast, this study found that women in rural areas had a awareness of maternal morbidity is critical to improve mothers’
lower prevalence of pregnancy morbidity and/or labor morbidity health-seeking behaviors and birth preparedness28-30. In 2012, the
than women in urban areas. However, these findings should be IDHS reported that only 53.0% of women received information on
interpreted cautiously, particularly due to the self-report nature of danger signs during pregnancy during their ANC visits, with
this study. significant rural–urban differences. Approximately 57.1% of urban
There are several potential explanations for the findings. First is the women received information on danger signs of pregnancy
higher maternal mortality in rural areas. In 2010, approximately complications compared to only 48.7% of women in rural areas31.
64% of maternal deaths in Indonesia happened in rural Therefore, integration of focused education on maternal morbidity

areas23. Second is under-reporting due to lower awareness of in ANC is indispensable. The educational intervention to improve
maternal complications, lower coverage of ANC and a higher knowledge should emphasize the types of morbidities more
proportion of socially disadvantaged women in rural areas. prevalent in the respective areas. This step must be followed with

Previous research has noted the importance of ANC visits in healthcare readiness for emergency cases, focusing on the more
improving knowledge and awareness of maternal morbidity24-26. prevalent morbidity cases in the area32.
Additionally, studies have reported that socially disadvantaged The higher prevalence of self-reported infection and bleeding in
women (ie women of low education and economic status) have rural areas highlights the importance of improving awareness of
lower knowledge of maternal morbidity24-28. In this study, the these morbidities. This study corroborates findings from a
proportion of women who knew about danger signs during systematic analysis by WHO, which reported that, globally, more
pregnancy and had the recommended ANC was significantly lower than 50% of maternal mortalities were attributed to bleeding,
hypertension or sepsis. In addition, indirect causes (pre-existing management of complications.
conditions including HIV and other medical conditions) contribute
to almost 25% of overall maternal deaths in the world33. In rural Previous studies have reported that social disadvantage including

Tanzania, a hospital-based study found that the most prevalent poverty and low education can increase the risk for severe
severe maternal morbidities and mortality included obstructive maternal morbidity44-47. Less contact with healthcare providers
labor hemorrhage, hypertensive disorders and abortion-related also increases the risk of these morbidities45-47. Although not
complications34. Although the Tanzanian study had a different significant, the authors found similar patterns in urban women,

source population from the present community-based study, the where women with social disadvantage reported a relatively higher
similarities in the most prevalent morbidity reported proportion of morbidity. However, in rural areas, a higher
(ie bleeding/hemorrhage) signify the importance of focusing on proportion of self-reported morbidity was found in women with
bleeding prevention and treatment during the maternal period. higher family wealth. This discrepancy might be due to the higher
Previous research in rural Malawi and Pakistan reported a higher knowledge of maternal morbidities in more socially advantaged

