DEV 102M: Using Analytical Frameworks for Smart Policy Design

No Mother Left Behind: Tackling Regional Disparities in Maternal Health Access in

Indonesia

Adho Adinegoro

1. Defining the Problem

Indonesia has made progress in reducing maternal deaths over the past two decades, but
its maternal mortality ratio (MMR) remains high, and improvement has lagged behind
peer countries. In 2000, Indonesia's maternal mortality ratio (MMR) was 299 maternal deaths
per 100,000 live births, significantly lower than India's rate of 384.1 However, by 2020,
Indonesia's progress had stalled at 173 deaths, while India remarkably reduced its rate to 103.
Indonesia's maternal mortality ratio (MMR) remains high compared to the Southeast Asian
regional average, which was around 134 in 2020. Currently, Indonesia has one of the highest
maternal death rates in the region, significantly exceeding neighboring middle-income
countries like Malaysia (21), Thailand (29), Vietnam (46), and the Philippines (78). This
concerning reversal signals that Indonesia’s earlier gains have not kept pace with global and
regional improvements which leaves the country as an alarming outlier in maternal health.

Figure 1. Trends in maternal mortality rate Figure 2. Maternal mortality in Southeast Asia
(deaths per 100,000 live births, 2000 – 2020) (deaths per 100,000 live births, 2020)
Indonesia India Southeast Asia 300
500
250
450
218
400 204
200
179 173
350
300 150
126
250
100
78
200 173
50 46 44
150
103 29 21
100 7
102 0
50
ya r

Th nei
sia

ili os

e
M and
am
do r

Vi nes
st ia

ng a
M imo
In ma

or
Si ysi
Ea bod

Ph La
ne

u
etn

ap
i

0
n

pp

ala
ai
Br
T
m
Ca

2000 2005 2010 2015 2020

One of the most significant concerns within Indonesia's maternal mortality crisis is the
substantial regional disparity. More developed regions in the western part of Indonesia, such
as Java-Bali and Sumatra, report relatively lower maternal mortality ratios (MMRs) of 125 and

1
180 per 100,000 live births, respectively.2 However, mothers in less-developed areas,
particularly in Eastern Indonesia, face considerably higher risks. In the region of Sulawesi, the
MMR reaches approximately 242, while Papua experiences an extremely alarming rate of
about 454 maternal deaths per 100,000 live births, almost thrice the national average. This high
regional disparity highlights deep-rooted inequalities, especially affecting women in rural and
remote areas who lack access to quality healthcare.

Figure 3. Maternal mortality rate by Indonesian regions

(deaths per 100,000 live births, 2020)
500
454
450

400

350

300 287
258
250 242
208
200 180
150 125
100

50

0
Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
(Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

The urgency to address Indonesia's maternal health crisis is highlighted by the country's
historical struggle to meet international goals. Indonesia missed the Millennium
Development Goal (MDG) target of reducing maternal deaths to 102 per 100,000 live births
by 2015 and recorded an MMR of 194 instead.3 Now, the Sustainable Development Goals
(SDGs) pose an even more ambitious target: to lower the maternal mortality ratio to less than
70 per 100,000 live births by 2030, with no country exceeding 140.4 With an existing rate of
173, Indonesia is not only above the ideal goal but also exceeds the absolute upper limit set by
the global community that underlines the critical need for immediate and effective action.

Notably, a substantial proportion of maternal deaths in Indonesia are preventable.

National health studies indicate postpartum hemorrhage, hypertensive disorders such as
eclampsia, and sepsis are the leading causes.5 A regional study in Papua, a province with one
of the highest maternal mortality rates, revealed that postpartum hemorrhage alone accounted
for about 40% of maternal deaths, followed closely by eclampsia and sepsis.6 These are
conditions that can be effectively treated or managed with basic medical care, timely access to
skilled birth attendants, essential drugs, and responsive emergency services. Thus, the problem

2
lies not in medical capability, but in the availability and equitable distribution of healthcare
services.

