Background: Sufficient staffing is essential in delivering health services to achieve positive patient outcomes. High rates of maternal mortality and the burden of severe maternal morbidity have challenged most developing countries with a shortage of health care workforce. Most maternal deaths occur in hospitals. However, few studies investigated the relationship between maternity staffing and adverse maternal outcomes at the hospital level. Most of those studies were conducted in developed countries with mixed results.
Objectives: to examine the relationships between maternity staffing levels, skill mix and adverse maternal outcomes in tertiary hospitals, after accounting for women’s characteristics and process indicators of maternity care.
Methods: This retrospective observational study was carried out between July 2017 to January 2018 in seven tertiary hospitals within Java region, Indonesia. Data of 10,981 singleton live births from the year 2015 were included in this study. The obstetric patient data was generated from the electronic medical record. Maternity staffing data was collected from the hospital personnel database system. Variables of maternity staffing levels and skill mix was measured by Full-time Equivalent (FTE) midwives per 100 births, FTE nurses per 100 births, FTE all staffs per 100 births and the nurse to midwife ratio. Adverse maternal outcomes include maternal deaths, near-miss cases, and potentially life-threatening conditions. The Donabedian model of structure-process-outcome was used to guide this study concept. Descriptive, univariate and multivariate logistic regression analyses were utilized to examine the association between maternity staffing variables, women’s characteristics, process indicators of maternity care and adverse maternal outcomes. The hierarchical logistic regression was employed to assess the contribution of other control variables beyond the staffing variables.
Results: The results of this study found that FTE midwives per 100 births and the nurse to midwife ratio showed a statistically significant inverse association to adverse maternal outcomes after controlling women’s characteristics and process indicators of maternity care (OR=.335; 95%CI=.252-.445, and OR=.143; 95%CI=.101-.202, respectively). FTE nurses per 100 births and FTE all staffs per 100 births were also significantly associated with adverse maternal outcomes, however in the opposite direction (OR=2.519; 95%CI: 2.021–3.140, and OR=1.587; 95%CI=1.194–2.109, respectively). Lack of variation of staffing variables among maternity units might affect this result. Women’s characteristic variables of age, residence, and the source of payment, and the maternal care process variables of hospital stay and mode of delivery were significantly associated with adverse maternal outcomes.
Conclusions: Findings of this study provide knowledge contribution about the significance of maternity staffing’s relationships with adverse maternal outcomes, adjusted to women characteristics and process indicators of maternal care. Developing a guideline for safe maternity staffing would be beneficial to assist planning, deployment, and monitoring the staffing level in maternity units for improved maternal outcomes. Further research is recommended to include the cost-effectiveness analysis and to expand the measurement at the hospital level to allow inclusion of other categories of the maternity workforce in the analysis.

AbouZahr, C. (2003). Global burden of maternal death and disability. British medical bulletin, 67(1), 1-11.
Achadi, E., Scott, S., Pambudi, E. S., Makowiecka, K., Marshall, T., Adisasmita, A., . . . Ronsmans, C. (2007). Midwifery provision and uptake of maternity care in Indonesia. Tropical Medicine and International Health, 12(12), 1490-1497. doi:10.1111/j.1365-3156.2007.01957.x
ACOG. (2015). Levels of maternal care. Obstetric care consensus no. 2. Obstetric Gynecolology, 125(2), 502-515.
Adisasmita, A. (2006). Maternal Near Miss Sebagai Salah Satu Indikator Mutu Pelayanan Kesehatan (Maternal near miss as one of quality indicators of health care). Paper presented at the Inititative for Maternal Mortality Program Assesment Bali.
Adisasmita, A., Deviany, P. E., Nandiaty, F., Stanton, C., & Ronsmans, C. (2008). Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy and Childbirth, 8(1), 10.
Ahmed, S., Qingfend, L., Scrafford, C., & Pullum, T. (2014). An assessment of DHS maternal mortality data and estimates. DHS Methodological Reports(13).
Aiken, Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., . . . Lesaffre, E. (2014). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, 383(9931), 1824-1830.
Amelink‐Verburg, M., Rijnders, M., & Buitendijk, S. (2009). A trend analysis in referrals during pregnancy and labour in Dutch midwifery care 1988–2004. BJOG: An International Journal of Obstetrics & Gynaecology, 116(7), 923-932. doi:doi:10.1111/j.1471-0528.2009.02202.x
Anand, S., & Bärnighausen, T. (2004). Human resources and health outcomes: cross-country econometric study. The Lancet, 364(9445), 1603-1609.
Anand, S., & Bärnighausen, T. (2012). Health workers at the core of the health system: Framework and research issues. Health Policy, 105(2–3), 185-191. doi:http://dx.doi.org/10.1016/j.healthpol.2011.10.012
Andalas, M. (2011). Insidensi Persalinan di Rumah Sakit Umum Zainoel Abidin (RSUZA)-Fakultas Kedokteran Universitas Syiah Kuala Periode Januari 2008-Oktober 2010 (Incidents of childbirth in Zainoel Abidin hospital (RSUZA)- College of Medicine Syiah Kuala University in the period of January 2008 to October 2010). Jurnal Kedokteran Syiah Kuala, 11(1), 8-15.
Anderson, I., Meliala, A., Marzoeki, P., & Pambudi, E. (2014). The production, distribution, and performance of physicians, nurses, and midwives in Indonesia : an update. Washington: World Bank Group.
ASEANstats. (2015). ASEAN Statistical Year Book 2015. Retrieved from http://asean.org/storage/2012/05/ASEAN-Statistic-Yearbook-2015_r.pdf
Ashcroft, B., Elstein, M., Boreham, N., & Holm, S. (2003). Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives. BMJ, 327(7415), 584.
