Determinants of Maternal Mortality Based on Grouping and

Mapping in Padang
Masrizal1*, Ainul Mardia Oktiara1, Ratno Widoyo1

Abstract
Background:Maternal Mortality Rate (MMR) in Padang period of 2013-2015 has increased.
Increased MMR was not independent of the various factors that affect such as factors of health
status and health behaviors. The description of MMR in Padang reached 246 per 100,000 live
births and MMR low of 0 per 100,000 live births, while the mean in Padang was 99 per 100,000
live births. This study aimed to determine the grouping and sub-district mapping based
determinants of maternal mortality in the city of Padang.
Method:Design was descriptive analysis using secondary data with seven variables that affect the
incidence of maternal deaths. Grouping of sub-districs did by using multivariate analysis include
cluster, biplot, and discriminant analysis. The unit of analysis in this study were all districts in the
city of Padang.
Results: Grouping optimum sub-district produced two clusters, namely cluster 1 consists of the
District of West Padang, East Padang, North Padang, South Padang, Nanggalo, Kuranji, Pauh, and
Lubuk Begalung, while the second cluster consists of Koto Tangah, Lubuk Kilangan, and Bungus.
The first cluster was a group of districts with many factors cause of maternal deaths, while the
second clusters was a district with a bit of the causes of maternal deaths. The mapping process
produced MMR mapping, mapping the results of grouping sub-district and sub-district mapping
based on the area of intervention.
Conclusion: District of high potential for the occurrence of maternal death was the District Pauh,
Kuranji, East Padang, and Lubuk Begalung (the intervention). Factors that cause of maternal
mortality in the region was the low percentage of pregnant women at high risk of
complication/handled, the low percentage of new family planning participants and active family
planning participants, the low percentage of pregnant women who implement the program K1 and
TT2 +. Suggested to Padang City Health Department to plan for area-based maternal health
program based on the characteristics of each district in the city of Padang.
Acknowledgements: Thanks to the City Health Office Padang who has given permission to do
this research.

