Literature Review: Analysis to Reduce Maternal Mortality

The maternal mortality rate in Indonesia is still high. Hard efforts are needed so that the Sustainable Development Goals target of 70 per 100,000 live births in 2030 can be achieved. The purpose of the study was to identify aspects related to the trend issue of maternal mortality, the determinants of causes, strategic efforts and the role of family planning in reducing maternal mortality. This literature review described sixteen peer-reviewed journals based on inclusion criteria. The results of the analysis of the literature review found that aspects of findings related to maternal mortality were as follows: trends issue maternal mortality (Maternal mortality is more common in developing countries), causative factors (Status health (nutrition, comorbidities and maternal complications), reproductive status (age, parity, gestational distance), access to health services and policies/regulations, health behavior (contraception use, socioeconomic)), strategic efforts (maternal and neonatal health management, Quality antenatal services, safe delivery and family planning) and family plans (Support system (women's status, family and community status)). The review analysis provides directions and patterns of strategic work steps, collaboration of various support systems ranging from the role of individuals, families, communities, health services and the government in ensuring maternal and child health .


INTRODUCTION
The maternal mortality rate is an indicator of women's welfare, an indicator of the welfare of a nation as well as describing the results of a country's development achievements. Information on maternal mortality is useful for the development of maternal health improvement programs, especially safe pregnancy and delivery services, increasing the number of deliveries assisted by health workers, management of the referral system in handling pregnancy complications (Hasanbasri, Lazuardi, Gadjah, Yogyakarta, & Anak, 2013).
Based on the results of estimates of maternal mortality from the WHO, the maternal mortality rate is 210 per 100,000 live births. The maternal mortality rate in developed countries ranges from 16 per 100,000 live births, while in developing countries this rate is almost 15 times higher at around 240 per 100,000 live births. Indonesia is one of the countries experiencing an increase in maternal mortality, far from the target of 102 per 100,000 live births. It takes a strong effort from the government to overcome the problem of maternal mortality so that the Sustainable Development Goals (SDGs) target of 70 per 100,000 live births in 2030 can be achieved (Callister & Edwards, 2017a).
Many factors have contributed to the increase in maternal mortality in Indonesia. In addition to direct causal factors, such as bleeding, hypertension, infection, prolonged labor, and abortion, the main causes of maternal death are also influenced by indirect or intermediate causes.
The government has implemented various intervention strategies to reduce maternal mortality, but many factors need to be analyzed further. It is the interest of researchers to obtain a framework for various aspects that affect maternal mortality (King, 2015). The focus of this literature review discusses trends in maternal mortality globally and in Indonesia, the determinants of maternal mortality, efforts to reduce maternal mortality and the role of family planning in reducing maternal mortality.

Study design
Literature review on Analysis to Reduce Maternal Mortality, in the literature search using the PICOS format as below. The dimensions analyzed as key variables in this study are Trends issue, determinant factors, strategic grands and family planning.

Search strategy
Alternative term for population (P) used "pregnant women of reproductive age" OR "post partum mothers of reproductive age" OR "mothers using contraception". Researchess did not use alternative terms for intervention (I). Alternative terms for the outcome (O), researchers used the aspects of Trends issue, determinant factors, strategic grands and family planning.

Selection Criteria
The inclusion criteria of this study included 2015-2021 journal collection, quantitative and qualitative researches, using original research and systematic review. Although research methods varied, researchers have paid attention to the depth of content aspect, to explore problems from various aspects, so that research problems can be clearly described. The area of journal about the aspects of trends issue, determinant factors, strategic grands and family planning. The exclusion criteria included conference papers, symposia, and discussion papers. Database scopus, proquest, pubmed, scient direct. Literature Review Algorithm using PRISMA flow. The results of the inclusion criteria screening obtained 16 journals. The ability of Indonesia to reach the 2030 SDG maternal mortality target of 70 maternal deaths per 100,000 live births will depend primarily upon health system effectiveness in addressing health risks to women once they are pregnant.
13 The role of birth spacing, family planning services, safe abortion services and post abortion care in reducing deaths in reducing maternal deaths (Ganatra, Faundes, & Coordinator, 2016) Design: Review Sample: Literature Variable: maternal mortality data Access to contraception and the provision of family planning is an essential reproductive health intervention that helps reduce maternal deaths by preventing or delaying pregnancy in women not intending to be pregnant or those at higher risk of morbidity and mortality. The provision of safe abortion is essential to prevent the complications arising from unsafe abortion and the provision of emergency care for complications is essential to avert deaths from those complications. Equally important, the provision of contraception and safe abortion go beyond preventing deaths -it is a telling indicator of our ability to respect women's decisions and ensure that they have access to timely, evidence-based care that protects their health and human rights. Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies.