Austin, P. C., & Merlo, J. (2017). Intermediate and advanced topics in multilevel logistic regression analysis. Statistics in medicine, 36(20), 3257-3277.
Balitbangkes-MoH. (2013). Riset Kesehatan Dasar Tahun 2013 [The 2013 Basic Health Research]. Retrieved from Jakarta: http://depkes.go.id/downloads/riskesdas2013/Hasil%20Riskesdas%202013.pdf
Balitbangkes-MoH, & UNFPA. (2012). Disparitas, Akses dan Kualitas. Kajian Determinan Kematian Maternal di Lima Region Indonesia (Disparity, Access and Quality. A study on Maternal Death Determinants in Five Regions of Indonesia). Jakarta: Kemenkes RI and UN Population Fund.
Bappenas. (2015). Laporan Tujuan Pembangunan Millenium di Indonesia 2014 (Report of the Indonesia Millenium Development Goals 2014). Jakarta: Bappenas.
Betran, A., Torloni, M., Zhang, J., & Gülmezoglu, A. (2016). WHO Statement on Caesarean Section Rates. BJOG: An International Journal of Obstetrics & Gynaecology, 123(5), 667-670. doi:doi:10.1111/1471-0528.13526
Betrán, A. P., Ye, J., Moller, A.-B., Zhang, J., Gülmezoglu, A. M., & Torloni, M. R. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One, 11(2), e0148343. doi:10.1371/journal.pone.0148343
Bhutta, Z. A., Lassi, Z. S., & Mansoor, N. (2010). Systematic review on human resources for health interventions to improve maternal health outcomes: evidence from developing countries: World health organization (WHO).
Blegen, M. A., Goode, C. J., & Reed, L. (1998). Nurse staffing and patient outcomes. Nursing research, 47(1), 43-50.
Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical Care, 49(4), 406-414.
Blot, S. I., Serra, M. L., Koulenti, D., Lisboa, T., Deja, M., Myrianthefs, P., . . . Rello, J. (2011). Patient to nurse ratio and risk of ventilator-associated pneumonia in critically ill patients. American Journal of Critical Care, 20(1), e1-9. doi:10.4037/ajcc2011555
BPS. (2010). Hasil sensus penduduk 2010 (The 2010 population census). Jakarta: BPS Retrieved from www.bps.go.id.
BPS. (2015). Hasil Survei Penduduk Antar Sensus 2015 [Result of the 2015 Inter-censal Population Survey]. Jakarta: Badan Pusat Statistik.
BPS, BKKBN, MoH, & ICF International. (2013). Indonesia Demographic and Health Survey 2012. Jakarta, Indonesia: BPS, BKKBN, Kemenkes, and ICF International.
Bradley, S., Kamwendo, F., Chipeta, E., Chimwaza, W., de Pinho, H., & McAuliffe, E. (2015). Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi. BMC Pregnancy and Childbirth, 15(1), 1.
Bruckner, T. A., Scheffler, R. M., Shen, G., Yoon, J., Chisholm, D., Morris, J., . . . Saxena, S. (2011). The mental health workforce gap in low-and middle-income countries: a needs-based approach. Bulletin Of The World Health Organization, 89(3), 184-194.
Buchan, J., & Dal Poz, M. R. (2002). Skill mix in the health care workforce: reviewing the evidence. Bulletin Of The World Health Organization, 80(7), 575-580.
Callaghan, W. M., Creanga, A. A., & Kuklina, E. V. (2012). Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstetrics & Gynecology, 120(5), 1029-1036.
Campbell, O. M. R., & Graham, W. J. (2006). Strategies for reducing maternal mortality: getting on with what works. The Lancet, 368, 1284 - 1299.
Castorr, A. H., Thompson, K. O., Ryan, J. W., Phillips, C. Y., Prescott, P. A., & Soeken, K. L. (1990). The process of rater training for observational instruments: Implications for interrater reliability. Research in Nursing & Health, 13(5), 311-318.
Cavazos-Rehg, P. A., Krauss, M. J., Spitznagel, E. L., Bommarito, K., Madden, T., Olsen, M. A., . . . Bierut, L. J. (2015). Maternal age and risk of labor and delivery complications. Maternal and Child Health Journal, 19(6), 1202-1211.
Chittawatanarat, K., & Sataworn, D. (2014). Effects of ICU characters, human resources and workload to outcome indicators in Thai ICUs: the results of ICU-RESOURCE I study. Journal of the Medical Association of Thailand, 97(1), S22-30.
Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M. S., Yoo, I. Y., . . . Aiken, L. H. (2015). Effects of nurse staffing, work environments, and education on patient mortality: an observational study. International Journal of Nursing Studies, 52(2), 535-542.
Cho, S.-H., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing research, 52(2), 71-79.
Choi, J., Bergquist‐Beringer, S., & Staggs Vincent, S. (2013). Linking RN workgroup job satisfaction to pressure ulcers among older adults on acute care hospital units. Research in Nursing & Health, 36(2), 181-190. doi:10.1002/nur.21531
D'Ambruoso, L., Achadi, E., Adisasmita, A., Izati, Y., Makowiecka, K., & Hussein, J. (2009). Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. Midwifery, 25(5), 528-539. doi:10.1016/j.midw.2007.08.008
Dabars, E. (2012). Making hospitals safe for patients and nursing / midwifery staff. Retrieved from https://www.anmfsa.org.au/wp-content/uploads/2013/03/Making-hospitals-safe-for-patients-and-nursing-midwifery-staff-final1.pdf
de Jonge, A., Mesman, J. A., Manniën, J., Zwart, J. J., Buitendijk, S. E., van Roosmalen, J., & van Dillen, J. (2015). Severe adverse maternal outcomes among women in midwife-led versus obstetrician-led care at the onset of labour in the Netherlands: a nationwide cohort study. PLoS One, 10(5), e0126266.