prevalence of infection-related morbidity, with approximately one- women. Women who are more aware of maternal morbidity are
third of women experiencing this morbidity during the maternal more likely to recognize the symptoms and report their
period35. The findings from the present study as well as evidence experience. This was reflected in the higher proportion of
from previous research underline the need to improve the morbidity among women who knew about danger signs in
mothers’ and healthcare providers’ awareness of and readiness to pregnancy, which was found in the present study. In previous
infection and bleeding during the maternal period, specifically in studies, education and household assets were reported to increase
rural areas of Indonesia. knowledge of maternal morbidity28,48. Additionally, the
information received during ANC can improve women’s
In this study, the authors were unable to estimate the prevalence knowledge and awareness26, and increase the reporting of
of hypertension in pregnancy due to data limitations. Although the maternal morbidity. The rural–urban differences in
IDHS reported whether women had blood pressure measurements sociodemographic patterns of maternal complications might be
during ANC visits, the actual values of blood pressure were not confounded by the differences in socioeconomic background and
recorded. Hypertension and other symptoms were classified as knowledge of maternal morbidities between rural and urban
‘other’ pregnancy morbidities, and could not be further classified. women. Therefore, more attention on improving knowledge and
Therefore, it will be important to further investigate hypertension awareness on maternal morbidity should be directed to rural
in pregnancy as well as other pre-existing medical conditions that women and women of low family wealth. Additionally, research
might influence pregnancy outcomes and cause maternal with more valid measures for maternal complications (ie medical
morbidity36. This step is especially important because this study records or medical examination) is needed to corroborate the
found that ‘other’ pregnancy morbidities were the most prevalent findings from this study.
morbidities, both in rural and urban areas. In addition, a previous
study on maternal morbidity in Indonesia reported that Limitations and strengths
hemorrhage and hypertensive disease were the most common
There are several limitations to this study. First, the authors were
diagnoses for maternal near miss (in which a woman survived life-
unable to report several major maternal morbidity types, including
threatening complications during the maternal period)37.
morbidities caused by pre-existing medical conditions. Second, the
Sociodemographic pattern of self-reported maternal self-reported morbidity status was susceptible to information bias.
complications This was particularly due to the knowledge of maternal morbidity,
family wealth and level of education. Although self-reported
This study showed that, in both rural and urban areas, a higher morbidity has its limitations, a previous validation study showed
proportion of maternal morbidity was observed in primiparous that the specificity and sensitivity are quite good49.
women. Consistent with previous findings, this study found that
nulliparity remains an important factor for self-reported maternal Despite these limitations, this study makes significant
morbidity38-40. Previous studies also reported that younger age is contributions. First, this study presents the types of morbidity by
a predictor of maternal morbidity40-42. In this study, significant rural/urban area, which can inform recommendations for
differences by age were observed in urban areas, but not in rural intervention. Second, this study was able to identify vulnerable
areas. Younger urban women had a higher proportion of maternal populations for maternal morbidity within rural and urban areas.
morbidity. In this study, there was no increase in morbidity These women can be the target of high-risk prevention strategies.
proportion in women who were older than 35, which was reported Third, this study highlights the relatively high prevalence of
as a risk factor for morbidity38-40. Other risk factors for morbidity maternal morbidities, which was amplified by the low knowledge
include prior history of complications39-41 and pre-existing of danger signs during the maternal period. These findings should
medical conditions38,43, which could not be measured in this study. further emphasize the importance of not only focusing maternal
The findings suggest the importance of a high-risk approach for mortality but also addressing maternal morbidities in public health
high-risk individuals: younger, primiparous women. The interventions.
intervention should be conducted both in rural and urban areas,
and include identification of high-risk mothers, screening and early
Conclusions family wealth and education in rural areas, but not in urban areas.
The higher proportion of self-reported morbidities in socially
The authors found similar patterns in pregnancy morbidity advantaged populations in rural areas, but not urban areas, might
between rural and urban areas. Meanwhile, the patterns of labor reflect differences in the knowledge and awareness of maternal
morbidity were slightly different. These findings also suggest rural– morbidity between rural and urban women. Therefore, it is crucial
urban disparities, specifically in knowledge and prevalence of to improve the knowledge and awareness of maternal
maternal morbidity. Therefore, intervention to improve knowledge complications, specifically for women of low family wealth living in
and awareness of maternal morbidity is needed. The educational rural areas.
intervention can be integrated in routine ANC, with more emphasis
on the types of morbidity more prevalent in the respective areas. Acknowledgements
Further research to classify types of pregnancy morbidity,
specifically complications related to chronic diseases, is needed. The authors thank the Demographic and Health Survey Program
for providing access to the data for this study. IDHS was a joint
This study observed differences in factors related to self-reported effort of the Statistics Indonesia, National Population and Family
morbidity. Although nulliparity was the dominant risk factor for Planning Board – BKKBN/Indonesia, Ministry of Health Indonesia,
morbidity in rural and urban areas, there were differences by and ICF International.

