F. Efendi, C. M. Chen, A. Kurniati, and S. M. Berliana, “Determinants of utilization of antenatal care services among adolescent girls and young women in Indonesia,” Women Heal., vol. 57, no. 5, pp. 614–629, 2017.
ABSTRACT
Due to the high number of maternal deaths, provision of antenatal care services (ANC) in Indonesia is one of the key
aims of the post-Millennium Development Goals agenda. This study aimed to assess the key factors determining use of ANC
by adolescent girls and young women in Indonesia. Data from the Indonesia Demographic and Health Survey 2012 were used, with a focus on married adolescent girls (aged 15–19 years, n = 543) and young women (20–24 years,n = 2,916) who were mothers. Bivariate and multiple logistic regression analyses were performed to determine the factors associated with ANC use. The findings indicated that adolescents were less likely to make ANC visits than young women. Richer women were more likely to make four ANC visits in both groups compared to the poorer women. Living in urban areas, higher educational attainment, and lower birth order were also all associated with higher levels of receiving ANC among young women. The results showed that socio-economic factors
were related to the use of ANC among adolescent girls and young women. Ongoing health-care interventions should thus put a priority on adolescent mothers coming from poor socioeconomic backgrounds.
Discussion:
A number of efforts have been made by the Indonesian government to improve the use of ANC in recent years, including the Universal Healthcare Delivery system, Integrated Health Posts in each village, and the Expanding Maternal and Neonatal Survival program (MoH 2014). However, as reported in the Indonesia Health Profile in 2012, the country still needs to increase its efforts to achieve the national and MDGs targets (MoH 2013). Mounting evidence from developed and developing countries shows that adolescent mothers are at high risk of suffering adverse health outcomes for both their babies and themselves (Fatusi and Hindin 2010; Gortzak-Uzan et al. 2001; Malamitsi-Puchner and Boutsikou 2006; UNICEF 2005). Among both age groups examined in the current study, ANC use was lower than the recommended national standards. Approximately 70% and 80% of the adolescent and young women mothers in this survey received at least four ANC visits, respectively. Our analysis found a number of factors that had a significant relation to the use of ANC for the different age groups. For adolescent girls, only socio-economic status had a positive association with four ANC visits. For the young women living in an urban area, mothers who had a higher level of educational attainment, higher income status, and greater mass media exposure were more likely to have adequate ANC use, while higher parity of young women was negatively associated with the use of four ANC visits. Adolescent girls with middle-income status were two times as likely to have the recommended number of ANC visits than those with low-income status. Meanwhile, young women in the high-income group were three times as likely to have four ANC visits compared to those in the low-income group. Similarly, Singh et al. (2012) found that women in rural India aged 15–19 years old with higher socio-economic status were more likely to use full ANC services than those in the poorest category. The government of Indonesia is now seriously addressing the issue of health inequality between provinces. The results of the current study clearly illustrate the importance of geographical factors in determining adequate use of ANC, with women in urban areas much more likely to achieve this than those in rural areas. This may be linked with the accessibility of ANC services in different areas, with women in urban areas finding these easier to access than those in rural areas. For example, data from the Ministry of Villages, Disadvantaged Regions and Transmigration noted that the average distance to a midwife practice within rural areas was 34 km, while nationally it was only 16 km (Kemendesa-PDT 2015). Moreover, Indonesia has about 74,405 rural villages with 52.97% categorized as underdeveloped and the majority located in the eastern part of Indonesia (Kemendesa-PDT 2015). In 1989, the Indonesian government launched a village-based midwife program in response to high mother and infant death rates. Within 7 years every village in Indonesia thus had a skilled birth attendant or midwife (MoH 2013). In addition, community initiatives undertaken with the establishment of Integrated Health Post (Posyandu) program further enhanced accessibility to such care (MoH 2013). However, despite these efforts inequalities between various regions still remain, and thus policy makers should focus on developing innovative or non-standard approaches to address this issue, based on the actual situations in various areas, with the current study providing findings to inform these approaches. The findings of this study indicated a significant association between maternal education and adequate use of ANC, which is supported by previous research (Ciceklioglu, Soyer, and Öcek 2005; Navaneetham and Dharmalingam 2002; Titaley, Dibley, and Roberts 2010). This may be because women who have higher educational attainment may have acquired more knowledge about maternal and child health and the potential benefits of ANC, thus resulting in a higher level of ANC use (Titaley, Dibley, and Roberts 2010). In this context it should be noted that Indonesia is on track to increase access to education among women across the nation. As reported in a recent study, the school participation rate increased from 55% in 2009 to 61% in 2012 among girls aged 16–18 (Badan Pusat Statistik 2014). However, even though Indonesia has a 9-year compulsory education system, 2.6% and 2.7% of adolescent girls and young women in this study, respectively, remained uneducated. It is thus suggested that by further working to improve the education level of its citizens, and meeting the specific needs of target populations, the government can get closer