Diya, L., Van den Heede, K., Sermeus, W., & Lesaffre, E. (2012). The relationship between in-hospital mortality, readmission into the intensive care nursing unit and/or operating theatre and nurse staffing levels. Journal of Advanced Nursing, 68(5), 1073-1081.
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748.
Donabedian, A. (2002). An introduction to quality assurance in health care: Oxford University Press.
Dubois, C.-A., & Singh, D. (2009). From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. Human Resources for Health, 7, 87-87. doi:10.1186/1478-4491-7-87
Dunton, N., Gajewski, B., Klaus, S., & Pierson, B. (2007). The Relationship of Nursing Workforce Characteristics to Patient Outcomes. OJIN: The Online Journal of Issues in Nursing, 12(3).
Fahdhy, M., & Chongsuvivatwong, V. (2005). Evaluation of World Health Organization partograph implementation by midwives for maternity home birth in Medan, Indonesia. Midwifery, 21(4), 301-310.
Filho, E. A. R., Costa, M. L., Cecatti, J. G., Parpinelli, M. A., Haddad, S. M., Pacagnella, R. C., . . . Souza, J. P. (2015). Severe maternal morbidity and near miss due to postpartum hemorrhage in a national multicenter surveillance study. International Journal of Gynecology & Obstetrics, 128(2), 131-136. doi:doi:10.1016/j.ijgo.2014.08.023
Filippi, V., Ronsmans, C., Gohou, V., Goufodji, S., Lardi, M., Sahel, A., . . . Brouwere, V. D. (2005). Maternity wards or emergency obstetric rooms? Incidence of near‐miss events in African hospitals. Acta Obstetricia et Gynecologica Scandinavica, 84(1), 11-16. doi:doi:10.1111/j.0001-6349.2005.00636.x
Firoz, T., Chou, D., von Dadelszen, P., Agrawal, P., Vanderkruik, R., Tunçalp, O., . . . Say, L. (2013). Measuring maternal health: focus on maternal morbidity. Bulletin Of The World Health Organization, 91(10), 794-796.
Forster, D. A., McLachlan, H. L., Yelland, J., Rayner, J., Lumley, J., & Davey, M.-A. (2006). Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia. BMC Health Services Research, 6(1), 83.
Gerova, V., Griffiths, P., Jones, S., & Bick, D. (2010). The association between midwifery staffing and outcomes in maternity units in England: observational study using routinely collected data. Retrieved from http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/NNRUMidwiferyReportDec10.pdf
Girasek, E., Kovács, E., Aszalós, Z., Eke, E., Ragány, K., Kovács, R., . . . Szócska, M. (2016). Headcount and FTE data in the European health workforce monitoring and planning process. Human Resources for Health, 14(1), 42.
Government of Indonesia. (2014a). Undang-undang Republik Indonesia Nomor 36 Tahun 2014 Tentang Tenaga Kesehatan (The Indonesia health workforce act number 36 year 2014). Jakarta: Kemenkes.
Government of Indonesia. (2014b). Undang-undang Republik Indonesia Nomor 38 Tahun 2014 Tentang Keperawatan (The Indonesia nursing act number 38 year 2014). Jakarta: Kemenkes.
Government of the Philippines. (2013). Revised Organizational Structure and Staffing Standards for Government Hospitals. Retrieved from https://www.dbm.gov.ph/wp-content/uploads/Issuances/2013/Joint%20Circular%202013/DOH/Manual%20RSSGH_%203%20levels.pdf
Graham, W., Woodd, S., Byass, P., Filippi, V., Gon, G., Virgo, S., . . . Singh, S. (2016). Diversity and divergence: the dynamic burden of poor maternal health. The Lancet, 388(10056), 2164-2175. doi:https://doi.org/10.1016/S0140-6736(16)31533-1
Grigg, C. P., Tracy, S. K., Tracy, M., Schmied, V., & Monk, A. (2015). Transfer from primary maternity unit to tertiary hospital in New Zealand ‐ timing, frequency, reasons, urgency and outcomes: Part of the Evaluating Maternity Units study. Midwifery, 31(9), 879-887. doi:10.1016/j.midw.2015.04.018
Handayani, R. R., & Adisasmita, A. C. (2013). Kejadian Komplikasi Maternal: Pelaporan di Rumah Sakit dan Hasil Riskesdas di Indonesia Tahun 2010 (Obstetric complication events: Comparison of Hospital Reporting system and The Indonesia Health Research year 2010). Retrieved from http://lib.ui.ac.id/naskahringkas/2015-09/S52981-Reisty%20Ria%20Handayani
Hanson, C., Cox, J., Mbaruku, G., Manzi, F., Gabrysch, S., Schellenberg, D., . . . Schellenberg, J. (2015). Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households. The Lancet Global Health, 3(7), e387-e395. doi:https://doi.org/10.1016/S2214-109X(15)00048-0
He, J., Almenoff, P. L., Keighley, J., & Li, Y.-F. (2013). Impact of patient-level risk adjustment on the findings about nurse staffing and 30-day mortality in Veterans Affairs acute care hospitals. Nursing research, 62(4), 226-232.
Hensher, M., Price, M., & Adomakoh, S. (2006). Referral Hospitals Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; Oxford University Press, New York.
Hugonnet, S., Uçkay, I., & Pittet, D. (2007). Staffing level: a determinant of late-onset ventilator-associated pneumonia. Crit Care, 11(4), R80-R80.