2007; 85(10): 774-782. https://doi.org/10.2471/BLT.06.033472

REFERENCES: PMid:18038059

1 Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela 10 Widyaningsih V, Khotijah, Balgis. Expanding the scope beyond
SM, et al. Maternal mortality for 181 countries, 1980–2008: a mortality: burden and missed opportunities in maternal morbidity
systematic analysis of progress towards Millennium Development in Indonesia. Global Health Action 2017; 10(1): 1339534.
Goal 5. Lancet 2010; 375(9726): 1609-1623. https://doi.org https://doi.org/10.1080/16549716.2017.1339534 PMid:28649930
/10.1016/S0140-6736(10)60518-1 11 Hardee K, Gay J, Blanc AK. Maternal morbidity: neglected
2 Statistics Indonesia (Badan Pusat Statistik). National Population dimension of safe motherhood in the developing world. Global
and Family Planning Board, Ministry of Health – Kementerian Public Health 2012; 7(6): 603-617. https://doi.org/10.1080
Kesehatan, ICF International. Indonesia Demographic and Health /17441692.2012.668919 PMid:22424546
Survey 2007. 2013. Available: http://wwwdhsprogram.com 12 United Nations Statistics Division. UNdata – country profile –
/publications/publication-fr275-dhs-final-reports.cfm (Accessed 3 Indonesia. 2016. Available: http://data.un.org
November 2016). /CountryProfile.aspx?crName=indonesia (Accessed 15 January
3 UNICEF Indonesia. IssueBriefs – maternal and child health. 2012. 2017).
Available: http://www.unicef.org/indonesia 13 Belton S, Myers B, Ngana FR. Maternal deaths in eastern
/A5-_E_Issue_Brief_Maternal_REV.pdf (Accessed 12 December Indonesia: 20 years and still walking: an ethnographic study. BMC
2016). Pregnancy and Childbirth 2014; 14-39. https://doi.org/10.1186
4 Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay TT, Firestone /1471-2393-14-39 PMid:24447873
R, et al. Maternal, neonatal, and child health in southeast Asia: 14 Tripathi V, Singh R. Regional differences in usage of antenatal
towards greater regional collaboration. Lancet 2011; 377(9764): care and safe delivery services in Indonesia: findings from a
516-525. https://doi.org/10.1016/S0140-6736(10)62049-1 nationally representative survey. BMJ Open 2017; 7(2): e013408.
5 Statistics Indonesia (Badan Pusat Statistik). Indonesia https://doi.org/10.1136/bmjopen-2016-013408 PMid:28159851
Demographic and Health Survey 2002-2003. Calverton, MA: BPS 15 Ansariadi A, Manderson L. Antenatal care and women's birthing
and ORC Macro, 2003. decisions in an Indonesian setting: does location matter? Rural and
6 WHO, UNICEF, UNFPA WBG and the UNPD. Trends in maternal Remote Health 2015; 15(2): 2959. Available: https://www.rrh.org.au
mortality. Geneva: WHO Document Publication Services, 2015. /journal/article/2959 PMid:26066607 (Accessed 10 September
2018).
7 Shefner-Rogers CLCL, Sood S. Involving husbands in safe
motherhood: effects of the SUAMI SIAGA campaign in Indonesia. 16 Mulyana W. Rural-urban linkages: Indonesia case study. Working
Journal of Health Communication 2004; 9(3): 233-258. Group: Development with Territorial Cohesion. Santiago: Territorial
https://doi.org/10.1080/10810730490447075 PMid:15360036 Cohesion for Development Program, 2014.

8 Hill PS, Goeman L, Sofiarini R, Djara MM. 'Desa SIAGA', the 'Alert 17 Hodge A, Firth S, Marthias T, Jimenez-Soto E. Location matters:
Village': the evolution of an iconic brand in Indonesian public trends in inequalities in child mortality in Indonesia. Evidence from
health strategies. Health Policy Planning 2014; 29(4): 409-420. repeated cross-sectional surveys. PLOS One 2014; 9(7): e103597.
https://doi.org/10.1093/heapol/czt027 PMid:23650333 https://doi.org/10.1371/journal.pone.0103597 PMid:25061950

9 Hatt L, Stanton C, Makowiecka K, Adisasmita A, Achadi E, 18 Fernandez RC, Awofeso N, Rammohan A. Determinants of
Ronsmans C. Did the strategy of skilled attendance at birth reach apparent rural–urban differentials in measles vaccination uptake in
the poor in Indonesia? Bulletin of the World Health Organization Indonesia. Rural and Remote Health 2011; 11(3): 1702. Available:
https://www.rrh.org.au/journal/article/1702 PMid:21899375 Kaye DK. Does knowledge of danger signs of pregnancy predict
(Accessed 10 September 2018). birth preparedness? A critique of the evidence from women
19 Jaacks LM, Slining MM, Popkin BM. Recent underweight and admitted with pregnancy complications. Health Research Policy
overweight trends by rural–urban residence among women in low- System 2014; 12(1): 60. https://doi.org/10.1186/1478-4505-12-60
and middle-income countries. Journal of Nutrition 2015; 145(2): PMid:25300499
352-357. https://doi.org/10.3945/jn.114.203562 PMid:25644358 31 Statistics Indonesia (Badan Pusat Statistik). National Population
20 Paciorek CJ, Stevens GA, Finucane MM, Ezzati M, Barquera S, and Family Planning Board, Ministry of Health – Kementerian
Bhutta Z, et al. Children's height and weight in rural and urban Kesehatan, ICF International. Indonesia Demographic and Health
populations in low-income and middle-income countries: a Survey 2012. Jakarta: BPS, BKKBN, Kemenkes and ICF International,
systematic analysis of population-representative data. Lancet 2013.
Global Health 2013; 1(5): e300-309. https://doi.org/10.1016 32 Gage AJ, Ilombu O, Akinyemi AI. Service readiness, health
/S2214-109X(13)70109-8 facility management practices, and delivery care utilization in five
21 Karunachandra NN, Perera IR, Fernando G. Oral health status states of Nigeria: a cross-sectional analysis. BMC Pregnancy and
during pregnancy: rural–urban comparisons of oral disease burden Childbirth 2016; 16(1): 297. https://doi.org/10.1186
among antenatal women in Sri Lanka. Rural and Remote Health /s12884-016-1097-3 PMid:27716208
2012; 12(3): 1902. Available: https://www.rrh.org.au/journal 33 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J, et al.
/article/1902 PMid:22799459 (Accessed 10 September 2018). Global causes of maternal death: a WHO systematic analysis.
22 Srinivasan CS, Zanello G, Shankar B. Rural–urban disparities in Lancet Global Health 2014; 2: 323-333. https://doi.org/10.1016
child nutrition in Bangladesh and Nepal. BMC Public Health 2013; /S2214-109X(14)70227-X
13(1): 581. https://doi.org/10.1186/1471-2458-13-581 34 Nelissen EJT, Mduma E, Ersdal HL, Evjen-Olsen B, van
PMid:23767425 Roosmalen JJM, Stekelenburg J. Maternal near miss and mortality

