Analysis of Modifiable Factors of Maternal Mortality Based on AMP-SR in East Kalimantan Province, 2023–2024

Maternal mortality remains a major public health concern in East Kalimantan Province, Indonesia, despite a decline in reported maternal deaths from 83 cases in 2023 to 74 cases in 2024. The implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR), known in Indonesia as Audit Maternal Perinatal–Surveilans dan Respons (AMP-SR), aims to identify modifiable factors contributing to maternal deaths and inform targeted preventive interventions. This study aimed to examine the characteristics of maternal deaths according to the timing and location of death and identify contributing factors using the Three Delays Model. A descriptive-analytical case series design was employed using secondary data from the Maternal and Perinatal Death Notification (Maternal Perinatal Death Notification, MPDN) system for 2023–2024. The variables included maternal characteristics, pregnancy status at the time of death, location of death, antenatal care (ANC) attendance, birth attendants, and modifiable factors identified through AMP-SR reviews. The findings indicated that more than half of maternal deaths occurred during the postpartum period, while over 75% occurred in hospitals. These patterns highlighted the importance of examining third-delay factors related to the timely provision of appropriate care within healthcare facilities, although the location of death alone did not establish the presence of a third delay. Additionally, 44.6% of the women who died had not received ANC, indicating substantial gaps in antenatal healthcare utilization that may have contributed to delays in recognizing complications and seeking appropriate care. Approximately 6.8% of deaths occurred during referral transportation, suggesting potential challenges associated with the second delay, particularly timely access to appropriate healthcare facilities. Overall, the findings identified important opportunities to prevent maternal deaths by addressing modifiable factors across the continuum of maternal healthcare. Strengthening comprehensive emergency obstetric and neonatal care (Pelayanan Obstetri Neonatal Emergensi Komprehensif, PONEK), improving the quality of postpartum care, optimizing referral coordination, and increasing ANC coverage and continuity were identified as priority strategies for reducing maternal mortality in East Kalimantan Province.