Hugonnet, S., Villaveces, A., & Pittet, D. (2007). Nurse staffing level and nosocomial infections: Empirical evaluation of the case-crossover and case-time-control designs. American Journal of Epidemiology, 165(11), 1321-1327.
Huntington, D., Banzon, E., & Recidoro, Z. D. (2012). A systems approach to improving maternal health in the Philippines. Bulletin Of The World Health Organization, 90(2), 104-110. doi:10.2471/BLT.11.092825
Hutcheon, J. A., Lisonkova, S., & Joseph, K. S. (2011). Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best practice & research Clinical obstetrics & gynaecology, 25(4), 391-403. doi:https://doi.org/10.1016/j.bpobgyn.2011.01.006
Ilvento, T. (n.d.). Module 5: Multiple Regression Analysis. Retrieved from http://www1.udel.edu/FREC/ilvento/BUAD820/MOD504.pdf
Indonesia Medical Council. (2006). Pengesahan Standar Pendidikan Profesi Dokter Spesialis (Validation of Professional Educational Standard of Medical Specialist). Jakarta: KKI.
International Confederation of Midwives. (2017). International Definition of the Midwife. Retrieved from http://internationalmidwives.org/who-we-are/policy-and-practice/icm-international-definition-of-the-midwife/
Jones, S., Bottle, A., & Griffiths, P. (2011). An assessment of “failure to rescue” derived from routine NHS data as a nursing sensitive patient safety indicator for surgical inpatient care. National Nursing Research Unit. King’s College London.
Joseph, K., Rouleau, J., Kramer, M., Young, D., Liston, R., & Baskett, T. (2007). Investigation of an increase in postpartum haemorrhage in Canada. BJOG: An International Journal of Obstetrics & Gynaecology, 114(6), 751-759.
Joyce, R., Webb, R., & Peacock, J. (2002). Predictors of obstetric intervention rates: case-mix, staffing levels and organisational factors of hospital of birth. Journal of Obstetrics and Gynaecology, 22(6), 618-625.
Kelly, D. M., Kutney-Lee, A., McHugh, M. D., Sloane, D. M., Aiken, L. H., & Faan, F. (2014). Impact of Critical Care Nursing on 30-Day Mortality of Mechanically Ventilated Older Adults*. Critical Care Medicine, 42(5), 1089-1095.
Kim, J. H., Hong, S.-K., Kim, K. C., Lee, M.-G., Lee, K. M., Jung, S. S., . . . Koh, Y. (2012). Influence of full-time intensivist and the nurse-to-patient ratio on the implementation of severe sepsis bundles in Korean intensive care units. Journal of Critical Care, 27(4), 414.e411-414.e421. doi:http://dx.doi.org/10.1016/j.jcrc.2012.03.010
Koblinsky, M., Chowdhury, M. E., Moran, A., & Ronsmans, C. (2012). Maternal morbidity and disability and their consequences: neglected agenda in maternal health. Journal of Health, Population, and Nutrition, 30(2), 124.
Kramer, M. S., Dahhou, M., Vallerand, D., Liston, R., & Joseph, K. (2011). Risk factors for postpartum hemorrhage: can we explain the recent temporal increase? Journal of Obstetrics and Gynaecology Canada, 33(8), 810-819.
Kurniati, A., Chen, C.-M., Efendi, F., & Berliana, S. M. (2017). Factors influencing Indonesian women's use of maternal health care services. Health care for women international, 1-16. doi:10.1080/07399332.2017.1393077
Kurniati, A., Chen, C.-M., Efendi, F., Ku, L.-J. E., & Berliana, S. M. (2017). Suami SIAGA: male engagement in maternal health in Indonesia. Health Policy and Planning, 32(8), 1203-1211. doi:10.1093/heapol/czx073
Kuruvilla, S., Schweitzer, J., Bishai, D., Chowdhury, S., Caramani, D., Frost, L., . . . Adam, T. (2014). Success factors for reducing maternal and child mortality. Bulletin Of The World Health Organization, 92(7), 533-544.
Laopaiboon, M., Lumbiganon, P., Intarut, N., Mori, R., Ganchimeg, T., Vogel, J., . . . Network, W. M. S. o. M. N. H. R. (2014). Advanced maternal age and pregnancy outcomes: a multicountry assessment. BJOG: An International Journal of Obstetrics & Gynaecology, 121, 49-56.
Lewis, M. (2007). Stepwise versus Hierarchical Regression: Pros and Cons. Paper presented at the The Annual Meeting of the Southwest Educational Research Association, San Antonio, TX.
Liu, S., Liston, R. M., Joseph, K., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal, 176(4), 455-460.
Long, Q., Zhang, T., Xu, L., Tang, S., & Hemminki, E. (2010). Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co‐operative Medical System). Tropical Medicine & International Health, 15(10), 1210-1217. doi:doi:10.1111/j.1365-3156.2010.02602.x
Lu, C., Chin, B., Lewandowski, J. L., Basinga, P., Hirschhorn, L. R., Hill, K., . . . Binagwaho, A. (2012). Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years. PLoS One, 7(6), e39282. doi:10.1371/journal.pone.0039282
Lumbiganon, P., Laopaiboon, M., Gülmezoglu, A. M., Souza, J. P., Taneepanichskul, S., Ruyan, P., . . . Villar, J. (2010). Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. The Lancet, 375(9713), 490-499. doi:https://doi.org/10.1016/S0140-6736(09)61870-5
Makowiecka, K., Achadi, E., Izati, Y., & Ronsmans, C. (2008). Midwifery provision in two districts in Indonesia: How well are rural areas served? Health Policy and Planning, 23(1), 67-75. doi:10.1093/heapol/czm036
Mboi, N. (2015). Indonesia: On the Way to Universal Health Care. Health Systems & Reform, 1(2), 91-97. doi:10.1080/23288604.2015.1020642
McDermott, J., Beck, D., Buffington, S. T., Annas, J., Supratikto, G., Prenggono, D., . . . Achadi, E. (2001). Two models of in-service training to improve midwifery skills: How well do they work? Journal of Midwifery and Women's Health, 46(4), 217-225. doi:10.1016/S1526-9523(01)00137-4
McIntosh, B., Cookson, G., & Sandall, J. (2012). A call to arms: The efficient use of the maternity workforce. British Journal of Midwifery, 20(2).
