How to cite:
Maryani Setyowati, Agung Wardoyo,, Jaka Prasetya,, Anastacia Rheinata Wibowo,,
Mufid Makantar. (2022). Maternal Decision Support Systems to Reduce Maternal
Mortality in Indonesia: Resolving Barriers to Implementation in Community Health
Centers. Journal Eduvest. Vol 2(2): 244-258
E-ISSN:
2775-3727
Published by:
https://greenpublisher.id/
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February, 2022
p- ISSN 2775-3735- e-ISSN 2775-3727
MATERNAL DECISION SUPPORT SYSTEMS TO REDUCE
MATERNAL MORTALITY IN INDONESIA: RESOLVING
BARRIERS TO IMPLEMENTATION IN COMMUNITY
HEALTH CENTERS
Maryani Setyowati
1
, Agung Wardoyo
2,
, Jaka Prasetya
3,
, Anastacia Rheinata
Wibowo
4,
, Mufid Makantar
5
Department of medical Record and health information of Faculty of Health,
Univesitas Dian Nuswantoro
Email: maryani.setyowat[email protected]us.ac.id, agung.[email protected]inus.ac.id,
ARTICLE INFO ABSTRACT
Received:
January, 26
th
2022
Revised:
February, 17
th
2022
Approved:
February, 18
th
2022
Aim: This paper aims to design a decision support system in
Maternal and Child Health services or MCH that can
monitor cases of pregnant women and prevent maternal
deaths because maternal deaths are still found in
Semarang. Indonesia. Method = Research and
Development with system development using the System
Development Life Cycle method, which includes studying
user needs, analyzing the system used, determining the
form of the system being developed, and designing the
Maternal Decision Support System. The sample of this
research is in the form of MCH service data in 2019 - 2021.
Meanwhile, respondent data collection is carried out by
interviewing MCH Program Holders and observing the
system used, analyzing MCH data, and designing a region-
based Decision Support System using PHP programming
and MySQL database. Result: The development of an MCH
decision support system application that can support the
area-based MCH program is https://spk-maternal.com/. It
is easy to use by officers at the community health centers
and the Health Office to monitor pregnancy history to
reduce maternal mortality. Conclusion = Results of our
study indicate that a district-based decision support system
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 245
is easy to use to reduce maternal mortality. The study's
findings indicate a need for tremendous support from the
government to make policies based on a decision support
system for appropriate maternal and child health services.
KEYWORDS
Decision Support System, Maternal Mortality, Maternal
and Child Health
This work is licensed under a Creative Commons
Attribution-ShareAlike 4.0 International
INTRODUCTION
Pregnancy is a necessary time to improve healthy behavior and parenting skills,
as well as the need for Antenatal Care attention from the family (Poote & McKenzie-
McHarg, 2019). The current finding is that 4.5 women die every day in Liberia from
pregnancy, childbirth, and postpartum complications, equivalent to about 1,100 women
per 100,000 live births (Bjegovic-Mikanovic, Broniatowski, Byepu, & Laaser, 2019).
Risk factors encountered during pregnancy in poor nutrition and smoking cause
premature birth in the Pleven region, Bulgaria (Kamburova, Hristova, Ludmilova, &
Khan, 2015).
The reduction in deaths in North-West Russia is due to increased investment by
the Russian government focusing on health care renovation (Burazeri, 2019), Maternal
and infant mortality rates are very high in Ethiopia because they did not maximize the
country's performance related to causes of death in 2015 (Misganaw et al., 2017). The
study to investigate the differences between PHS identified more pregnancy-related
outcomes than HDSS in this study. Inquiring about pregnancy and its outcomes may be a
valuable way to improve the measurement of pregnancy outcomes (Kadobera et al.,
2017).
