Community-based health communication model as maternal mortality mitigation

Modelo de comunicação em saúde baseado na comunidade para mitigar a mortalidade materna

Modelo comunitario de comunicación sanitaria para mitigar la mortalidad materna

Abstract

The study aimed to map a community-based health communication model as a mitigation effort to reduce the risk of maternal mortality in Indonesia using a social support theory. To achieve the objective, a case study method was adopted, and data were collected through in-depth interviews, participant observation, focus group discussions, and document review. The results showed that community-based health communication through the Alert Church and Village programs effectively mitigated the risk of maternal mortality in the South Central Timor Regency. This method includes the active participation of the community in monitoring the health of pregnant women within the village.

Keywords
Community-based health communication; Maternal mortality rate; Maternal mortality mitigation

Resumo

O estudo teve como objetivo mapear um modelo de comunicação em saúde baseado na comunidade como estratégia de mitigação para reduzir o risco de mortalidade materna na Indonésia, utilizando uma teoria de apoio social. Para atingir tal objetivo, foi adotado um método de estudo de caso, onde os dados foram coletados por meio de entrevistas aprofundadas, observação participante, discussões em grupo focal e análise de documentos. Os resultados mostraram que a comunicação de saúde baseada na comunidade, por meio dos programas Alert Church e Village, mitigou efetivamente o risco de mortalidade materna na região centro-sul de Timor. Esse método inclui a participação ativa da comunidade no monitoramento da saúde das mulheres grávidas dentro da aldeia

Palavras-chave
Comunicação em saúde baseada na comunidade; Taxa de mortalidade materna; Mitigação da mortalidade materna

Resumen

El estudio pretendía trazar un modelo de comunicación sanitaria de base comunitaria como medida de mitigación para reducir el riesgo de mortalidad materna en Indonesia utilizando una teoría de apoyo social. Para lograr el objetivo, se adoptó un método de estudio de casos y los datos se recopilaron mediante entrevistas en profundidad, observación participante, debates en grupos focales y revisión de documentos. Los resultados mostraron que la comunicación sanitaria basada en la comunidad a través de los programas Alert Church y Village mitigaba eficazmente el riesgo de mortalidad materna en la regencia de Timor Central Sur. Este método implica la participación activa de la comunidad en el seguimiento de la salud de las mujeres embarazadas dentro de la aldea.

Palabras clave
Comunicación sanitaria comunitaria; Tasa de mortalidad maternal; Mitigación de la mortalidad maternal

Introduction

Indonesia is a large archipelagic nation facing challenges with persistent poverty. In 2023, the 3 poorest provinces out of 38 in the country were Papua (26.03%), West Papua (20.49%), and East Nusa Tenggara (19.96%)¹. In addition to poverty, health challenges remain a significant concern, particularly in terms of the high maternal mortality rate².

Maternal Mortality Rate (MMR) is an important indicator of the overall health of a nation. In Indonesia, the trend of maternal mortality has remained concerning in recent years. According to 2021 data from the Directorate General of Public Health of the Ministry of Health, there were 7,389 maternal deaths recorded in the country. This represents a significant increase of 56.69% from the 4,627 reported in the previous year. An increase was experienced in 2022 which was attributed to complications related to Covid-19, thereby affecting 2,982 women. Additionally, 1,320, 1077, 335, 207, 80, 65, 14, and 1,309 maternal deaths were due to postpartum hemorrhage, hypertension in pregnancy, heart disease, infections, metabolic disorders, circulatory disorders, abortion, and other causes, respectively. These statistics are presented more clearly in Figure 1.

Figure 1
Number of maternal mortality in Indonesia (per person).

The province of East Nusa Tenggara significantly contributes to the high MMR in Indonesia. In 2019, the region reported 118 maternal deaths which rose to 151 in 2020 and further elevated to 181 in 2021. In 2022, there was a slight decline to 167 cases⁴, the reduction was minimal, amounting to only 9.94%, as presented in Figure 2.

Figure 2
Number of maternal mortality cases in East Nusa Tenggara Province, Indonesia from 2019 to 2022⁴.

Analyzing the distribution of maternal mortality data shows that South Central Timor recorded the highest in both 2021 and 2022, with 17 deaths each year⁴. According to the Indonesian Health Profile of 2017, the proportion of deliveries attended in healthcare facilities in the region remains very low, at 51.96%, which is significantly below the national coverage rate of 83.67%.