McLachlan, H. L., Forster, D. A., Yelland, J., Rayner, J., & Lumley, J. (2008). Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia. Midwifery, 24(3), 358-370. doi:10.1016/j.midw.2006.10.006
McPake, B., Maeda, A., Araújo, E. C., Lemiere, C., El Maghraby, A., & Cometto, G. (2013). Why do health labour market forces matter? Bulletin Of The World Health Organization, 91(11), 841-846.
Mensah, J., Oppong, J. R., & Schmidt, C. M. (2010). Ghana's national health insurance scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Economics, 19(S1), 95-106. doi:doi:10.1002/hec.1633
MERAS. (2014). Midwifery Staffing Standards for Maternity Facilities. Retrieved from https://www.midwife.org.nz/pdf/MERAS/MERAS%20Mid%20Staff%20Stds%202014.pdf
Midi, H., Sarkar, S. K., & Rana, S. (2010). Collinearity diagnostics of binary logistic regression model. Journal of Interdisciplinary Mathematics, 13(3), 253-267. doi:10.1080/09720502.2010.10700699
MoH. (1997). Buku Kesehatan Ibu dan Anak (Handbook of Maternal and Child Health). Jakarta: Kemenkes RI & JICA.
MoH. (2004). Keputusan Menteri Kesehatan Republik Indonesia Nomor : 81/Menkes/SK/I/2004 Tentang Pedoman Penyusunan Perencanaan Sumber Daya Manusia Kesehatan Di Tingkat Propinsi, Kabupaten/Kota Serta Rumah Sakit (The Indonesia Health Minister deecree number 81/2004 concerning staffing in the province level, the district level, and hospitals). Jakarta: Kemenkes RI.
MoH. (2006). Pedoman Penyelenggaraan Prosedur Rekam Medis di Rumah Sakit (Guidelines for the Medical Record Procedure at Hospital). Jakarta: Depkes RI.
MoH. (2007). Keputusan Menteri Kesehatan nomor 369/2007 tentang Standar Profesi Bidan (The Health Ministry decree number 369/2007 concerning midwifery professional standard). Jakarta: Kemenkes.
MoH. (2008). Peraturan Menteri Kesehatan Republik Indonesia No: 269/MENKES/PER/III/2008Tentang Rekam Medis (The Indonesia Health Minister Decree number 69/MENKES/PER/III/2008 concerning medical record). Jakarta: Kementerian Kesehatan.
MoH. (2010). Peraturan Menteri Kesehatan Republik Indonesia Nomor 340 Tahun 2010 Tentang Klasifikasi Rumah Sakit [Regulation of the Minister of Health of the Republic of Indonesia Number 340 Year 2010 Regarding the Classification of Hospital]. Jakarta: Kementerian Kesehatan.
MoH. (2012a). Pedoman penyelenggaraan PONEK 24 jam rumah sakit (Guidelines for the Comprehensive Emergency Obstetric and Newborn Care in 24 hour hospitals). Jakarta: Kemenkes RI.
MoH. (2012b). Peraturan Menteri Kesehatan Republik Indonesia Nomor 001 Tahun 2012 Tentang Sistem Rujukan Pelayanan Kesehatan Perorangan (the Indonesia Health Minister Regulation Number 2012 Concerning the Referral System for Individual Health Service). Jakarta: Kemkes RI.
MoH. (2013a). Buku Saku Pelayanan Kesehatan Ibu Di Fasilitas Kesehatan Dasar Dan Rujukan (Handbook of Maternal Health Service in Primary and Referral Facilities). Jakarta: Kemenkes.
MoH. (2013b). Peraturan Menteri Kesehatan Republik Indonesia Nomor 71 Tahun 2013 Tentang Pelayanan Kesehatan Pada Jaminan Kesehatan Nasional (The Indonesia Health Minister Regulation Number 71 Year 2013 Concerning Health Services within the National Health Insurance System). Jakarta: Kemkes RI.
MoH. (2013c). Peraturan Menteri Kesehatan Republik Indonesia Nomor 82 Tahun 2013 Tentang Sistem Informasi Manajemen Rumah Sakit (The Indonesia Health Minister Decree number 82 year 2013 concerning the hospital information system). Jakarta: Kemkes RI.
MoH. (2013d). Rencana Kebutuhan SDM Kesehatan 2014 [The 2014 Health Workforce Requirement Plan ]. Kementerian Kesehatan.
MoH. (2014a). Peraturan Menteri Kesehatan Republik Indonesia Nomor 28 Tahun 2014 Tentang Pedoman Pelaksanaan Program Jaminan Kesehatan Nasional (The Indonesia Health Minister regulation number 28 year 2014 concerning the guidelines of national health insurance program). Jakarta: Kemenkes.
MoH. (2014b). Peraturan Menteri Kesehatan Republik Indonesia Nomor 56 Tahun 2014 Tentang Klasifikasi dan Perizinan Rumah Sakit [the Health Minister regulation numberr 56 year 2014 concerning the classification and licensing hospital]. Jakarta: Kementerian Kesehatan.