Keywords : Determinants, Maternal, Mapping, Grouping

* Correspondence: masrizal_khaidir@yahoo.com,
1
Epidemiology and Biostatistics of Public Health,
Andalas University, Padang, Indonesia, 25148, Indonesia
Background
Maternal mortality is a global health
problem that became important indicator of
the success of maternal health programs at
the same time one of the indicators in
describing the degree of public health. World
Health Organization (WHO) estimates that
every day 800 women die from
complications of pregnancy and childbirth.
WHO report in 2014 showed MMR in the
world amounted to 289,000 people, which is
divided into several countries, including the
United States reached 9,300 souls, North
Africa and Southeast Asia 179 000
inhabitants 16,000 inhabitants. Maternal
mortality rate in developed countries is 16
per 100,000 live births, while in developing
countries reached 230 per 100,000 live
births, meaning that developing countries
accounted for 99% of maternal deaths in the
world.
Indonesia as a developing country
ranks highest MMR in South East Asia in
2014 that is 214 per 100,000 live births,
followed by Fhilipina 170, Vietnam 160,
Thailand 44, Brunei 60 and Malaysia 39 per
100,000 live births. This illustrates the high
mortality rate of the low level of public
health and has the potential to cause
economic and social deterioration in the level
of the household, community and national
levels.
Maternal Mortality nationally
fluctuate from 1991-2015. Indonesia Basic
Health Survey (IDHS) showed a decrease in
MMR over the period 1991 to 2007 from 390
to 228 per 100,000 live births, in 2012
increased to 359 per 100,000 live births,and
the results of the Inter-Census Population
Survey (SUPAS) 2015 again showed a
decrease in MMR to 305 per 100,000 live
births. The decline in the death rate has not
reached the MDG target, namely reducing
the MMR to 102 per 100,000 live births 2015
and still far from the output SDGs to reduce
the MMR to 70 per 100,000 live births on
2030.
West Sumatra is one of the provinces
in Indonesia which has not reached the target
MMR 2015 West Sumatra Provincial Health
Office in 2015 and 2016 records the number
of maternal deaths in a row as many as 110
and 108 maternal deaths (pregnancy,
childbirth, and postpartum). When compared
with the number of live births in the same
year, the MMR in West Sumatra in 2015 and
2016 respectively for 115 and 114 per
100,000 live births, means reducing maternal
mortality rate in West Sumatra during the
period 2015 to 2016 were not significant.
Padang city as capital of West
Sumatra province is a center of education and
health that became a model for districts/cities
Filling in West Sumatra. Over the past four
years, the maternal mortality ratio in Padang
experienced a significant increase. This is
evident from the City Health Department
data estimates MMR in 2013 amounted to
84, 2014 rose to 94, 2015 reached 99, and in
2016 jumped to 120 per 100,000 live births.
Data Provincial Health Department in 2014-
2016 put Padang as the largest contributor to
maternal mortality of 19 districts/cities
scattered throughout the province of West
Sumatra.In addition, the city of Padang are
also included in the top ten views of the
highest MMR in 2015-2016.
The high maternal mortality rate in
Padang is influenced by factors such as the
health service indicators handling obstetric
complications and percentage of households
with clean and healthy living behavior. Based
on data from the City Health Office in 2015,
divided by districts in the city of Padang, the
low percentage reported handling obstetric
complications in each district with an
average value of 41.70%. In addition, the
availability of health services as Posyandu
active in every district is also uneven. This
indicates that the health efforts in Padang has
not gone up.
Maternal mortality is a complex event
that is caused by several factors. McCarthy
and Maine in 1992 classifying cause of
maternal deaths into three factors, among
others: 1) the determinant close, covering the
pregnancy itself and complications in
pregnancy, childbirth and the postpartum
period; 2) the determinant between, including
maternal health, reproductive status, access
to health services, behavioral health service
use and factors that are unknown or
unexpected; 3) the determinant far, such as
socio-cultural and economic.
Some research on the causes of
maternal mortality analysis had been done
before, including by Fibriana 2007 using
case-control design that states that
complications of childbirth, postpartum
complications, maternal medical history,
family history of planning and delays in
referrals is a risk factor of maternal
deaths.This study is in line with the results of
the multivariate analysis conducted by
Sarwani in 2009 which found that the risk
factors for maternal mortality are obstetric
complications, maternal history of the
disease, and abnormalities at birth.Aeni study
in 2011 using the same design also found a
significant association between obstetric
complications, complications of childbirth,
and history of the disease with the incidence
of maternal deaths.
Aristia in 2011 to conduct research on
maternal mortality by modeling the maternal
mortality using a negative binomial
regression and Geographically Weighted
Poisson Regression (GWPR). The results of
this study concluded that the best method to
use GWPR and prove that the variable
household clean and healthy living behavior
significantly affect the number of maternal
deaths. Recent research conducted by Sari
2016 using path analysis. The results of the
analysis of household variables declared a
clean and healthy living behavior and the
percentage of births assisted by herbalists
significant impact on maternal mortality.
This research grouping and mapping
of districts in the city of Padang based on the