Reducing maternal mortality is very important, as it affects the health of mothers as well
as social and economic conditions. Studies from other countries have shown that maternal
deaths can lead to increased child mortality, nutritional problems, reduced educational
opportunities, and long-term family instability.9 However, studies measuring these impacts in
Indonesia are still very limited. Nevertheless, Indonesia's persistently high maternal mortality
signals serious and urgent issues within its healthcare system. Given the complexity of this
issue, the next section explores in detail the causes and challenges contributing to persistently
high maternal mortality rates, with a particular focus on Eastern Indonesia, including Papua,
Maluku, Nusa Tenggara, and Sulawesi.

2. Diagnosing the Problem

Figure 4. Diagnostic tree for Indonesia’s high maternal mortality rate

Limited awareness Lack of adequate maternal health education and knowledge

and weak health-
seeking behavior Limited community outreach and information campaigns

Low demand of Strong traditional beliefs against formal maternal healthcare

Socio-cultural and
quality maternal
gender barriers
health services Limited women's autonomy and decision-making power

Weak social health insurance coverage and financial protection

Financial and physical
Indonesia faces high accessibility barriers
Poor physical infrastructure and transportation networks in remote areas
maternal mortality
rate
Insufficient number of skilled maternal health providers
Inadequate health
workforce capacity
Low incentives for rural health workforce retention

Low supply of quality Limited availability Inadequate maternal and emergency obstetric healthcare infrastructure
maternal health and readiness of
services healthcare services Frequent shortages of essential medicines and medical supplies

Inconsistent adherence to established clinical guidelines

Poor quality and
unsafe maternal care
Weak oversight and accountability mechanisms in healthcare provision

Binding constraint

To effectively reduce Indonesia's high maternal mortality rate, it is essential to

understand the key constraints driving this issue. This section analyzes two primary drivers:
the demand for quality maternal health services and the supply of these services. The analysis
primarily relies on data from two main sources, the Indonesia Health Survey 2023 and the
Indonesia Health Facility Survey 2019, which are among the most comprehensive and
nationally representative health surveys in the country. Figure 4 summarizes these constraints,
and the following analysis discusses each constraint in detail.

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Demand-Side Constraints

Figure 5. Shares emergency-seeking behavior

(in percentage, 2023)

By Region By Area
100 100

90 90

80 80

70 70 67
65 64 63 63
60
60 60 57
55
53
50 50
45

40 40

30 30

20 20

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

Figure 6. Reasons not to seek emergency care: Not necessary

(in percentage, 2023)

By Region By Area
100 100

90 90

80 80 77

70 66 70 66 66 66
62
59 60
60 60 57

50 50 48

40 40

30 30

20 20

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

A significant factor behind Indonesia’s maternal mortality is the low awareness and weak
health-seeking behavior among pregnant women. As seen in Figure 5, in Eastern Indonesia,
only 53% of women seek emergency medical care when facing complications during labor,

4
significantly lower than the 65% observed in Western Indonesia.7 When asked about the
reasons for not seeking emergency assistance in Figure 6, approximately 66% of women in
Eastern Indonesia stated that they felt such care was unnecessary, compared to 59% in the
West. These statistics indicate a gap in awareness of maternal health risks and suggest a critical
need for targeted educational interventions, especially in Eastern provinces.

Figure 7. Reasons not to seek antenatal care: Not being permitted by family
(in percentage, 2023)

By Region By Area
10 10

9 9

8 8

7 7

6
6 6

5 5

4 4
4 4

3 3
3 3

2 2 2
2 2

1
1 1

0
0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

Socio-cultural and gender-related barriers also limit the demand for maternal health
services. For instance in Figure 7, while fewer than 1% of women in Java-Bali cite family
permission as a barrier to antenatal care (ANC), this issue is reported by 6% of women in
Papua, which is far above the national average of 3%.7 These figures demonstrate how cultural
beliefs and social norms can restrict women’s healthcare access that creates disparities across
regions and places women in Eastern Indonesia at greater risk during pregnancy.