Based on health statistics data, the location with the highest maternal mortality rate is in Nunkolo Sub-district, South Central Timor Regency, East Nusa Tenggara Province, Indonesia⁴. In the province, a Variety of efforts have been implemented to reduce maternal mortality. These efforts are manifested in 5 strategies launched by the Ministry of Health of Indonesia. Firstly, regional action plans were prepared to facilitate the achievement of the Millennium Development Goals (MDGs), which include alleviating extreme poverty and hunger, reducing child mortality, improving maternal health, as well as combating HIV/AIDS and other infectious diseases. Second, the provision of Health Operational Assistance (BOK) ranges from Rp 75 million to 250 million per year to each health center, starting in 2011. Thirdly, the Community Health Development Index (CHI), a composite indicator comprising health status, behavior, environment, and access to health services, was established to identify regencies or cities with health problems. Fourthly, the placement of strategic personnel (doctors and midwives) and the provision of health facilities in Remote Areas, Borders, and Islands (DTPK). Fifthly, a maternity insurance program that covers prenatal check-ups, delivery services, postnatal care, postpartum family planning, and neonates was launched. Through this program, delivery by health workers in facilities is expected to increase, as well as early breastfeeding, newborn care, postpartum care, and postpartum family planning.

Several previous studies have identified key factors contributing to high MMR in various regions, including South Central Timor Regency, Indonesia. These factors include the underutilization of healthcare facilities and a lack of awareness about the risks associated with pregnancy and childbirth. The situation is further elevated due to economic constraints, particularly by limiting ability of a family to maintain adequate nutrition. Additionally, the lack of support from husbands, who are often preoccupied with earning a livelihood, serves as another significant barrier. A study was conducted in South Denpasar on the awareness of pregnant women about pregnancy danger signs. The results showed that, on average, these women lacked sufficient knowledge and information about pregnancy-related risks⁵. According to Tasuib, Manurung, and Limbu, the elevated maternal mortality rate in South Central Timor is closely related to the limited knowledge of the community about the importance of health information⁶. A study titled “Critical Factors Associated with Postpartum Maternal Death in Ethiopia”⁷ identified the postpartum period as crucial for reducing maternal mortality. It advocates for enhanced health education, increased utilization of healthcare services, and improved facility readiness as essential strategies for effectively addressing the situation in Ethiopia. Similarly, another study titled “Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies”⁸, outlined extreme poverty, low educational attainment, gender inequality, and inadequate employment among husbands as structural determinants of maternal mortality in Sri Lankan families.

Based on relevant previous studies, mapping community-based health communication models is crucial for addressing maternal mortality cases within communities. This method enables the development of targeted preventive measures tailored to the specific conditions and processes. However, existing studies have not explored how to map the forms and models of community-based health communication specifically aimed at reducing postnatal maternal mortality in Indonesia, particularly in the South Central Timor Regency, East Nusa Tenggara Province. Due to the high rates of postnatal maternal mortality observed in recent years, this study introduces novel value by focusing on the formulation and mapping of community-based health communication models.

Community-based health communication comprises the dissemination of information regarding disease prevention, health promotion, health maintenance policies, and regulations in the health sector. It aims to enhance and renew the quality of individuals within a community by considering both scientific and ethical aspects⁹. A key objective of this intervention is to reduce MMR. According to Sari, Sutarto, & Utama¹⁰, Maternal Mortality Rate (MMR) refers to the number of women who die from pregnancy-related causes, excluding accidents, suicides, or incidental cases, during pregnancy, childbirth, and the postpartum period, per 100,000 live births.

Community-based health communication can be effectively implemented by leveraging health facilities. According to Fitri and Riswari¹¹, health service facilities are tools or places used to organize services, including promotive, preventive, curative, and rehabilitative efforts, conducted by the central government, local government, or the community. Therefore, mapping community-based health communication should not only include health service facilities but also the community, central and local governments, and religious institutions as integral parts. This study aimed to map the forms and models of community-based health communication that can contribute to reducing MMR. Specifically, the collaborative efforts of the South Central Timor Regency government, health workers, and the community in addressing maternal mortality cases were examined.

This study adopted social support theory, which posits a positive correlation between social support and health outcomes. According to the theory, social support can enhance health outcomes by fostering connections with others and thereby increasing access to various health resources. Additionally, it acts as a buffer against trauma or stress, which can positively influence physical health¹².

Method

This study adopted the constructivism paradigm, viewing social reality as a construct shaped by social interactions and asserting that the realities were relative¹³. Using a qualitative case study method, it aimed to explore and interpret the meanings, processes, and deeper understanding associated with individuals, groups, or specific situations^14,15.

