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Regional differences in utilization of antenatal care and safe delivery services in Indonesia: Findings from a nationally

representative survey.

Journal: BMJ Open

Manuscript ID bmjopen-2016-013408

Article Type: Research

Date Submitted by the Author: 11-Jul-2016

Complete List of Authors: Tripathi, Vrijesh; University of The West Indies - Saint Augustine Campus, Mathematics and Statistics Singh, Rajvir; Hamad Medical Corporation (HMC),, Cardiology Research

Centre, Heart Hospital

<b>Primary Subject Heading</b>:

Global health

Secondary Subject Heading: Health policy, Health services research

Keywords: Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Antenatal care, Safe delivery, IDHS-2012

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Title: Regional differences in utilization of antenatal care and safe delivery services

in Indonesia: Findings from a nationally representative survey.

Authors:

1. Vrijesh Tripathi, Ph. D

Department of Mathematics and Statistics

Faculty of Science and Technology

The University of The West Indies

St. Augustine, Trinidad and Tobago

2. Rajvir Singh, Ph. D

Cardiology Research Centre, Heart Hospital

Hamad Medical Corporation (HMC)

Doha, Qatar

Corresponding Author:

Dr. Vrijesh Tripathi



The University of the West Indies


Tel: 1(868) 662-2002 ext 83872

E-mail: [email protected]

Key words: Health inequalities, Maternal Health, Reproductive health, Health

Services.

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Abstract:

Background: Indonesia has shown a nominal increase in utilizing ANC services from

93% to 96% in the IDHS 2012 survey. However, safe delivery services need to be

seen in conjunction with ANC services to assess and target universal maternal health

coverage in Indonesia.

Material and Methods: The study uses survey data from the Indonesia Demographic

and Health Survey 2012 that was conducted among women aged 15-49 years who

gave births during the last three years preceding the survey. Socio-economic and

demographic factors affecting utilization of ANC and safe delivery services were

analysed by segregating the data into seven regions of Indonesia.

Results and Conclusion: Multivariate results show that regional differences

significantly affect utilization of ANC and safe delivery services across the seven

regions besides wealth and education differentials. Univariate analyses show that

Sulawesi, Maluku and Western New Guinea islands are at a disadvantage in accessing

ANC and safe delivery services.

Strengths and limitations of this study:

• ANC and safe delivery services are related to maternal morbidity and mortality.

• No prior study has analysed determinants of ANC and safe delivery services in

Indonesia in a single study.

• Regional differences exist even within countries such as Indonesia that have achieved

a high overall ANC coverage of 96%. These regional differences show the way for

further policy planning.

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Introduction

Indonesia is the second most populous country in Asia and the fourth largest in the

world after People’s Republic of China, India and the United States of America. It

consists of more than 17,000 islands spread over 1.9 million square kilometers and

home to some 240 million people. There are five major islands: Sumatera, Java,

Kalimantan, Sulawesi, and Papua. Two remaining groups of islands are Maluku and

Nusa Tenggara, running from Sulawesi to Papua in the north and from Bali to Timor

in the south. The country is divided into 34 provinces that comprise some 500

districts, divided into nearly 7,000 sub-districts in which there are almost 80,000

villages1. For the purposes of this study, we have divided the country into seven

regions, Sumatra, Java, Lesser Sunda islands comprising of Bali, West and East Nusa

Tenggara, Kalimantan, Sulawesi, Maluku islands and Western New Guinea islands.

The United Nations defined millennium development goals (MDGs) 4 and 5 were

aimed at reducing under five-child mortality (U5M) by two thirds and to improve

maternal mortality ratios by three quarters between 1990 and 20152-3. Indonesia has

recorded a huge reduction in U5M down from 85 to 27 deaths per 1000 live births in

2015 4. Though this is significant progress, it is clear that the MDG4 target of

reducing U5M to 24 per 1000 live births will not be achieved in Indonesia. According

to IDHS 2012 report, while the number of mothers receiving ante-natal care (ANC)

has increased from 93% in 2007 to 96% in 2012, more than half of all deliveries still

take place at home in the absence of specialized services to deal with potential

complications5. The ministry of health reported a wide discrepancy in ANC utilization

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across provinces with Jakarta recording 96% to Papua province with only 38% of

mothers utilizing ANC services6-7. Thus, it is clear that ANC coverage and safe

delivery services need to be extended across the country.

This paper uses data collected from the IDHS 2012 on maternity health care services

to examine the association of social-economic and demographic factors in the use of

two components of maternity care services, ANC utilization and self-delivery services

across the seven regions of Indonesia.

Methods

The study uses raw data from nationally representative samples of ever-married

mothers aged 15-49 years in Indonesia Demographic and Health Survey (IDHS-2012)

conducted during May 7th to July 31

st, 2012. Among 45,607 mothers interviewed in

the survey with 96% response rate, a total of 23,809 mothers had births (10168 of first

order, 6483 of second order , 3468 of third order, 1731 of fourth order and 1959 of

fifth and above order births ) in the three years preceding the survey. There were 1558

(6.5%) deaths out of 23,809 births1.

Ethics Statement

The Indonesia Demographic and Health Survey was conducted in accordance to

internationally agreed ethical principles for the conduct of medical research. Since

this study is based on the IDHS data, which is available in the public domain with no

identifiable information on the survey participants, this work is exempted from ethical

review1.

Outcome Events

For the purposes of analysing ANC services, the study population consists of those

mothers who had at least three ANC visits or at least two tetanus toxoid injections

during pregnancy or one tetanus toxoid injection in pregnancy and at least one tetanus

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toxoid injection in the preceding three years and received iron and folic acid tablets

for 90 or more days8-10

. Safe delivery is described as delivery attended by a general

practitioner or obstetrician or nurse or midwife or village midwife or traditional birth

attendant (TBA) or others.

Covariates

Data was segregated according to the seven regions in Indonesia. There is merit in

segregating data for it allows us to focus on aspects of ANC and Safe Delivery

services that may remain hidden in national level indicators11-12

. Selected socio-

economic and demographic factors examined include age, place of residence,

education of self and father, occupation of self and father, wealth quintile, frequency

of listening to radio/ reading newspaper and magazines, birth order and child status at

birth. Though age is a continuous variable, it is tabulated into age groups 15-19 years,

20-24 years, 25-29 years and above 30 years. Place of residence is categorised as rural

or urban. Education is classified as no formal education, up to primary level, up to

secondary level and higher. Occupation is arranged into categories as not working,

unskilled or skilled work, or agriculture. A composite wealth index was computed

using principal component analysis of household items related to possession of

durable assets, access to utilities and infrastructure, and housing characteristics to

assess the economic status of the mothers. Each woman was ranked based on a

household asset score and was assigned to wealth quintiles, labelled as poorest,

poorer, middle, richer and richest, each comprising of 20% of the population. A

detailed description on the methodology adopted to construct the wealth index in

IDHS dataset is given in the IDHS 2012 report1. Public messaging is an important

source of getting information for the woman and therefore, Frequency of listening to

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the radio/ reading newspaper and magazines is included to gauge the woman’s level

of perception regarding family health initiatives.

Statistical Analyses

Data was downloaded from DHS site with due permission for analyses. Frequencies

with percentages are calculated for predictors and outcome variables. Relationships of

mothers’ social and demographic variables and healthcare outcomes data are stratified

according to seven regions with the dependent variables as ANC and safe delivery

services. Chi-square tests are done to see associations and univariate logistic

regression analysis are performed to know about odds ratios and 95% confidence

interval (C.I.) for all predictors. Multivariate logistic regression analyses are

performed and adjusted Odds Ratios with 95% C.I. and p-values are presented in the

tables 13-15

. Statistical significance was set at P<0.05 16. SPSS 21.0 statistical package

is used for the analyses (IBM SPSS 2012)17.

Results

ANC Services

Table 1 presents characteristics of mothers utilizing ANC services across the seven

regions including 2744 births in the Sumatra region, 2320 births in the Java region,

847 in the Lesser Sunda Islands, 999 in the Kalimantan, 1525 in Sulawesi, 467 in

Maluku Islands, and 559 births in the Western New Guinea islands. Most births took

place in rural areas than urban areas in all regions except Java where more births took

place in the urban areas. Most mothers and fathers were educated up to the secondary

level. Most mothers were not working across the seven regions while most fathers

were either in unskilled/ other occupations (Sumatra, Lower Sunda islands,

Kalimantan, Sulawesi) or did skilled work (Java, Maluku and Western New Guinea

islands). Except Java where most mothers belonged to the richest wealth quartile,

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most mothers belonged to either poorer (Sumatra, Lower Sunda islands) or poorest

(Kalimantan, Sulawesi, Maluku and Western New Guinea) wealth quartiles.

Frequency of listening to radio/reading newspapers/magazines was “at least once a

week” in all regions except Sulawesi which reported “not at all” as the most frequent

response. Most mothers received ANC for their first birth order and most children

were born alive.

Table 2 shows the results of univariate analyses with odds ratios and 95% C.I. of

socio-economic and demographic characteristics of mothers who received ANC

services according to the seven regions. As the age of the mother increases, utilization

of ANC decreases across the seven regions (p=0.001) especially for mothers above

the age of 25 years. The ANC services are utilized by only 6-18 % mothers above 30

years of age as compared with those in the 15-19 age groups across all regions. ANC

services are utilized by 94% in the Java region (OR 0.94, 95% CI 0.84-1.06) while

they are utilized by less than 50% in Western New Guinea region (OR 0.46, 95% CI

0.36-0.59) in the rural areas compared to urban areas of residence. Except for Java

island, there is a significant difference between those who utilize ANC services in the

other six regions between the urban and rural areas. Only 70-80 % mothers utilize

ANC services in the rural as compared to urban place of residence in the Sumatra

(OR 0.77, 95% CI 0.7-0.8), Kalimantan (OR 0.8, 95% CI 0.67-0.93), Sulawesi (OR

0.7, 95% CI 0.62-0.80) and Maluku islands (OR 0.74, 95% CI 0.6-0.93). Mothers

with primary and secondary level education use ANC services by two and six times,

respectively, across the seven regions when compared to mothers with no formal

education except in Lesser Sunda Islands region where primary and no formal

education shows no difference (OR 1.8, 95% CI 1.2-2.8 and OR 2.4, 95% CI 1.4-3.9).

Mothers with higher than secondary education also utilize ANC varyingly from two

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and half times (Lesser Sunda Islands OR 2.4, 95% CI 1.4-3.9) to nine times (Western

New Guinea OR 8.9, 95% CI 5.6-14.4). The proportion of mothers utilizing ANC

services increases as the level of education of mothers increases (p=0.001). A higher

level of father’s education also increases the utilization of ANC services across all

regions (p=0.001). Fathers with primary, secondary and higher than secondary level

education help mothers use these services increasingly as compared with fathers with

no formal education across the seven regions except in Lesser Sunda Islands where

educational qualifications of father does not significantly affect mothers’ utilization of

ANC services (OR 0.9, 95% CI 0.5-1.62; OR1.2, 95% CI 0.7- 2.2 and OR 1.3, 95%

CI 0.7-2.5), respectively.

Mothers engaged in agriculture are at a significant disadvantage in utilizing ANC

services compared to those not working outside home, skilled and unskilled workers

in all the seven regions. Mothers involved in unskilled work are not at a significant

disadvantage in utilizing ANC services compared to those not working outside home

excepted in regions like Sumatra and Western New Guinea where the difference was

significant compared to not working mothers (OR 0.6, 95% CI 0.5-0.7; OR 0.7, 95%

CI 0.5- 1.1). Father’s occupation did not show a consistent effect across the regions.

Father’s occupation did not show any difference in the Java region while in

Kalimantan there was a difference between skilled and unskilled workers but had no

difference between those not working and those engaged in agriculture. In the other

five regions, fathers occupied in agriculture were at a significant disadvantage to

those not working. Fathers engaged in agriculture suffer from a similar disadvantage

compared to those engaged in skilled work, unskilled work and not working in all

regions except Kalimantan where utilization of ANC services was more or less equal

compared to other regions where differences were higher. As wealth index increases,

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utilization of ANC services increases significantly by one and half to two times for

poorer to richest across all regions excepts Western New Guinea where utilization of

ANC services increases from two and half times to four times for poorer to richest

compared to the poorest wealth quartile. Utilization of ANC services in Sumatra,

Lesser Sunda Islands and Kalimantan regions is not affected by listening to radio

and/or reading newspapers and magazines less than once a week compared to not

listening or reading newspapers at all. Those listening to radio and/or reading

newspapers and magazines at least once a week utilize ANC services by one and half

to two times more than those who do not across all regions except in Western New

Guinea region, where utilization increases significantly by four and half times (OR

4.6, 95%CI 1.9-11.2) compared to those not listening/ reading newspapers at all. As

birth order increases from first to third birth order, mothers show greater awareness

and utilize ANC services compared at first birth order across all regions. However,

ANC utilization shows a decreasing trend with 4th and 5

th and above birth order.

Those who reported the status of child at birth as dead did not utilize ANC services

compared to those whose child was alive at birth.

Safe Delivery

The total number of safe deliveries in Indonesia in the three years prior to the survey

is 10071 or 42.3% of the total burden of deliveries in Indonesia. These comprised of

6833 births in the Sumatra region, 4819 births in the Java region, 2093 births in the

Lesser Sunda Islands region, 2440 births in the Kalimantan, 4483 births in the

Sulawesi, 1573 births in the Maluku Islands, and 1568 births in the Western New

Guinea islands. Table 3 shows that most mothers who used safe delivery services

were over 30 years old. Most safe deliveries occurred in rural rather than urban place

of residence except in Java where it was the opposite. Most mothers and fathers were

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educated up to the secondary level. Most mothers were not working and most fathers

were engaged in skilled work in Java, Kalimantan, Maluku and Western New Guinea

islands while they were engaged in unskilled or other work in Sumatra, Lower Sunda

and Sulawesi islands. Most families were in the richest quartile in the Java islands, in

poorer wealth quartile in Sumatra islands and in poorest wealth quartile in the rest of

the five regions. Most mothers who utilized safe delivery services listened to radio,

read newspapers/ magazines at least once a week. Most safe deliveries were of first

birth order and most children were reported alive.

Table 4 presents the results of univariate analyses of socio-economic and

demographic characteristics of safe delivery according to seven regions in Indonesia.

Mothers who are 25 years and older have significantly less chances of safe delivery

compared with those in the 15-19 age group in the Sumatra, Java, Lesser Sunda

Islands, Kalimantan and Sulawesi while in Maluku and Western New Guinea islands,

mothers over 30 are less likely to have safe delivery. Mothers living in rural place of

residence have significantly less chances of safe delivery as compared to urban place

of residence in Sumatra, Java, Lesser Sunda Islands, Kalimantan, Sulawesi, Maluku

Islands and Western New Guinea islands, respectively. Level of schooling has a

significant effect on safe delivery across all regions. The chances of safe delivery for

mothers with primary and secondary and above level education increase by 2 to 23

times, in Sumatra, Java, Kalimantan, Sulawesi and Western New Guinea islands,

when compared to mothers with no formal education. Lesser Sunda Islands and

Maluku Islands show no statistical difference between mothers with primary

education and no formal education in utilizing safe delivery services. Fathers’

education to secondary and higher level significantly increases the chances of safe

delivery compared to those fathers with no formal education. In Kalimantan, Sulawesi

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and Western New Guinea, even primary education shows significant difference in

utilization of safe delivery services compared with fathers with no formal education.

