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Root cause analysis of maternal deaths at Dr. Soetomo General Academic Hospital Surabaya, Indonesia in 2019

  • Dimas Ryan Desetyaputra ,
  • Budi Prasetyo ,
  • Hanifa Erlin Damayanti ,


Introduction: Maternal mortality in Indonesia especially in dr. Soetomo General Hospital is still very high, and the biggest problem is obstetric complications. It is possible that the mother who has obstetric complications is safe and recovered or died. This study aimed to identify the root cause of maternal death at Dr. Soetomo General Academic Hospital in 2019.

Methods: This is a descriptive retrospective study with the Root Cause Analysis method to analyze total of 87 maternal deaths at Dr. Soetomo General Academic Hospital in 2019.

Results: There were 87 cases of maternal death at Dr. Soetomo General Academic Hospital in 2019. Direct maternal death was the leading cause of maternal death, contributing 59 cases (67.8%). From 59 cases, 31 cases (35.6%) direct maternal deaths were caused by preeclampsia/eclampsia. Contributing factors that influence maternal mortality are including organizational management, medical personnel, equipment, materials, & ward, environmental, and family barriers factors. Organizational management factors, the most common factor that causes maternal death is a poor information sharing system at the referring hospital, as many as 17 cases (27.4%). Medical personnel factors, maternal death was mostly caused by lack of knowledge and skills during antenatal care, as many as 42 cases (44.2%). Equipment, materials,  and ward factors, the most common cause was the unavailability of the ward, contributing 5 cases (55.6%). Family barrier factors, most maternal deaths were caused by the families that did not understand about the emergency condition of the patient, as many as 52 cases (67.5%).

Conclusion: The maternal deaths at Dr. Soetomo General Academic Hospital in 2019 were mostly caused by the family barrier factor which did not understand about patient’s emergency condition, followed by the medical personnel factor which was lack of knowledge and skills during antenatal care.


  1. Kemenkes RI. Situasi kesehatan ibu. Kementerian Kesehatan Republik Indonesia. Jakarta: Kementerian Kesehatan Republik Indonesia; 2014.
  2. Bongaarts J. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Trends in Maternal Mortality: 1990 to 2015 Geneva: World Health Organization, 2015. Popul Dev Rev. 2016;42(4):726. Available from:
  3. Mahmood MA, Mufidah I, Scroggs S, Siddiqui AR, Raheel H, Wibdarminto K, et al. Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors. Biomed Res Int. 2018;2018:1–11. Available from:
  4. Djasri H, Utarini A. Keselamatan pasien dan mutu pelayanan: menuju kemana? J Man Pel Kes. 2012;15(4):159–60.
  5. RSUD Dr Soetomo. Unit terkait rawat inap [Internet]. Rumah Sakit Umum Daerah Dr. Soetomo. 2021. Available from:
  6. Van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG An Int J Obstet Gynaecol. 2009;116:18–21. Available from:
  7. Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay TT, Firestone R, et al. Maternal, neonatal, and child health in southeast Asia: towards greater regional collaboration. Lancet. 2011;377(9764):516–25. Available from:
  8. Ghulmiyyah L, Sibai B. Maternal Mortality From Preeclampsia/Eclampsia. Semin Perinatol. 2012;36(1):56–9. Available from:
  9. Prasetyo B, Damayanti HE, Pranadyan R, Habibie PH, Romdhoni AC, Islami D. Maternal mortality audit based on district maternal health performance in East Java Province, Indonesia. Bali Med J. 2018;7(1):61–7. Available from:
  10. Madzimbamuto FD, Ray SC, Mogobe KD, Ramogola-Masire D, Phillips R, Haverkamp M, et al. A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement. BMC Pregnancy Childbirth. 2014;14(1):231. Available from:
  11. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388(10056):2176–92. Available from:
  12. Mahmood MA, Hendarto H, Laksana MAC, Damayanti HE, Suhargono MH, Pranadyan R, et al. Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia. PLoS One. 2021;16(2):e0247911. Available from:
  13. Foronda C, MacWilliams B, McArthur E. Interprofessional communication in healthcare: An integrative review. Nurse Educ Pract. 2016;19:36–40. Available from:
  14. UNICEF. Trends in maternal mortality (estimates by WHO, UNICEF, UNFPA, World Bank Group, and the UN Population Division). [Internet]. UNICEF. 2019. Available from:
  15. Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OMR, Feigl AB, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet. 2016;388(10057):2307–20. Available from:

How to Cite

Desetyaputra, D. R., Prasetyo, B., & Damayanti, H. E. (2021). Root cause analysis of maternal deaths at Dr. Soetomo General Academic Hospital Surabaya, Indonesia in 2019. Bali Medical Journal, 10(3), 874–880.




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Dimas Ryan Desetyaputra
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Budi Prasetyo
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Hanifa Erlin Damayanti
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