Original Research
Socio-economic and healthcare contributing factor of high maternal death in Papua, Indonesia: multilevel analysis of census population data
AUTHORS
Danik Iga Prasiska1,2 MPH 
Suk-Yong Jang3 PhD
Min Jin Ha4,5 PhD, Assistance Professor *
AFFILIATIONS
1 Department of Global Health Security, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
2 Department of Public Health, Regional Health Office, Nganjuk, Indonesia
3 Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
4 Department of Health Informatics and Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
5 Biohealth Data Science, Graduate School of Transdisciplinary Health Science, Yonsei University, Seoul, Republic of Korea
ACCEPTED: 24 September 2025
Early Abstract:
Background: Maternal mortality remains a major public health challenge in Indonesia, with Papua Province experiencing the highest provincial maternal mortality ratio. Evidence on how both individual and community-level factors contribute to maternal deaths in this setting is limited.
Methods: We analyzed data from the 2020 Indonesian Population Census, including 18,886 women aged 15–49 in Papua Province, of whom 169 experienced maternal death. Maternal deaths were identified using the census mortality module. Descriptive statistics and chi-square tests examined bivariate associations. Multilevel logistic regression models were applied to estimate the effects of individual and community-level determinants, accounting for district-level clustering. Sensitivity analysis using modified Poisson regression with robust variance was conducted to assess robustness of estimates.
Results: Maternal mortality was significantly associated with advanced maternal age (>35 years, aOR 2.92, 95% CI: 2.45–3.47), nulliparity (aOR 5.94, 95% CI: 4.74–7.44), unmarried status (aOR 2.79, 95% CI: 2.19–3.56), low education (aOR 2.03, 95% CI: 1.38–3.00), and rural residence (aOR 1.95, 95% CI: 1.56–2.45). Community-level variables, including health worker density and facility counts, were not significantly associated with maternal deaths. District-level heterogeneity remained substantial (ICC = 0.61; MOR = 8.95).
Conclusions: Maternal mortality in Papua is strongly influenced by socio-demographic disadvantage and rural residence, while community-level health system factors alone did not explain variation between districts. Policies should prioritize improving access and quality of care for first-time and unmarried mothers, enhancing youth-friendly health services, and addressing rural barriers through referral strengthening, maternity waiting homes, and integration of traditional birth attendants. Long-term investments in education and health workforce retention in remote areas remain critical to reducing maternal deaths in Papua.
Keywords: health system access, maternal death, rural health, socio-demographic factors, Papua Indonesia