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Colombia is in one of the most active seismic zones on Earth, where the Nazca, Caribbean, and South American plates converge. Approximately 83 % of the national population lives in intermediate to high seismic hazard zones, and a significant part of the country’s building inventory dates from before the nation’s first seismic design code (1984). At present, seismic risk scenarios are available for the major cities of the country, but there is still a need to undertake such studies in other regions. This paper presents a seismic risk scenario for the “Sabana Centro” province, an intermediate hazard zone located close to the country’s capital. An exposure model was created combining information from the Global Earthquake Model (GEM) Foundation, surveys, and the national census. Fragility and vulnerability curves were assigned to the building types of the region. A hazard model was developed for the region and eighteen earthquake scenarios with a return period of 475 years were simulated using the OpenQuake (OQ) hazard and risk assessment tool to estimate damage and economic losses. In addition, a social vulnerability index (SVI) based on demographic information was used to assess the direct economic loss in terms of replacement costs. The results show that 18 % of all buildings considered in the region would experience collapse, and 7 % would suffer severe damage. Losses account for 18 % of the total replacement cost of the buildings and represent 15 % of the annual Gross Domestic Product (GDP) of the region.

El complejo volcánico Cayambe representa una amenaza para los 85 795 habitantes que basan su economía en la floricultura. Hasta el momento no se han hecho estimaciones del impacto económico que tendría una eventual erupción del Cayambe en la zona. La determinación de zonas de afectación por caída de ceniza se obtuvo mediante análisis estadístico de simulaciones numéricas de escenarios eruptivos. Se digitalizaron 39 006 edificaciones a partir de fotografía aérea para identificar y cuantificar la infraestructura que potencialmente podría ser afectada ante la ocurrencia de este fenómeno. El análisis y procesamiento de los datos censales permitió caracterizar el área de estudio y describir el impacto que un evento de este tipo tendría sobre la población local. Así se determinó espesores de ceniza de 15 mm a 45 mm que cubren el 97.83% de la superficie con pérdidas estimadas que ascienden los USD 140 millones en plantas e invernaderos. La superficie del cantón en su totalidad se vería afectada por caída de ceniza. Esto afectaría a más de 100 poblados, 21 844 hogares y 7 611 plazas de trabajo en las florícolas. A mediano y largo plazo, las economías de al menos 3 500 familias se verían afectadas por el desempleo a causa de las pérdidas económicas que sufriría la industria florícola.

An understanding of the experiences of men and women who marry before adulthood is important in motivating social change. Using fixed effects estimation (the inclusion of geographic fixed effects at diminishing levels of aggregation and sister fixed effects where possible) on panel data from the Indonesian Family Life Survey (IFLS), we follow the lives of a sample of 40,800 women and men for up to two decades and examine a wide range of factors associated with child marriage. We examine the lives of both girls and boys who marry early, and the differential experience of girls marrying older men versus young boys. Child marriage is found to be associated with lesser educational attainment, lower earnings and less say in household decision-making, for both men and women. Women are less likely to have a medically-supervised birth and their children are more likely to die, be stunted and perform worse on cognitive tests. Negative factors are mostly exacerbated when young girls marry similarly underage men.

Background: In the Australian state of New South Wales nearly 60,000 approved applicants are waiting for social housing. Future Directions for Social Housing is a response to this challenge. This collection of housing programs aims to provide more social housing, support and incentives for leaving social housing and a better social housing experience. This document presents the protocol of the evaluation of these programs and the overarching Future Directions Strategy. Methods/Design: The evaluation will use a Type 1 effectiveness-implementation hybrid design, with an integrated, dual focus on assessing the effectiveness of Future Directions and better understanding the context for reform implementation. Program effectiveness will be examined using quasi-experimental techniques applied to linked administrative data. The implementation context will be examined via program level data, qualitative interviews and focus groups with stakeholders and tenants. Some quantitative survey and administrative data will also be used. Findings from the implementation evaluation will be used to inform and interpret the effectiveness evaluation. Economic evaluations will also be conducted. Discussion: This methodology will produce a high-quality evaluation of a large, complex government program which aims to facilitate rapid translational gains, real-time adoption of effective implementation strategies and generate actionable insights for policymakers.