Mothers who are in agriculture are at a disadvantage in all regions compared to not

working mothers. But mothers engaged in skilled work are significantly advantaged

in utilizing safe delivery services across all regions. Mothers who are in unskilled or

other jobs are at a significant disadvantage to having safe delivery except in Java

region where there is no difference between unskilled/others and not working mothers

in the context of safe delivery (OR 1.1, 95%CI 0.9-1.3). Fathers who are in

agriculture are at a statistically significant disadvantage compared to those not

working in ensuring safe delivery in all regions except Kalimantan and Java regions.

Fathers engaged in skilled work are at an advantage in their wife having safe delivery

in all regions except Maluku Islands region (OR 0.8, 95%CI 0.5-1.4) though it is not

significant. Unskilled fathers are at par to utilize safe delivery services compared to

those not working except in Western New Guinea region where they are two times

more likely to have safe delivery (OR 2.3, 95% CI 1.3 -4.0). As wealth index

increases safe deliveries increase from two to eight times in all regions. Those

listening to radio and/or reading newspapers and magazines at least once a week are

more likely to have safe deliveries by about three times compared to those who do

not, except in Sumatra region where there is no difference whether they listen to

radio/read newspapers and magazines less than once a week or at least once a week

compared to not listening or reading newspapers at all. In Sumatra, as birth order

increases from first to fourth birth order, mothers utilize safe delivery services though

there is no difference for the fifth and above birth order compared to first birth order.

In Java, there is significant difference from first to third but there is no difference for

fourth and fifth and above birth order. In Lesser Sunda islands, Sulawesi, and Maluku

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islands, there is no significant difference between the first four birth orders but there

is a significant decline (30-40%) in ensuring safe deliveries for fifth and above birth

order. In Kalimantan and Western New Guinea islands, there is no difference between

first and more birth orders. Those who reported the status of child at birth as dead did

not avail safe delivery services across all regions compared to those who reported

child as alive at birth.

Multivariate Analyses

Findings of selected socio-economic and demographic predictors related to ANC and

safe delivery services after adjusting mother’s age at child birth, woman’s occupation,

father’s occupation, frequency of listening to radio/reading newspaper/magazines,

birth order and child status are presented in Table 5. Mothers residing in rural areas

are slightly more likely (OR 1.02, 95%CI 0.9-1.1) to receive ANC than those living in

urban areas. In other words, mothers in rural and urban areas in Indonesia tend to

receive comparable ANC services. However, mothers living in rural areas are 14%

less likely (OR 0.86, 95%CI 0.80-0.92) to have safe delivery compared to those in

urban areas. Different regions show significant differences in utilization of ANC.

ANC utilization is significantly more in Java and Lesser Sunda Islands, compared to

Sumatra and Kalimantan region. If we compare the regional difference in safe

deliveries with reference category of Sumatra, only Java and Lesser Sunda Islands

show no difference while safe deliveries are significantly less in Kalimantan,

Sulawesi, Maluku Islands and Western New Guinea islands. An increase in wealth

index ensures better utilization of ANC and safe delivery services. Mother’s

education and father’s education have comparable but significant role both in

utilization of ANC services and in ensuring safe delivery. No formal education is a

disadvantage in utilization of ANC and safe delivery services while higher than

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secondary level education of mothers is an advantage in utilization of ANC services

(OR 6.2, 95% CI 4.87-7.85) and ensuring safe delivery (OR 10.37, 95% CI 8.06-

13.3). Listening/ reading news at least once a week has impact on ANC services and

safe delivery. However, listening /or reading news less than once a week has impact

on safe delivery but not on ANC where not listening or listening less than once a

week makes no difference.

Discussion

This study examines the factors that affect the utilization of ANC and safe delivery

services in Indonesia. Since Indonesia is a large country geographically spread over

17000 islands, there are regional disparities in the utilization of ANC and safe

delivery services across its many islands. Our study proves that there are socio-

economic and demographic disparities that affect the use of ANC and safe delivery

services and these need to be addressed urgently.

Multivariate analyses shows that though there are no differences in the utilization of

ANC services among the rural and urban areas. This is against the disparities

associated with mothers living in urban and rural areas in other studies 18-21

. It is also

against our own univariate findings that highlight disparities in utilization of ANC

services across the seven regions. This may be due to adjusting other important

variables for ANC services like age, education and wealth quintile in the study.

Multivariate analyses reveals that while mothers in Java and Lesser Sunda islands are

significantly better in ensuring ANC services than mothers in Sumatra. Kalimantan

and Sumatra are comparable while mothers in Sulawesi, Maluku and Western New

Guinea islands are significantly disadvantaged in utilizing ANC services. Though

regional disparities are known to exist in Indonesia, the multivariate results are closer

to the univariate results in Java. This may be because 58% of Indonesia’s population

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resides in Java 22. It justifies the need to disaggregate the data so that regional

disparities are brought into focus.

Differences in wealth index hurt the chances of mothers utilizing ANC services 23-26

.

Our univariate analyses reveals that this is more the case in regions other than Java,

Sumatra and Kalimantan where the wealth differentials affect utilization of ANC up

to two times only. In Sulawesi, Maluku and Western New Guinea islands the wealth

differentials increase to three times.

While differences in education levels of both mothers and fathers affects ANC

utilization, mothers’ education level has proved to be a significant factor in utilization

of ANC services 7, 18, 20, 27

. Mothers educated up to primary, secondary and higher

levels utilize ANC services by almost two, three and six times more than those who

have received no education. It is also significant that listening to radio/ reading

newspapers and magazines at least once a week significantly affects the utilization of

ANC services7.

Multivariate Analyses of Safe Delivery services show that safe deliveries are

significantly less in the rural areas compared to urban areas28-30

. While Sumatra, Java

and Lesser Sunda islands are comparable in mothers’ utilization of safe delivery

services, mothers are significantly disadvantaged in Kalimantan, Sulawesi, Maluku

and Western New Guinea islands. Wealth differentials affect the use of safe delivery

services while low education levels of mothers are disadvantageous to their use of

safe delivery services. Though there is no significant difference between fathers with

no formal education and educated up to only primary level, fathers with secondary

and higher levels of education positively impact the use of safe delivery services in

Indonesia. Listening to radio/reading newspapers and magazines also affects the use

of safe delivery services positively.

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Thus, in developing countries, including Indonesia, access to safe delivery services

remains a great challenge31-32

. These include the out-of-pocket (OOP) share of total

health expenditure remains high at almost 40 percent. Although household health

insurance population coverage rates have increased in the last decade or so—from 15

percent in 1995 to more than 40 percent in 2010—almost 60 percent of the population

still remains without any coverage, and OOP spending remains high even among

those with coverage33. This needs to be expanded because regional and wealth

inequalities affect maternal mortality and U5M in Indonesia.

Limitations

There is a recall bias because of the inherent nature of survey data that is collected at

a single point of time. Also, the data are self-reported and there is no way to assess the

truth quotient of the information collected. Further, most of the variables (age, wealth

index, education, occupation) are recorded at the time of the survey rather than at the

time of birth of the child. These variables may have changed since the birth of the

child.

Conclusion

We surmise that ANC services have increased nominally from the last IDHS survey.

However, since it is still not 100%, we need to look at factors affecting poor coverage

by ANC and safe delivery services. Poor utilization of services is related to a complex

set of social and demographic factors that affect the use, accessibility, affordability

and perception about the need and utility of such services34-36

. The international

community is now working on a new framework of defining the sustainable

development goals (SDGs) that look forward to achieving a target of reducing U5M

to as low as 25 per 1000 live births37-38

. While being poor with no formal education of

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self and husband were a deterrent to accessing ANC services, the odds of utilizing

ANC and safe delivery services were significantly less in the Sulawesi, Maluku and

Western New Guinea islands. It means that the areas covered by TBAs are increased

and special incentives are offered to train women social workers in the Sulawesi,

Maluku and Western New Guinea islands. The study recommends that disaggregated

regional targets be set so as to further reduce maternal mortality rates in Indonesia.

Competing Interests

VT & RS declare that they have no competing interests.

Funding

The authors declare there was no funding for this research.

Author Contributions

VT and RS conceived and designed the study, analysed the data, and equally

contributed and reviewed drafts of the paper.

Data Sharing

The DHS website provides access to data upon submission and approval for a

proposal of study: http://dhsprogram.com/data/new-user-registration.cfm.

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Table 1: Socio-economic and demographic characteristics of ANC services according to regions in Indonesia, IDHS-2012.

Sumatra

region Java Region

Lesser Sunda

Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region

Variable ANC(6833) ANC (4819) ANC (2093) ANC(2440) ANC (4483) ANC (1573) ANC(1568)

Age(Years)

15-19 89(75.4) 92(90.2) 35(85.4) 77(82.8) 108(76.6) 20(66.7) 19(51.4)

20-24 550(71.8) 496(85.2) 187(70.6) 252(72.6) 362(59.9) 111(54.4) 90(36.3)

25-29 859(49.5) 659(58.1) 254(49.7) 271(47.6) 386(43.7) 113(36.8) 121(32.2)

30+ 1246(29.6) 1043(34.8) 371(29.1) 399(27.9) 669(23.4) 223(21.6) 143(15.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1189(44) 1529(48) 354(48.6) 434(44.3) 605(39.3) 179(33.9) 163(34.2)

Rural 1555(37.7) 791(46.5) 493(36.1) 565(38.7) 920(31.3) 288(27.6) 210(19.2)

P-value 0.001 0.32 0.001 0.005 0.001 0.009 0.001

Mother’s Education

No education 27(16.4) 13(21) 30(32.6) 13(13.1) 29(12.3) 5(12.5) 41(10.3)

Primary 691(31.3) 615(36.3) 271(32) 322(34.1) 466(25.6) 115(22.4) 85(18.1)

Secondary 1612(43.9) 1330(54.1) 433(46) 544(46.2) 790(40.3) 269(31.5) 181(31.7)

Higher 414(52.5) 332(55.2) 113(53.6) 120(54.8) 240(51.6) 78(47) 66(50.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Father’s Education

No education 16(14.2) 15(27.3) 19(38.8) 14(18.7) 32(17.4) 6(16.7) 17(8.1)

Primary 753(3.3) 606(38.5) 280(35.3) 296(32.8) 514(28.1) 96(21.6) 70(17.4)

Secondary 1669(44.2) 1327(52.1) 422(43.1) 550(45.7) 765(38.3) 284(31.6) 217(28.8)

Higher 303(46.5) 341(53.8) 124(45.8) 139(53.9) 211(45.3) 78(41.5) 65(36.3)

P-value 0.001 0.001 0.002 0.001 0.001 0.001 0.001

Mother’s occupation

Not working 1342(43.8) 1210(46.8) 319(42) 526(44.3) 811(34.8) 263(31.9) 201(30.1)

Skilled 814(42.3) 683(49) 241(45.8) 277(43.9) 453(39.6) 130(33.6) 106(36.3)

Agriculture 317(31.0) 82(38) 142(33.3) 119(28.6) 140(22.7) 45(18.3) 48(11.4)

Unskilled/others 268(32.8) 313(50.4) 145(38) 75(36.9) 115(30.5) 29(25) 16(8.7)

P-value 0.001 0.008 0.001 0.001 0.001 0.001 0.001

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Continued….

Sumatra region Java Region Lesser Sunda

Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region

Variable ANC(6833) ANC(4819) ANC(2093) ANC(2440) ANC(4483) ANC(1573) ANC(1568)

Father’s occupation

Not working 34(42) 29(42) 17(54.8) 7(28) 29(38.2) 21(38.9) 22(24.7)

Skilled work 844(45.8) 1042(49.4) 266(45.1) 354(46.6) 491(40.1) 155(35.4) 147(31.5)

Agriculture 764(34.9) 218(41.1) 228(32.4) 235(32.2) 443(27) 138(22.2) 97(14.8)

Unskilled/ others 1049(40.3) 999(47.4) 336(43.8) 403(43.6) 554(36.3) 152(33.2) 106(29.9)

P-value 0.001 0.006 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 587(31.4) 186(35.8) 38(33.6) 328(35.3) 597(27.1) 191(24.2) 152(16.2)

Poorer 639(41.3) 352(45.7) 187(42.9) 268(41.7) 328(38.7) 103(29.9) 65(32.7)

Middle 604(45.5) 447(47.2) 131(46.0) 176(45.8) 253(38.2) 86(38.6) 68(38)

Richer 537(44.9) 611(50.3) 113(49.1) 121(47.5) 214(45.7) 61(40.9) 50(43.1)

Richest 377(43.6) 694(50.8) 108(48) 106(46.5) 133(44.5) 26(38.8) 28(37.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Frequency listening radio/reading newspaper/magazine

Not at all 222(30.2) 140(34.7) 242(34.5) 76(33) 165(22.3) 115(23.3) 124(15.2)

Less than once a week 48(28.7) 58(52.3) 30(40) 16(47.1) 42(32.3) 8(44.4) 9(45)

At least once a week 2474(41.7) 2092(48.6) 575(43.7) 907(41.7) 1318(36.5) 344(32.4) 493(32.7)

P-value 0.001 0.001 0.001 0.03 0.001 0.001 0.001

Birth order

1st 982(33.1) 964(40.6) 318(35.4) 407(36.9) 507(29.5) 145(26) 118(21.7)

2nd 863(44.8) 781(56.3) 236(41.8) 293(44.2) 438(37.5) 108(27.7) 90(23.5)

3rd 495(49) 337(56.7) 15(47.8) 159(46.2) 266(38.4) 95(36.3) 70(27.9)

4th 233(49.3) 107(46.3) 71(46.1) 75(44.6) 156(39.2) 47(31.3) 39(24.9)

5Th & above 171(37.3) 101(43.2) 72(44.4) 65(40.1) 158(31.9) 72(33.8) 56(23.9)

P value 0.001 0.001 0.001 0.004 0.02 0.46

Child status

Dead 38(10.2) 50(21.9) 25(16.2) 22(14.8) 36(10.1) 12(9.4) 206(11.7)

Alive 2706(41.9) 224(48.8) 822(42.4) 977(42.6) 1489(36.1) 455(31.5) 353(25.3)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Table 2: Univariate analyses of socio-economic and demographic factors influencing use of ANC services according to regions in Indonesia,

IDHS-2012


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region

Variable OR & 95%CI OR & 95%CI OR & 95%CI OR & 95%CI OR & 95%CI OR & 95%CI OR & 95%CI

Age (Years)

15-19 1 1 1 1 1 1 1

20-24 0.83(0.53-1.3) 0.63(0.32-1.3) 0.41(0.17-1.02) 0.55(0.31-0.99) 0.46(0.30-0.70) 0.60(0.27-1.34) 0.54(0.27-1.08)

25-29 0.32(0.21-0.50) 0.15(0.08-0.3) 0.17(0.07-0.41) 0.19(0.11-0.33) 0.24(0.16-0.36) 0.30(0.13-.64) 0.45(0.23-0.89)