to achieving its goals with regard to reducing adolescent pregnancy, as well as maternal and infant death rates. Mass media exposure was found to be significantly associated with the use of ANC among young women, consistent with previous studies (Navaneetham and Dharmalingam 2002; Pallikadavath, Foss, and Stones 2004), as the communication channel used to convey health-related messages plays an important role in the decision to use health-care services (Grilli et al. 2000). Television is an especially good medium, because it persuades the audience in a visual and auditory manner and is likely to influence significantly more people than other forms of media. Moreover, health messages need to be tailored to the target populations, particularly when these are illiterate women in Indonesia. The current study found that young women who had their first birth between ages 20–24 years were more likely to have four ANC visits than women who had more births by this age. Earlier research showed that women were significantly more likely to use antenatal health-care services for their first deliveries (Chakraborty et al. 2003; Rai, Singh, and Singh 2012), as these are seen by the mothers as riskier than subsequent deliveries. The time and resource constraints faced by women with higher parity have also been reported to have an association with the low use of ANC in larger families (Elo 1992; Wong et al. 1987), and thus messages about the importance of ANC during pregnancy should be targeted at this group. The results of the present study showed that the income status of mothers was significantly associated with the use of ANC for both age groups. Similarly, other studies have found that high-income status is positively related to greater use of maternal health-care services (Målqvist et al. 2013; Matijasevich et al. 2010). Low economic status is generally a barrier to accessing health-care services (Celik and Hotchkiss 2000; Overbosch et al. 2004). This issue is especially important in Indonesia, which has around 28 million people living in poverty, or 11.47% of the total population (BPS 2013). To address this issue, the government launched a Universal Delivery Care (Jampersal) plan, which allows pregnant women to deliver their children in a health-care facility for free (MoH 2013). This plan also covers ANC services for up to four visits, with more visits available to those women who have complications during pregnancy. However, as noted in an earlier study, not all women who are able to use this plan, due to the mother’s preferences, additional costs that can be incurred during labor, distance to the health facility, and administrative problems (Trisnantoro 2011). One of the solutions that has been suggested to address this issue is to rely on the initiative of the local communities. One of the unique aspects of Indonesia’s health system is the concept of community empowerment (MoH 2009), and the main goal of health development is independence. To achieve this, however, each community needs sufficient knowledge, and the health workers who are on the frontline of such efforts, for instance, nurses, midwives, and other health workers, need to be empowered to convey health messages to the community. The results of this study call for a deeper debate on early marriage and pregnancy, and the negative outcomes of these life events on every level of the community. In Indonesia, the minimum age of marriage for girls is 16 years, and for boys it is 19 years (Government of Indonesia 1974). This study showed that the mean age at marriage was 15.9 years for the adolescent girls, and this young age is an issue that requires special attention from a reproductive health perspective. In addition, some studies showed that early
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sexual activity and childbearing can harm the health of both the mother and infant, and this should be highlighted in the related educational efforts (Hampton 2010; Raj et al. 2010). The Indonesian government has claimed that, with the current population make-up, the nation is expected to have a demographic dividend in the near future (Kemenkokesra 2012). As stated by Tirtosudarmo (2013), “A demographic dividend is when the proportion of people in the productive age group (15–64 years) reaches a maximum, and the dependency ratio is at its lowest level.” Preparation for this golden period should thus be made in advance. In thisregard,itistimetoinvestinyoungwomen’shealth,particularlyadolescents and young mothers, who play a great role in determining the well-being of the next generation. Taking into account the results of this study, future policies andprogramsmustaddressadolescents andyoungmothersto meettheirneeds better for accessible, reliable, and affordable ANC. The present study, makes several noteworthy contributions to the issue of ANC use among adolescent girls and young women in Indonesia. The ANC use rates for both age groups were found to be below the national standard, and this issue needs to be urgently addressed. Current government policies and programs should thus target low-income households, with an emphasis on the sexual and reproductive rights of adolescent girls. Limitations The Indonesia Demographic Health Survey (IDHS) provided limited information on certain topics, and this restricted available detailed data and may have resulted in certain uncontrolled factors confounding the results. Moreover, the data were all self-reported, which might have resulted in recall and/or social acceptability bias. In addition, all variables were assumed to be fixed over a period of 5 years prior to the survey (ceteris paribus). A further limitation was that the use of secondary data may have resulted in misclassification of information and/or a lack of comparability with regard to the results from earlier works that used standard instruments. In addition, this study used a cross-sectional design, which prohibited the assessment of the temporal and thus potentially cauasal relations among the variables.
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