5
Figure 8. BPJS utilization Figure 9. Public hospital utilization Figure 10. Barrier to reach hospital
(in percentage, 2023) (in percentage, 2023) (in percentage, 2023)
100 100 100

90 90 90

80 80 80

70 70 70

60 59 59
60 60 60

50 50 50

40 40 40
35
32
30
30 30 30
24
20
20 20 17 20

10 10 10

0 0 0
Western Eastern National Western Eastern National Western Eastern National
Region Region Region Region Region Region

Financial and physical accessibility constraints also impact maternal health services
utilization. While utilization of the national health insurance scheme (BPJS) is similar in both
Western (60%) and Eastern (59%) Indonesia as reflected in Figure 8, there are notable
differences in hospital accessibility.7 From Figure 9, we can see that women in Eastern
Indonesia are more reliant on public hospitals but report significantly lower perceived ease of
access compared to their Western counterparts as seen in Figure 10. This reliance implies that
women in Eastern regions often have no option but to use distant public facilities which result
in higher transportation costs and greater physical barriers to accessing care.

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Supply-Side Constraints

Figure 11. Availability of skilled providers: Antenatal Care

(in percentage, 2023)

By Region By Area
100 100

90 90

80 80

70 70

60 60

50 50

40 40

29
30 26 30
24 25 24 23 22
21
20 20 17
15

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

Figure 12. Availability of skilled providers: At birth

(in percentage, 2023)

By Region By Area
100 100

90 90

80 80

70 70

60 60

50
50 50

40 38 40
35
33 33
30
30 26 30
24
21
20 20 17

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

On the supply side, the shortage of skilled health providers significantly restricts
maternal health services. Nationally, only about 24% of women receive antenatal care from
skilled providers, such as obstetricians. Looking at Figure 12, regional disparities are high:

7
Western regions like Sumatera and Java report approximately 25-29%, whereas Eastern areas,
including Maluku and Nusa Tenggara, have significantly lower proportions, around 15-17%.
Similar disparities exist regarding skilled attendance at birth: around 38% in Western Indonesia
compared to only 26% in Eastern Indonesia.7 These figures highlight a critical shortage of
qualified healthcare workers in Eastern regions.

Figure 13. Place of birth delivery: Any healthcare facilities

(in percentage, 2023)

By Region By Area
100 100 96
90 90 90
90 90
83 84

80 80 76
73
70 70

60
60 60 56

50 50

40 40

30 30

20 20

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

Additionally, inadequate healthcare infrastructure presents a significant barrier. While

around 90% of births nationwide occur in health facilities as shown in Figure 13, this figure is
only 73% in Eastern Indonesia, substantially lower than the 91% seen in Western regions.
Maluku, in particular, has one of the lowest facility-based birth rates at 56%.7 Such differences
show infrastructure deficiencies which result in limited access to quality maternal health
facilities, especially in rural and remote areas.

8
Figure 14. Shares of receiving all recommended antenatal care (ANC) services
(in percentage, 2023)

By Region By Area
100 100

90 90

80 80
71
70 70 67
62
60 57 56 60 57
54
49
50 50 47
41
40 40

30 30

20 20

10 10

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

The quality of maternal care provided also remains inconsistent. Data on essential
antenatal care treatments illustrate quality gaps: nationally, about 58% of women receive all
recommended ANC services, but this percentage varies widely by region. From Figure 14, we
can see that the Eastern provinces such as Maluku (41%), Papua (49%), and Sulawesi (57%)
fall below the national average. In contrast, more developed regions like Java-Bali (67%) and
Kalimantan (62%) perform considerably better.7 This quality disparity suggests serious
limitations in healthcare standards and clinical practices in Eastern areas.

The Most Binding Constraint

Considering the above factors, a mix of demand-side and supply-side constraints emerge as
the most binding issues restricting reductions in maternal mortality.