30+ 0.14(0.09-0.21) 0.06(0.03-0.11) 0.07(0.03-0.17) 0.08(0.05-0.14) 0.09(0.86-0.14) 0.14(0.06-0.30) 0.18(0.09-0.35)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.77(0.7-0.8) 0.94(0.84-1.06) 0.60(0.5-0.7) 0.8(0.67-0.93) 0.7(0.62-0.8) 0.74(0.6-0.93) 0.46(0.36-0.59)

Mother Education

No education 1 1 1 1 1 1 1

Primary 2.3(1.5-3.5) 2.0(1.2-3.9) 0.97(0.6-1.5) 3.4(1.9-6.2) 2.5(1.6-3.7) 2.0(0.8-5.3) 1.9(1.3-2.9)

Secondary 4.0(2.6-6.1) 4.4(2.4-8.2) 1.8(1.1-2.8) 5.7(3.1-10.3) 4.8(3.2-7.2)) 3.2(1.2-8.3) 4.0(2.8-5.8)

Higher 5.6(3.7-8.7) 4.7(2.5-8.8) 2.4(1.4-3.9) 8.0(4.2-15.2) 7.6(5.0-11.7) 6.2(2.3-16.6) 8.9(5.6-14.4)

Father Education


Primary 3.0(1.7-5.1) 1.7(0.9-3.0) 0.9(0.5-1.62) 2.1(1.2-3.9) 1.9(1.2-2.8) 1.4(0.6-3.4) 2.4(1.4-4.2)

Secondary 4.8(2.8-8.2) 2.9(1.6-5.3) 1.2(0.7-2.2) 3.7(2.0-6.6) 2.9(2.0-4.4) 2.3(1.0-5.6) 4.6(2.7-7.7)

Higher 5.3(3.8-9.2) 3.1(1.7-5.7) 1.3(0.7-2.5) 5.1(2.7-9.6) 3.9(2.6-6.0) 3.5(1.4-8.9) 6.4(3.6-11.5)

Mother occupation

Not working 1 1 1 1 1 1 1

Skilled 0.9(0.8-1.1) 1.1(0.9-1.2) 1.2(0.9-1.5) 1.0(0.8-1.2) 1.2(1.1-1.4) 1.1(0.8-1.4) 1.3(1.0-1.8)

Agriculture 0.6(0.5-0.7) 0.7(0.5-0.9) 0.7(0.5-0.8) 0.5(0.4-0.6) 0.5(0.4-0.7) 0.5(0.3-0.7) 0.3(0.2-0.4)

Unskilled/ others 0.6(0.53-0.7) 1.2(0.9-1.4) 0.8(0.7-1.1) 0.7(0.5-1.0) 0.8(0.6-1.04) 0.7(0.45-1.1) 0.2(0.1-0.4)

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Continued….

Sumatra

Region

Java Region Lesser Sunda

Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Father occupation


Skilled work 1.2(0.7-1.8) 1.3(0.8-2.2) 0.7(0.3-1.4) 2.2(0.9-5.4) 1.1(0.7-1.7) 0.9(0.5-1.5) 1.4(0.8-2.4)

Agriculture 0.7(0.5-1.2) 1.0(0.6-1.6) 0.4(0.2-0.8) 1.2(0.5-3.0) 0.6(0.4-1.0) 0.4(0.3-08) 0.5(0.3-0.9)

Unskilled others 0.9(0.6-1.5) 1.3(0.8-2.0) 0.6(0.3-1.3) 1.9(0.8-4.8) 0.9(0.6-1.5) 0.8(0.4-1.4) 1.3(0.8-2.2)

Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.5(1.3-1.8) 1.5(1.2-1.9) 1.5(1.2-1.9) 1.3(1.1-1.6) 1.7(1.4-2.0) 1.5(1.0-1.8) 2.5(1.8-3.5)

Middle 1.8(1.5-2.0) 1.6(1.3-2.0) 1.7(1.3-2.2) 1.6(1.2-2.0) 1.6(1.3-2.0) 2.0(1.4-2.7) 3.2(2.2-4.5)

Richer 1.8(1.5-2.1) 1.8(1.5-2.2) 1.9(1.4-2.6) 1.7((1.3-2.2) 2.3(1.9-2.8) 2.2(1.5-3.1) 3.9(2.6-5.9)

Richest 1.7(1.4-2.0) 1.9(1.5-2.3) 1.8(1.4-2.5) 1.6(1.2-2.0) 2.2(1.7-2.8) 2.0(1.2-3.3) 3.0(1.9-5.2)


Not at all 1 1 1 1 1 1 1

Less than once a week 0.9(0.6-1.4) 2.0(1.3-3.2) 1.3(0.8-2.1) 1.8(0.9-3.7) 1.7(1.1-2.5) 2.6(1.0-6.8) 4.6(1.9-11.2)

At least once a week 1.7(1.4-2.0) 1.8(1.4-2.2) 1.5(1.2-1.8) 1.4(1.1-1.9) 2.0(1.7-2.4) 1.6(1.2-2.0) 2.7(2.0-3.5)

Birth order

1st 1 1 1 1 1 1 1

2nd 1.6(1.5-1.8) 1.9(1.6-2.0) 1.3(1.0-1.6) 1.4(1.1-1.6) 1.4(1.2-1.7) 1.0(0.8-1.5) 1.1(0.8-1.5)

3rd 1.9(1.7-2.2) 1.9(1.6-2.3) 1.7(1.3-2.2) 1.5(1.2-1.9) 1.5(1.2-1.8) 1.6(1.2-2.2) 1.4(1.0-2.0)

4th 2.0(1.6-2.4) 1.3(1.0-1.7) 1.6(1.1-2.2) 1.4(1.0-1.9) 1.6(1.2-1.9) 1.3(0.9-1.9) 1.2(0.8-1.8)

5Th & above 1.2(1.0-1.5) 1.1(0.8-1.5) 1.5(1.0-2.0) 1.1(0.8-1.6) 1.1(0.9-1.4) 1.5(1.0-2.0) 1.1(0.8-1.6)

Child status

Dead 1 1 1 1 1 1 1

Alive 6.3(4.4-8.8) 3.4(2.5-4.7) 3.8(2.5-5.9) 43(2.7-6.8) 5(3.5-7.1) 4.4(2.4-8.1) 2.6(1.6-4.1)

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Table 3: Socio-economic and demographic characteristics of safe delivery services according to regions in Indonesia, IDHS2012.

Sumatra

Region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea Region

Variable Safe delivery

(6833)

Safe delivery

(4819)

Safe delivery

(2093)

Safe delivery

(2440)

Safe delivery

(4483)

Safe delivery

(1573)

Safe delivery

(1568)

Age (Years)

15-19 90(76.2) 81(79.4) 34(82.9) 70(75.3) 89(63.1) 10(33.3) 18(48.6)

20-24 607(79.2) 474(81.6) 190(71.7) 238(68.6) 347(57.5) 101(49.5) 99(39.9)

25-29 1056(60.8) 740(65.2) 284(55.6) 288(50.6) 402(45.5) 111(36.2) 142(37.8)

30+ 1534(36.4) 1167(38.9) 382(29.9) 435(30.4) 720(25.2) 184(17.8) 178(19.6)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1502(55.6) 1751(55) 418(57.4) 509(52) 707(45.9) 193(36.6) 216(45.3)

Rural 1785(43.2) 711(43.5) 472(34.6) 522(35.7) 851(28.9) 213(20.4) 221(20.3)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 30(18.2) 9(14.5) 24(26.1) 13(13.1) 19(8.1) 4(10) 31(7.8)

Primary 753(34.1) 569(33.5) 239(28.2) 293(31) 378(20.7) 61(11.9) 92(19.6)

Secondary 1972(53.8) 1469(59.7) 475(50.4) 578(49.1) 857(43.7) 256(30) 228(39.9)

Higher 532(67.4) 415(69.1) 152(72) 147(67.1) 304(65.4) 85(51.2) 86(66.2)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 33(29.2) 16(29.1) 13(26.5) 13(17.3) 26(14.1) 3(8.3) 9(4.3)

Primary 817(35.87) 556(35.3) 253(31.9) 265(29.3) 454(24.8) 48(10.8) 66(16.4)

Secondary 2027(53.7) 1470(57.7) 463(47.3) 592(49.2) 814(40.7) 264(29.4) 272(36.1)

Higher 408(62.7) 418(65.9) 160(59) 161(62.4) 260(55.8) 88(46.8) 84(46.9)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not working 1622(53) 1271(49.2) 353(46.5) 543(45.7) 849(36.5) 227(27.5) 241(36.1)

Skilled 998(51.8) 800(57.4) 283(53.8) 315(49.7) 508(44.4) 138(35.7) 138(47.3)

Agriculture 343(33.5) 66(30.6) 111(26.1) 107(25.7) 81(13.1) 26(10.6) 37(8.8)

Unskilled/others 321(39.2) 322(51.9) 143(37.4) 64(25.7) 112(29.7) 15(12.6) 18(9.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Continued……

Sumatra

region


Islands Region

Kalimanta

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea Region


Not working 41(50.6) 31(44.9) 17(54.8) 10(40) 31(40.8) 23(42.6) 21(23.6)

Skilled work 1148(58.8) 1199(56.8) 321(54.4) 411(54.2) 572(46.7) 165(37.7) 199(42.6)

Agriculture 859(39.2) 211(39.8) 200(28.4) 200(27.4) 352(21.4) 84(13.5) 67(10.2)


P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 662(35.4) 160(30.8) 265(28.9) 287(30.9) 499(22.6) 112(14.2) 162(16.2)

Poorer 757(48.9) 348(45.2) 196(45) 270(42) 339(40) 91(26.4) 79(39.7)

Middle 724(53.4) 480(50.7) 155(54.4) 204(53.1) 301(45.5) 95(42.6) 89(49.7)

Richer 655(54.8) 663(54.6) 138(60) 140(54.9) 262(56) 75(50.3) 71(61.2)

Richest 489(56.5) 811(59.3) 136(60.4) 130(57) 157(52.5) 33(49.3) 36(48.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not at all 259(35.2) 137(33.9) 208(29.7) 65(28.3) 131(17.7) 90(18.2) 120(14.7)

Less than once a week 61(36.5) 63(56.8) 32(42.7) 17(50) 37(28.5) 10(55.6) 10(50)

At least once a week 2967(50) 2262(52.6) 650(49.4) 949(43.6) 1390(38.5) 306(28.8) 307(41.9)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Birth order

1st 1295(43.6) 1084(45.7) 387(43.1) 439(39.8) 598(34.6) 159(28.5) 153(28.2)

2nd 955(49.6) 820(59.1) 244(43.2) 292(44) 425(36.4) 99(25.4) 108(28.2)

3rd 565(55.9) 350(58.9) 142(45.2) 157(45.6) 250(36.1) 69(26.3) 74(29.5)

4th 263(55.6) 106(45.9) 63(40.9) 77(45.8) 147(36.9) 36(24) 48(30.6)

5Th & above 210(45.9) 102(43.6) 54(33.3) 66(40.7) 138(27.8) 43(20.2) 54(23.1)

P-value 0.001 0.001 0.14 0.18 0.01 0.20 0.46

Child status

Dead 86(23.2) 80(35.1) 32(20.8) 31(20.8) 51(14.3) 12(9.4) 24(14)

Alive 3201(49.5) 2382(51.9) 858(44.2) 1000(43.6) 1567(36.5) 394(27.3) 413(29.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Table 4: Univariate analyses of socio-economic and demographic factors influencing utilization of safe delivery services according to regions

in Indonesia, IDHS-2012.


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region

Variable OR & 95%C.I. OR & 95%C.I. OR & 95%C.I. OR & 95%C.I. OR & 95%C.I. OR & 95%C.I. OR & 95%C.I.

Age (Years)

15-19 1 1 1 1 1 1 1

20-24 1.2(0.8-1.9) 1.1(0.7-1.9) 0.5(0.2-1.2) 0.7(0.4-1.2) 0.8(0.5-1.2) 2.0(0.9-4.4) 0.7(0.4-1.4)

25-29 0.5(0.3-0.7) 0.5(0.3-0.8) 0.3(0.1-0.6) 0.3(0.2-0.6) 0.5(0.3-0.7) 1.1(0.5-2.5) 0.6(0.3-1.3)

30+ 0.2(0.1-0.3) 0.2(0.1-0.3) 0.1(0.04-0.2) 0.1(0.09-0.2) 0.2(0.1-0.3) 0.4(0.2-0.9) 0.3(0.1-0.5)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.6(0.5-0.7) 0.6(0.56-0.71) 0.4(0.3-0.5) 0.5(0.4-0.6) 0.5(0.4-0.5) 0.4(0.3-0.6) 0.3(0.2-0.47)

Women Education


Primary 2.3(1.6-3.5) 3.0(1.5-6.0) 1.1(0.7-1.8) 3.0(1.6-5.4) 3.0(1.8-4.8) 1.2(0.4-3.5) 2.9(1.9-4.4)

Secondary 5.2(3.5-7.8) 8.7(4.0-17.7) 2.9(1.8-4.7) 6.4(3.5-11.6) 8.9(5.5-14.3) 3.9(1.4-11.0) 7.8(5.2-11.7)

Higher 9.3(6.1-14.2) 13.0(6.0-27.0) 7.3(4.0-12.7) 13.5(7.0-25.8) 21.6(13-35.8) 9.4(3.2-27.7) 23.0(13.7-38.7)

Husband Education


Primary 1.4(0.9-2.0) 1.3(0.7-2.4) 1.3(0.7-2.5) 2.0(1.1-3.7) 2.0(1.3-3.0) 1.3(0.4-4.5) 4.4(2.0-8.9)

Secondary 2.8(1.9-4.2) 3.3(1.8-5.9) 2.5(1.3-4.8) 4.6(2.5-8.5) 4.0(2.7-6.4) 4.6(1.4-15) 12.5(6.0-24.9)

Higher 4.0(2.6-6.3) 4.7(2.6-8.6) 4.0(2.0-7.9) 8.0(4.1-15.1) 7.7(4.9-12.0) 9.7(3.0-32) 20.0(9.0-40.8)

Mother occupation


Skilled 1.0(0.9-1.1) 1.4(0.3-0.6) 1.3(1.1-1.7) 1.2(1.0-1.4) 1.4(1.2-1.6) 1.5(1.1-1.9) 1.6(1.2-2.0)

Agriculture 0.95(0.40-0.5) 0.5(0.3-0.6) 0.4(0.3-0.5) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.3(0.2-0.5) 0.2(0.1-0.2)

Unskilled/

others

0.60(0.5-0.7) 1.1(0.9-1.3) 0.7(0.5-0.9) 0.5(0.4-0.8) 0.7(0.6-0.9) 0.4(0.2-0.7) 0.2(0.1-0.3)

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region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku

islands Region

Western New

Guinea region

Variable OR & 95%CI OR & 95%CI OR & 95%C.I. OR & 95%CI OR & 95%C.I. OR & 95%C.I. OR & 95%C.I.