While the primary aim of most Conditional Cash Transfer (or CCT) programs is to increase the level of human capital of children in poor households, there are also potentially large spillover effects associated with such programs. We illustrate this using data from the Familias en Accion (FA) program that has been in operation in Colombia for almost a decade. The health and nutrition component of the program was targeted at households with at least one child aged between 0 and 5. Receipt of the cash transfer was conditional upon fulfilling specific health care requirements: growth and development check-ups for children, and attendance at sessions on nutrition, hygiene and contraception by the children's primary caregivers. We find significant improvement in the health of non-targeted adults in treatment households, both in terms of incidence of illness (in the short and the medium run) and on the severity of illness (over the medium run). The main mechanism behind this effect appears to be the availability of better information and creation of health public goods within the household as a result of this program.

La infección por Salmonella spp. es una importante causa de morbi-mortalidad a nivel mundial. La enteritis aguda es la forma de presentación más frecuente y es generalmente autolimitada. Este estudio tiene como objetivo determinar cuáles son las características sociodemográficas, clínicas y microbiológicas de los pacientes con aislamiento de Salmonella spp. en coprocultivo. Se realizó un estudio observacional descriptivo retrospectivo del 1 de enero de 2016 al 31 de marzo de 2018 en la Fundación Clinica Infantil Club Noel, en pacientes mayores de 1 mes y menores de 18 años con aislamiento de Salmonella spp. en coprocultivo. Se incluyeron 55 casos donde: el aislamiento fue más frecuente en lactantes, el síntoma predominante fue la diarrea y se inició el tratamiento con ampicilina en la mayoría de casos. Los coprocultivos fueron interpretados en un (45.5%) y el tratamiento dirigido más utilizado fue ceftriaxona. Se encontró un predominio de Salmonella spp. con patrón de resistencia Amp C y una alta resistencia específica a ampicilina (76.4%). Los lactantes fueron el grupo más afectado al igual que en textos académicos. Los síntomas fueron claves para definir el diagnóstico y el inicio de antibiótico. Se observó en los perfiles de susceptibilidad un aumento en la resistencia a betalactámicos. Se observó un sobreuso de antibióticos pese a que las recomendaciones se centran en el manejo de soporte. Las tasas de resistencias en el presente estudio fueron altas comparadas con los últimos registros nacionales. Además, se debe considerar Salmonella en el diagnóstico diferencial de EDA asociada a fiebre.

The number of studies examining the effects of cash transfer (CT) programs on Intimate Partner Violence (IPV) has rapidly grown over the last decade. Depending on how violence is modelled, CTs coul...

Conditional cash transfers (CCTs) aim to increase human capital in poor families. They do this directly through conditions but may also influence household decision-making in other ways. Us...

Objectives: Australia9s public health restrictions (9lockdown9) in 2020 successfully contained the spread of COVID-19. These included a national 9initial9 lockdown (March-May), and 9ongoing9 lockdown (July-November) for metropolitan Victorian residents only. Australia9s experience offers an opportunity to assess impacts of lockdown on families with children, in the relative absence of disease morbidity and mortality. This study (1) described the experience of initial lockdown and (2) evaluated the impact of ongoing lockdown, on family finances and mental health. Methods: Data were drawn from the June and September 2020 Royal Children9s Hospital National Child Health Polls. Caregivers of children from the states of Victoria and New South Wales reported on job/income loss; material deprivation (inability to pay for essential items); income-poverty; mental health (Kessler-6); impact on caregiver/child mental health; and caregiver/child coping. Data from N=1207/902 caregivers in June/September were analyzed; Aim (1) with weighted descriptives; Aim (2) with Difference-in-Difference adjusted linear regression models (New South Wales provided the comparator). Results: Following initial lockdown, one-quarter of families reported job/income loss; one-third reported material deprivation. Negative impacts on mental health were reported for half the caregivers and one-third of children. Few caregivers or children had difficulties coping. During Victoria9s ongoing lockdown, job/income loss increased by 11% (95%CI: 3-18%); Kessler-6 poor mental health by 6% (95%CI: 0.3-12%) and negative mental health impacts by 12% for caregivers (95%CI: 6-23%) and 14% for children (95%CI: 4-20%). Female (versus male) caregivers, metropolitan (versus regional/rural) families, and families with elementary school-aged children (versus pre-/high-school) were most affected. Conclusions: Ongoing lockdown had negative impacts on mental health, employment, and income, but not deprivation or poverty, likely because of the government income supplements introduced early in the pandemic. Balancing the benefits and harms of lockdown requires planned responses to outbreaks, and evidence-informed financial and mental health supports.