MoH. (2014c). Situasi Kesehatan Ibu di Indonesia (The maternal health situation in Indonesia). Retrieved from Jakarta: http://www.depkes.go.id/resources/download/pusdatin/infodatin/infodatin-ibu.pdf
MoH. (2015a). Peraturan Menteri Kesehatan Republik Indonesia No: 10/2015Tentang Standar Pelayanan Keperawatan Di Rumah Sakit Khusus (the Health Minister Decree of the Republic of Indonesia number 10/2015 concerning the standard of nursing care in the hospital). Jakarta: Kementerian Kesehatan.
MoH. (2015b). Peraturan Menteri Kesehatan Republik Indonesia Nomor 33 Tahun 2015 tentang Pedoman Penyusunan Perencanaan Kebutuhan Sumber Daya Manusia Kesehatan (The Indonesia Health Minister Regulation number 33 year 2015 concerning the guidelines for the development of health workforce requirment plan). Jakarta: Kemenkes.
MoH. (2015c). Rencana Kebutuhan SDM Kesehatan Tahun 2015 (Health Workforce Requirement Plan 2015). Jakarta: Kementerian Kesehatan.
MoH. (2016a). Laporan Akuntabilitas Kinerja Instansi Pemerintah Tahun 2016 (The 2016 performance cccountability report of the Indonesia Government instititution). Jakarta: Kemenkes RI.
MoH. (2016b). Profil Kesehatan Indonesia 2015 [Indonesia Health Profile Year 2015]. Jakarta: Kemenkes.
MoH, & GIZ (Producer). (2009). A Toolkit For Implementing Workload Indicators Of Staffing Need (WISN) To Improve Health Workforce Planning And Management In Decentralized Health Systems. Retrieved from http://www.epos.de/sites/epos.de/files/users/wisn/wisn_toolkit_english_01.pdf
Montagu, D., Yamey, G., Visconti, A., Harding, A., & Yoong, J. (2011). Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One, 6. doi:10.1371/journal.pone.0017155
Moyer, C. A., Adanu, R. M., & Engmann, C. M. (2013). The relationship between facility‐based delivery and maternal and neonatal mortality in Sub‐Saharan Africa. International Journal of Gynecology & Obstetrics, 122(3), 263-265. doi:doi:10.1016/j.ijgo.2013.04.010
Moyer, C. A., & Mustafa, A. (2013). Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reproductive health, 10(1), 40. doi:10.1186/1742-4755-10-40
MSRI. (2014). Indonesia Profile. Retrieved from http://www.setneg.go.id/?lang=en
Nazneen, R., Begum, R., & Sultana, K. (2011). Rising trend of caesarean section in a tertiary hospital over a decade. Journal of Bangladesh College of Physicians & Surgeons, 29(3), 126.
Neto, A. F. O., Parpinelli, M. A., Cecatti, J. G., Souza, J. P., & Sousa, M. H. (2009). Factors associated with maternal death in women admitted to an intensive care unit with severe maternal morbidity. International Journal of Gynecology & Obstetrics, 105(3), 252-256. doi:doi:10.1016/j.ijgo.2009.01.025
Oliveira, F. C., Surita, F. G., Pinto e Silva, J. L., Cecatti, J. G., Parpinelli, M. A., Haddad, S. M., . . . Souza, J. P. (2014). Severe maternal morbidity and maternal near miss in the extremes of reproductive age: results from a national cross- sectional multicenter study. BMC Pregnancy and Childbirth, 14(1), 77. doi:10.1186/1471-2393-14-77
Poon, L., Kametas, N., Chelemen, T., Leal, A., & Nicolaides, K. (2010). Maternal risk factors for hypertensive disorders in pregnancy: a multivariate approach. Journal Of Human Hypertension, 24(2), 104.
Pritasari, K. (2012). Kebijakan dan strategi percepatan sasaran 5 MDGs dan pelayanan kesehatan yang mendukung revitalisasi KB (Policies and strategies to accelerate the achievement of five MDGs targets and health services supporting the revitalization of family planning). Jakarta: Kementerian Kesehatan Retrieved from http://www.bkkbn.go.id/materi/Documents/Materi%20Rakernas%202012/KEMENKES%20DIRJEN%20GIZI%20[Compatibility%20Mode].pdf.
Purnama, D. I., Madjid, O. A., & Iljanto, S. (2010). Evaluation of Obstetric Emergency Referral Cases at Dr. Cipto Mangunkusumo Hospital January - December 2008. Indonesian Journal of Obstetrics and Gynecology(Vol. 34. No. 4. October 2010), 164-169.
Ravelli, A., Jager, K., de Groot, M., Erwich, J., Rijninks-van Driel, G., Tromp, M., . . . Mol, B. (2011). Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. BJOG: An International Journal of Obstetrics & Gynaecology, 118(4), 457-465. doi:doi:10.1111/j.1471-0528.2010.02816.x
Roberts, C. L., Ford, J. B., Algert, C. S., Bell, J. C., Simpson, J. M., & Morris, J. M. (2009). Trends in adverse maternal outcomes during childbirth: a population-based study of severe maternal morbidity. BMC Pregnancy and Childbirth, 9(1), 1.
Ronsmans, C., Scott, S., Qomariyah, S. N., Achadi, E., Braunholtz, D., Marshall, T., . . . Graham, W. J. (2009). Professional assistance during birth and maternal mortality in two Indonesian districts. Bulletin Of The World Health Organization, 87(6), 416-423. doi:10.2471/BLT.08.051581
Sandall, J., Homer, C., Sadler, E., Rudisill, C., Bourgeault, I., Bewley, S., . . . Curry, N. (2011). Staffing in maternity units. Getting the right people in the right place at the right time.