Husband occupation


Skilled work 1.4(0.9-2.2) 1.6(1.0-2.6) 1.0(0.5-2.3) 1.2(1.0-1.4) 1.4(1.2-1.6) 0.8(0.5-1.4) 2.4(1.4-4.0)

Agriculture 0.6(0.4-0.9) 0.8(0.5-1.3) 0.3(0.2-0.7) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.2(0.1-0.4) 0.4(0.2-0.6)


Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.7(1.5-2.0) 1.9(1.5-2.3) 2.0(1.6-2.5) 1.6(1.3-2.0) 2.3(1.9-2.7) 2.2(1.6-3.0) 3.4(2.4-4.7)

Middle 2.1(1.8-2.4) 2.3(1.8-2.9) 2.9(2.2-3.9) 2.5(2.0-3.0) 2.9(2.4-3.4) 4.5(3.0-6.3) 5.1(3.6-7.2)

Richer 2.2(1.9-2.6) 2.7(2.2-3.4) 3.7(2.7-5.0) 2.7(2.0-3.6) 4.4(3.5-5.4) 6.1(4.2-8.9) 8.2(5.4-12.2)

Richest 2.4(2.0-2.8) 3.3(2.6-4.0) 3.8(2.8-5.1) 3.0(2.2-4.0) 3.8(3.0-4.8) 5.9(3.5-10.0) 4.9(3.0-7.9)


Not at all 1 1 1 1 1 1 1

Less than once a

week

1.0(0.7-1.5) 2.6(1.7-3.9) 1.8(1.1-2.9) 2.5(1.2-5.3) 1.9(1.2-2.8) 5.6(2.2-14.6) 5.8(2.4-14.2)


Birth order

1st 1 1 1 1 1 1 1

2nd 1.3(1.1-1.4) 1.7(1.5-2.0) 1.0(0.8-1.2) 1.2(0.9-1.4) 1.1(0.9-1.3) 0.8(0.6-1.1) 1.0(0.7-1.3)

3rd 1.6(1.4-1.9) 1.7(1.4-2.1) 1.1(0.8-1.4) 1.3(0.9-1.6) 1.1(0.9-1.3) 0.9(0.7-1.2) 1.1(0.8-1.5)

4th 1.6(1.3-2.0) 1.0(0.8-1.3) 0.9(0.6-1.3) 1.3(0.9-1.8) 1.1(0.9-1.4) 0.8(0.5-1.2) 1.1(0.8-1.7)

5Th & above 1.1(0.9-1.3) 0.9(0.7-1.2) 0.7(0.5-0.9) 1.0(0.7-1.5) 0.7(0.6-0.9) 0.6(0.4-0.9) 0.8(0.5-1.1)

Child status

Dead 1 1 1 1 1 1 1

Alive 3.3(2.5-4.2) 2.0(1.5-2.6) 3.0(2.0-4.5) 3.0(2.0-4.4) 3.5(2.6-4.7) 3.6(2.0-6.6 2.6(1.6-4.6)

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Table 5: Selected socioeconomic predictors for complete antenatal care and safe delivery in

Indonesia.

Antenatal care Safe delivery

Variable OR

95%C.I. P-value OR 95%C.I. P-value

Place of residence

Urban 1.0 1.0

Rural 1.02 0.95-1.10 0.58 0.86 0.80-0.92 0.001

Region

Sumatra 1 - - 1 - -

Java 1.50 1.32-1.59 0.001 0.99 0.90-1.08 0.80

Lesser Sunda Islands 1.22 1.08-1.37 0.001 0.96 0.86-1.09 0.54

Kalimantan 1.07 0.96-1.20 0.23 0.79 0.71-0.08 0.001

Sulawesi 0.76 0.70-0.83 0.001 0.56 0.51-0.61 0.001

Maluku Islands 0.56 0.49-0.64 0.001 0.30 0.26-0.35 0.001

Western New guinea 0.46 0.40-0.54 0.001 0.44 0.38-0.51 0.001

Wealth quintile

Poorest 1 - - 1 -

Poorer 1.45 1.32-1.60 0.001 1.64 1.50-1.80 0.001

Middle 1.57 1.42-1.74 0.001 1.89 1.70-2.10 0.001

Richer 1.75 1.56-1.96 0.001 2.02 1.81-2.26 0.001

Richest 1.52 1.33-1.73 0.001 1.72 1.51-1.96 0.001

Mother’s education

No education 1 - - 1 - -

Primary 1.85 1.51-2.27 0.001 2.06 1.65-2.56 0.001

Secondary 2.94 2.40-3.63 0.001 3.98 3.19-4.97 0.001

Higher 6.20 4.87-7.85 0.001 10.37 8.06-13.3 0.001


No education 1 - 1 - -

Primary 1.50 1.18-1.90 0.001 1.16 0.91-1.47 0.24

Secondary 1.81 1.43-2.31 0.001 1.61 1.26-2.05 0.001

Higher 1.79 1.37-2.33 0.001 1.68 1.28-2.20 0.001

Frequency listening radio/reading news paper/magazine

Not all 1 1

Less than once a week 1.16 0.94-1.44 0.18 1.25 1.01-1.55 0.01

At least once a week 1.24 1.13-1.37 0.001 1.26 1.15-1.39 0.001

• Mother’s age at child birth, women occupation, husband occupation, birth order, and child

status are controlled in multivariate analysis.

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Journal: BMJ Open

Manuscript ID bmjopen-2016-013408.R1


Date Submitted by the Author: 21-Oct-2016




Global health


Keywords: Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Antenatal care, Safe delivery, IDHS-2012


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Authors:









Doha, Qatar







Tel: 1(868) 662-2002 ext 83872


Key words: Health inequalities, Maternal Health, Reproductive health, Health

Services.

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Abstract

Background: Indonesia has shown a nominal increase in utilizing antenatal care

(ANC) services from 93% to 96% in the Indonesia Demographic Health Survey

(IDHS)— 2012 survey. However, safe delivery services need to be seen in

conjunction with ANC services to assess and target universal maternal health

coverage in Indonesia.

Material and Methods: The study uses survey data from the Indonesia Demographic

and Health Survey 2012 that was conducted among women aged 15-49 years who

gave births during the last three years preceding the survey. Socio-economic and

demographic factors affecting utilization of ANC and safe delivery services were

analysed by segregating the data into seven regions of Indonesia.

Results: Multivariate results show that regional differences significantly affect

utilization of ANC and safe delivery services across the seven regions besides wealth

and education differentials. Univariate analyses show that Sulawesi, Maluku and

Western New Guinea islands are at a disadvantage in accessing ANC and safe

delivery services.

Conclusion: The study recommends that disaggregated regional targets be set so as to

further reduce maternal mortality rates in Indonesia.

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Strengths and limitations of this study



• There is a recall bias because of the cross-sectional design of the survey data that is

collected at a single point of time.

• The data are self-reported and there is no way to assess the truth quotient of the

information collected.

• Most of the variables (age, wealth index, education, occupation) are recorded at the

time of the survey rather than at the time of birth of the child and thus, may have

changed.

• Another limitation of the study design is that it does not include child births outside

the institution of marriage since the data were collected only of ever married women

between the ages of 15—49 years.

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Introduction














maternal mortality ratios by three quarters between 1990 and 20152. Indonesia has


2015 3. Thus, the MDG4 target of reducing U5M to 24 per 1000 live births has not

been achieved in Indonesia. The international community has now defined sustainable

development goals (SDGs) that look forward to achieving a target of reducing U5M

to as low as 25 per 1000 live births4. According to IDHS 2012 report, while the

number of mothers receiving ante-natal care (ANC) has increased from 93% in 2007

to 96% in 2012, more than half of all deliveries still take place at home in the absence

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of specialized services to deal with potential complications5. The ministry of health

reported a wide discrepancy in ANC utilization across provinces with Jakarta

recording 96% to Papua province with only 38% of mothers utilizing ANC services6-

7. Thus, it is clear that ANC coverage and safe delivery services need to be evaluated

and extended across the country.

Methods

The study uses raw data from nationally representative samples of ever-married

mothers aged 15-49 years in Indonesia Demographic and Health Survey (IDHS-2012)

conducted during May 7th

to July 31st, 2012. Among 45,607 mothers interviewed in

the survey with 96% response rate, a total of 23,809 mothers had births in the three

years preceding the survey. There were 1558 (6.5%) deaths out of 23,809 births1.

Ethics Statement

The Indonesia Demographic and Health Survey was conducted in accordance to

internationally agreed ethical principles for the conduct of medical research. Since

this study is based on the IDHS data, which are available in the public domain with no

identifiable information on the survey participants, this work is exempted from ethical

review1.

Outcome Events

For the purposes of analysing ANC services, the study population consists of those






practitioner or obstetrician or nurse or trained midwife who have been educated and

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trained to manage normal pregnancies while those attended by faith healers or elders

or relatives or traditional birth attendants or others are not included in safe delivery.11

Covariates

Data were segregated according to the seven regions in Indonesia. There is merit in



. Selected socio-







secondary level and higher. Occupation is arranged into categories as not working

outside home for money, unskilled or skilled work, or agriculture. A composite

wealth index was computed using principal component analysis of household items

related to possession of durable assets, access to utilities and infrastructure, and

housing characteristics to assess the economic status of the mothers. Each woman was

ranked based on a household asset score and was assigned to wealth quintiles,

labelled as poorest, poorer, middle, richer and richest, each comprising of 20% of the

population. A detailed description on the methodology adopted to construct the

wealth index in IDHS dataset is given in the IDHS 2012 report1. Public messaging is

an important source of getting information for the woman and therefore, Frequency of

listening to the radio/ reading newspaper and magazines is included to gauge the

woman’s level of perception regarding family health initiatives.

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Data were downloaded from DHS site with due permission for analyses. Frequencies



according to seven regions with the dependent variables as ANC and safe delivery

services. Chi-square tests are done to see associations and univariate logistic




tables 14-16

. Statistical significance was set at P<0.05 17

. SPSS 21.0 statistical package

is used for the analyses (IBM SPSS 2012)18

.

Results

Population Characteristics of the study population for ANC services

The study population of 23809 births consisted of 6833 births in the Sumatra region,

4819 births in the Java region, 2093 births in the Lesser Sunda Islands region, 2440

births in the Kalimantan, 4483 births in the Sulawesi, 1573 births in the Maluku

Islands, and 1568 births in the Western New Guinea islands (Figure 1). Table 1

presents characteristics of mothers utilizing ANC services across the seven regions

including 2744 births in the Sumatra region, 2320 births in the Java region, 847 in the

Lesser Sunda Islands, 999 in the Kalimantan, 1525 in Sulawesi, 467 in Maluku

Islands, and 559 births in the Western New Guinea islands. The table shows the

number of mothers in a particular category utilizing ANC services with the

accompanying percentage of the total number of mothers in that category. As the age

of the mother increases, utilization of ANC decreases across the seven regions

(p=0.001) especially for mothers above the age of 25 years. More births took place in

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rural areas than urban areas in all regions except Java where more births took place in

the urban areas. Most mothers and fathers were educated up to the secondary level.

The proportion of mothers utilizing ANC services increases as the level of education

of mothers and fathers increase (p=0.001). Most mothers were not working outside

home across the seven regions while most fathers were either in unskilled/ other

occupations (Sumatra, Lower Sunda islands, Kalimantan, Sulawesi) or did skilled

work (Java, Maluku and Western New Guinea islands). Except Java where most

mothers belonged to the richest wealth quartile, most mothers belonged to either

poorer (Sumatra, Lower Sunda islands) or poorest (Kalimantan, Sulawesi, Maluku

and Western New Guinea) wealth quartiles. Frequency of listening to radio/reading

newspapers/magazines was “at least once a week” in all regions except Sulawesi

which reported “not at all” as the most frequent response. There were 10168 births of

first order, 6483 of second order, 3468 of third order, 1731 of fourth order and 1959

of fifth and above order births. Most mothers received ANC for their first birth order

and most children were born alive.

Univariate Analyses for ANC services



services according to the seven regions. The ANC services are utilized by only 6-18%

mothers above 30 years of age as compared with those in the 15-19 age groups across

all regions. ANC services are utilized by 94% in the Java region (OR 0.94, 95% CI

0.84-1.06) while they are utilized by less than 50% in Western New Guinea region

(OR 0.46, 95% CI 0.36-0.59) in the rural areas compared to urban areas of residence.

Except for Java island, there is a significant difference between those who utilize

ANC services in the other six regions between the urban and rural areas. Mothers with

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primary and secondary level education use ANC services by two and six times,



education shows no difference. Mothers with higher than secondary education also

utilize ANC varyingly from two and half times (Lesser Sunda Islands OR 2.4, 95% CI

1.4-3.9) to nine times (Western New Guinea OR 8.9, 95% CI 5.6-14.4). Fathers with

primary, secondary and higher than secondary level education help mothers use these

services increasingly as compared with fathers with no formal education across the

seven regions except in Lesser Sunda Islands where educational qualifications of

father does not significantly affect mothers’ utilization of ANC services (OR 0.9, 95%

CI 0.5-1.62; OR1.2, 95% CI 0.7- 2.2 and OR 1.3, 95% CI 0.7-2.5), respectively.

Mothers engaged in agriculture are at a significant disadvantage in utilizing ANC

services compared to those not working outside home, skilled and unskilled workers

in all the seven regions. Mothers involved in unskilled work are not at a significant

disadvantage in utilizing ANC services compared to those not working outside home

except in regions like Sumatra and Western New Guinea where the difference was

significant compared to mothers not working outside home. Father’s occupation did

not show any difference in the Java region while in Kalimantan there was a difference

between skilled and unskilled workers but there was no difference between those not

working and those engaged in agriculture. In the other five regions, fathers occupied

in agriculture were at a significant disadvantage to those not working, those engaged

in skilled work and unskilled work in all regions except Kalimantan where utilization

of ANC services was more or less equal compared to other regions where there were

differences. As wealth index increases, utilization of ANC services increases

significantly by one and half to two times for poorer to richest across all regions

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excepts Western New Guinea where utilization of ANC services increases from two

and half times to four times for poorer to richest compared to the poorest wealth

quartile. Utilization of ANC services in Sumatra, Lesser Sunda Islands and

Kalimantan regions is not associated with listening to radio and/or reading

newspapers and magazines less than once a week compared to not listening or reading

newspapers at all. Those listening to radio and/or reading newspapers and magazines

at least once a week utilize ANC services by one and half to two times more than

those who do not across all regions except in Western New Guinea region, where

utilization increases significantly by four and half times (OR 4.6, 95%CI 1.9-11.2)

compared to those not listening/ reading newspapers at all. As birth order increases

from first to third birth order, mothers show greater awareness and utilize ANC

services compared at first birth order across all regions. However, ANC utilization

shows a decreasing trend with 4th

and 5th

and above birth order. Those who reported

the status of child at birth as dead did not utilize ANC services compared to those

whose child was alive at birth.

Population Characteristics of study population for Safe Delivery

The total number of safe deliveries in Indonesia in the three years prior to the survey

is 10071 or 42.3% of the total burden of deliveries in Indonesia. These comprised

3287 births in the Sumatra region, 2462 births in the Java region, 890 births in the

Lesser Sunda Islands region, 1031 births in the Kalimantan, 1558 births in the

Sulawesi, 406 births in the Maluku Islands, and 437 births in the Western New

Guinea islands. Table 3 shows the number of mothers in a particular category

utilizing safe delivery services with the accompanying percentage of the total number

of mothers in that category. Table 3 shows that most mothers who used safe delivery

services were over 30 years old. More safe deliveries occurred in rural rather than

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urban place of residence except in Java where it was the opposite. Most mothers and

fathers were educated up to the secondary level. Most mothers were not working

outside home and most fathers were engaged in skilled work in Java, Kalimantan,

Maluku and Western New Guinea islands while they were engaged in unskilled or

other work in Sumatra, Lower Sunda and Sulawesi islands. Most families were in the

richest quartile in the Java islands, in poorer wealth quartile in Sumatra islands and in

poorest wealth quartile in the rest of the five regions. Most mothers who utilized safe

delivery services listened to radio, read newspapers/ magazines at least once a week.

