Contraceptive use and maternal mortality in Indonesia: a community-level ecological analysis

BACKGROUND: Prior studies have shown that contraceptive use reduces maternal mortality independently of other maternal health services. The present study took advantage of geographically detailed Indonesian data to study the interplay between contraceptive use and other risk and protective factors for maternal mortality at the community level, a level of analysis where the protective effects of family planning can be best understood. METHODS: Data from the 2015 Intercensal Population Survey (SUPAS) and the 2014 Village Potential Survey (PODES) were used to construct a series of census block-level variables measuring key risk and protective factors for maternal mortality. The relationships between these factors and maternal mortality, measured via natural log-transformation of past five-year maternal mortality ratios in each of the 40,748 census blocks were assessed via log-linear regressions. RESULTS: Higher community maternal mortality ratios were associated with lower community contraceptive prevalence, higher percentage of parity four-plus births, higher proportion of poor households, lower population density of hospitals, higher density of traditional birth attendants (TBA), and residence outside of Java-Bali. For every percentage point increase in CPR, community maternal mortality ratios were lower by 7.0 points (95% CI = 0.9, 14.3). Community-level household wealth was the strongest predictor of maternal mortality. CONCLUSIONS: Community contraceptive prevalence made a significant contribution to reducing maternal mortality net of other risk and protective factors during 2010–2015. Increased health system responsiveness to the needs of pregnant women and reductions in socioeconomic and geographic disparities in maternal health services will be needed for Indonesia to reach the 2030 SDG maternal mortality goal.