RESULT
The results of the analysis of the literature review found that aspects of findings related to maternal mortality were as follows: trends issue maternal mortality (Maternal mortality is more common in developing countries, trends in maternal mortality in developed countries are more related to obesity and complications of hypertension and diabetes), causative factors (Status health (nutrition, comorbidities and maternal complications), reproductive status (age, parity, gestational distance), access to health services and policies/regulations, health behavior (contraception use, socioeconomic)), strategic efforts (maternal and neonatal health management, Quality antenatal services, safe delivery and family planning) and family plans (Support system (women's status, family and community status)). The framework of the review results is described in Figure 1 below. Figure 1. The framework of the analysis to reduce maternal mortality

DISCUSSION
Maternal mortality is more common in low and middle income countries. Maternal mortality is correlated with multiples of socio-economic factors, health care system associated factors disease burden and their complex interactions. While in developed countries, factors contributing to maternal mortality, such as overweight and obesity, hypertension, type 2 diabetes and increased maternal age at the birth of a child.
According to Mcarthy and Maine (1992)  determinants are directly influenced by the determinants, namely health status, reproductive status, access to health services, and behavior in using health services. Distant determinants are determinants related to demographic and sociocultural factors, namely the status of women in the family and society, the status of the family in society, and the status of society.
From close determinants, there are complications that can occur, including bleeding, infection, pre-eclampsia and eclampsia, obstructed labor or prolonged labor and uterine rupture. All of which have an impact not only on pregnancy, childbirth and postpartum, but also the risk of death for the mother and baby. The condition of the three determinants previously described, either directly or indirectly, integratedly must be anticipated in a planned manner since early pregnancy (No Title, 2015).
Most obstetric complications occur at the time of delivery. For this reason, we need professionals who can quickly recognize complications that can threaten the mother's life and at the same time carry out timely treatment to save the mother's life. The maternal mortality rate will be reduced adequately if 15% of births are handled by doctors and 85% are handled by midwives. This ratio is most effective when midwives can manage normal deliveries, and can effectively refer 15% of deliveries with complications to a doctor. Indonesia has launched Making Pregnancy Safer (MPS) as a public health development strategy towards a healthy Indonesia 2010 on October 12, 2000, as part of the Safe Motherhood program. The purpose of Safe Motherhood and Making Pregnancy Safer is the same, namely protecting reproductive rights by reducing the burden of illness, disability, and death associated with pregnancy and childbirth that should not have occurred (Akanbi & Mordi, 2017).
Safe Motherhood is an effort to save women so that pregnancy and childbirth are healthy and safe, as well as giving birth to healthy babies. The goal of Safe Motherhood efforts is to reduce morbidity and mortality rates for pregnant, maternity and postpartum women, and reduce morbidity and mortality rates for newborns. This effort is mainly aimed at developing countries because 99% of maternal deaths in the world occur in these countries.
Strategic interventions in Safe Motherhood efforts are stated as the four pillars of Safe Motherhood, namely: 1). Family Planning, which ensures that every person/couple has access to family planning information and services in order to plan the right time for pregnancy, the interval between pregnancies and the number of children; 2). Antenatal care, to prevent obstetric complications where possible, and to ensure that complications are detected as early as possible and adequately treated; 3). Safe delivery, ensuring that all birth attendants have the knowledge, skills and tools to provide safe and clean assistance, and provide postpartum services to mothers and babies; 4). Essential obstetric services, ensuring that obstetric services for high risk and complications are available to pregnant women who need them (Soedarmono, 2017).
Another intervention that also has a contribution is the empowerment of women and communities. Empowerment can be interpreted as an effort to increase the community's ability to participate and negotiate. Intensive Community influences and controls its people for the betterment of life. Empowerment can also be interpreted as an effort to provide power or strength to the community. The author tries to provide a solution through an idea, namely Intensive Community Empowerment, which is an intensive effort to make the community more empowered and independent in maintaining their health, where the outcome is expected to be an alternative to reduce maternal mortality (King, 2015).

CONCLUSION
Referring to the results of the review, various aspects of principles related to the reduction of maternal mortality were obtained, both in terms of trends issues, causative factors and risks, existing treatment strategies and the role of family planning. All of them give meaning, the need for collaboration with various support systems in building grand strategies to reduce maternal mortality. The review analysis of how to reduce maternal mortality provides directions and patterns of strategic work steps that can be taken by the role of individuals, families, communities, health services and the government in ensuring maternal and child health.

SUGGESTION
In reducing maternal mortality, it is very important to empower women and the role of health workers in collaboration with families in a comprehensive manner.