Most safe deliveries were of first birth order and most children were reported to be

alive.

Univariate Analyses for Safe Delivery Services









Islands and Western New Guinea islands, respectively. The chances of safe delivery

for mothers with primary and secondary and above level education increase by 2 to 23


respectively when compared to mothers with no formal education. Fathers’ education

to secondary and higher level significantly increases the chances of safe delivery

compared to those fathers with no formal education. In Kalimantan, Sulawesi and

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Western New Guinea, even primary education shows significant difference in

utilization of safe delivery services compared with fathers with no formal education.

Mothers engaged in agriculture are at a disadvantage in all regions compared to

mothers not working outside home. But mothers engaged in skilled work are

significantly advantaged in utilizing safe delivery services across all regions. Mothers

who are in unskilled or other jobs are at a significant disadvantage to having safe

delivery except in Java region where there is no difference between unskilled/others

and not working mothers in the context of safe delivery (OR 1.1, 95%CI 0.9-1.3).

Fathers who are in agriculture are at a statistically significant disadvantage compared

to those not working in ensuring safe delivery in all regions except Kalimantan and

Java regions. Fathers engaged in skilled work are at an advantage in their wife having

safe delivery in all regions except Maluku Islands region (OR 0.8, 95%CI 0.5-1.4)

though it is not significant. Unskilled fathers are at par to utilize safe delivery services

compared to those not working except in Western New Guinea region where they are

two times more likely to have safe delivery (OR 2.3, 95% CI 1.3 -4.0). As wealth

index increases safe deliveries increase from two to eight times in all regions. Those

listening to radio and/or reading newspapers and magazines at least once a week are

more likely to have safe deliveries by about three times compared to those who do

not, except in Sumatra region where there is no difference whether they listen to

radio/read newspapers and magazines less than once a week or at least once a week

compared to not listening or reading newspapers at all. In Sumatra, as birth order





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first and more birth orders. Those who reported the status of child at birth as dead did

not avail safe delivery services across all regions compared to those who reported



Findings of selected socio-economic and demographic predictors related to ANC and

safe delivery services after adjusting mother’s age at child birth, woman’s occupation,

father’s occupation, frequency of listening to radio/reading newspaper/magazines,

birth order and child status are presented in Table 5. Mothers residing in rural areas

are only slightly more likely (OR 1.02, 95%CI 0.9-1.1) to receive ANC than those

living in urban areas. However, mothers living in rural areas are 14% less likely (OR

0.86, 95%CI 0.80-0.92) to have safe delivery compared to those in urban areas.

Different regions show significant differences in utilization of ANC. ANC utilization

is significantly more in Java and Lesser Sunda Islands, compared to Sumatra and

Kalimantan region. If we compare the regional difference in safe deliveries with

reference category of Sumatra, only Java and Lesser Sunda Islands show no

difference while safe deliveries are significantly less in Kalimantan, Sulawesi,

Maluku Islands and Western New Guinea islands. An increase in wealth index

ensures better utilization of ANC and safe delivery services. Mother’s education and

father’s education have comparable and significant roles both in utilization of ANC

services and in ensuring safe delivery. No formal education is a disadvantage in

utilization of ANC and safe delivery services while higher than secondary level

education of mothers is an advantage in utilization of ANC services (OR 6.2, 95% CI

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4.87-7.85) and ensuring safe delivery (OR 10.37, 95% CI 8.06-13.3). Listening/

reading news at least once a week has impact on ANC services and safe delivery.

However, listening /or reading news less than once a week has impact on safe

delivery but not on ANC where not listening or listening less than once a week makes

no difference.

Discussion


services in Indonesia. Since Indonesia is a large country geographically spread over

17000 islands, there are regional disparities in the utilization of ANC and safe

delivery services across its many islands. Our study proves that there are socio-

economic and demographic disparities that affect the use of ANC and safe delivery

services and these need to be addressed urgently.

Multivariate analyses show that though there are no differences in the utilization of

ANC services among the rural and urban areas. This is against the disparities

associated with mothers living in urban and rural areas in other studies 19-22

. It is also

against our own univariate findings that highlight disparities in utilization of ANC

services across the seven regions. This may be due to adjusting other important

variables for ANC services like age, education and wealth quintile in the study.

Multivariate analyses reveals that while mothers in Java and Lesser Sunda islands are

significantly better in ensuring ANC services than mothers in Sumatra. Kalimantan

and Sumatra are comparable while mothers in Sulawesi, Maluku and Western New

Guinea islands are significantly disadvantaged in utilizing ANC services. Though

regional disparities are known to exist in Indonesia, the multivariate results are closer

to the univariate results in Java. This may be because 58% of Indonesia’s population

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resides in Java 23

. It justifies the need to disaggregate the data so that regional

disparities are brought into focus.

Differences in wealth index hurt the chances of mothers utilizing ANC services 24-27

.

Our univariate analyses reveals that this is more the case in regions other than Java,

Sumatra and Kalimantan where the wealth differentials affect utilization of ANC up

to two times only. In Sulawesi, Maluku and Western New Guinea islands the wealth

differentials increase to three times.








ANC services7.










and higher levels of education are positively associated with the use of safe delivery

services in Indonesia. Listening to radio/reading newspapers and magazines also

affects the use of safe delivery services positively.

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Thus, in low-income countries, including Indonesia, access to safe delivery services

remains a great challenge32-33

. These include the out-of-pocket (OOP) share of total

health expenditure remains high at almost 40 percent. Although household health

insurance population coverage rates have increased in the last decade or so—from 15

percent in 1995 to more than 40 percent in 2010—almost 60 percent of the population

still remains without any coverage, and OOP spending remains high even among

those with coverage34

. This needs to be expanded because regional and wealth

inequalities affect maternal mortality and U5M in Indonesia.

Conclusion



by ANC and safe delivery services. Poor utilization of services is related to a complex

set of social and demographic factors that affect the use, accessibility, affordability

and perception about the need and utility of such services35-37

. While being poor with

no formal education of self and husband were a deterrent to accessing ANC services,

the odds of utilizing ANC and safe delivery services were significantly less in the

Sulawesi, Maluku and Western New Guinea islands. It means that the areas covered

by trained nurses/midwives are increased and special incentives are offered to train

women social workers in the Sulawesi, Maluku and Western New Guinea islands.

The study recommends that disaggregated regional targets be set so as to further

reduce maternal mortality rates in Indonesia.

Competing Interests


Funding


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Data Sharing



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Table 1: Socio-economic and demographic characteristics of ANC services according to regions in Indonesia, IDHS-2012.

Sumatra

region Java Region

Lesser Sunda

Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age(Years)

15-19 89(75.4) 92(90.2) 35(85.4) 77(82.8) 108(76.6) 20(66.7) 19(51.4)

20-24 550(71.8) 496(85.2) 187(70.6) 252(72.6) 362(59.9) 111(54.4) 90(36.3)

25-29 859(49.5) 659(58.1) 254(49.7) 271(47.6) 386(43.7) 113(36.8) 121(32.2)

30+ 1246(29.6) 1043(34.8) 371(29.1) 399(27.9) 669(23.4) 223(21.6) 143(15.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1189(44) 1529(48) 354(48.6) 434(44.3) 605(39.3) 179(33.9) 163(34.2)

Rural 1555(37.7) 791(46.5) 493(36.1) 565(38.7) 920(31.3) 288(27.6) 210(19.2)

P-value 0.001 0.32 0.001 0.005 0.001 0.009 0.001


No education 27(16.4) 13(21) 30(32.6) 13(13.1) 29(12.3) 5(12.5) 41(10.3)

Primary 691(31.3) 615(36.3) 271(32) 322(34.1) 466(25.6) 115(22.4) 85(18.1)

Secondary 1612(43.9) 1330(54.1) 433(46) 544(46.2) 790(40.3) 269(31.5) 181(31.7)

Higher 414(52.5) 332(55.2) 113(53.6) 120(54.8) 240(51.6) 78(47) 66(50.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 16(14.2) 15(27.3) 19(38.8) 14(18.7) 32(17.4) 6(16.7) 17(8.1)

Primary 753(3.3) 606(38.5) 280(35.3) 296(32.8) 514(28.1) 96(21.6) 70(17.4)

Secondary 1669(44.2) 1327(52.1) 422(43.1) 550(45.7) 765(38.3) 284(31.6) 217(28.8)

Higher 303(46.5) 341(53.8) 124(45.8) 139(53.9) 211(45.3) 78(41.5) 65(36.3)

P-value 0.001 0.001 0.002 0.001 0.001 0.001 0.001


Not working

outside home 1342(43.8) 1210(46.8) 319(42) 526(44.3) 811(34.8) 263(31.9) 201(30.1)

Skilled 814(42.3) 683(49) 241(45.8) 277(43.9) 453(39.6) 130(33.6) 106(36.3)

Agriculture 317(31.0) 82(38) 142(33.3) 119(28.6) 140(22.7) 45(18.3) 48(11.4)


P-value 0.001 0.008 0.001 0.001 0.001 0.001 0.001

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Continued….


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region



Not working 34(42) 29(42) 17(54.8) 7(28) 29(38.2) 21(38.9) 22(24.7)

Skilled work 844(45.8) 1042(49.4) 266(45.1) 354(46.6) 491(40.1) 155(35.4) 147(31.5)

Agriculture 764(34.9) 218(41.1) 228(32.4) 235(32.2) 443(27) 138(22.2) 97(14.8)


P-value 0.001 0.006 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 587(31.4) 186(35.8) 38(33.6) 328(35.3) 597(27.1) 191(24.2) 152(16.2)

Poorer 639(41.3) 352(45.7) 187(42.9) 268(41.7) 328(38.7) 103(29.9) 65(32.7)

Middle 604(45.5) 447(47.2) 131(46.0) 176(45.8) 253(38.2) 86(38.6) 68(38)

Richer 537(44.9) 611(50.3) 113(49.1) 121(47.5) 214(45.7) 61(40.9) 50(43.1)

Richest 377(43.6) 694(50.8) 108(48) 106(46.5) 133(44.5) 26(38.8) 28(37.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not at all 222(30.2) 140(34.7) 242(34.5) 76(33) 165(22.3) 115(23.3) 124(15.2)



P-value 0.001 0.001 0.001 0.03 0.001 0.001 0.001

Birth order

1st 982(33.1) 964(40.6) 318(35.4) 407(36.9) 507(29.5) 145(26) 118(21.7)

2nd 863(44.8) 781(56.3) 236(41.8) 293(44.2) 438(37.5) 108(27.7) 90(23.5)

3rd

495(49) 337(56.7) 15(47.8) 159(46.2) 266(38.4) 95(36.3) 70(27.9)

4th 233(49.3) 107(46.3) 71(46.1) 75(44.6) 156(39.2) 47(31.3) 39(24.9)

5Th & above 171(37.3) 101(43.2) 72(44.4) 65(40.1) 158(31.9) 72(33.8) 56(23.9)

P value 0.001 0.001 0.001 0.004 0.02 0.46

Child status

Dead 38(10.2) 50(21.9) 25(16.2) 22(14.8) 36(10.1) 12(9.4) 206(11.7)

Alive 2706(41.9) 224(48.8) 822(42.4) 977(42.6) 1489(36.1) 455(31.5) 353(25.3)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Table 2: Univariate analyses of socio-economic and demographic factors influencing use of ANC services according to regions in Indonesia,

IDHS-2012


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age (Years)

15-19 1 1 1 1 1 1 1

20-24 0.83(0.53-1.3) 0.63(0.32-1.3) 0.41(0.17-1.02) 0.55(0.31-0.99) 0.46(0.30-0.70) 0.60(0.27-1.34) 0.54(0.27-1.08)

25-29 0.32(0.21-0.50) 0.15(0.08-0.3) 0.17(0.07-0.41) 0.19(0.11-0.33) 0.24(0.16-0.36) 0.30(0.13-.64) 0.45(0.23-0.89)

30+ 0.14(0.09-0.21) 0.06(0.03-0.11) 0.07(0.03-0.17) 0.08(0.05-0.14) 0.09(0.86-0.14) 0.14(0.06-0.30) 0.18(0.09-0.35)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.77(0.7-0.8) 0.94(0.84-1.06) 0.60(0.5-0.7) 0.8(0.67-0.93) 0.7(0.62-0.8) 0.74(0.6-0.93) 0.46(0.36-0.59)



Primary 2.3(1.5-3.5) 2.0(1.2-3.9) 0.97(0.6-1.5) 3.4(1.9-6.2) 2.5(1.6-3.7) 2.0(0.8-5.3) 1.9(1.3-2.9)

Secondary 4.0(2.6-6.1) 4.4(2.4-8.2) 1.8(1.1-2.8) 5.7(3.1-10.3) 4.8(3.2-7.2)) 3.2(1.2-8.3) 4.0(2.8-5.8)

Higher 5.6(3.7-8.7) 4.7(2.5-8.8) 2.4(1.4-3.9) 8.0(4.2-15.2) 7.6(5.0-11.7) 6.2(2.3-16.6) 8.9(5.6-14.4)



Primary 3.0(1.7-5.1) 1.7(0.9-3.0) 0.9(0.5-1.62) 2.1(1.2-3.9) 1.9(1.2-2.8) 1.4(0.6-3.4) 2.4(1.4-4.2)

Secondary 4.8(2.8-8.2) 2.9(1.6-5.3) 1.2(0.7-2.2) 3.7(2.0-6.6) 2.9(2.0-4.4) 2.3(1.0-5.6) 4.6(2.7-7.7)

Higher 5.3(3.8-9.2) 3.1(1.7-5.7) 1.3(0.7-2.5) 5.1(2.7-9.6) 3.9(2.6-6.0) 3.5(1.4-8.9) 6.4(3.6-11.5)


Not working outside

home

1 1 1 1 1 1 1

Skilled 0.9(0.8-1.1) 1.1(0.9-1.2) 1.2(0.9-1.5) 1.0(0.8-1.2) 1.2(1.1-1.4) 1.1(0.8-1.4) 1.3(1.0-1.8)

Agriculture 0.6(0.5-0.7) 0.7(0.5-0.9) 0.7(0.5-0.8) 0.5(0.4-0.6) 0.5(0.4-0.7) 0.5(0.3-0.7) 0.3(0.2-0.4)


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Continued….