9
Figure 15. Place of birth delivery: Home
(in percentage, 2023)

By Region By Area
100 100

90 90

80 80

70 70

60 60

50 50

39 39
40 40

30 30
24

20 20
14
12
10 10 8 7
6 5 4

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

Figure 16. Place of birth delivery: Private hospitals

(in percentage, 2023)

By Region By Area
100 100

90 90

80 80

70 70

60 60

50 50

40 40 37

30 26 30
25
21
19
20 20
13 14
11 10
10 10 7

0 0
Western Eastern National Sumatera Jawa-Bali Kalimantan Sulawesi Maluku Nusa Tenggara Papua
Region Region (Western) (Western) (Western) (Eastern) (Eastern) (Eastern) (Eastern)

First, women in Eastern Indonesia frequently bypass inadequate or inaccessible

healthcare facilities by giving birth at home. In Figure 15, there are 24% of Eastern
Indonesian women having birth delivery at home, compared to only 6% in Western.7
Additionally, while private hospitals represent about 26% of birth locations in Western
Indonesia, they account for only 13% in the Eastern regions. For example in Figure 16, Maluku

10
has just 7% of deliveries occurring in private hospitals, significantly below Java-Bali’s 37%.
This disparity highlights limited access to quality maternal healthcare facilities that push
women into potentially unsafe home births.

Figure 17. Shares of pregnancy risk Figure 18. Birth at Puskesmas Figure 19. Puskesmas w/o doctors
(in percentage, 2023) (in percentage, 2023) (in percentage, 2019)
100 100 100

90 90 90

80 80 80

70 70 70

60 60 60

50 50 50

40 40 40

30 30 29 30

20
20 20 20 17
14
12 12 12
10 10 10 8
4

0 0 0
Western Eastern National Western Eastern National Western Eastern National
Region Region Region Region Region Region

Second, although Eastern Indonesian women generally experience similar pregnancy-

related risk factors compared to Western counterparts, maternal deaths remain higher.
This paradox, shown in Figure 17, indicates significant delays in receiving timely medical care
rather than delays in seeking it which clearly reflects supply-side issues. Further evidence is
seen in the reliance on community health centers (puskesmas) for delivery care: 29% of Eastern
Indonesian women deliver at these centers compared to only 14% in Western regions, which
can be seen in Figure 18. However, looking at Figure 18, approximately 17% of puskesmas in
Eastern Indonesia lack a doctor altogether, compared to only 4% in the West.8 Such gaps in
service availability directly contribute to poorer maternal outcomes by delaying necessary
medical interventions.

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Figure 20. Reasons not attending Figure 21. Childbirth classes Figure 22. Shares of women seeking
childbirth classes: No classes exist attendance doctors for pregnancy complaints
(in percentage, 2023) (in percentage, 2023) (in percentage, 2019)
100 100 100

90 90 90

80 80 80

70 70 70

60 60 60

50 50 50 46

40
40 40 40
35 35 35
30
30 30 30

20 20 17 20
15
12
10 10 10

0 0 0
Western Eastern National Western Eastern National Western Eastern National
Region Region Region Region Region Region

Third, limited health-seeking behavior contributes to the low use of maternal health
services. In Figure 20, when asked why they did not attend childbirth classes, 35% of women
in both Western and Eastern regions cited the lack of availability nearby. However, the actual
participation rate in childbirth classes is lower in the Eastern region (12%) compared to the
Western region (17%) as seen in Figure 21. This pattern is also reflected in how women respond
to pregnancy-related complaints. Only 30% of women in the Eastern region seek care from a
doctor, compared to 46% in the Western region if we look numbers in Figure 22. These
differences suggest that even when healthcare infrastructure is similar, demand for maternal
health services tends to be lower in the Eastern region.

3. Policy Design and Implementation

Having identified limited health-seeking behavior and the shortage of skilled providers
as the drivers of high maternal mortality in Indonesia, particularly in the Eastern region,
this section outlines a policy solution to address them. The proposed intervention focuses
on deploying mobile midwives who can deliver maternal health services directly to remote
communities. This section explains the policy design, how it responds to the core challenges,
the roles and incentives of key actors, and its overall feasibility.