high maternal mortality rate and the factors
that influence it, using a multivariate analysis
includes a cluster analysis, biplot, and
discriminant. Cluster analysis aims to group
the objects based on similar characteristics
among these objects. Biplot analysis aims to
see the closeness between objects and
characteristics, and to investigate the
relationship between variables to describe the
elements of rows and columns in the form of
graphs,while discriminant analysis aims to
determine the distinguishing variable and the
accuracy of the classification of the grouping
obtained.
Aspects of this research area related
to the different characteristics of the
respective districts in the city of Padang,
such as demographics and geography.
Differences in these characteristics will also
result in differences in the quality of health
and load problems encountered between
regions/districts, and will affect the maternal
mortality ratio in each district in the city of
Padang. Grouping and mapping of districts in
the city of Padang based determinants of
maternal mortality using multivariate
analysis (cluster, biplot, and discriminant)
has never been done before. Therefore, it is
necessary to do research or theoretical study
on the determinants of maternal mortality by
grouping and mapping of districts in the city
of Padang, so that can know the right
strategies to reduce maternal mortality rate in
the city of Padang, which will improve the
health of the people of Padang.
Method
This research is an analytic
descriptive study using secondary data
collected in 2015 from the City Health Office
(DKK) Padang. The unit of analysis in this
study were all districts in the city of Padang
covers eleven districts will be grouped
hierarchically based determinants of maternal
mortality. The variables used in this study
consists of seven variables or attributes as
follows: Percentage of pregnant women at
high risk/complications handled (X1), the
percentage of new family planning
participants (X2), the percentage of
participants active family planning (X3), the
percentage of pregnant women who
implement the program K1 (X4), the
percentage of pregnant women who carry out
the program K4 (X5), the percentage of
births assisted by skilled health personnel
(X6), and the percentage of pregnant women
who carry out immunization TT2 + (X7).
This study using univariate and multivariate
analysis. Multivariate analysis used consisted
of a hierarchical cluster analysis, biplot
analysis and discriminant analysis.
Result
Maternal Mortality in 2015 the
highest maternal mortality rate in the District
Pauh (245.90%), followed by the District
Kuranji (151.34%), District of Lubuk
Begalung (137.61%), and the District of East
Padang (130.38%). The fourth sub-district is
a district that has not reached the MDG target
by 2015, while the districts which are free
from maternal mortality District of West
Padang, North Padang, and Bungus.
Cluster analysis resulted in two
groups. One cluster consists of the District of
West Padang, East Padang, North Padang,
South Padang, Nanggalo, Kuranji, Pauh, and
Lubuk Begalung. Cluster consists of two
Tangah Koto subdistrict, Lubuk Kilangan,
and Bungus.
Picture 1. Dendogram of Cluster Analysis
 Each cluster is influenced by certain
variables are depicted in two dimensions
through visualization biplot, biplot analysis
results illustrate the differences in the length
of each vector. Variable percentage of
pregnant women at high risk/complications
handled (X1), new family planning
participants (X2), pregnant women who carry
out the program K1 (X4), pregnant women
who carry out the program K4 (X5), births
assisted by skilled health personnel (X6), and
pregnant women who are carrying out
immunization TT2 + (X7) has a vector length
category, while the percentage of active
family planning participants (X3) vectors
short category.
The results of the analysis biplot also
showed a positive correlation and negative
between variables, including variable
percentage of new family planning
participants have a positive correlation with
the percentage of pregnant women who are
carrying out immunization TT2 +, visible
from a narrow angle formed between the
variables, while both these variables have a
negative correlation with variable percentage
of high-risk pregnant women/complications
handled, active family planning participants,
pregnant women who carry out the K1
program, pregnant women who carry K4
program, and births assisted by skilled health
personnel, as evidenced by the obtuse angle
formed between these variables.
Discriminant analysis resulted in
distinguishing variable between clusters ie
the percentage of births assisted by skilled
health personnel.
Mapping sub-districts based
determinants of maternal deaths in sub-
districts of Padang generating groups based
on MMR, result clustering, and the
intervention areas the incidence of maternal
deaths. Mapping results showed that the
District Pauh, Kuranji, East Padang, and
Lubuk Begalung is an area with a high
potential level; South of Padang District and
Nanggalo an area with medium potential
level; East Padang, North Padang, West
Padang, Koto Tangah, and Lubuk Kilangan
an area with low potential for occurrence rate
of maternal mortality; whereas areas not yet
the potential for the occurrence of maternal
death is the District Bungus Teluk Kabung.
Picture 2. Intervention Areas the Incidence of Maternal Deaths
In Padang City 2015
Discussion
Maternal Mortality Rate in Padang
during the period of 2013-2015 has
increased. Increased MMR is not
independent of the various factors that affect
such factors of health status and health
behavior factors. Based on the description of
MMR in Padang in Table 4.1, the highest
MMR reached 246 per 100,000 live births
and MMR low of 0 per 100,000 live births,