This study was conducted in Nunkolo and Kesetnana villages, South Central Timor Regency, East Nusa Tenggara Province, Indonesia, identified as areas with the highest maternal mortality rates. A total of 16 informants were engaged in the study, comprising families affected by maternal mortality, the village head, the secretary of the Health Office/District Head, community leaders, and members of the village government. Data were collected through in-depth interviews, observation, focus group discussions (FGDs), and document analysis.

Data were analyzed using a 6-step process as outlined by Creswell¹⁶. It begins with processing and preparing the data for analysis, followed by a thorough reading to capture general ideas and assess the depth of the information from informants. Detailed coding was conducted, which included characterization based on the study topic. Following this, themes were created from the categorized data, in accordance with the objectives and utilizing the insights gained from coding. The results were presented through qualitative descriptions or narratives. Finally, the data was interpreted to draw meaningful insights and conclusions.

To address potential issues related to data collection, information triangulation was adopted, incorporating both data source and method triangulation. The collected information was re-examined in collaboration with the informants to verify the accuracy. Additionally, the information was cross-checked with other sources deemed knowledgeable about the issue under study. Method triangulation was also applied to validate information obtained from a data collection technique by comparing it with data gathered through others.

Research findings

Factors triggering maternal mortality in the community

1) Lack of access to health facilities

The study results from both Nunkolo and Kesetnana villages showed that maternal mortality were primarily attributable to the infrequent use of antenatal care and the low rate of deliveries in available health facilities. According to the head of the Kesetnana Health Centre, maternal mortality were often precipitated by a tendency among mothers to seek less comprehensive care at nearby health facilities.

This is because pregnant women rarely go for health check-ups, hence, they are not well monitored. As a result, there is potential for various complications during childbirth.

(Interview Informant A, the head of the Kesetnana Health Centre)

The health cadre in Kesetnana village also affirmed that a primary cause of maternal deaths was the infrequent occurrence of routine and intensive health checks. According to Informant E, a health cadre, “This is because pregnant women rarely undergo health check-ups, leading to uncontrolled consumption patterns and medication use.”

Limited access to health services is closely related to the location of residents’ homes, which were often situated in remote areas far from health facilities. This challenge was further compounded by insufficient economic support, as additional transportation costs are needed to reach health services. According to the head of Nunkolo village, a key factor contributing to maternal mortality was the considerable distance between residents’ homes and available health facilities.

The observations made by the 2 informants were corroborated by an official from the South Central Timor Regency Health Office. The official stated that, before the implementation of government health intervention programs, many community behaviors were not in line with expectations. This included a reluctance to utilize health facilities such as Puskesmas (community health centers), and the contributing factors were husbands being occupied with work, economic constraints, as well as a limited understanding of the importance of using the health services.

Based on the explanations provided by several informants, health information literacy within families and communities was generally inadequate. Consequently, the community relied on established habits for maintaining health, often disregarding health regulations and standards.

2) Homebirth

Insufficient awareness of the benefits of childbirth in healthcare facilities has led to a prevalent tendency of birth at home. This practice significantly increased the susceptibility of mothers to numerous risks, including mortality. The preference for home births was deeply rooted in the traditions of the community and was influenced by various factors, such as economic constraints and the considerable distance from healthcare facilities.

The risk for pregnant women who give birth at home includes complications such as hemorrhages, pregnancy complications, high blood pressure during pregnancy, and death.

(Interview Informant A, the head of the Kesetnana Health Centre)

According to the Secretary of the South Central Timor Regency Health Office, approximately 10% of pregnant women still deliver at home. The Government has initiated various efforts to increase public awareness of the risks associated with home births and to encourage the use of health facilities.

So far, we have followed the A-type revolution, but during Covid, the number of home deliveries increased again. It has become more often for women to get pregnant elsewhere, such as migrant workers who conceive in Kalimantan or Java and then return to their hometown to give birth without the knowledge of the midwife.

(Informant B, the secretary of the South Central Timor Regency Health Office)

To address this issue, the government ensures that all mothers deliver in health facilities. This is facilitated by village health workers who provide education on the benefits of giving birth in a healthcare setting.

During the postpartum period, we visit mothers who have just given birth to check their health. The activity was called maternity check-up.

(Interview Informant F, Village health cadre)

3) Unbalanced nutrition

Several health workers, including village health cadres, have identified unbalanced nutrition as another factor contributing to maternal mortality.

[…] pregnant women rarely go for medical check-ups, leading to uncontrolled consumption patterns and medicines, as well as bleeding during pregnancy [...].