23 Hull TH. Reducing maternal and neonatal mortality in in a rural referral hospital in northern Tanzania: a cross-sectional
Indonesia: saving lives, saving the future. Bulletin of Indonesian study. BMC Pregnancy and Childbirth 2013; 13(1): 141.
Economic Studies 2015; 51: 154-155. https://doi.org/10.1080 https://doi.org/10.1186/1471-2393-13-141 PMid:23826935
/00074918.2015.1023418 35 Zafar S, Jean-Baptiste R, Rahman A, Neilson JP, Van Den Broek

24 Pembe AB, Urassa DP, Carlstedt A, Lindmark G, Nyström L, Darj NR. Non-life threatening maternal morbidity: cross sectional
E. Rural Tanzanian women's awareness of danger signs of obstetric surveys from Malawi and Pakistan. PLOS One 2015; 10(9): 1-17.
complications. BMC Pregnancy and Childbirth 2009; 9(1): 12. https://doi.org/10.1371/journal.pone.0138026 PMid:26390124
https://doi.org/10.1186/1471-2393-9-12 PMid:19323836 36 Firoz T, Chou D, von Dadelszen P, Agrawal P, Vanderkruik R,
25 Okour A, Alkhateeb M, Amarin Z. Awareness of danger signs Tunçalp O, et al. Measuring maternal health: focus on maternal
and symptoms of pregnancy complication among women in morbidity. Bulletin of the World Health Organization 2013; 91(10):
Jordan. International Journal of Gynecology and Obstetrics 2012; 794-796. https://doi.org/10.2471/BLT.13.117564 PMid:24115804
118(1): 11-14. https://doi.org/10.1016/j.ijgo.2012.01.020 37 Adisasmita A, Deviany PE, Nandiaty F, Stanton C, Ronsmans C.
PMid:22503521 Obstetric near miss and deaths in public and private hospitals in
26 Anya SE, Hydara A, Jaiteh LE. Antenatal care in The Gambia: Indonesia. BMC Pregnancy and Childbirth 2008; 8(1): 10.
missed opportunity for information, education and https://doi.org/10.1186/1471-2393-8-10 PMid:18366625
communication. BMC Pregnancy and Childbirth 2008; 8-9. 38 Gray KE, Wallace ER, Nelson KR, Reed SD, Schiff MA.
https://doi.org/10.1186/1471-2393-8-9 PMid:18325122 Population-based study of risk factors for severe maternal
27 Amenu G, Mulaw Z, Seyoum T, Bayu H. Knowledge about morbidity. Paediatric and Perinatal Epidemiology 2012; 26(6):
danger signs of obstetric complications and associated factors 506-514. https://doi.org/10.1111/ppe.12011 PMid:23061686
among postnatal mothers of Mechekel District Health Centers, East 39 Norhayati MN, Nik Hazlina NH, Aniza AA, Sulaiman Z. Factors
Gojjam Zone, Northwest Ethiopia. Scientifica 2016; 3495416. associated with severe maternal morbidity in Kelantan, Malaysia: a
28 Kabakyenga JK, Östergren P-O, Turyakira E, Pettersson KO. comparative cross-sectional study. BMC Pregnancy and Childbirth
Knowledge of obstetric danger signs and birth preparedness 2016; 16(1): 185. https://doi.org/10.1186/s12884-016-0980-2
practices among women in rural Uganda. Reproductive Health PMid:27460106
2011; 8(1): 33. https://doi.org/10.1186/1742-4755-8-33 40 Sikder SS, Labrique AB, Shamim AA, Ali H, Mehra S, Wu L, et al.
PMid:22087791 Risk factors for reported obstetric complications and near misses
29 Bogale D, Markos D. Knowledge of obstetric danger signs in rural northwest Bangladesh: analysis from a prospective cohort
among child bearing age women in Goba district, Ethiopia: a cross- study. BMC Pregnancy and Childbirth 2014; 14(1): 347.