Sumatra

Region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region




Skilled work 1.2(0.7-1.8) 1.3(0.8-2.2) 0.7(0.3-1.4) 2.2(0.9-5.4) 1.1(0.7-1.7) 0.9(0.5-1.5) 1.4(0.8-2.4)

Agriculture 0.7(0.5-1.2) 1.0(0.6-1.6) 0.4(0.2-0.8) 1.2(0.5-3.0) 0.6(0.4-1.0) 0.4(0.3-08) 0.5(0.3-0.9)


Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.5(1.3-1.8) 1.5(1.2-1.9) 1.5(1.2-1.9) 1.3(1.1-1.6) 1.7(1.4-2.0) 1.5(1.0-1.8) 2.5(1.8-3.5)

Middle 1.8(1.5-2.0) 1.6(1.3-2.0) 1.7(1.3-2.2) 1.6(1.2-2.0) 1.6(1.3-2.0) 2.0(1.4-2.7) 3.2(2.2-4.5)

Richer 1.8(1.5-2.1) 1.8(1.5-2.2) 1.9(1.4-2.6) 1.7((1.3-2.2) 2.3(1.9-2.8) 2.2(1.5-3.1) 3.9(2.6-5.9)

Richest 1.7(1.4-2.0) 1.9(1.5-2.3) 1.8(1.4-2.5) 1.6(1.2-2.0) 2.2(1.7-2.8) 2.0(1.2-3.3) 3.0(1.9-5.2)


Not at all 1 1 1 1 1 1 1



Birth order

1st 1 1 1 1 1 1 1

2nd

1.6(1.5-1.8) 1.9(1.6-2.0) 1.3(1.0-1.6) 1.4(1.1-1.6) 1.4(1.2-1.7) 1.0(0.8-1.5) 1.1(0.8-1.5)

3rd 1.9(1.7-2.2) 1.9(1.6-2.3) 1.7(1.3-2.2) 1.5(1.2-1.9) 1.5(1.2-1.8) 1.6(1.2-2.2) 1.4(1.0-2.0)

4th 2.0(1.6-2.4) 1.3(1.0-1.7) 1.6(1.1-2.2) 1.4(1.0-1.9) 1.6(1.2-1.9) 1.3(0.9-1.9) 1.2(0.8-1.8)

5Th & above 1.2(1.0-1.5) 1.1(0.8-1.5) 1.5(1.0-2.0) 1.1(0.8-1.6) 1.1(0.9-1.4) 1.5(1.0-2.0) 1.1(0.8-1.6)

Child status

Dead 1 1 1 1 1 1 1

Alive 6.3(4.4-8.8) 3.4(2.5-4.7) 3.8(2.5-5.9) 43(2.7-6.8) 5(3.5-7.1) 4.4(2.4-8.1) 2.6(1.6-4.1)

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Table 3: Socio-economic and demographic characteristics of safe delivery services according to regions in Indonesia, IDHS2012.

Sumatra

Region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea Region


(3287)

Safe delivery

(2462)

Safe delivery

(890)

Safe delivery

(1031)

Safe delivery

(1558)

Safe delivery

(406)

Safe delivery

(437)

Age (Years)

15-19 90(76.2) 81(79.4) 34(82.9) 70(75.3) 89(63.1) 10(33.3) 18(48.6)

20-24 607(79.2) 474(81.6) 190(71.7) 238(68.6) 347(57.5) 101(49.5) 99(39.9)

25-29 1056(60.8) 740(65.2) 284(55.6) 288(50.6) 402(45.5) 111(36.2) 142(37.8)

30+ 1534(36.4) 1167(38.9) 382(29.9) 435(30.4) 720(25.2) 184(17.8) 178(19.6)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1502(55.6) 1751(55) 418(57.4) 509(52) 707(45.9) 193(36.6) 216(45.3)

Rural 1785(43.2) 711(43.5) 472(34.6) 522(35.7) 851(28.9) 213(20.4) 221(20.3)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 30(18.2) 9(14.5) 24(26.1) 13(13.1) 19(8.1) 4(10) 31(7.8)

Primary 753(34.1) 569(33.5) 239(28.2) 293(31) 378(20.7) 61(11.9) 92(19.6)

Secondary 1972(53.8) 1469(59.7) 475(50.4) 578(49.1) 857(43.7) 256(30) 228(39.9)

Higher 532(67.4) 415(69.1) 152(72) 147(67.1) 304(65.4) 85(51.2) 86(66.2)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 33(29.2) 16(29.1) 13(26.5) 13(17.3) 26(14.1) 3(8.3) 9(4.3)

Primary 817(35.87) 556(35.3) 253(31.9) 265(29.3) 454(24.8) 48(10.8) 66(16.4)

Secondary 2027(53.7) 1470(57.7) 463(47.3) 592(49.2) 814(40.7) 264(29.4) 272(36.1)

Higher 408(62.7) 418(65.9) 160(59) 161(62.4) 260(55.8) 88(46.8) 84(46.9)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not working outside

home

1622(53) 1271(49.2) 353(46.5) 543(45.7) 849(36.5) 227(27.5) 241(36.1)

Skilled 998(51.8) 800(57.4) 283(53.8) 315(49.7) 508(44.4) 138(35.7) 138(47.3)

Agriculture 343(33.5) 66(30.6) 111(26.1) 107(25.7) 81(13.1) 26(10.6) 37(8.8)


P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Continued……

Sumatra

region


Islands Region

Kalimanta

Region

Sulawesi

Region

Maluku

islands Region

Western New

Guinea Region


(3287)

Safe delivery

(2462)

Safe delivery

(890)

Safe delivery

(1031)

Safe delivery

(1558)

Safe delivery

(406)

Safe delivery

(437)


Not working 41(50.6) 31(44.9) 17(54.8) 10(40) 31(40.8) 23(42.6) 21(23.6)

Skilled work 1148(58.8) 1199(56.8) 321(54.4) 411(54.2) 572(46.7) 165(37.7) 199(42.6)

Agriculture 859(39.2) 211(39.8) 200(28.4) 200(27.4) 352(21.4) 84(13.5) 67(10.2)


P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 662(35.4) 160(30.8) 265(28.9) 287(30.9) 499(22.6) 112(14.2) 162(16.2)

Poorer 757(48.9) 348(45.2) 196(45) 270(42) 339(40) 91(26.4) 79(39.7)

Middle 724(53.4) 480(50.7) 155(54.4) 204(53.1) 301(45.5) 95(42.6) 89(49.7)

Richer 655(54.8) 663(54.6) 138(60) 140(54.9) 262(56) 75(50.3) 71(61.2)

Richest 489(56.5) 811(59.3) 136(60.4) 130(57) 157(52.5) 33(49.3) 36(48.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not at all 259(35.2) 137(33.9) 208(29.7) 65(28.3) 131(17.7) 90(18.2) 120(14.7)



P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Birth order

1st 1295(43.6) 1084(45.7) 387(43.1) 439(39.8) 598(34.6) 159(28.5) 153(28.2)

2nd

955(49.6) 820(59.1) 244(43.2) 292(44) 425(36.4) 99(25.4) 108(28.2)

3rd

565(55.9) 350(58.9) 142(45.2) 157(45.6) 250(36.1) 69(26.3) 74(29.5)

4th 263(55.6) 106(45.9) 63(40.9) 77(45.8) 147(36.9) 36(24) 48(30.6)

5Th

& above 210(45.9) 102(43.6) 54(33.3) 66(40.7) 138(27.8) 43(20.2) 54(23.1)

P-value 0.001 0.001 0.14 0.18 0.01 0.20 0.46

Child status

Dead 86(23.2) 80(35.1) 32(20.8) 31(20.8) 51(14.3) 12(9.4) 24(14)

Alive 3201(49.5) 2382(51.9) 858(44.2) 1000(43.6) 1567(36.5) 394(27.3) 413(29.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age (Years)

15-19 1 1 1 1 1 1 1

20-24 1.2(0.8-1.9) 1.1(0.7-1.9) 0.5(0.2-1.2) 0.7(0.4-1.2) 0.8(0.5-1.2) 2.0(0.9-4.4) 0.7(0.4-1.4)

25-29 0.5(0.3-0.7) 0.5(0.3-0.8) 0.3(0.1-0.6) 0.3(0.2-0.6) 0.5(0.3-0.7) 1.1(0.5-2.5) 0.6(0.3-1.3)

30+ 0.2(0.1-0.3) 0.2(0.1-0.3) 0.1(0.04-0.2) 0.1(0.09-0.2) 0.2(0.1-0.3) 0.4(0.2-0.9) 0.3(0.1-0.5)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.6(0.5-0.7) 0.6(0.56-0.71) 0.4(0.3-0.5) 0.5(0.4-0.6) 0.5(0.4-0.5) 0.4(0.3-0.6) 0.3(0.2-0.47)



Primary 2.3(1.6-3.5) 3.0(1.5-6.0) 1.1(0.7-1.8) 3.0(1.6-5.4) 3.0(1.8-4.8) 1.2(0.4-3.5) 2.9(1.9-4.4)

Secondary 5.2(3.5-7.8) 8.7(4.0-17.7) 2.9(1.8-4.7) 6.4(3.5-11.6) 8.9(5.5-14.3) 3.9(1.4-11.0) 7.8(5.2-11.7)

Higher 9.3(6.1-14.2) 13.0(6.0-27.0) 7.3(4.0-12.7) 13.5(7.0-25.8) 21.6(13-35.8) 9.4(3.2-27.7) 23.0(13.7-38.7)



Primary 1.4(0.9-2.0) 1.3(0.7-2.4) 1.3(0.7-2.5) 2.0(1.1-3.7) 2.0(1.3-3.0) 1.3(0.4-4.5) 4.4(2.0-8.9)

Secondary 2.8(1.9-4.2) 3.3(1.8-5.9) 2.5(1.3-4.8) 4.6(2.5-8.5) 4.0(2.7-6.4) 4.6(1.4-15) 12.5(6.0-24.9)

Higher 4.0(2.6-6.3) 4.7(2.6-8.6) 4.0(2.0-7.9) 8.0(4.1-15.1) 7.7(4.9-12.0) 9.7(3.0-32) 20.0(9.0-40.8)



Skilled 1.0(0.9-1.1) 1.4(0.3-0.6) 1.3(1.1-1.7) 1.2(1.0-1.4) 1.4(1.2-1.6) 1.5(1.1-1.9) 1.6(1.2-2.0)

Agriculture 0.95(0.40-0.5) 0.5(0.3-0.6) 0.4(0.3-0.5) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.3(0.2-0.5) 0.2(0.1-0.2)

Unskilled/

others

0.60(0.5-0.7) 1.1(0.9-1.3) 0.7(0.5-0.9) 0.5(0.4-0.8) 0.7(0.6-0.9) 0.4(0.2-0.7) 0.2(0.1-0.3)

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Sumatra

region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku

islands Region

Western New

Guinea region




Skilled work 1.4(0.9-2.2) 1.6(1.0-2.6) 1.0(0.5-2.3) 1.2(1.0-1.4) 1.4(1.2-1.6) 0.8(0.5-1.4) 2.4(1.4-4.0)

Agriculture 0.6(0.4-0.9) 0.8(0.5-1.3) 0.3(0.2-0.7) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.2(0.1-0.4) 0.4(0.2-0.6)


Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.7(1.5-2.0) 1.9(1.5-2.3) 2.0(1.6-2.5) 1.6(1.3-2.0) 2.3(1.9-2.7) 2.2(1.6-3.0) 3.4(2.4-4.7)

Middle 2.1(1.8-2.4) 2.3(1.8-2.9) 2.9(2.2-3.9) 2.5(2.0-3.0) 2.9(2.4-3.4) 4.5(3.0-6.3) 5.1(3.6-7.2)

Richer 2.2(1.9-2.6) 2.7(2.2-3.4) 3.7(2.7-5.0) 2.7(2.0-3.6) 4.4(3.5-5.4) 6.1(4.2-8.9) 8.2(5.4-12.2)

Richest 2.4(2.0-2.8) 3.3(2.6-4.0) 3.8(2.8-5.1) 3.0(2.2-4.0) 3.8(3.0-4.8) 5.9(3.5-10.0) 4.9(3.0-7.9)


Not at all 1 1 1 1 1 1 1

Less than once a

week

1.0(0.7-1.5) 2.6(1.7-3.9) 1.8(1.1-2.9) 2.5(1.2-5.3) 1.9(1.2-2.8) 5.6(2.2-14.6) 5.8(2.4-14.2)


Birth order

1st 1 1 1 1 1 1 1

2nd 1.3(1.1-1.4) 1.7(1.5-2.0) 1.0(0.8-1.2) 1.2(0.9-1.4) 1.1(0.9-1.3) 0.8(0.6-1.1) 1.0(0.7-1.3)

3rd

1.6(1.4-1.9) 1.7(1.4-2.1) 1.1(0.8-1.4) 1.3(0.9-1.6) 1.1(0.9-1.3) 0.9(0.7-1.2) 1.1(0.8-1.5)

4th 1.6(1.3-2.0) 1.0(0.8-1.3) 0.9(0.6-1.3) 1.3(0.9-1.8) 1.1(0.9-1.4) 0.8(0.5-1.2) 1.1(0.8-1.7)

5Th

& above 1.1(0.9-1.3) 0.9(0.7-1.2) 0.7(0.5-0.9) 1.0(0.7-1.5) 0.7(0.6-0.9) 0.6(0.4-0.9) 0.8(0.5-1.1)

Child status

Dead 1 1 1 1 1 1 1

Alive 3.3(2.5-4.2) 2.0(1.5-2.6) 3.0(2.0-4.5) 3.0(2.0-4.4) 3.5(2.6-4.7) 3.6(2.0-6.6 2.6(1.6-4.6)

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Table 5: Multivariate Analyses of selected socioeconomic predictors for complete antenatal

care and safe delivery in Indonesia.


Variable OR


Place of residence

Urban 1.0 1.0

Rural 1.02 0.95-1.10 0.58 0.86 0.80-0.92 0.001

Region

Sumatra 1 - - 1 - -

Java 1.50 1.32-1.59 0.001 0.99 0.90-1.08 0.80


Kalimantan 1.07 0.96-1.20 0.23 0.79 0.71-0.08 0.001

Sulawesi 0.76 0.70-0.83 0.001 0.56 0.51-0.61 0.001

Maluku Islands 0.56 0.49-0.64 0.001 0.30 0.26-0.35 0.001

Western New Guinea 0.46 0.40-0.54 0.001 0.44 0.38-0.51 0.001

Wealth quintile

Poorest 1 - - 1 -

Poorer 1.45 1.32-1.60 0.001 1.64 1.50-1.80 0.001

Middle 1.57 1.42-1.74 0.001 1.89 1.70-2.10 0.001

Richer 1.75 1.56-1.96 0.001 2.02 1.81-2.26 0.001

Richest 1.52 1.33-1.73 0.001 1.72 1.51-1.96 0.001



Primary 1.85 1.51-2.27 0.001 2.06 1.65-2.56 0.001

Secondary 2.94 2.40-3.63 0.001 3.98 3.19-4.97 0.001

Higher 6.20 4.87-7.85 0.001 10.37 8.06-13.3 0.001

Father’s education


Primary 1.50 1.18-1.90 0.001 1.16 0.91-1.47 0.24

Secondary 1.81 1.43-2.31 0.001 1.61 1.26-2.05 0.001

Higher 1.79 1.37-2.33 0.001 1.68 1.28-2.20 0.001

Frequency listening radio/reading news paper/magazine

Not all 1 1



• Mother’s age at child birth, women occupation, husband occupation, birth order, and child

status are controlled in multivariate analysis.