(Interview Informant A, the head of the Kesetnana Health Centre)

According to other reports, the limited understanding among pregnant women about the importance of balanced nutrition is a key factor in maternal mortality. This lack of understanding is closely related to inadequate health information literacy. Furthermore, the situation is worsened by the limited economic capacity of the community to purchase and access nutritious food essential for the health of mothers and babies.

As health cadres, we conduct socialization every month. Firstly, for pregnant women, we urge them to be diligent in coming for health checks at the health centers, to eat nutritious food at home, drink potable and clean water, wash hands before and after eating.

(Interview Informant F, Village Health cadre).

4) Low Social Support

Another contributing factor is the lack of support from husbands to their wives. There was minimal attention given by husbands or family members to the health of pregnant women. This neglect was attributed to limited interaction between spouses and infrequent discussions regarding health and nutrition. The wives were often expected to manage health independently, while the husbands prioritized earning a living.

The husband is often busy gardening far from home, working there all day and typically returning late at night. As a result, his time to pay attention to me as his wife is limited.

(Informant G, pregnant woman)

In Nunkolo Village, pregnant women often took independent measures to maintain their health without fully relying on their husbands. Traditional knowledge passed down through generations played a significant role during the labor period. However, the lack of attention and support from husbands impacts the care provided to wives during pregnancy and childbirth, adversely affecting maternal health. Several informants stated that the limited support is a contributing factor to maternal mortality.

Community-based health communication pattern in reducing maternal mortality

A strategy adopted by the South Central Timor Regency Health Office to reduce maternal mortality is a community-based health communication method. This strategy leveraged strategic platforms within the community, specifically churches and village government institutions. The institutions were selected not only because they are integral to the daily lives of the community but also due to the high level of compliance and engagement from community members. The implementation of this approach was manifested through the Allert Church and Village programs.

1) Allert Church

The Caring Church Movement includes church organizations as key forums for monitoring pregnant women within the community. This community-based health communication initiative is currently being piloted in 5 churches across various sub-districts, including 2 in the Batu Putih sub-district, 1 in the Soe City sub-district, 1 in Amanuban Barat sub-district, and 1 in the Polen sub-district.

The engagement of the church in monitoring the health of pregnant women is a significant effort to reduce MMR. The community shares a strong emotional bond with this religious institution, enhancing the possibility of the messages being heeded by the congregation. Consequently, with the active participation of church workers and leaders, residents, especially pregnant women, have a high chances to comply with utilizing the health services provided by the government.

A monthly report card, with a format set by the Health Office and Community Health Center, ensures uniformity. Pregnant women nearing delivery are cared for by the rayon in the Protestant church and the base group in the Catholic church. When birth is imminent, prayer visits from the church are conducted.

(interview informant C, health worker)

In addition to conducting regular visits, the church actively utilizes the pulpit to issue appeals and instructions to families with pregnant women. These directives typically emphasize the importance of maintaining good health, encourage routine antenatal care at the nearest health facility, and appeal to avoid home births. The primary aim of utilizing the pulpit was to collectively address and reduce maternal mortality within the community. To ensure the sustainability of this alert program, the leadership of each church has issued a decree appointing a designated person in charge and a monitoring officer for the respective area.

The engagement of the alert church in addressing maternal mortality received a significant positive response from the community. There is a discernible positive trend following the implementation of the alert initiative. Pregnant women are now more effectively monitored and are proactively utilizing health facilities, particularly the health centers in their respective areas. This represents a significant improvement, as a primary factor contributing to maternal mortality has been a reluctance to seek delivery services at hospitals or health centers.

We started the alert program in Soe City, and in the future, it will be implemented by other churches. Even in Amanatun Utara and Amanatun Timur sub-districts, the pastors and priests invited the health office to discuss and socialize the establishment of alert churches.

(Interview (Informant B, the secretary of the South Central Timor Regency Health Office)

To support the needs of mothers in labor, the church also provides aid finance under the name of Diakonia funds. The money is specifically intended to ensure mothers give birth in health facilities.

2) Alert Village

The establishment of an alert village is another strategy designed to complement community-based health communication, alongside the alert church initiative. Similar to the alert church program, the creation of the alert village resulted from a collaborative effort between the regency government, represented by the South Central Timor Regency Health Office, and the village government. Each village that pioneered the program, established a committee, with a decree issued to formalize the tasks and responsibilities of the members. The current number of active alert villages is 66.

Through the alert village program, the local government, in collaboration with the community, established a fund known as Dasolin (Maternity Solidarity Fund), similar to a social gathering fund. Each head of household participating in this initiative was required to contribute IDR 10,000 per month, which was then managed by the village treasurer.