Recent evidence from transitional Albania showing a higher multi-morbidity
burden among female patients than men is cause for concern. Thus further raising
awareness of health professionals and, in particular, policymakers and decision-makers to
address gender issues and inequality gaps in health outcomes and disease burden of the
Albanian population (Collaku, Resuli, Gjermeni, & Tase, 2018). Despite the remarkable
progress in maternal survival in China with a 75% reduction in maternal mortality in
1990 and 2015, significant disparities remain, especially for poor, less educated, and
ethnic minorities in remote areas of western China (Gao et al., 2017).
Research findings show the potential for Chamas, or group-based health and
financial education programs for pregnant women, to achieve MCH benefits in Kenya
(Maldonado et al., 2020).
Studies show that there are still cases of maternal death in Southeast Asia due to
the lack of women receiving treatment to avoid neonatal complications (Kikuchi et al.,
2018). Most deliveries in Ethiopia occur at home and are not assisted by skilled birth
attendants. In contrast, birth attendants with midwifery skills during labour are critical
interventions in reducing maternal morbidity and mortality (Roro, M. A., Hassen, E. M.,
Lemma, A. M., Gebreyesus, S. H., & Afework, 2014).
Based on research on decision support systems for chronic disease
administration, a recommendation message is generated through a web service that
supports management, including scheduling the implementation of chronic disease
screening (J.-I., J.-G., Y.-H., & U.-G., 2014) (Dissanayake, Colicchio, & Cimino, 2020)
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February 2022
246 http://eduvest.greenvest.co.id
The challenge described by the World Health Organization is the widespread lack
of data on adolescent fertility, including teenage pregnancy and childbirth. Access to
reliable data is necessary to develop meaningful policies (Sentell et al., 2019).
The emergence of the SDG's Program is a development of innovative programs
introduced in response to the Millennium Development Goals demonstrating promise to
reduce the global impact of maternal mortality, which was introduced by the country in
2015, designed to build on this progress (Callister & Edwards, 2017). The maternal
mortality ratio has decreased rapidly and universally across China at the county level in
the last two decades, which is possible even in economically less developed places with
limited resources. This finding has important implications for improving the maternal
mortality ratio in developing countries in the era of the Sustainable Development Goals
(Liang et al., 2019). Another system development is a sexual health CDS system that is
easy to use and can facilitate evidence-based care to reduce disparities in health outcomes
(Miller et al., 2020).
A decision support system or policy is an integrated computer device that allows
every decision-maker to interact directly with a computer that is useful in making
decisions using data and models to solve semi-structured and unstructured problems
(ŞAM, 2017) (Siemens Healthcare GmbH, 2018). Africa can achieve Universal Health
Coverage with the adoption of digital health technology, which offers a new approach to
providing quality health (Ohia, Ongolo-Zogo, & Fawole, 2021). Mobile health or m-
Health is one of the potential solutions to maximize the impact and efficiency of health
workers to achieve Sustainable Development Goals 3.1 and 3.2, especially in sub-Saharan
African countries. Poor quality clinical decision-making is associated with poor
pregnancy and birth outcomes (Amoakoh et al., 2017). The World Health Organization
publishes some health reports each year, containing recommendations for addressing
social challenges and system barriers to targeting unmet health needs, requiring the
development of an implementation strategy for the recommendations of the WHO public
health report (von Groote, Comanescu, Ungureanu, Bickenbach, & Lavis, 2018).
The 2016 Annual Report of the Directorate of Family Health shows that the
Maternal Mortality Rate and Infant Mortality Rate are critical because they are indicators
of Health development in the 2019 RPJMN and Sustainable Development Goals. And
based on data from the Indonesian Basic Health Survey or IDHS, it shows a decrease in
the Maternal Mortality Rate in 1994 – 2012, which was 390 per 100,000 live births in
1994 and 334 per 100,000. Still, there was an increase in the Maternal Mortality Rate in
2012 of 359 per 100,000 live births compared to 2007, which was 228 per 100,000 live
births. Meanwhile, data from SUPAS in 2015 showed that both maternal mortality rate or
AKI and IMR decreased, namely AKI by 305 per 100,000 live births and IMR by 22.23
per 100,000 live births. So in terms of indicators, there is a strategic plan that is part of
efforts to reduce MMR, and IMR shows success in achieving the target. However, the
achievement is still a gap when compared to the target of the entire population of
Indonesia (Directorate of Family Health, 2016).