Late Cretaceous carbonate rocks of the Eagle Ford Formation are widely distributed in north-western Mexico (Nuevo Leon, Coahuila, Chihuahua) and southern USA (Texas). Around the La Bolita locality, Castanos town (Coahuila State), this unit consists of approximately 31 m of marine deposits, characterized by thin-bedded, slightly clayey limestones. Within the scope of a microfacial analysis, 20 hand samples were collected from selected limestone levels. Identified microfossil remains are mostly represented by planktonic foraminifers, among which: Planoheterohelix moremani, P. reussi, P. globulosa, Globigerinelloides bollii, Globigerinelloides spp., Muricohedbergella delrioensis, M. planispira, Muricohedbergella spp., Whiteinella archaeocretacea, W. aprica, W. baltica, W. brittonensis, W. inornata, W. paradubia, Whiteinella spp., Clavihedbergella moremani, C. simplex, Marginotruncana renzi, M. sigali, M. schneegansi, M. pseudolinneiana, Marginotruncana spp., Praeglobotruncana algeriana, and Dicarinella canaliculata. There are also abundant calcispheres, such as Risserella rablingae, Pithonella ovalis, and Calcisphaerula innominata; as well as roveacrinoid ossicles (genus Roveacrinus), and unidentified radiolarians. Based on the stratigraphic range of both the genus Marginotruncana and the species Praeglobotruncana algeriana, an early–middle Turonian age is assigned to the studied section. The pelagic microfossil assemblage and the lithological features all suggest deposition of the studied sediments in an open marine platform, with poorly oxygenated, nutrient-rich waters.

This paper examines and disentangles the factors that have led to the largely unchanged participation (about 51%) of women in Indonesia’s labour force in the past two decades. We use data from the ...

IntroductionPoverty and deprivation can harm children’s future health, learning, economic productivity and societal participation. The Australian Healthier Wealthier Families project seeks to reduce the childhood inequities caused by poverty and deprivation by creating a systematic referral pathway between two free, community-based services: universal, well-child nursing services, which provide health and development support to families with children from birth to school entry, and financial counselling. By adapting the successful Scottish ‘Healthier Wealthier Children’ model, the objectives of this Australian pilot are to test the (1) feasibility of systematising the referral pathway, and (2) short-term impacts on household finances, caregiver health, parenting efficacy and financial service use.Methods and analysisThis pilot randomised controlled trial will run in three sites across two Australian states (Victoria and New South Wales), recruiting a total of 180 participants. Nurses identify eligible caregivers with a 6-item, study-designed screening survey for financial hardship. Caregivers who report one or more risk factors and consent are randomised. The intervention is financial counselling. The comparator is usual care plus information from a government money advice website. Feasibility will be evaluated using the number/proportion of caregivers who complete screening, consent and research measures, and access financial counselling. Though powered to assess feasibility, impacts will be measured 6 months post-enrolment with qualitative interviews and questionnaires about caregiver-reported income, loans and costs (adapted from national surveys, for example, the Household, Income and Labour Dynamics in Australia Survey); health (General Health Questionnaire 1, EuroQol five-dimensional questionnaire, Depression, Anxiety, Stress Scale short-form); efficacy (from the Longitudinal Study of Australian Children); and financial service use (study-designed) compared between arms.Ethics and disseminationEthics committees of the Royal Children’s Hospital (HREC/57372/RCHM-2019) and South West Sydney Local Health District (2019/ETH13455) have approved the study. Participants and stakeholders will receive results through regular communication channels comprising meetings, presentations and publications.Trial registration numberACTRN12620000154909; prospectively registered. Pre-results.

