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Factors Influencing Indonesian Women’s Use of Maternal Health Care Services

Kurniati, A., Chen, C. M., Efendi, F., & Berliana, S. M. (2017). Factors Influencing Indonesian Women’s Use of Maternal Health Care Services. Health Care for Women International, (just-accepted), 00-00.

Employing the 2012 Indonesia Demographic and Health Survey data, we aimed to examine factors influencing married women to use maternity services. Data of married women who had given birth in the last five years before the survey were included in the analysis (n = 14,672). Factors of education, employment, women’s age at first marriage, age at first birth, spousal education difference, contraceptive use, place of residence, and woman’s attitude toward wife beating were associated with the use of antenatal care, institutional delivery, and postnatal care services. The likelihood of women using those recommended maternal health care services increased along with the increased educational attainment among women and their spouses, and the older age at first birth. Higher schooling years may contribute to improving adequate maternal health care. Community awareness on maternal health issues should be promoted and to include the prevention of early marriage, teenage pregnancies, and domestic violence.


By the end of Millennium Development Goals (MDGs) the maternal mortality ratio (MMR) has been successfully reduced by almost half since 1990 (United Nations, 2015). Nevertheless, more than three hundred thousand women around the world died during pregnancy and childbirth in 2015, while millions of women experience risks of obstetric complications and other health problems (World Health Organization, 2015). Almost 59% of these maternal deaths were from ten developing countries including Indonesia (World Health Organization, 2015). This country ranks the fourth highest maternal mortality ratio among Southeast Asia countries after Lao PDR, Myanmar, and Cambodia (ASEANstats, 2015). Based on the 2012 Indonesian Demographic and Health Survey (the 2012 IDHS), the maternal mortality ratio fell slightly from 390 deaths per 100,000 live births in 1991 to 359 deaths per 100,000 live births in 2012 (Bappenas, 2015). Every year, about ve million women give birth in this country bringing more concern on this persistent high mortality rate (MoH, 2015).
Utilization of maternal health care is central to reducing maternal mortality. Having a minimum of four antenatal care (ANC) visits and childbirth assistance from the skilled health worker are among major essential recommendations to prevent adverse pregnancy outcomes (World Health Organization, 2007). The United Nations (1999) set up the ultimate target of skilled birth attendance at 90% by 2015. Globally, the utilization of maternal health is lower than the expected target as indicated by 71% of births were assisted by health professionals and approximately 50% pregnant women in developing countries received recommended ANC services in 2014 (United Nations, 2015). Compared to this global situation, Indonesia shows a more remarkable achievement. Between 1991 and 2014, the percentage of Indonesian women having four or more ANC visits and the skilled birth attendance increased from 56% to 86% and from 41% to 87%, respectively (Bappenas, 2015). However, the utilization rate of the facility-based delivery services was 63% in 2012 (Statistics Indonesia (Badan Pusat Statistik —BPS), National Population and Family Planning Board (BKKBN), Kementerian Kesehatan (Kemenkes-MOH), & ICF International, 2013), much lower than the national target of 90% (Pritasari, 2012). In addition, poor health service quality and inequity in accessing maternal health services between the poor and the wealthy people as well as urban and rural regions remain challenging (The National Academy of Sciences, 2013).
Various factors are considered attributing to the levels of utilization and pregnancy outcomes. Thaddeus and Maine (1994) suggested a theoretical framework explaining socioeconomic/cultural aspects, accessibility to a health service institution, and quality of care as the key factors determining the care-seeking decision and ultimately inuencing the utilization and outcome of maternal health services. The socioeconomic/cultural factors emphasize especially on the status of women in the domestic and public sphere, which comprises of education, culture, wealth, and autonomy (Thaddeus & Maine, 1994). In line with this theory, many previous studies investigated factors aecting the use of maternity care services.
A systematic review incorporating studies from developing countries by Çal??kan, K?l?ç, Öztürk, and At?lgan (2015) identied numerous determinants which correlated to the use of maternal health care services including wealth, educational attainment, race/ethnicity/religion, age, parity, place of living, household size, knowledge about maternal health, autonomy status of women, and health insurance. In Sub-Sahara Africa, maternal factors namely education, place of residence, parity, level of household income and frequency of antenatal visits strongly associated with institutional delivery (Moyer & Mustafa, 2013). Other studies of the less developed world found that women with low income, residing in rural regions, and having a low level of education are less likely to take ANC services (Abou-Zahr & Wardlaw, 2003) and to seek childbirth assistance from skilled attendants (Gabrysch & Campbell, 2009). At the individual level, variables of education, age at the last childbirth and attitude towards family planning are the strongest predictors of the utilization of ANC services and postnatal care (PNC) in Nigeria (Babalola & Fatusi, 2009).
In the same vein, several studies in Southeast Asia countries with high maternal mortality also found that women’s education, household wealth index, and residential place were among major determinants for the utilization of antenatal and postnatal care (Prusty, Buoy, Kumar, & Pradhan, 2015; Sein, 2012). In their previous study in Indonesia, Beegle, Frankenberg, and Thomas (2001) reported the signicant association between variables of age and the husband-wife educational gap, and the use of prenatal and delivery care. Likewise, another study of Indonesia revealed that several factors, such as living in rural region, lower family income, poor maternal knowledge, and high birth orders with closely spaced births (less than two years), had signicant associations with the low utilization of ANC (Titaley, Dibley, & Roberts, 2010).
As the reduction of maternal mortality remains signicant in the next global development agenda, it is imperative to have a better understanding of factors associated with the utilization of three aspects of maternity care ? antenatal, delivery and postnatal services using the most recent available nationwide data. In this study, therefore, authors aimed to examine factors that aect the use of maternal health care services among Indonesian women. We expect that the results of this study contribute to supporting effective policies and approaches as well as identifying further research for improving the utilization of maternal health care. As a service to authors and researchers we are providing this version of an accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proofs will be undertaken on this manuscript before nal publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could aect the content, and all legal disclaimers that apply to the journal relate to these versions also

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