Sociodemographic disadvantage and low healthcare access as contributing factors to high maternal death in Papua, Indonesia: multilevel analysis of census population data

Abstract

Introduction: 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 context remains limited. Methods: This study analyzed data from the 2020 Indonesian Population Census, including 18,886 women aged 15-49 years in Papua, of whom 169 experienced maternal death. Maternal deaths were identified using the census mortality module. Descriptive statistics and chi tests examined bivariate associations. Multilevel 2 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, adjusted odds ratio (aOR) 2.92, 95% confidence interval (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). None of the community-level variables were statistically significant. Substantial between-regency variation persisted in the final multilevel model (intraclass correlation coefficient = 0.61; median odds ratio = 8.95), indicating strong contextual disparities. Conclusion: Maternal mortality in Papua is driven primarily by sociodemographic disadvantage and rural residence, while community-level health system factors alone did not explain between-regency variation. 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.