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation

Reported on page

#

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 4-5

Objectives 3 State specific objectives, including any prespecified hypotheses 4-5

Methods

Study design 4 Present key elements of study design early in the paper 5

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

5

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 5-6

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic

criteria, if applicable

5-6

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

5-6

Bias 9 Describe any efforts to address potential sources of bias 5-6

Study size 10 Explain how the study size was arrived at 5-7

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen

and why

6

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 7

(b) Describe any methods used to examine subgroups and interactions N/A

(c) Explain how missing data were addressed 5-7

(d) If applicable, describe analytical methods taking account of sampling strategy N/A

(e) Describe any sensitivity analyses N/A

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, 7, See Figure 1

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confirmed eligible, included in the study, completing follow-up, and analysed

(b) Give reasons for non-participation at each stage 7, Figure 1

(c) Consider use of a flow diagram Figure 1

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and

potential confounders

7, 10-11

(b) Indicate number of participants with missing data for each variable of interest N/A

Outcome data 15* Report numbers of outcome events or summary measures 8-10, 11-13

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%

confidence interval). Make clear which confounders were adjusted for and why they were included

Tables 2, 4 and 5

(b) Report category boundaries when continuous variables were categorized 6

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period N/A

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses N/A

Discussion

Key results 18 Summarise key results with reference to study objectives 14-16

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction

and magnitude of any potential bias

3

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results

from similar studies, and other relevant evidence

14-16

Generalisability 21 Discuss the generalisability (external validity) of the study results 16

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

16

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional

studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting.

The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of

Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-

statement.org.

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Caption : Flow chart of the process of selection of mothers' sample available for analyses of ANC and Safe delivery services

Figure 1 184x148mm (300 x 300 DPI)

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Journal: BMJ Open

Manuscript ID bmjopen-2016-013408.R2


Date Submitted by the Author: 26-Nov-2016




Global health


Keywords: Health inequalities, Maternal Health, Health Services, Safe delivery, Antenatal Care


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Original Title: Regional differences in utilization of antenatal care and safe delivery

services in Indonesia: Findings from a nationally representative survey.

Revised Title: Regional differences in utilization of antenatal care and safe delivery

services in Indonesia: Secondary data analyses from a nationally representative

survey.

Authors:









Doha, Qatar







Tel: 1(868) 662-2002 ext 83872


Key words: Health inequalities, Maternal Health, Health Services, Antenatal Care,

Safe Delivery

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Abstract

Background: Indonesia has shown a nominal increase in antenatal care (ANC)

coverage from 93% to 96% in the Indonesia Demographic Health Survey (IDHS)—

2012 survey. This is high but for a comprehensive assessment of maternal health

coverage in Indonesia, safe delivery services need to be assessed in conjunction with

ANC coverage.

Material and Methods: The study uses survey data from the IDHS-2012 that was

conducted among women aged 15-49 years who gave birth during the last three years

preceding the survey. Socio-economic and demographic factors affecting ANC

coverage and safe delivery services are analysed by segregating the data into seven

regions of Indonesia.

Results: Multivariate results show that besides wealth and education differentials,

regional differences significantly affect utilization of ANC and safe delivery services

across the seven regions.. Univariate analyses show that Sulawesi, Maluku and

Western New Guinea islands are at a disadvantage in accessing ANC and safe

delivery services.

Conclusion: The study recommends that disaggregated regional targets be set in order

to further reduce maternal mortality rates in Indonesia.

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Strengths and limitations of this study



• The sampling design is robust and is representative of the country.

• The IDHS-2012 covered ever-married and never-married women aged 15-49 years.

• There is a recall bias because of the cross-sectional design of the survey data that is

self-reported at a single point of time.

• Most of the variables (age, wealth index, education, occupation) are recorded at the

time of the survey rather than at the time of birth of the child and thus, may have

changed.

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Original Title: Regional differences in utilization of antenatal care and safe delivery

services in Indonesia: Findings from a nationally representative survey.

Revised Title: Regional differences in utilization of antenatal care and safe delivery

services in Indonesia: Secondary data analyses from a nationally representative

survey.

Introduction














maternal mortality ratios by three quarters between 1990 and 20152. Indonesia has


2015 3. The international community has now defined sustainable development goals

(SDGs) that look forward to achieving a target of reducing U5M to as low as 25 per

1000 live births4. According to IDHS 2012 report, while the number of mothers

receiving ante-natal care (ANC) has increased from 93% in 2007 to 96% in 2012,

more than half of all deliveries still take place at home in the absence of specialized

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services to deal with potential complications5. The ministry of health reported a wide

discrepancy in ANC utilization across provinces with Jakarta recording 96% to Papua

province with only 38% of mothers utilizing ANC services6-7

. Thus, This study

assesses whether regional differences affect ANC coverage and safe delivery services

across Indonesia.

Methods

The study uses raw data from nationally representative samples of women aged 15-49

years in Indonesia Demographic and Health Survey (IDHS-2012) conducted during

May 7th

to July 31st, 2012. Among 45,607 women interviewed in the survey with 96%

response rate, a total of 23,809 women gave birth in the three years preceding the

survey. There were 1558 (6.5%) reported deaths1.

Ethics Statement

The IDHS-2012 was conducted in accordance to internationally agreed ethical

principles for the conduct of medical research. Since this study is based on the IDHS

data, which are available in the public domain with no identifiable information on the

survey participants, this work is exempted from ethical review1.

Outcome Events

For the purposes of analysing ANC coverage, the study population consists of






practitioner or obstetrician or nurse or trained midwife who have been educated and

trained to manage normal pregnancies while those attended by faith healers or elders

or relatives or traditional birth attendants or others are not included in safe delivery11.

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Covariates

Data were segregated according to the seven regions in Indonesia. There is merit in



. Selected socio-







secondary level and higher. Occupation is arranged into categories as not working

outside home for money, unskilled or skilled work, or agriculture. A composite

wealth index was computed using principal component analysis of household items

related to possession of durable assets, access to utilities and infrastructure, and

housing characteristics to assess the economic status of the mothers. Each woman was

ranked based on a household asset score and was assigned to wealth quintiles,

labelled as poorest, poorer, middle, richer and richest, each comprising of 20% of the

population. A detailed description on the methodology adopted to construct the

wealth index in IDHS dataset is given in the IDHS 2012 report1. Public messaging is

an important source of getting information for the woman and therefore, frequency of

listening to the radio/ reading newspaper and magazines is included to gauge the

mother’s level of perception regarding family health initiatives.


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Data were downloaded from DHS site with due permission for analyses. Frequencies



according to seven regions with the dependent variables as ANC coverage and safe

delivery services. Chi-square tests are done to see associations and univariate logistic




tables 14-16

. Statistical significance was set at P<0.05 17

. SPSS 21.0 statistical package

is used for the analyses (IBM SPSS 2012)18

.

Results

Population Characteristics of the study population for ANC services

The study population of 23809 births consisted of 6833 births in the Sumatra region,

4819 births in the Java region, 2093 births in the Lesser Sunda Islands region, 2440

births in the Kalimantan, 4483 births in the Sulawesi, 1573 births in the Maluku

Islands, and 1568 births in the Western New Guinea islands (Figure 1). Table 1

presents characteristics of mothers utilizing ANC services across the seven regions

including 2744 births in the Sumatra region, 2320 births in the Java region, 847 births

in the Lesser Sunda Islands, 999 births in the Kalimantan, 1525 births in Sulawesi,

467 births in Maluku Islands, and 559 births in the Western New Guinea islands. The

table shows the number of mothers in a particular category utilizing ANC services

with the accompanying percentage of the total number of mothers in that category. As

the age of the mother increases, utilization of ANC decreases across the seven regions

(p=0.001) especially for mothers above the age of 25 years. More births took place in

rural areas than urban areas in all regions except Java where more births took place in

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the urban areas. Most mothers and fathers were educated up to the secondary level.

The proportion of mothers utilizing ANC services increases as the level of education

of mothers and fathers increase (p=0.001). Most mothers were not working outside

home across the seven regions while most fathers were either in unskilled/ other

occupations (Sumatra, Lower Sunda islands, Kalimantan, Sulawesi) or did skilled

work (Java, Maluku and Western New Guinea islands). Except Java where most

mothers belonged to the richest wealth quintile, most mothers belonged to either

poorer (Sumatra, Lower Sunda islands) or poorest (Kalimantan, Sulawesi, Maluku

and Western New Guinea) wealth quintiles. Frequency of listening to radio/reading

newspapers/magazines was “at least once a week” in all regions except Sulawesi

which reported “not at all” as the most frequent response. There were 10168 births of

first order, 6483 of second order, 3468 of third order, 1731 of fourth order and 1959

of fifth and above order births. Most mothers received ANC for their first birth order

and most children were born alive.

Univariate Analyses for ANC services



services according to the seven regions. The ANC services are utilized by only 6-18%

mothers above 30 years of age as compared with those in the 15-19 age groups across

all regions. ANC services are utilized by 94% in the Java region (OR 0.94, 95% CI

0.84-1.06) while they are utilized by less than 50% in Western New Guinea region

(OR 0.46, 95% CI 0.36-0.59) in the rural areas compared to urban areas of residence.

Except for Java island, there is a significant difference between those who utilize

ANC services in the other six regions between the urban and rural areas. Mothers with

primary and secondary level education use ANC services by two and six times,

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education shows no difference. Mothers with higher than secondary education also

utilize ANC varyingly from two and half times (Lesser Sunda Islands OR 2.4, 95% CI

1.4-3.9) to nine times (Western New Guinea OR 8.9, 95% CI 5.6-14.4). Fathers with

primary, secondary and higher than secondary level education help mothers use these

services as compared with fathers with no formal education across the seven regions

except in Lesser Sunda Islands where educational qualifications of father does not

significantly affect mothers’ utilization of ANC services (OR 0.9, 95% CI 0.5-1.62;

OR1.2, 95% CI 0.7- 2.2 and OR 1.3, 95% CI 0.7-2.5), respectively. Mothers engaged

in agriculture are at a significant disadvantage in utilizing ANC services compared to

those not working outside home, skilled and unskilled workers in all the seven

regions. Mothers involved in unskilled work are not at a significant disadvantage in

utilizing ANC services compared to those not working outside home except in regions

like Sumatra and Western New Guinea where the difference was significant compared

to mothers not working outside home. Father’s occupation did not show any

difference in the Java region while in Kalimantan there was a difference between

skilled and unskilled workers but there was no difference between those not working

and those engaged in agriculture. In the other five regions, fathers occupied in

agriculture were at a significant disadvantage in accessing ANC services to those not

working, those engaged in skilled work and unskilled work. Utilization of ANC

services increases significantly by one and half to two times for those in poorer to

richest wealth quintiles across all regions excepts Western New Guinea where it

increases from two and half times to four times for those in poorer to richest quintiles

compared to those in the poorest wealth quintile. Utilization of ANC services in

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Sumatra, Lesser Sunda Islands and Kalimantan regions is not associated with

listening to radio and/or reading newspapers and magazines less than once a week

compared to not listening or reading newspapers at all. Those listening to radio and/or

reading newspapers and magazines at least once a week utilize ANC services by one

and half to two times more than those who do not across all regions except in Western

New Guinea region, where ANC utilization increases significantly by almost four and

half times (OR 4.6, 95%CI 1.9-11.2). As birth order increases from first to third birth

order, mothers show greater awareness and utilize ANC services compared at first

birth order across all regions. However, ANC utilization shows a decreasing trend

with 4th

and 5th

and above birth order. Those who reported the status of child at birth

as dead did not utilize ANC services compared to those whose child was alive at

birth.

Population Characteristics of study population for Safe Delivery

The total number of safe deliveries in Indonesia in the three years preceding the

survey is 10071 or 42.3% of the total burden of deliveries in Indonesia. These

comprised 3287 births in the Sumatra region, 2462 births in the Java region, 890

births in the Lesser Sunda Islands region, 1031 births in the Kalimantan, 1558 births

in the Sulawesi, 406 births in the Maluku Islands, and 437 births in the Western New

Guinea islands. Table 3 shows the number of mothers in a particular category

utilizing safe delivery services with the accompanying percentage of the total number

of mothers in that category. Most mothers who used safe delivery services were over

30 years old. More safe deliveries occurred in rural rather than urban place of

residence except in Java where it was the opposite. Most mothers and fathers were

educated up to the secondary level. Most mothers were not working outside home and

most fathers were engaged in skilled work in Java, Kalimantan, Maluku and Western

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New Guinea islands while they were engaged in unskilled or other work in Sumatra,

Lower Sunda and Sulawesi islands. Most families were in the richest quintile in the

Java islands, in poorer wealth quintile in Sumatra islands and in poorest wealth

quintile in the rest of the five regions. Most mothers who utilized safe delivery

services listened to radio, read newspapers/ magazines at least once a week. Most safe

deliveries were of first birth order and most children were reported to be alive.

Univariate Analyses for Safe Delivery Services









Islands and Western New Guinea islands, respectively. The chances of safe delivery

for mothers with primary and secondary and above level education increase by 2 to 23


respectively when compared to mothers with no formal education. Fathers’ education

to secondary and higher level significantly increases the chances of safe delivery

compared to those fathers with no formal education. In Kalimantan, Sulawesi and

Western New Guinea, even upto primary level education of fathers shows significant

difference in utilization of safe delivery services compared with fathers with no

formal education. Mothers engaged in agriculture are at a disadvantage in all regions

compared to mothers not working outside home. But mothers engaged in skilled work

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are significantly advantaged in utilizing safe delivery services across all regions.

Mothers who are in unskilled or other jobs are at a significant disadvantage in having

safe delivery except in Java region where there is no difference between

unskilled/others and those not working outside home (OR 1.1, 95%CI 0.9-1.3).

Fathers who are in agriculture are at a statistically significant disadvantage compared

to those not working in ensuring safe delivery in all regions except Kalimantan and

Java regions. Fathers engaged in skilled work are at an advantage in all regions except

Maluku Islands region (OR 0.8, 95%CI 0.5-1.4) though this association is not

significant. Fathers engaged in unskilled work utilize safe delivery services on par

with those not working except in Western New Guinea region where they are two

times more likely to have safe delivery (OR 2.3, 95% CI 1.3 -4.0). As wealth index

increases safe deliveries increase from two to eight times in all regions. Those

listening to radio and/or reading newspapers and magazines less than once a week or

at least once a week are more likely to have safe deliveries by about two to four times

compared to those who do not, except in Sumatra region. In Sumatra, as birth order








first and higher birth orders. Those who reported the status of child at birth as dead

did not avail safe delivery services across all regions compared to those who reported


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Findings of selected socio-economic and demographic predictors related to ANC

coverage and safe delivery services after adjusting mother’s age at childbirth,

mother’s occupation, father’s occupation, frequency of listening to radio/reading

newspaper/magazines, birth order and child status are presented in Table 5. Mothers

residing in rural areas are only slightly more likely (OR 1.02, 95%CI 0.9-1.1) to

receive ANC than those living in urban areas. However, mothers living in rural areas

are 14% less likely (OR 0.86, 95%CI 0.80-0.92) to have safe delivery compared to

those in urban areas. Different regions show significant differences in utilization of

ANC. ANC utilization is significantly more in Java and Lesser Sunda Islands,

compared to Sumatra and Kalimantan regions. Safe delivery services show no

difference in Java and Lesser Sunda Islands but are significantly less in Kalimantan,

Sulawesi, Maluku Islands and Western New Guinea islands when compared to

Sumatra region. An increase in wealth index ensures better utilization of ANC and

safe delivery services. Mother’s education and father’s education have comparable

and significant roles both in utilization of ANC services and in ensuring safe delivery.