Semarang City is the Capital of Central Java Province. More and more people
live, and there is mobility in the Semarang City area, so the government is increasing the
health facilities provided so that they are easily accessible by the community. However,
cases of maternal death are still found to be a health problem. Based on information from
the Semarang City Health Profile in 2019, there were 18 cases of maternal death or AKI
from 23,544 live births or around 75.8 per 100,000 live births; this remains a concern for
MCH services by increasing the Maternal and Child Mortality Rate Reduction Program
(Semarang City Health Office, 2020).
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 247
The problem is that there are still cases of maternal mortality in the Semarang
City area, even though the MCH service program has implemented various information
systems such as SIMPUS and Sigaspol, which are used for recording and reporting the
MCH Program. Semarang so that this research has benefits to support the policy of the
MCH Program. The area-based MCH Program produces reports in the form of online
mapping so that the government can find out the distribution of cases of comorbidities in
pregnant women and the incidence of maternal deaths quickly and precisely and based on
region.
RESEARCH METHOD
This type of research is Research and Development using the System Development
Life Cycle or SDLC method was carried out in 2021. We use maternal pregnancy history
data from 2019 to 2021 as input for the maternal decision support system. Data in the
form of the number of pregnant women, the number of high-risk pregnancies and the
number of obstetric complications during pregnancy
Data collection methods by observation and interviews to observe and explore
information about information systems in MCH health services. Interviews were
conducted with the Head of the MCH Health Office of Semarang City as a critical
informant to obtain information about policies and the role of MCH Information Systems
in supporting decisions on the Maternal and Child Mortality Reduction Program at the
Community health centers. As well as the method of observation carried out by direct
observation of the MCH information system and MCH service data. We researched at
Semarang, Indonesia, in 2021.
The stages in system development include:
1. User needs study or feasibility study which aims to determine user needs for
regional-based MCH decision support system development, conducted by interviewing
key informants
2. Analyzing the information system currently running on the MCH program
service, which aims to assess the features of the MCH information system
3. Determine the form of a new decision support system based on the results of the
current MCH information system analysis
4. Design of area-based MCH Decision Support System using PHP programming
and MySQL database.
The data analysis method used is descriptive, which describes the research results
in the form of an MCH decision support system design.
The study was conducted under the supervision of the Chair of the IRB
(Institutional Review Board). The right of privacy of the studied subjects was guaranteed.
Only the leading investigator had access to the identifying information.
RESULT AND DISCUSSION
The MCH program implemented in the Semarang City area is the responsibility
of the Semarang City Health Office by carrying out various health efforts, namely public
health efforts and individual health efforts. For community efforts, including essential
health efforts, one of which is MCH services.
The implementation of MCH services in routine activities is inseparable from the
use of information systems in recording and reporting, which aims to improve maternal
and child health. For this reason, a decision support system was developed using the
SDLC method. The stages of this research are a study of system feasibility, conducted by
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February 2022
248 http://eduvest.greenvest.co.id
interviewing the person in charge of the MCH Program Health Office who has used the
SIMPUS application for recording and reporting at the Community health centers in
MCH services. Stakeholders of the MCH program, according to data needs at the
Community Health Centers, then report to the Semarang City Health Office. Sigaspol for
recording and reporting of pregnant women's health carried out by Gasurkes or health
workers recorded directly according to findings in the field and reported to the Semarang
City Health Office. However, there is still a gap between Sigaspol and SIMPUS because
data duplication can occur.