Each mother who is about to give birth can obtain funds amounting to approximately IDR 300,000 from the village treasurer. This money is intended to cover needs, particularly transportation to health facilities and other urgent necessities. According to Informant D, a village health worker, the establishment of the maternity solidarity fund should put a stop to home birth due to financial constraints.

According to the monitoring results of the South Central Timor Regency Health Office, the alert village program has brought about several positive changes. Among the direct impacts, as assessed by the Health Office, is the better monitoring of mothers.

Before this program, some women preferred to give birth at home due to the distance of houses to the health facility as well as lack of financial resources.

(Informant B, the secretary of the South Central Timor Regency Health Office)

The descriptions of the forms of community-based health communication can be visualized in Figure 3.

Figure 3
Community-based health communication model to reduce the maternal mortality cases in South Central Timor Regency.

The model of community-based health communication, as shown in Figure 3, is exemplified by the effective networking with 2 formal institutions in the village, namely the government and the church. The South Central Timor Regency Government aimed to enhance the roles of these institutions to collaboratively address maternal mortality through active engagement in monitoring the health of pregnant women.

Through the vigilant village and church movement, the sustainability of community-based health program interventions was ensured. Additionally, both organizations offer financial support to mothers to alleviate the costs associated with delivery in hospitals or other health facilities, such as Puskesmas (community health centers). To further enhance community engagement, village health cadres who are trained community members, conduct visits and monitoring during both the pregnancy and postnatal periods, referred to as antenatal check-ups.

Discussion

Maternal mortality during pregnancy and childbirth are deep concern, and several factors contribute to the high incidence, including economic constraints that diminish individuals’ motivation to utilize available health services. Additionally, education and cultural factors are believed to play a significant role in the limited use of maternal health services, thereby increasing vulnerability to mortality¹⁷. These factors are further worsened by misconceptions related to socio-cultural norms, such as myths and other beliefs, which negatively impact access to health services¹⁸. An example of socio-cultural norms that continue to prevail in rural communities in South Central Timor is the belief in the reliability and skill of traditional birth attendants in assisting with delivery. Additionally, there is a widespread myth of illness being caused by a curse, a violation of customary rules, or the actions of evil spirits. Consequently, numerous individuals do not seek immediate treatment at hospitals or other healthcare facilities during illness.

Unequal gender roles between husbands and wives may influence adherence to health maintenance efforts, potentially undermining the ability to stay healthy¹⁹. Ideally, the role of husbands is crucial and essential in supporting the wives’ health, particularly during pregnancy, to ensure regular health check-ups at appropriate health facilities²⁰.

The engagement of various stakeholders closely connected to the community, especially in rural areas, is crucial. In the context of this study in the South Central Timor Regency, the active role of the community has been effectively realized through the collaboration between religious organizations and villages. This partnership led to the establishment of the Alert Church and Village programs.

Church workers or administrators who are part of the alert church program, alongside residents engaged in the alert village program, actively monitor the health of pregnant women and offer guidance on appropriate healthcare practices. This approach represents a form of community-based health communication strategy. Furthermore, engaging the community in the management and prevention of maternal mortality is regarded as an effective and sustainable intervention. The study by Wright, Achieng, Tindi, et al.²¹ confirmed that community engagement in maternal and child health was highly effective, especially when adopting peer-mother mentoring. This is because a multi-stakeholder approach to health interventions, alongside active community engagement, can bridge gaps in access to health services²². The multi-stakeholder and community-centered health intervention method proved valuable in addressing disparities in access to health services, particularly within economically and socially marginalized communities^23,24.

In practice, community-based health communication utilizing the alert church and village method extends beyond merely monitoring the health of pregnant women and childbirth. Home visits represent a key innovation aimed at enhancing the intensity of health communication between pregnant women or new mothers with church and village officials. This intervention is highly beneficial for improving the health status of the community. According to Sampson, Xu, & Prabhu²⁵, home visit programs targeting pregnant women were particularly effective in raising awareness, providing education, and improving health information literacy. In summary, community-based health education programs have proved effective in reducing MMR²⁶. A study showed that communication strategies are instrumental in addressing community health issues. Effective health communication fosters better health literacy, enabling individuals to understand diseases, preventive measures, and treatment options²⁷.

