Qualitative Analysis of Maternal Mortality Reporting Gaps and the Emerging Fourth Delay in Garut Regency, Indonesia

Indonesia's maternal mortality ratio (MMR) remains among the highest in Southeast Asia, with significant subnational disparities. Despite national reforms and insurance coverage have expanded, maternal deaths continue in districts with high facility birth rates, including Garut Regency, West Java. Investigating social, clinical, and systemic factors contributing to these deaths can inform improvements in maternal surveillance and care quality.

We conducted a qualitative study in Garut Regency through in-depth interviews with bereaved family members (n = 3), frontline midwives (n = 5), and the district maternal death registrar (n = 1). Thematic analysis followed Braun and Clarke's six-phase reflexive method, supported by NVivo 14™. Triangulation, audit trails, member-checking, and reflexive journaling were employed to ensure rigour.

Three interrelated themes emerged: (1) the support system surrounding women, (2) the actions and constraints of healthcare providers, and (3) the architecture of maternal death reporting. Despite high antenatal coverage and BPJS insurance, delays in care-seeking, transport, referral, and a newly identified "fourth delay"- administrative and digital barriers in the Maternal Death Notification (MDN) system. COVID-19 further strained services through ambulance delays, oxygen shortages, and MDN system interruptions. Indirect causes-such as asthma, tuberculosis, and cardiomyopathy-featured prominently, reflecting a shift in maternal mortality epidemiology. While community innovations (eg, mobile ultrasound, WhatsApp triage) were noted, structural and training gaps persist.

Maternal mortality in Garut reflects systemic gaps across health and reporting systems, including the newly identified fourth delay (digital barriers), rather than individual lapses. To achieve SDG targets, Indonesia must invest in digital resilience, integrated chronic disease services during ANC, equitable transport infrastructure, and respectful maternity care. A robust, real-time MPDSR system that includes maternal deaths outside of facilities is essential. Maternal survival depends on aligning national commitment with district-level readiness and action.