The MCH program stakeholder by the needs of the data in the Community health
centers then reported to the Semarang City Health Office, Indonesia. The Sigaspol for
recording and reporting on the health of pregnant women was carried out by Gasurkes or
health workers who recorded directly according to the findings in the field and reported to
the Health Office Semarang City. However, there is still a gap between Sigaspol and
SIMPUS because there can be a duplication of data. The Community health center can
record repeated visits by pregnant women from the exact identity of pregnant women.
Data Population
The city of Semarang has 37 Community health centers, which are spread out in
each sub-district. Based on data on the health status of pregnant women from 2019 to
2021, it is shown in the following table:
Table.1. Number of Pregnancies in Semarang City, Indonesia in 2019-2021
number of
pregnancies in 2019
number of
pregnancies in 2020
number of
pregnancies in 2021
N
Valid
37
37
37
Missing
0
0
0
Mean
645.5405
702.19
461.9189
Median
565.0000
603.00
402.0000
Std. Deviation
395.94981
474.172
319.59978
Variance
156776.255
224839.158
102144.021
Table 1 shows the number of pregnancies in Semarang City, Indonesia, from
2019 to 2021, with the highest average in 2020. The lowest number of pregnancies is in
2021 because it was collected data cut down September 2021.
Table.2. Number of High-risk Pregnancies in Semarang City, Indonesia in 2019-2021
number of high-risk
pregnancies in 019
number of high-risk
pregnancies in 2020
number of high-risk
pregnancies in 2021
N
Valid
37
37
37
Missing
0
0
0
Mean
269.6486
248.84
173.7838
Median
202.0000
215.00
122.0000
Std. Deviation
195.56644
200.720
156.62413
Variance
38246.234
40288.473
24531.119
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 249
Table 2 shows the number of high-risk pregnancies in Semarang City, Indonesia,
from 2019 to 2021, with the highest average in 2019. The lowest number of high-risk
pregnancies is in 2021 because it was collected data cut down September 2021.
Table.3. Number of Pregnancies with obstetric complications in Semarang City,
Indonesia in 2019-2021
Number of
pregnancies with
obstetric
complications in
2019
Number of
pregnancies with
obstetric
complications in
2020
Number of
pregnancies with
obstetric
complications in
2021
N
Valid
37
37
37
Missing
0
0
0
Mean
36.9189
47.05
23.7027
Median
25.0000
30.00
9.0000
Std. Deviation
34.58595
72.231
29.30004
Variance
1196.188
5217.275
858.492
Table 3 shows the number of pregnancies with obstetric complications in
Semarang City, Indonesia, from 2019 to 2021, with the highest average in 2020. The
lowest number of pregnancies with obstetric complications in 2021 because it was
collected data cut down September 2021
Decision Support System Development
The stages of information system analysis include: 1) Studying the system that
has been used in MCH services so far, according to the information from the MCH
Program holder that SIMPUS and Sigaspol are computer-based applications. Various
types of applications that have been used in MCH services are still found to have no
menus that support to help monitor the distribution of cases of comorbidities in pregnant
women and the incidence of maternal deaths by region. 2) Analyzing the decision support
system designed by making a regional-based MCH decision support system using PHP
programming and MySQL database. 3) Analyzing the hardware used in the form of a
computer from the MCH Program holder who already uses a laptop and has a device or
mobile phone. Analysis of system requirements to find the information required by the
Head of the MCH Service, Staff of the MCH Program, and the MCH Program Holder at
the Community health centers.
Analysis of system decisions by determining the form of the system based on
several alternative solutions from the new system that can meet the needs of system users,
according to the feasibility and recommendations of the candidate systems being
developed, namely: policy of the MCH Program Holder. The approach process is carried
out to determine the input, output, database, operating procedures, models; Determining
the selection of decision support system development software in the form of applications
that suit the needs of system users, Selection of the operating system from the decision
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February 2022
250 http://eduvest.greenvest.co.id
support system, which uses Windows and can be used using Android or Mac
applications. Selection of new system users, namely the new decision support system that
is multi-user in nature, with a communication network that allows interaction from the
community health center with the MCH sub Program. Selection of tools for a new
decision support system using PHP programming and database using MySQL and Google
Maps for mapping.