To ensure optimal maternal health, the full support of the partner or husband is crucial²⁸. Increases in maternal mortality, including the cases observed in the South Central Timor Regency, have often been associated with hemorrhage complications where the affected individual was not promptly transported to the nearest health facility for delivery. This issue is caused by the community’s insufficient understanding and knowledge of maternal health and associated risks. Furthermore, limited awareness of the warning signs of childbirth can significantly elevate the risk of maternal mortality²⁹.

In an effort to enhance health information literacy regarding the importance of maternal health among married couples, information campaigns should intensified. This is achieved through the integration of various communication forms and formats, utilizing both traditional media and digital platforms. Igbinoba et al.³⁰ explained that health communication through mass media has a significant and positive impact on increasing health awareness, thereby reducing the risk of maternal and childbirth-related mortality. Similarly, Ohmen, De Sanctis, Waiyaiya, et al.³¹ stated that digital platform-based media significantly improved adherence to available healthcare pathways among pregnant women in rural areas. The role and support of local governments in enhancing public health literacy are crucial. As public leaders, it is important to pioneer innovative and sustainable programs that incorporate public health literacy³².

Efforts to enhance community health information literacy include strengthening the role and support of health cadres in each village. These local community members, trained in basic health skills, contribute to the community through the Posyandu (Integrated Service Post) which plays a crucial role in offering convenient access to basic health services³³.

When analyzing the results of this study through the lens of social support theory¹², it becomes evident that the role of key individuals surrounding pregnant women is crucial in ensuring maternal health throughout pregnancy and childbirth. According to this theory, social support comprises relevant health information and appropriate healthcare interventions provided to pregnant women and mothers during childbirth. The buffering effect of the social support of a husband on maternal health is shown in Figure 4.

Figure 4
The buffering effect of the husband’s social support on maternal health.

This study identified gender inequality within the community Despite pregnant women receiving information from health workers about maternal and child health as well as balanced nutrition, access to healthcare services remains relatively limited. The decision to demand these services is largely contingent upon the approval of the husband. When often preoccupied with work, husbands provide insufficient support and attention to their wives. This lack of support contributes to reluctance to perform routine health checks. The situation is further attributed to the entrenchment of patriarchal norms in the village communities of South Central Timor Regency, leaving women feeling powerless and resigned to the circumstances.

Conclusion

In conclusion, maternal mortality was predominantly attributed to the low health information literacy within the community of South Central Timor Regency, Indonesia. Consequently, community-based health communication strategies, such as the alert church and alert village programs, represented critical interventions to mitigate the risk. These programs facilitated active community engagement in monitoring the health of pregnant women within the village. Furthermore, the alert village initiative provided practical solutions for families preparing for childbirth, particularly those experiencing financial difficulties due to economic constraints.

The presence of health cadres in the village was strategically significant in enhancing public health information literacy regarding the risks of maternal mortality. In addition to conducting basic health promotion activities for the community, these cadres actively monitored the health of pregnant women. This proactive engagement was crucial in mitigating the risk of maternal mortality.

The implications of this study offered a new perspective on improving community health literacy through the development of local, community-based health communication models. This approach facilitated the engagement of various stakeholders, particularly local communities within the village, allowing active contribution towards reducing the risk of maternal mortality.

This study recommended that the government, particularly through the health department, should consider adapting the communication model by leveraging the programs of religious and village organizations to collaboratively monitor public health. Additionally, the village government should allocate incentive funds for health cadres to ensure the continued sustainability and effectiveness of their strategic role within the community.

• Andung PA, Jelahut FE, Swan MVDP, Ali MNS. Community-based health communication model as maternal mortality mitigation. Interface (Botucatu). 2025; 29: e230652 https://doi.org/10.1590/interface.230652
• Funding
  This work was supported by Faculty of Social and Political Sciences, Universitas Nusa Cendana, Fiscal Year 2023 under Grant [486/UN15.15.PPK/SPP/PL/2023].