Background Social disadvantage is a key determinant of multimorbidity. Pathways through which social disadvantage leads to multimorbidity are yet undefined. In this study, we first examined the causal effect of moving into financial hardship on multimorbidity among Australian adults, and then the role of social support as a mediator of the relationship between financial hardship and multimorbidity. Methods Data were obtained from the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2009–2013). We identified individuals who moved into financial hardship between 2010 and 2011 (n = 5775). Inverse probability treatment weighting with regression adjustment was used to examine the relationship between financial hardship and multimorbidity. Causal mediation analysis was applied to decompose the total effect of financial hardship on multimorbidity into the proportion attributable to social support and the proportion not occurring through measured pathways. We accounted for baseline covariates including age, sex, marital status, educational attainment, employment status, income, country of birth, multimorbidity and social support. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs). Results The risk of multimorbidity was higher in those with financial hardship by 19% [relative risk 1.19 (95% CI: 1.02–1.37) and absolute risk difference 0.036 (95% CI: 0.004–0.067)] than those without financial hardship. Social support accounted for 30% of the total effect of financial hardship on multimorbidity, risk difference 0.009 (95% CI: 0.003–0.018). Conclusions Financial hardship leads to increased risk of multimorbidity. Interventions directed at increasing social support among those in financial hardship may reduce their risk of multimorbidity.

Financial counselling and income-maximisation services have the potential to reduce financial hardship and its associated burdens on health and wellbeing in High Income Countries. However, referrals to financial counselling services are not systematically integrated into existing health service platforms, thus limiting our ability to identify and link families who might be experiencing financial hardship. Review evidence on this is scarce. The purpose of this study is to review “healthcare-income maximisation” models of care in high-income countries for families of children aged between 0 and 5 years experiencing financial difficulties, and their impacts on family finances and the health and wellbeing of parent(s)/caregiver(s) or children. A systematic review of the MEDLINE, EMBase, PsycInfo, CINAHL, ProQuest, Family & Society Studies Worldwide, Cochrane Library, and Informit Online databases was conducted according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) statement. A total of six studies (five unique samples) met inclusion criteria, which reported a total of 11,603 families exposed to a healthcare-income maximisation model. An average annual gain per person of £1661 and £1919 was reported in two studies reporting one Scottish before–after study, whereby health visitors/midwives referred 4805 clients to money advice services. In another UK before–after study, financial counsellors were attached to urban primary healthcare centres and reported an average annual gain per person of £1058. The randomized controlled trial included in the review reported no evidence of impacts on financial or non-financial outcomes, or maternal health outcomes, but did observe small to moderate effects on child health and well-being. Small to moderate benefits were seen in areas relating to child health, preschool education, parenting, child abuse, and early behavioral adjustment. There was a high level of bias in most studies, and insufficient evidence to evaluate the effectiveness of healthcare-income maximisation models of care. Rigorous (RCT-level) studies with clear evaluations are needed to assess efficacy and effectiveness.

Poor household water supply and sanitation can affect maternal and newborn health outcomes through several pathways, including the quality of drinking water consumed by pregnant woman and exposure to harmful fecal pathogens in the environment due to poor quality sanitation. Using data on 14,098 pregnancies across four rounds of the Indonesian Family Life Survey (IFLS), we investigate the relationship between water and sanitation and outcomes along the course of a pregnancy - health and complications during pregnancy, probability of a miscarriage, complications during child birth, probability of live birth, and neonatal outcomes including birth weight and newborn survival rates. After controlling for confounding factors, we find that access to at least basic household sanitation is strongly associated with substantially decreased overall risk during pregnancy and birth. Whether or not a household has access to at least basic sanitation is strongly significantly associated with a lower probability of miscarriage and is a strong predictor of high fever during labor (an indicator of infection). We find no systematic association between household access to basic water and maternal and newborn outcomes. We also find no evidence of herd protection resulting from high levels of sanitation within the community.