System feasibility analysis includes: 1) Technology Feasibility Analysis where
computer hardware and software development is very dynamic and in line with the
improvement of data communication networks or the internet that are easily accessible in
all areas. 2) Legal Feasibility Analysis that application development software is open
source can be developed for all parties. 3) Operational Feasibility Analysis, namely
currently the use of android and internet data usage is necessary so that its use does not
make it difficult for officers and the public. 4) Economic Feasibility Analysis: This DSS-
maternal application is easy to access and does not require a fee to access it.
The design of the new decision system includes the design of a Maternal Health
Decision Support System or SPK-maternal using the UML Design or Unified Modeling
Language, which is shown in the following figure:
FIGURE 1. UML Design with Use-case Diagrams
Figure 1 shows that the UML design describes the maternal decision support
system entities in the form of users, namely admins, community health centers, and
government offices. The activities carried out include inputting data from the community
health center in pregnant women's health data, which will automatically be reported to the
Health Office with the system. The service can access reports from the community health
center by updating data based on the reports sent. At the same time, the admin is the
facilitator and updating of the information system that has been created.
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 251
Figure 2. UML Design with Activity Diagram
Figure 2 describes the maternal decision support system; that when you first log
in to this system, verification from the user's email will be carried out. A form of system
security allows users interested in MCH program services to access this decision support
system. Furthermore, after verification on the email, the user at the community health
center level inputs the health data of pregnant women. If the data entered is correct,
verification is carried out from the community health center by adding information to the
DSS menu, namely MCH Program Achievements. Furthermore, the agency will access
this decision support system by viewing reports in the form of mapping of the distribution
of cases of comorbid illnesses in pregnant women and the incidence of maternal deaths
and follow up on the results of the MCH program achievements by providing decisions in
the form of narratives in this system.
Figure 3. DSS-maternal Database Relations
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February 2022
252 http://eduvest.greenvest.co.id
Figure 3 shows the database structure design made to explain the fields in the
data file accompanied by the data type and width or the number of characters. We can
access the maternal decision support system via the link http://spk-maternal.com/ . The
menu display for logging in to the maternal decision support system can be seen in the
following figure:
Figure 4.a. Menu for System login Figure 4.b. Menu for Login verification
Figure 4.a. shows the initial login to the maternal decision support system that
uses the email and password of each user so that it can distinguish it for access from the
community health center, the service, and the admin. While Figure 4.b. shows the
verification of this system login, this is made to maintain the security of the maternal
decision support system for users who are interested in MCH services
Figure 5. Map Menu on SPK-maternal
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 253
Figure 5 shows the appearance of the Semarang City area in the form of a map
and can bring up the distribution of the incidence of disease and maternal mortality if the
health data for pregnant women has been inputted from the community health centers.
Figure 6. MCH Program Achievement Menu
Figure 6 shows the display of decision support activities in the form of an MCH
Program Achievement menu, which displays a summary of MCH programs that have
been carried out from the community health center, which will follow up from input from
the service. An advantage of the MCH Program decision support system, especially for
maternal and maternal health monitoring.