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Policy Element Role
Mobile midwives provide antenatal care, delivery assistance,
Scope of
postpartum and newborn care, health education, and referrals for
Services
complications.
Midwives travel from the puskesmas to villages on a set schedule using
Deployment
motorcycles or mobile units. They carry basic medical kits and report
Model
back to their base.
Midwives receive financial allowances, career benefits, and housing or
Incentive
transport support. New graduates may be bonded to serve in remote
Mechanisms
areas for 2 - 3 years.
Midwives receive pre-deployment training and follow national care
Quality
protocols. Supervision and regular reporting help ensure consistent and
Standards
high-quality service delivery.

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Underlying Causes Policy Features Theory of Change
• Mobile midwives regularly visit remote
villages to provide health education and
check-ups.
• Women and families become more aware
Mobile midwives of pregnancy risks and the importance of
Lack of adequate provide health skilled care.
maternal health education and • Better knowledge leads to improved
education and regular outreach health-seeking behavior, such as more
knowledge services in remote antenatal visits and choosing facility-
communities based deliveries.
• Early detection of complications allows
faster treatment or referral.
• More timely and appropriate care helps
reduce preventable maternal deaths.
• New midwives are trained and placed in
areas that have few skilled health
workers.
• These midwives offer antenatal, delivery,
Recruitment and and postpartum care in hard-to-reach
deployment of areas.
Insufficient
newly trained • More births are attended by trained
number of skilled
midwives to professionals who can manage or refer
maternal health
underserved areas complications.
providers
with structured • Families rely less on untrained birth
incentives attendants, improving the safety of
childbirth.
• Access to skilled care leads to better
health outcomes and lower maternal
mortality.

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 Actor Role Incentives
• Achieve national health
• Develops and approves the policy goals
Ministry of • Allocates national funding and sets • Meet SDG targets
Health standards • Gains credibility from
• Monitors implementation and results national health
improvements
• Better local health outcomes
• Manage day-to-day operations at the
• May need support with
district level
District budget and planning
• Provide logistical support
Governments • Gain recognition through
• Supervise midwife deployment
improved district
through puskesmas
performance
• Deliver antenatal, delivery, and
• Receive financial bonuses
postnatal services
Mobile and housing support
• Provide health education to families
Midwives • Career growth
• Report data and follow referral
• Community respect
protocols
• Train new midwives • Improve graduate
Medical and • Collaborate with government for employment rates
Midwifery recruitment • Build partnerships with
Schools • Help prepare students for remote government programs
practice • Stronger program reputation
• Access safer and more
Pregnant • Receive care and education from convenient care
Women and mobile midwives • Increased awareness leads to
Familes • Participate in check-ups and referrals better health decisions
• Trusted support
• Maintain social status in the
• Identify and refer pregnant women
Traditional community
• Support mobile midwives during
Birth • Small rewards
delivery
Attendants • Feel respected and included,
• Assist with community engagement
reducing resistance to change

In terms of financial feasibility, this program requires some funding, but the cost is still
manageable. Main costs include salaries for midwives, training, transport, and basic medical
tools. The Ministry of Health can pay for midwife salaries, while district governments can
support transport and housing. Donors may help at the beginning, but the program should be

15
part of the regular health budget of the state in the long term. Spending on prevention now can
also reduce bigger costs later.

In terms of administrative feasibility, this program can work through the current health
system. Midwives will be based at puskesmas and report to local health officers at the district
level. The Ministry of Health will give guidance and check progress. District health offices
will manage the daily work. A small team at the province level can help with planning and
solving problems. Some training for local managers may be needed.

In terms of operational feasibility, midwives will travel to villages using motorbikes or

boats. Supplies will come from the nearest puskesmas. Mobile phones will help midwives stay
in touch and call for help if needed. Support from village leaders and traditional birth attendants
can also make the program easier to run.

4. Monitoring and Evaluation Plan

This section presents how the policy will be monitored to track progress and results. It
focuses on two main actions: mobile midwives providing health education, and trained
midwives being deployed in target areas. These aim to improve awareness, increase use of
services, and lower maternal deaths. The monitoring plan for each part is shown in the tables
below.