References

• ¹ Badan Pusat Statistik. Persentase penduduk miskin (P0) Menurut Provinsi dan Daerah (Persen), 2023 [Internet]. Central Jakarta: BPS; 2023 [cited 2024 Aug 7]. Available from: https://www.bps.go.id/id/statistics-table/2/MTkyIzI=/persentase-penduduk-miskin--maret-2023.html
  » https://www.bps.go.id/id/statistics-table/2/MTkyIzI=/persentase-penduduk-miskin--maret-2023.html
• ² Sari GK. Peran PBB Melalui MDGs dalam peningkatan indeks pembangunan manusia di Indonesia. J Multidiscip Res Dev. 2024; 1(2):102-7.
• ³ Kusnandar VB. Jumlah kematian ibu capai 7 ribu pada 2021 [Internet]. Hovedstaden: Databoks; 2021 [cited 2024 Aug 7]. Available from: https://databoks.katadata.co.id/layanan-konsumen-kesehatan/statistik/70da1ef9073e99b/jumlah-kematian-ibu-capai-7-ribu-pada-2021-terbesar-karena-covid-19
  » https://databoks.katadata.co.id/layanan-konsumen-kesehatan/statistik/70da1ef9073e99b/jumlah-kematian-ibu-capai-7-ribu-pada-2021-terbesar-karena-covid-19
• ⁴ Romlah S. Evaluasi Hasil Kegiatan Tahun 2022 Seksi Kesga Gizi Dan KB. Kupang: Dinas Kesehatan Kota; 2022.
• ⁵ Agustini NKT. Pengetahuan ibu hamil tentang tanda bahaya kehamilan di puskesmas II denpasar selatan. J Med Usada. 2022; 5(1):5-9.
• ⁶ Tasuib N, Manurung IFE, Limbu R. Factors related to antenatal care visit in pregnant women in the work area of Se’i primary health care, Timor Tengah Selatan District. Media Kesehat Masy. 2022; 4(1):50-9.
• ⁷ Tesfay N, Tariku R, Zenebe A, Woldeyohannes F. Critical factors associated with postpartum maternal death in Ethiopia. PLoS One. 2022; 17(6):e0270495.
• ⁸ Irangani L, Prasanna IR, Gunarathne SP, Shanthapriya SH, Wickramasinghe ND, Agampodi SB, et al. Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies. Reprod Health. 2022; 19(1):221.
• ⁹ Lestari SS. Pengaruh komunikasi kesehatan reisa broto asmoro dalam meningkatkan kesadaran mematuhi protokol kesehatan. J Commun Soc. 2022; 1(1):45-61.
• ¹⁰ Sari RDP, Sutarto S, Utama WT. Pemberdayaan skill dan pengetahuan kader kesehatan mengenai penanganan kegawatdaruratan obstetri sebagai upaya menurunkan nilai Angka Kematian Ibu (AKI) di desa cipadang kecamatan gedong tataan kabupaten pesawaran. J Ilmu Medis Indones. 2023; 2(2):95-103.
• ¹¹ Fitri N, Riswari RM. Identifikasi faktor risiko keselamatan dan kesehatan kerja di fasilitas pelayanan kesehatan (studi kasus di puskesmas kota Malang). Media Publ Promosi Kesehat Indones. 2022; 5(6):721-6.
• ¹² Littlejohn SW, Foss KA, Oetzel JG. Theories of human communication. Eleventh. Long Grove: Waveland Press; 2017.
• ¹³ Haqqu R, Hidayati S. Feminisme dalam film little women karya Greta Gerwig. Represent J Ilmu Sos Seni Desain Media. 2023; 2(1):23-31.
• ¹⁴ Assyakurrohim D, Ikhram D, Sirodj RA, Afgani MW. Metode studi kasus dalam penelitian kualitatif. J Pendidik Sains Komput. 2023; 3(1):1-9. doi: 10.47709/jpsk.v3i01.1951.
  » https://doi.org/10.47709/jpsk.v3i01.1951
• ¹⁵ Pradana IPYB, Kumorotomo W, Susanto E. The institutionalization of public innovation: evidence from Indonesia. Adm Soc. 2023; 55(4):726-51.
• ¹⁶ Creswell J. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oaks: Sage Publications; 2013.
• ¹⁷ Hamal M, Dieleman M, De Brouwere V, Buning TC. Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India. Public Health Rev. 2020; 41(1):13. doi: 10.1186/s40985-020-00125-6.
  » https://doi.org/10.1186/s40985-020-00125-6
• ¹⁸ Jones GL, Mitchell CA, Hirst JE, Anumba DOC. Understanding the relationship between social determinants of health and maternal mortality: scientific impact paper no. 67. BJOG. 2022; 129(7):1211-28.
• ¹⁹ Uddin MF, Molyneux S, Muraya K, Hossain MA, Islam MA, Shahid ASMSB, et al. Gender-related influences on adherence to advice and treatment-seeking guidance for infants and young children post-hospital discharge in Bangladesh. Int J Equity Health. 2021; 20(1):64. doi: 10.1186/s12939-021-01404-7.
  » https://doi.org/10.1186/s12939-021-01404-7