Objective Since its emergence in late 2019, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the novel coronavirus that causes novel coronavirus disease 2019 (COVID-19), has spread globally. Within the United States, some of the most affected regions have been New York, and Northern New Jersey. Our objective is to describe the impact of COVID-19 in a large delivery service in Northern New Jersey, including its effects on labor and delivery (L&D), the newborn nursery, and the neonatal intensive care unit (NICU). Materials and Methods Between April 21, 2020 and May 5, 2020, a total of 78 mothers (3.6% of deliveries) were identified by screening history or examination to either be COVID-19 positive or possible positives (persons under investigation). Of the mothers who were tested after admission to L&D, 28% tested positive for SARS-CoV-2. Discussion Isolation between mother and infant was recommended in 62 cases, either because the mother was positive for SARS-CoV-2 or because the test was still pending. Fifty-four families (87%) agreed to isolation and separation. The majority of infants, 51 (94%), were initially isolated on the newborn nursery. Six needed NICU admission. No infants had clinical evidence of symptomatic COVID-19 infection. Fourteen infants whose mothers were positive for SARS-CoV-2, and who had been separated from the mother at birth were tested for SARS-CoV-2 postnatally. All were negative. Results COVID-19 posed a significant burden to mothers, infants, and staff over the 5-week study period. The yield from screening mothers for COVID-19 on L&D was high. Most families accepted the need for postnatal isolation and separation of mother and newborn. Conclusion Our study suggests that the transmission of SARS-CoV-2 from mother to her fetus/newborn seems to be uncommon if appropriate separation measures are performed at birth. Key Points The yield of targeted testing for SARS-CoV-2, on mothers on Labor and Delivery is high. Agreement to separation of mothers and infants to reduce transmission of SARS-CoV-2 was high. The incidence of symptomatic COVID-19 in newborns is low, if appropriate separation occurs at birth.

On February 27, 2010, a magnitude 8.8 Mw earthquake struck Chile and provoked a tsunami that wreaked havoc on the Chilean coast. A total of 830 failures in the transportation system were registered on roads, with 91 concession bridges and 221 public bridges suffered damage or collapsed. This study aims to test a methodology for teaching people about the characteristics of each post-disaster phase concerning road infrastructure and business continuity. The methodology is based on ludic activities designed as a non-structural mitigation action to reduce cascading risk and enhance business continuity. Activities include answering questions related to experiences with earthquakes, completing puzzles as a metaphor of a city during the reconstruction process and associating scale models of vehicles and machinery with a specific post-disaster phase. The methodology was tested with Chilean high school students aged 11 to 15. Answers from the participants indicate that girls were more aware of protection techniques during earthquakes than boys. In contrast, boys were more mindful of terminology and engaged in decision-making activities. The similarity between completing a puzzle and a city in reconstruction after an earthquake was easy for participants to understand. Initially, participants only identified relief as a post-disaster phase but did not recognise the other post-disaster phases of early recovery, recovery and development. After the workshop, they managed to identify vehicles related to the relief phase, some vehicles and machinery related to the early recovery and recovery phases, and others that can be used in more than one or two post-disaster phases.

ObjectiveTo document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity.DesignScoping review.MethodsA search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results.ResultsA total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity.ConclusionGiven the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.

IntroductionPoverty has far-reaching and detrimental effects on children’s physical and mental health, across all geographies. Financial advice and income-maximisation services can provide a promising opportunity for shifting the physical and mental health burdens that commonly occur with financial hardship, yet awareness of these services is limited, and referrals are not systematically integrated into existing healthcare service platforms. We aim to map and synthesise evidence on the impact of healthcare-income maximisation models of care for families of children aged 0–5 years in high-income countries on family finances, parent/caregiver(s) or children’s health and well-being.Methods and analysisTo be included in the review, studies must be families (expectant mothers or parents/caregivers) of children who are aged between 0 and 5 years, accessing a healthcare service, include a referral from healthcare to an income-maximisation service (ie, financial counselling), and examine impacts on child and family health and well-being. A comprehensive electronic search strategy will be used to identify studies written in English, published from inception to January 2021, and indexed in MEDLINE, EMBase, PsycINFO, CINAHL, Proquest, Family & Society Studies Worldwide, Cochrane Library, and Informit Online. Search strategies will include terms for: families, financial hardship and healthcare, in various combinations. Bibliographies of primary studies and review articles meeting the inclusion criteria will be searched manually to identify further eligible studies, and grey literature will also be searched. Data on objective and self-reported outcomes and study quality will be independently extracted by two review authors; any disagreements will be resolved through a third reviewer. The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.Ethics and disseminationEthical approval is not required. The results will be disseminated widely via peer-reviewed publication and presentations at conferences related to this field.PROSPERO registration numberCRD42020195985.