while the mean in Padang is 99 per 100,000
live births. District which has the highest
MMR at a time yet to reach the MDGs by
2015 is District of East Padang, Kuranji,
Pauh, and Lubuk Begalung, while districts
that are free of maternal deaths in 2015 was
the District of West Padang, North Padang,
and Bungus.
The result of grouping sub-district
produces two clusters optimum namely
cluster one consisted of the District of West
Padang, East Padang, North Padang, South of
Padang, Nanggalo, Kuranji, Pauh, and
LubukBegalung, while clusters of two
consisting of the District Koto Tangah,
Lubuk Kilangan, and Bungus. Cluster one is
a group of districts with many factors cause
of maternal deaths, while the two clusters is a
district with little factor cause of maternal
deaths. The results of this study are not
consistent with research Novita and Earth
who categorize districts/ cities in East Java
into five clusters, and also different from the
research Qomariyah that classifies districts/
cities into three clusters based on the
distribution of the number of maternal deaths
in each district/city in East Java.
The results of biplot analysis shows
that there is considerable diversity of
variables that affect maternal mortality in
each sub-district, it is visible from the
diversity of the length of each vector,
because the length of the vector will be even
greater effect on objects. Two variables that
have a value of a positive correlation would
be described as two lines in the same
direction or form a narrow angle, while the
two variables that have a value of negative
correlation will be illustrated in the form of
two lines in the opposite direction or forms
an obtuse angle, and the two variables
berkorekasi not be described in terms of two
lines at an angle close to 90. In this study,
there are variables that correlated positive
and negative.
Determination of the discriminant
variable each cluster is expressed in the table
discriminant variable between two clusters
and discriminant variable table based
clusters, starting with a look at the difference
between the two clusters (between groups) is
then determined which are the most
distinguishing variable effect on the cluster.
Based on these two tables, discriminant
variable or distinguishing the clusters one
and two arethe percentage of births assisted
by skilled health personnel.
The final results of the discriminant
analysis which test the accuracy of the
grouping. Based on the test results of
discriminant analysis obtained the degree of
accuracy of the grouping was perfect that the
result reached 100% or it can be said without
an error occurs in the process of grouping, so
that the discriminant function generated
provides a level of high accuracy and can be
used as a function of distinguishing the sub-
district by the influence of the determinants
of maternal deaths Padang city.
Intervention regions based on the
mapping of sub-districts in 2015 are divided
into four categories: the intervention area
consists of the District Pauh, Kuranji, East
Padang, and Lubuk Begalung; consist of two
intervention areas of South Padang and
Nanggalo, consisting of three intervention
areas of East Padang, North Padang, West
Padang, Koto Tangah, and Lubuk Kilangan
and four intervention areas namely District
Bungus Teluk Kabung. The division of the
intervention site visits by high maternal
mortality rate and the number of
determinants of maternal deaths in each
district.
Factors that cause of maternal
mortality in the intervention area includes the
low percentage of high-risk pregnant
women/complications are dealt, the low
percentage of new family planning
participants, active family planning
participants, pregnant women who carry out
the K1 program, and pregnant women who
carry out TT2 +; The two intervention areas
include the low percentage of high-risk
pregnant women/complications are
addressed, new family planning participants,
active family planning participants, pregnant
women who carry out the K1 program,
pregnant women who carry K4 program, and
pregnant women who carry out TT2+; while
in the area of intervention include low
percentage of high-risk pregnant
women/complications are addressed, new
family planning participants, active family
planning participants, pregnant women who
carry out the K1 program, pregnant women
who carry K4 program, and pregnant women
who carry out TT2+; and in the intervening
four regions namely the low percentage of
new family planning participants.
Conclusion
The study concluded that the District
high potential for the occurrence of maternal
death is the District Pauh, Kuranji, East
Padang, and Lubuk Begalung (the
intervention). Factors that cause of maternal
mortality in the region is the low percentage
of pregnant women at high
risk/complications are dealt, the low
percentage of new family planning
participants, the low percentage of
participants active family planning, low
percentage of pregnant women who carry out
the program K1, and the low percentage of
pregnant women who carry out TT2+.
Therefore, the results of this study are
expected to be beneficial to Padang City
Health Department as policy makers in
planning maternal health program based
strategic areas based on the needs and
characteristics of the sub-districts in an effort
to give special attention from both the
government and the holder of the maternal
health program of sub districts included in
the intervention.
Acknowledgements:
Thanks to the City Health Office
Padang who has given permission to do this
research.
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PICTURES

Picture 1 : Dendogram Cluster Analysis

Picture 2 : Map of Maternal Mortality in Padang 2015

Picture 3 : Map of the District Cluster Based Determinants of Maternal

Mortality in Padang 2015
Picture 4 : Map of the Regional Intervention Maternal Mortality in Padang