• ²⁰ Maesaroh DAT. The relationship between the role of midwives, maternal knowledge and husband support with compliance of pregnant women in Hbsag examination at PMB Wagi Koja, North Jakarta in 2023. Syntax Admirat. 2023; 4(7):821-34.
• ²¹ Wright JL, Achieng F, Tindi L, Patil M, Boga M, Kimani M, et al. Design and implementation of a community-based mother-to-mother peer support programme for the follow-up of low birthweight infants in rural western Kenya. Front Pediatr. 2023; 11:1173238.
• ²² Richardson MB, Toluhi AA, Baskin ML, Budhwani H, Julian ZI, Knight CC, et al. Community and systems contributors and strategies to reduce racial inequities in maternal health in the deep south: provider perspectives. Health Equity. 2023; 7(1):581-91.
• ²³ Khan Z, Vowles Z, Turienzo CF, Barry Z, Brigante L, Downe S, et al. Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review. Int J Equity Health. 2023; 22:131. doi: 10.1186/s12939-023-01948-w.
  » https://doi.org/10.1186/s12939-023-01948-w
• ²⁴ Ayangunna E, Kalu KA, Shah GH. Role of community-level health behaviors and social determinants of health in preventable hospitalizations. J Georg Public Heal Assoc. 2022; 8(3):1-9. doi: 10.20429/jgpha.2022.080312.
  » https://doi.org/10.20429/jgpha.2022.080312
• ²⁵ Sampson M, Xu W, Prabhu S. Tailoring perinatal health communication: centering the voices of mothers at risk for maternal mortality and morbidity. Int J Environ Res Public Health. 2022; 20(1):186. doi: 10.3390/ijerph20010186.
  » https://doi.org/10.3390/ijerph20010186
• ²⁶ Kamau M, Mirie W, Kimani S, Mugoya I. Effect of community based health education on knowledge and attitude towards iron and folic acid supplementation among pregnant women in Kiambu County, Kenya: a quasi experimental study. PLoS One. 2019; 14(11):e0224361. doi: 10.1371/journal.pone.0224361.
  » https://doi.org/10.1371/journal.pone.0224361
• ²⁷ Solihin O, Lubis DP, Muljono P, Amanah S. Implementation of health communication in tb management in Indonesia. Libr Philos Pract [Internet]. 2023 [cited 2024 Aug 7]; 7649. Available from: https://digitalcommons.unl.edu/libphilprac/7649
  » https://digitalcommons.unl.edu/libphilprac/7649
• ²⁸ Fetena N, Negash A, Kebede A, Sertsu A, Nega A, Nigussie K, et al. Utilization of preconception care and associated factors among pregnant mothers in Fiche Town, Central Ethiopia: a community-based cross-sectional study 2021. Front Glob Women’s Heal. 2023; 4:1159693. doi: 10.3389/fgwh.2023.1159693.
  » https://doi.org/10.3389/fgwh.2023.1159693
• ²⁹ Egal JA, Essa A, Osman F, Klingberg-Allvin M, Erlandsson K. Facility-based maternal deaths: their prevalence, causes and underlying circumstances. A mixed method study from the national referral hospital of Somaliland. Sex Reprod Healthc. 2023; 37:100862. doi: 10.1016/j.srhc.2023.100862.
  » https://doi.org/10.1016/j.srhc.2023.100862
• ³⁰ Igbinoba AO, Soola EO, Omojola O, Odukoya J, Adekeye O, Salau OP. Women’s mass media exposure and maternal health awareness in Ota, Nigeria. Cogent Soc Sci. 2020;6(1):1766260. doi: 10.1080/23311886.2020.1766260.
  » https://doi.org/10.1080/23311886.2020.1766260
• ³¹ Dohmen P, De Sanctis T, Waiyaiya E, Janssens W, Wit TR, Spieker N, et al. Implementing value-based healthcare using a digital health exchange platform to improve pregnancy and childbirth outcomes in urban and rural Kenya. Front Public Health. 2022; 10:1040094. doi: 10.3389/fpubh.2022.1040094.
  » https://doi.org/10.3389/fpubh.2022.1040094
• ³² Pradana IPYB, Susanto E, Kumorotomo W. Analyzing the critical factors for innovation sustainability in the public sector: evidence from Indonesia. Int J Public Sector Manag. 2022; 35(2):733-48.
• ³³ Kusuma AN. The presence of Posyandu as an approach in improving health development in the community. J Eduhealt. 2022; 13(1):137-46.

Edited by

• Editor
  Antonio Pithon Cyrino

• Editor associado
  Katia Lerner

Publication Dates

• Publication in this collection
  21 Feb 2025
• Date of issue
  2025

History

• Received
  01 Sept 2024
• Accepted
  28 Oct 2024