The fossil-rich limestones (La Negra Facies of the El Doctor Formation) in the Muhi Quarry, northwestern State of Hidalgo, Mexico are of late Albian age based on the occurrence of the ammonites Mortoniceras sp., Hamites aff. renzi and ?Beudanticeras sp. Their occurrence establishes the possible presence of the M. fallax, M. rostratum, M. prinflatum, and A. briacensis Zones (upper Albian) in North America. The late Albian age of the El Doctor Formation makes its teleostean aulopiforms and acanthomorphs the oldest in the world and the occurrence of the chondrichthyans Ptychodus decurrens and Squalicorax falcatus, and the teleostean Tselfatiiformes are their oldest records in Mexico.

This paper explores aspects of household livelihoods and welfare among poor rural farmers in Kenya, Uganda and Tanzania. The models use data from an extensive cross-sectional household survey undertaken in 2013 of over 3,500 rural households. Interest is in identifying the main input constraints to improving farm production, with a particular focus on labour constraints, and the impacts of farm production on the well-being of children — their food security, resilience and engagement in school. The results show low agricultural productivity, and that yields per hectare decline significantly with land size. This is consistent with poor quality land and a labour constraint in agricultural activity: there is insufficient return on labour to justify further investment of effort to cultivate the land, given the typically low-input, labour-intensive farming methods. Food shortage models also show that adult labour is relatively unproductive: having more adults in the household produces little reduction in the incidence of food shortages. Overall the results suggest some directions for development interventions, by highlighting that the critical issue for economic and social development among these communities is to improve the productivity of both land and labour.

BackgroundFor countries to contribute to Sustainable Development Goal 3.1 of reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030, identifying the drivers of maternal mortality is critically important. The ability of countries to identify the key drivers is however hampered by the lack of data sources with sufficient observations of maternal death to allow a rigorous analysis of its determinants. This paper overcomes this problem by utilising census data. In the context of Indonesia, we merge individual-level data on pregnancy-related deaths and households' socio-economic status from the 2010 Indonesian population census with detailed data on the availability and quality of local health services from the Village Census. We use these data to test the hypothesis that health service access and quality are important determinants of maternal death and explain the differences between high maternal mortality and low maternal mortality provinces.MethodsThe 2010 Indonesian Population Census identifies 8075 pregnancy-related deaths and 5,866,791 live births. Multilevel logistic regression is used to analyse the impacts of demographic characteristics and the existence of, distance to and quality of health services on the likelihood of maternal death. Decomposition analysis quantifies the extent to which the difference in maternal mortality ratios between high and low performing provinces can be explained by demographic and health service characteristics.FindingsHealth service access and characteristics account for 23% (CI: 17.2% to 28.5%) of the difference in maternal mortality ratios between high and low-performing provinces. The most important contributors are the number of doctors working at the community health centre (8.6%), the number of doctors in the village (6.9%) and distance to the nearest hospital (5.9%). Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies.ConclusionIndonesia has employed a strategy over the past several decades of increasing the supply of midwives as a way of decreasing maternal mortality. While there is evidence of reductions in maternal mortality continuing to accrue from the provision of midwife services at village health posts, our findings suggest that further reductions in maternal mortality in Indonesia may require a change of focus to increasing the supply of doctors and access to hospitals. If data on maternal death is collected in a subsequent census, future research using two waves of census data would prove a useful validation of the results found here. Similar research using census data from other countries is also likely to be fruitful.