Sandall, J., Murrells, T., Dodwell, M., Gibson, R., Bewley, S., Coxon, K., . . . Hamilton-Fairley, D. (2014). The efficient use of the maternity workforce and the implications for safety and quality in maternity care: a population-based, cross-sectional study.
Sasichay-Akkadechanunt, T., Scalzi, C. C., & Jawad, A. F. (2003). The relationship between nurse staffing and patient outcomes. Journal of Nursing Administration, 33(9), 478-485.
Schwab, F., Meyer, E., Geffers, C., & Gastmeier, P. (2012). Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? Journal of Hospital Infection, 80(2), 133-139. doi:http://dx.doi.org/10.1016/j.jhin.2011.11.014
Selo-Ojeme, D. O., Omosaiye, M., Battacharjee, P., & Kadir, R. A. (2005). Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study. Archives of gynecology and obstetrics, 272(3), 207-210.
Setkab-RI. (2012). Presidential Decree Number 72/2012 on the National Health System (Peraturan Presiden Republik Indonesia Nomor 72 Tahun 2012 Tentang Sistem Kesehatan Nasional). Jakarta: Sekretaris Kabinet RI.
Sheikh, M. (2011). Commitment and action to boost health workforce. The Lancet, 379(9810), e2-e4. doi:http://dx.doi.org/10.1016/S0140-6736(11)60023-8
Shiffman, J. (2003). Generating political will for safe motherhood in Indonesia. Social Science & Medicine, 56(6), 1197-1207. doi:http://dx.doi.org/10.1016/S0277-9536(02)00119-3
Sibbald, B., Shen, J., & McBride, A. (2004). Changing the skill-mix of the health care workforce. Journal of Health Services Research & Policy, 9(1_suppl), 28-38. doi:10.1258/135581904322724112
Silver, R. M., Landon, M. B., Rouse, D. J., Leveno, K. J., Spong, C. Y., Thom, E. A., . . . Wapner, R. J. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology, 107(6), 1226-1232.
Simbolon, D., Chalidyanto, D., & Ernawati, E. (2013). Determinan Kinerja Pelayanan Kesehatan Ibu dan Anak di Rumah Sakit Pemerintah Indonesia: Analisis data Riset Fasilitas Kesehatan Tahun 2011. Determinants of the performance of maternal and child health care service in Indonesia public hospitals: data analysis of the 2011 national health facility survey) Jurnal Kebijakan Kesehatan Indonesia, 2(04).
Sirait, A. M. (2012). Prevalensi Hipertensi pada Kehamilan di Indonesia dan Berbagai Faktor yang Berhubungan (Riset Kesehatan Dasar 2007). Buletin Penelitian Sistem Kesehatan, 15(2 Apr).
Sørbye, I. K., Vangen, S., Oneko, O., Sundby, J., & Bergsjø, P. (2011). Caesarean section among referred and self-referred birthing women: a cohort study from a tertiary hospital, northeastern Tanzania. BMC Pregnancy and Childbirth, 11(1), 55. doi:10.1186/1471-2393-11-55
Sousa, M. H., Cecatti, J. G., Hardy, E. E., & Serruya, S. J. (2008). Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveillance. Reproductive health, 5, 6-6. doi:10.1186/1742-4755-5-6
Souza, J., Gülmezoglu, A., Lumbiganon, P., Laopaiboon, M., Carroli, G., Fawole, B., & Ruyan, P. (2010). Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Medicine, 8(1), 71. doi:10.1186/1741-7015-8-71
Souza, J., Gülmezoglu, A., Vogel, J., Carroli, G., Lumbiganon, P., Qureshi, Z., . . . Say, L. (2013). Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. The Lancet, 381(9879), 1747-1755. doi:10.1016/S0140-6736(13)60686-8
Speybroeck, N., Kinfu, Y., Dal Poz, M. R., & Evans, D. B. (2006). Reassessing the relationship between human resources for health, intervention coverage and health outcomes. Geneva: World Health Organization.
Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., . . . Kattan, M. W. (2010). Assessing the performance of prediction models: a framework for some traditional and novel measures. Epidemiology (Cambridge, Mass.), 21(1), 128-138. doi:10.1097/EDE.0b013e3181c30fb2
Stoltzfus, J. C. (2011). Logistic regression: a brief primer. Academic Emergency Medicine, 18(10), 1099-1104.
Stone, P. W., Mooney-Kane, C., Larson, E. L., Horan, T., Glance, L. G., Zwanziger, J., & Dick, A. W. (2007). Nurse working conditions and patient safety outcomes. Med Care, 45(6), 571-578. doi:10.1097/MLR.0b013e3180383667
Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., . . . Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386. doi:10.1111/j.1365-2648.2012.05998.x
Talsma, A., Jones, K., Guo, Y., Wilson, D., & Campbell, D. A. (2014). The relationship between nurse staffing and failure to rescue: where does it matter most? J Patient Saf, 10(3), 133-139. doi:10.1097/PTS.0b013e31829954e2
Tejayanti, T., Perwitasari, D., & Sulistyowati, N. (2014). Kajian Layanan Kesehatan Ibu (Review of Maternal Health Service) (Trihono & Atmarita Eds.). Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan.
