From Risk Scores to Real-time Networks: A Systematic Review and Health-system Engineering Synthesis of Indonesia’s Jaminan Kesehatan Nasional Maternal Referral Pathways for Hypertensive Disorders and Pregnancy-associated Cardiac Disease

Abstract Maternal mortality in Indonesia has entered a paradoxical phase. As deaths from hemorrhage and sepsis have gradually declined, hypertensive disorders of pregnancy and pregnancy-associated cardiac disease now account for a growing and disproportionate share of maternal deaths. This shift has occurred despite widespread antenatal risk screening and the national expansion of universal health coverage through Jaminan Kesehatan Nasional (JKN). The persistence of preventable deaths suggests that the critical failure no longer lies in risk recognition alone, but in how risk is translated into timely, coordinated action across the health system. We conducted a systematic review, guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 standards, to examine how maternal risk stratification, referral pathways, and health-system responses interact in real-world Indonesian settings. Thirty-two peer-reviewed studies were included, encompassing population-based analyses, hospital cohorts, qualitative system studies, program evaluations, and digital health interventions. Rather than synthesizing outcomes alone, we examined decision points, delays, and structural constraints along the referral pathway, with particular attention to hypertensive and cardiac conditions. Across diverse settings, a consistent pattern emerged. Risk is often identified early, yet referral decisions are delayed, fragmented, or deferred until clinical deterioration occurs. Transport availability, bed capacity, interfacility communication, subspecialty access, and administrative processes under JKN repeatedly act as sequential bottlenecks. Digital tools and guideline initiatives show promise, but their impact is blunted by downstream capacity mismatches and the absence of time-bound referral standards. This review reframes maternal mortality as a system-performance problem rather than a guideline or knowledge gap. We propose a shift from static risk scores toward real-time, network-based cardio-obstetric referral models, with clinical urgency, financing, and accountability aligned. Such a redesign has implications.