sectional study. BMC Pregnancy and Childbirth 2015; 15(1): 77. https://doi.org/10.1186/1471-2393-14-347 PMid:25282340
https://doi.org/10.1186/s12884-015-0508-1 PMid:25886509 41 Oliveira FC De, Costa ML, Cecatti JG, Pinto e Silva JL, Surita FG.
30 Mbalinda SN, Nakimuli A, Kakaire O, Osinde MO, Kakande N, Maternal morbidity and near miss associated with maternal age:
the innovative approach of the 2006 Brazilian demographic health https://doi.org/10.1111/1471-0528.12634 PMid:24641536
survey. Clinics 2013; 68(7): 922-927. https://doi.org/10.6061/clinics 46 Adisasmita A, Smith C V, El-Mohandes AAE, Deviany PE, Ryon JJ,
/2013(07)06
Kiely M, et al. Maternal characteristics and clinical diagnoses
42 Oliveira FCJ, Surita FG, Pinto E, Silva JL, Cecatti JG, Parpinelli MA, influence obstetrical outcomes in Indonesia. Maternal and Child
et al. Severe maternal morbidity and maternal near miss in the Health Journal 2015; 19(7): 1624-1633. https://doi.org/10.1007
extremes of reproductive age: results from a national cross- /s10995-015-1673-6 PMid:25656716
sectional multicenter study. BMC Pregnancy and Childbirth 2014; 47 Noor NM, Nik Hussain NH, Sulaiman Z, Abdul Razak A.
14: 77. https://doi.org/10.1186/1471-2393-14-77 PMid:24555831 Contributory factors for severe maternal morbidity: a 10-year
43 Zanette E, Parpinelli MA, Surita FG, Costa ML, Haddad SM, review of the literature. Asia-Pacific Journal of Public Health 2015;
Sousa MH, et al. Maternal near miss and death among women with 27(8S): 9S-18S. https://doi.org/10.1177/1010539515589811
severe hypertensive disorders: a Brazilian multicenter surveillance PMid:26069164
study. Reproductive Health 2014; 11(1): 4. https://doi.org/10.1186 48 Wiradnyani LAA, Khusun H, Achadi EL, Ocviyanti D, Shankar AH.
/1742-4755-11-4 PMid:24428879 Role of family support and women's knowledge on pregnancy-
44 Lindquist A, Noor N, Sullivan E, Knight M. The impact of related risks in adherence to maternal iron–folic acid
socioeconomic position on severe maternal morbidity outcomes supplementation in Indonesia. Public Health Nutrition 2016;
among women in Australia: a national case-control study. BJOG: 19(15): 2818-2828. https://doi.org/10.1017/S1368980016001002
An International Journal of Obstetrics and Gynaecology 2015; PMid:27181394
122(12): 1601-1609. https://doi.org/10.1111/1471-0528.13058 49 Souza JP, Parpinelli MA, Amaral E, Cecatti JG. Population
PMid:25227712 surveys using validated questionnaires provided useful information
45 Tunçalp Ö, Souza J, Hindin M, Santos C, Oliveira T, Vogel J, et al. on the prevalence of maternal morbidities. Journal of Clinical
Education and severe maternal outcomes in developing countries: Epidemiology 2008; 61(2): 169-176. https://doi.org/10.1016
a multicountry cross-sectional survey. BJOG: An International /j.jclinepi.2007.04.009 PMid:18177790
Journal of Obstetrics and Gynaecology 2014; 121: 57-65.

This PDF has been produced for your convenience. Always refer to the live site https://www.rrh.org.au/journal/article/4609 for the
Version of Record.