The city of Semarang has 37 Community health centers, which are spread out in
each sub-district. Based on data on the health status of pregnant women from 2019 to
2021, it is shown in the following table:
Table.1. Number of Pregnant Women in Semarang City, Indonesia in 2019-2021
number of high-risk
pregnancies in 019
number of high-risk
pregnancies in 2020
number of high-risk
pregnancies in 2021
number of
pregnancies in 2019
number of
pregnancies in 2020
number of
pregnancies in 2021
N
Valid
37
37
37
Missing
0
0
0
Mean
645.5405
702.19
461.9189
Median
565.0000
603.00
402.0000
Std. Deviation
395.94981
474.172
319.59978
Variance
156776.255
224839.158
102144.021
Eduvest – Journal of Universal Studies
Volume 2 Number 2, February 2022
254 http://eduvest.greenvest.co.id
N
Valid
37
37
37
Missing
0
0
0
Mean
269.6486
248.84
173.7838
Median
202.0000
215.00
122.0000
Std. Deviation
195.56644
200.720
156.62413
Variance
38246.234
40288.473
24531.119
Number of
pregnancies with
obstetric
complications in
2019
Number of
pregnancies with
obstetric
complications in
2020
Number of
pregnancies with
obstetric
complications in
2021
N
Valid
37
37
37
Missing
0
0
0
Mean
36.9189
47.05
23.7027
Median
25.0000
30.00
9.0000
Std. Deviation
34.58595
72.231
29.30004
Variance
1196.188
5217.275
858.492
CONCLUSION
The results showed that pregnancy in Semarang City, Indonesia, mainly occurred
at the beginning of the Covid-19 pandemic. Pregnant women and babies are among the
high-risk groups during the Covid-19 pandemic. Research shows that pregnant women
with COVID-19 in the third trimester are more likely to need intensive care when
compared to pregnant women without COVID-19. When pregnant women with COVID-
19 symptoms requiring hospital admission have worse maternal outcomes, including
death, although the absolute risk remains very low (Elsaddig & Khalil, 2021). Meeting
the very ambitious 2030 SDG targets to eliminate maternal mortality, high mortality
countries can do based on the efforts that have been made to reduce maternal mortality
between 2000 and 2010 (Alkema et al., 2016). Malnutrition of children and mothers is
still a significant risk factor for disease burden in India from 1990 to 2017, and this can
affect nutritional intake for pregnant women (Swaminathan et al., 2019).
Results from an assessment of the influence of clinical decision-making support
systems or CDMSS directed at frontline healthcare providers on neonatal and maternal
health outcomes suggest that evidence-based recommendations exist for the use of mobile
CDMSS in Ghana and other West African countries (Amoakoh et al., 2017).
A knowledge discovery-based interactive decision support system has been
developed on a web platform that will help health care policymakers to design evidence-
based decisions aimed at reducing inequality of maternal and child health service
indicators against regional socioeconomic differences; strategic location-specific policies
should be designed and based on increasing the scope of this intervention will help reduce
inequality and improve local health care indicators (Saha, 2019).
The role of information in every organization is significant because the value of
information depends on its application and use. The success of an organization's activities
is highly dependent on the quality of the information it produces. So that information can
Maryani Setyowati, Agung Wardoyo
,
, Jaka Prasetya
,
, Anastacia Rheinata
Wibowo
,
, Mufid Makantar
Maternal Decision Support Systems to Reduce Maternal Mortality in Indonesia:
Resolving Barriers to Implementation in Community Health Centers 255
be used as raw material for decision making. A computer-based information system or
CBIS aims to make the process very effective and efficient when it involves significant
data. Although there are several types of information systems that support decision
making, decision support systems are one of them (Tripathi, 2011).
Based on the results of the design of a maternal decision support system, according
to developing an application to monitor the delivery process using a Support Vector
Machine or SVM. It is hoped that it can provide a tool for midwives to automatically
monitor the progress of the delivery process so that if there is an emergency in the
delivery process, it can be overcome (Sulistiyanti, Farida, & Widodo, 2018).
The results of a study involving pregnant women with SCD showed a decrease in
maternal mortality. The need for a multidisciplinary obstetric and hematology team
approach that can reduce maternal and perinatal mortality (Asare et al., 2020).
Decision Support System application to monitor the labour process using the
Support Vector Machine method, the first stage is developing a maternity medical record
data management application. The second application development stage is to monitor the
labour process using the Support Vector Machine or SVM. The hope is that it can provide
aids for midwives in monitoring the progress of the labour process automatically so that
they can overcome emergencies in the delivery process (Sulistiyanti et al., 2018).
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