16
 Policy Features: Mobile midwives provide health education
Category Stage 1 Stage 2 Final Stage
More women know More women attend Maternal mortality rate
key pregnancy danger 4+ ANC visits, deliver (MMR) declines over
Outcomes
signs and make birth in health facilities, and time
plans receive postnatal care
• Shares of women • MMR per 100,000
• Shares of women with 4+ ANC visits live births in target
who know 3+ danger • Shares of skilled areas
signs birth attendance
Indicators • Shares of women • Shares of facility
with a birth plan births
• Number of education • Shares of women
sessions conducted receiving postnatal
care within 7 days
Reviewed quarterly,
Collected quarterly via with annual
Timeline and Collected quarterly
midwife logs and comparison against
Frequency from puskesmas
puskesmas surveys baseline and SDG
targets
District Health Offices Provincial Health Ministry of Health,
Who receives
(Suku Dinas Offices (Dinas with feedback to
the data?
Kesehatan) Kesehatan) districts
If awareness is low, If service uptake is If MMR remains high,
strengthen midwife low, explore barriers conduct audits and
training, use local (distance, cost, beliefs) review delays in care
Action taken
language tools, or and strengthen referral
involve community pathways or local
leaders support

17
 Policy Features: Recruitment and deployment of trained midwives
Category Stage 1 Stage 2 Final Stage
More women attend Maternal mortality rate
More midwives are
4+ ANC visits, deliver (MMR) declines over
Outcomes present in hard-to-
in health facilities, and time
reach areas
receive postnatal care
• Shares of midwives • Shares of women • MMR per 100,000
deployed to target with 4+ ANC visits live births in target
areas • Shares of skilled areas
• Shares of villages birth attendance
Indicators with at least one • Shares of facility
midwife births
• Number of • Shares of women
emergency referrals receiving postnatal
managed care within 7 days
Reviewed quarterly,
with annual
Timeline and
Collected quarterly from puskesmas comparison against
Frequency
baseline and SDG
targets
District Health Offices Provincial Health Ministry of Health,
Who receives
(Suku Dinas Offices (Dinas with feedback to
the data?
Kesehatan) Kesehatan) districts
If deployment is low, If skilled care remains If MMR remains high,
adjust incentive low, assess quality of review midwife
Action taken
packages or improve care, workload, or performance and
recruitment barriers to access referral capacity

In addition to regular monitoring, an evaluation plan is needed to measure the policy’s

overall effectiveness and long-term impact. This is outlined below.

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 Category Description
A cluster-randomized controlled trial (RCT) will be used to measure the
Evaluation impact of mobile midwives on maternal health outcomes. Villages will
Method be randomly assigned to treatment and control groups to ensure a valid
counterfactual.
Villages will be randomized within districts. This helps balance local
Randomization conditions such as access to services, geography, and district-level
management.
The main outcome is the Maternal Mortality Ratio (MMR), defined as
Primary
the number of maternal deaths per 100,000 live births. This aligns with
Outcome
2030 SDG and Indonesia’s national targets (RPJMN).
We will track key indicators including:
(1) at least four antenatal care visits
Intermediate (2) skilled birth attendance
Outcome (3) facility-based deliveries
(4) postnatal care within seven days. These reflect service uptake and
improved access.
• The treatment and control groups must be similar at baseline to
Key ensure causality
Assumptions • There are no spillover effects between groups
• Data is measured consistently across locations
2025: Baseline data and randomization
2027: Midline data collection
Timeline
2030: Endline evaluation Monitoring will be conducted quarterly
throughout the program.
The primary data sources will be midwives’ service logbooks and
Data
administrative records from puskesmas. Maternal deaths will be verified
Collection
using existing reporting tools such as verbal autopsies.
We will use an Intent-to-Treat (ITT) framework where we compare
Strategy outcomes based on original group assignment. This reflects the average
effect of offering the program, regardless of take-up.
Maternal mortality is a low-frequency outcome, so the study will need a
Feasibility large number of villages and several years to detect effects. However,
more frequent intermediate outcomes will help assess early progress.
Control villages will receive the intervention after the trial period. The
Ethical
evaluation will follow ethical standards, including informed consent and
Considerations
cooperation with government agencies.

Word Count: 2,000

19
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