ten Hoope-Bender, P., de Bernis, L., Campbell, J., Downe, S., Fauveau, V., Fogstad, H., . . . Van Lerberghe, W. (2014). Improvement of maternal and newborn health through midwifery. The Lancet, 384(9949), 1226-1235. doi:10.1016/S0140-6736(14)60930-2
Tey, N.-P., & Lai, S.-l. (2013). Correlates of and Barriers to the Utilization of Health Services for Delivery in South Asia and Sub-Saharan Africa. The Scientific World Journal, 2013, 423403. doi:10.1155/2013/423403
The National Academy of Sciences. (2013). Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Retrieved from Washington DC, USA:
Thiessen, K., Nickel, N., Prior, H. J., Banerjee, A., Morris, M., & Robinson, K. (2016). Maternity Outcomes in Manitoba Women: A Comparison between Midwifery-led Care and Physician-led Care at Birth. Birth, 43(2), 108-115. doi:10.1111/birt.12225
Titaley, C. R., Dibley, M. J., & Roberts, C. L. (2011). Utilization of Village Midwives and Other Trained Delivery Attendants for Home Deliveries in Indonesia: Results of Indonesia Demographic and Health Survey 2002/2003 and 2007. Maternal and Child Health Journal, 15(8), 1400-1415. doi:10.1007/s10995-010-0697-1
Trisnantoro, Kosen, S., Soto, E. J., Firth, S., & Hollingworth, S. (2009). Developing an Investment Case for Financing Equitable Progress towards MDGs 4 and 5 in the Asia Pacific Region - Country Mapping Report – Indonesia. Retrieved from Jakarta:
Triyana, M. (2016). The effects of Indonesia's ‘Midwife in the Village’programme 10 years post-launch. Population Studies, 70(3), 365-376.
Tunçalp, Ö., Hindin, M. J., Adu‐Bonsaffoh, K., & Adanu, R. M. (2013). Assessment of maternal near‐miss and quality of care in a hospital‐based study in Accra, Ghana. International Journal of Gynecology & Obstetrics, 123(1), 58-63. doi:doi:10.1016/j.ijgo.2013.06.003
Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2012). Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study. Journal of Advanced Nursing, 68(12), 2710-2718.
UNICEF-Indonesia. (2012). Maternal and Child Health. Retrieved from http://www.unicef.org/indonesia/A5-_E_Issue_Brief_Maternal_REV.pdf
United Nations. (1999). General Assembly Resolution S-21/2, Key actions for the further implementation of the Programme of Action of the International Conference on Population and Development. A/RES/S-21/2, 9th plenary meeting, 2 July 1999. Retrieved from http://www.un.org/documents/ga/res/21sp/a21spr02.htm
United Nations. (2015). The Millennium Development Goals Report 2015 C. Way (Ed.) Retrieved from http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf
Walker, D., McDermott, J. M., Fox-Rushby, J., Tanjung, M., Nadjib, M., Widiatmoko, D., & Achadi, E. (2002). An economic analysis of midwifery training programmes in South Kalimantan, Indonesia. Bulletin Of The World Health Organization, 80(1), 47-55.
Wang, X., Hellerstein, S., Hou, L., Zou, L., Ruan, Y., & Zhang, W. (2017). Caesarean deliveries in China. BMC Pregnancy and Childbirth, 17(1), 54. doi:10.1186/s12884-017-1233-8
Weinstein, R. A., Stone, P. W., Pogorzelska, M., Kunches, L., & Hirschhorn, L. R. (2008). Hospital staffing and health care–associated infections: a systematic review of the literature. Clinical Infectious Diseases, 47(7), 937-944.
WHO, UNFPA, & Unicef. (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.). Geneva: World Health Organization.
Widyaningsih, V., Khotijah, & Balgis. (2017). Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia. Global health action, 10(1), 1339534. doi:10.1080/16549716.2017.1339534
Wilson, R. E., & Salihu, H. M. (2007). The paradox of obstetric "near misses": converting maternal mortality into morbidity. Int J Fertil Womens Med, 52(2-3), 121-127.
Word Health Organization. (2016). Maternal health. Retrieved from http://www.who.int/topics/maternal_health/en/
World Health Organization. (2004). Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO.
World Health Organization. (2005). The World Health Report 2005: Make Every Mother and Child Count. Geneva: World Health Organization.
World Health Organization. (2006). The world health report 2006: working together for health: World Health Organization.
World Health Organization. (2009). WHO Recommended Interventions for Improving Maternal and Newborn Health. 2nd. Retrieved from http://www.who.int/maternal_child_adolescent/documents/who_mps_0705/en/
World Health Organization. (2011). Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health.
World Health Organization. (2012). The WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD-MM: World Health Organization.
World Health Organization. (2015a). Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Geneva: World Health Organization.
World Health Organization. (2015b). Trends in maternal mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization.
World Health Organization. (2016a). Standards for improving quality of maternal and newborn care in health facilities. Retrieved from http://apps.who.int/iris/bitstream/10665/249155/1/9789241511216-eng.pdf?ua=1
World Health Organization. (2016b). Workload Indicators Of Staffing Need (WISN): Selected Country Implementation Experiences. Retrieved from http://apps.who.int/iris/bitstream/10665/205943/1/9789241510059_eng.pdf
World Health Organization. (2018). WHO recommendations: intrapartum care for a positive childbirth experience WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: world Health Organization.
Yego, F., D’Este, C., Byles, J., Williams, J. S., & Nyongesa, P. (2014). Risk factors for maternal mortality in a Tertiary Hospital in Kenya: a case control study. BMC Pregnancy and Childbirth, 14(1), 38. doi:10.1186/1471-2393-14-38
Yelland, A., Winter, C., Draycott, T., & Fox, R. (2013). Midwifery staffing: Variation and mismatch in demand and capacity. British Journal of Midwifery, 21(8).
Zeeman, G. G. M. D. P. (2006). Obstetric critical care: A blueprint for improved outcomes. Critical Care Medicine Critical Care Challenges in Special Patient Populations, 34(9), S208-S214.
Zwart, J., Richters, J., Öry, F., De Vries, J., Bloemenkamp, K., & Van Roosmalen, J. (2008). Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population‐based study of 371 000 pregnancies. BJOG: An International Journal of Obstetrics & Gynaecology, 115(7), 842-850.