No formal education is a disadvantage in utilization of ANC and safe delivery

services while higher than secondary level education of mothers is an advantage in

utilization of ANC services (OR 6.2, 95% CI 4.87-7.85) and ensuring safe delivery

(OR 10.37, 95% CI 8.06-13.3). Listening to radio/ reading newspapers and magazines

at least once a week has an impact on utilization of ANC and safe delivery services.

However, listening to radio/reading news less than once a week has an impact on safe

delivery but not on ANC services where not listening to radio/reading newspapers and

magazines or listening to radio/reading newspapers and magazines less than once a

week make no difference.

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Discussion


services in Indonesia. Since Indonesia is geographically spread over a wide area, there

are regional disparities in the utilization of ANC and safe delivery services across its

many islands. Our study proves that there are socio-economic and demographic

disparities that affect the use of ANC and safe delivery services and these need to be

addressed urgently.

Multivariate analyses show that there are no differences in the utilization of ANC

services among the rural and urban areas. This is against the disparities associated

with mothers living in urban and rural areas in other studies 19-22

. It is also against our

own univariate findings that highlight disparities in utilization of ANC services across

the seven regions. This may be due to adjusting of other important variables for ANC

services like age, education and wealth quintile in the study.

Multivariate analyses reveals that compared to Sumatra mothers in Java and Lesser

Sunda islands are significantly better, Kalimantan is comparable while mothers in

Sulawesi, Maluku and Western New Guinea islands are significantly disadvantaged in

utilizing ANC services. Though regional disparities are known to exist in Indonesia,

multivariate results are closer to the univariate results in Java. This may be because

58% of Indonesia’s population resides in Java 23

. It justifies the need to disaggregate

the data so that regional disparities are brought into focus.

It is known that differences in wealth index affect mothers utilizing ANC services 24-

27. Our univariate analyses reveals that mothers in richer and richest wealth quintiles

are two times more likely in Java, Sumatra and Kalimantan and three times more

likely in Sulawesi, Maluku and Western New Guinea islands to utilize ANC services

than those in the poorest wealth quintile.

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ANC services7.










and higher levels of education are positively associated with the use of safe delivery

services in Indonesia. Listening to radio/reading newspapers and magazines also

affects the use of safe delivery services positively.

Thus, in low-middle income countries, including Indonesia, access to safe delivery

services remains a great challenge32-33

. This along with the fact of low household

health insurance coverage and high out-of-pocket spending on health impedes

universal health coverage34

. These need to be corrected further because regional and

wealth inequalities affect maternal mortality and U5M in Indonesia.

Conclusion

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by ANC and safe delivery services. Poor utilization of these services is related to a

complex set of social and demographic factors that affect the use, accessibility,

affordability and perception about the need and utility of such services35-37

. While

being poor with no formal education was a deterrent to accessing ANC services, the

odds of utilizing ANC and safe delivery services were significantly less in the

Sulawesi, Maluku and Western New Guinea islands. This means that the areas

covered by trained nurses/midwives are increased and special incentives are offered to

train women social workers in the Sulawesi, Maluku and Western New Guinea

islands. The study recommends that disaggregated regional targets be set so as to

further reduce maternal mortality rates in Indonesia.

Competing Interests


Funding





Data Sharing



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Table 1: Socio-economic and demographic characteristics influencing utilization of ANC services according to regions in Indonesia, IDHS-2012.

Sumatra

region Java Region

Lesser Sunda

Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age(Years)

15-19 89(75.4) 92(90.2) 35(85.4) 77(82.8) 108(76.6) 20(66.7) 19(51.4)

20-24 550(71.8) 496(85.2) 187(70.6) 252(72.6) 362(59.9) 111(54.4) 90(36.3)

25-29 859(49.5) 659(58.1) 254(49.7) 271(47.6) 386(43.7) 113(36.8) 121(32.2)

30+ 1246(29.6) 1043(34.8) 371(29.1) 399(27.9) 669(23.4) 223(21.6) 143(15.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1189(44) 1529(48) 354(48.6) 434(44.3) 605(39.3) 179(33.9) 163(34.2)

Rural 1555(37.7) 791(46.5) 493(36.1) 565(38.7) 920(31.3) 288(27.6) 210(19.2)

P-value 0.001 0.32 0.001 0.005 0.001 0.009 0.001


No education 27(16.4) 13(21) 30(32.6) 13(13.1) 29(12.3) 5(12.5) 41(10.3)

Primary 691(31.3) 615(36.3) 271(32) 322(34.1) 466(25.6) 115(22.4) 85(18.1)

Secondary 1612(43.9) 1330(54.1) 433(46) 544(46.2) 790(40.3) 269(31.5) 181(31.7)

Higher 414(52.5) 332(55.2) 113(53.6) 120(54.8) 240(51.6) 78(47) 66(50.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 16(14.2) 15(27.3) 19(38.8) 14(18.7) 32(17.4) 6(16.7) 17(8.1)

Primary 753(3.3) 606(38.5) 280(35.3) 296(32.8) 514(28.1) 96(21.6) 70(17.4)

Secondary 1669(44.2) 1327(52.1) 422(43.1) 550(45.7) 765(38.3) 284(31.6) 217(28.8)

Higher 303(46.5) 341(53.8) 124(45.8) 139(53.9) 211(45.3) 78(41.5) 65(36.3)

P-value 0.001 0.001 0.002 0.001 0.001 0.001 0.001


Not working

outside home 1342(43.8) 1210(46.8) 319(42) 526(44.3) 811(34.8) 263(31.9) 201(30.1)

Skilled 814(42.3) 683(49) 241(45.8) 277(43.9) 453(39.6) 130(33.6) 106(36.3)

Agriculture 317(31.0) 82(38) 142(33.3) 119(28.6) 140(22.7) 45(18.3) 48(11.4)


P-value 0.001 0.008 0.001 0.001 0.001 0.001 0.001

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Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region



Not working 34(42) 29(42) 17(54.8) 7(28) 29(38.2) 21(38.9) 22(24.7)

Skilled work 844(45.8) 1042(49.4) 266(45.1) 354(46.6) 491(40.1) 155(35.4) 147(31.5)

Agriculture 764(34.9) 218(41.1) 228(32.4) 235(32.2) 443(27) 138(22.2) 97(14.8)


P-value 0.001 0.006 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 587(31.4) 186(35.8) 38(33.6) 328(35.3) 597(27.1) 191(24.2) 152(16.2)

Poorer 639(41.3) 352(45.7) 187(42.9) 268(41.7) 328(38.7) 103(29.9) 65(32.7)

Middle 604(45.5) 447(47.2) 131(46.0) 176(45.8) 253(38.2) 86(38.6) 68(38)

Richer 537(44.9) 611(50.3) 113(49.1) 121(47.5) 214(45.7) 61(40.9) 50(43.1)

Richest 377(43.6) 694(50.8) 108(48) 106(46.5) 133(44.5) 26(38.8) 28(37.8)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Frequency of listening to radio/reading newspaper/magazine

Not at all 222(30.2) 140(34.7) 242(34.5) 76(33) 165(22.3) 115(23.3) 124(15.2)



P-value 0.001 0.001 0.001 0.03 0.001 0.001 0.001

Birth order

1st 982(33.1) 964(40.6) 318(35.4) 407(36.9) 507(29.5) 145(26) 118(21.7)

2nd 863(44.8) 781(56.3) 236(41.8) 293(44.2) 438(37.5) 108(27.7) 90(23.5)

3rd

495(49) 337(56.7) 15(47.8) 159(46.2) 266(38.4) 95(36.3) 70(27.9)

4th 233(49.3) 107(46.3) 71(46.1) 75(44.6) 156(39.2) 47(31.3) 39(24.9)

5Th & above 171(37.3) 101(43.2) 72(44.4) 65(40.1) 158(31.9) 72(33.8) 56(23.9)

P value 0.001 0.001 0.001 0.004 0.02 0.46

Child status

Dead 38(10.2) 50(21.9) 25(16.2) 22(14.8) 36(10.1) 12(9.4) 206(11.7)

Alive 2706(41.9) 224(48.8) 822(42.4) 977(42.6) 1489(36.1) 455(31.5) 353(25.3)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Table 2: Univariate analyses of socio-economic and demographic factors influencing utilization of ANC services according to regions in

Indonesia, IDHS-2012


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age (Years)

15-19 1 1 1 1 1 1 1

20-24 0.83(0.53-1.3) 0.63(0.32-1.3) 0.41(0.17-1.02) 0.55(0.31-0.99) 0.46(0.30-0.70) 0.60(0.27-1.34) 0.54(0.27-1.08)

25-29 0.32(0.21-0.50) 0.15(0.08-0.3) 0.17(0.07-0.41) 0.19(0.11-0.33) 0.24(0.16-0.36) 0.30(0.13-.64) 0.45(0.23-0.89)

30+ 0.14(0.09-0.21) 0.06(0.03-0.11) 0.07(0.03-0.17) 0.08(0.05-0.14) 0.09(0.86-0.14) 0.14(0.06-0.30) 0.18(0.09-0.35)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.77(0.7-0.8) 0.94(0.84-1.06) 0.60(0.5-0.7) 0.8(0.67-0.93) 0.7(0.62-0.8) 0.74(0.6-0.93) 0.46(0.36-0.59)



Primary 2.3(1.5-3.5) 2.0(1.2-3.9) 0.97(0.6-1.5) 3.4(1.9-6.2) 2.5(1.6-3.7) 2.0(0.8-5.3) 1.9(1.3-2.9)

Secondary 4.0(2.6-6.1) 4.4(2.4-8.2) 1.8(1.1-2.8) 5.7(3.1-10.3) 4.8(3.2-7.2)) 3.2(1.2-8.3) 4.0(2.8-5.8)

Higher 5.6(3.7-8.7) 4.7(2.5-8.8) 2.4(1.4-3.9) 8.0(4.2-15.2) 7.6(5.0-11.7) 6.2(2.3-16.6) 8.9(5.6-14.4)



Primary 3.0(1.7-5.1) 1.7(0.9-3.0) 0.9(0.5-1.62) 2.1(1.2-3.9) 1.9(1.2-2.8) 1.4(0.6-3.4) 2.4(1.4-4.2)

Secondary 4.8(2.8-8.2) 2.9(1.6-5.3) 1.2(0.7-2.2) 3.7(2.0-6.6) 2.9(2.0-4.4) 2.3(1.0-5.6) 4.6(2.7-7.7)

Higher 5.3(3.8-9.2) 3.1(1.7-5.7) 1.3(0.7-2.5) 5.1(2.7-9.6) 3.9(2.6-6.0) 3.5(1.4-8.9) 6.4(3.6-11.5)


Not working outside home

1 1 1 1 1 1 1

Skilled 0.9(0.8-1.1) 1.1(0.9-1.2) 1.2(0.9-1.5) 1.0(0.8-1.2) 1.2(1.1-1.4) 1.1(0.8-1.4) 1.3(1.0-1.8)

Agriculture 0.6(0.5-0.7) 0.7(0.5-0.9) 0.7(0.5-0.8) 0.5(0.4-0.6) 0.5(0.4-0.7) 0.5(0.3-0.7) 0.3(0.2-0.4)


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Sumatra

Region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region




Skilled work 1.2(0.7-1.8) 1.3(0.8-2.2) 0.7(0.3-1.4) 2.2(0.9-5.4) 1.1(0.7-1.7) 0.9(0.5-1.5) 1.4(0.8-2.4)

Agriculture 0.7(0.5-1.2) 1.0(0.6-1.6) 0.4(0.2-0.8) 1.2(0.5-3.0) 0.6(0.4-1.0) 0.4(0.3-08) 0.5(0.3-0.9)


Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.5(1.3-1.8) 1.5(1.2-1.9) 1.5(1.2-1.9) 1.3(1.1-1.6) 1.7(1.4-2.0) 1.5(1.0-1.8) 2.5(1.8-3.5)

Middle 1.8(1.5-2.0) 1.6(1.3-2.0) 1.7(1.3-2.2) 1.6(1.2-2.0) 1.6(1.3-2.0) 2.0(1.4-2.7) 3.2(2.2-4.5)

Richer 1.8(1.5-2.1) 1.8(1.5-2.2) 1.9(1.4-2.6) 1.7((1.3-2.2) 2.3(1.9-2.8) 2.2(1.5-3.1) 3.9(2.6-5.9)

Richest 1.7(1.4-2.0) 1.9(1.5-2.3) 1.8(1.4-2.5) 1.6(1.2-2.0) 2.2(1.7-2.8) 2.0(1.2-3.3) 3.0(1.9-5.2)


Not at all 1 1 1 1 1 1 1



Birth order

1st 1 1 1 1 1 1 1

2nd

1.6(1.5-1.8) 1.9(1.6-2.0) 1.3(1.0-1.6) 1.4(1.1-1.6) 1.4(1.2-1.7) 1.0(0.8-1.5) 1.1(0.8-1.5)

3rd 1.9(1.7-2.2) 1.9(1.6-2.3) 1.7(1.3-2.2) 1.5(1.2-1.9) 1.5(1.2-1.8) 1.6(1.2-2.2) 1.4(1.0-2.0)

4th 2.0(1.6-2.4) 1.3(1.0-1.7) 1.6(1.1-2.2) 1.4(1.0-1.9) 1.6(1.2-1.9) 1.3(0.9-1.9) 1.2(0.8-1.8)

5Th & above 1.2(1.0-1.5) 1.1(0.8-1.5) 1.5(1.0-2.0) 1.1(0.8-1.6) 1.1(0.9-1.4) 1.5(1.0-2.0) 1.1(0.8-1.6)

Child status

Dead 1 1 1 1 1 1 1

Alive 6.3(4.4-8.8) 3.4(2.5-4.7) 3.8(2.5-5.9) 43(2.7-6.8) 5(3.5-7.1) 4.4(2.4-8.1) 2.6(1.6-4.1)

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Table 3: Socio-economic and demographic characteristics influencing utilization of safe delivery services according to regions in

Indonesia, IDHS2012.

Sumatra

Region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea Region


(3287)

Safe delivery

(2462)

Safe delivery

(890)

Safe delivery

(1031)

Safe delivery

(1558)

Safe delivery

(406)

Safe delivery

(437)

Age (Years)

15-19 90(76.2) 81(79.4) 34(82.9) 70(75.3) 89(63.1) 10(33.3) 18(48.6)

20-24 607(79.2) 474(81.6) 190(71.7) 238(68.6) 347(57.5) 101(49.5) 99(39.9)

25-29 1056(60.8) 740(65.2) 284(55.6) 288(50.6) 402(45.5) 111(36.2) 142(37.8)

30+ 1534(36.4) 1167(38.9) 382(29.9) 435(30.4) 720(25.2) 184(17.8) 178(19.6)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Place of Residence

Urban 1502(55.6) 1751(55) 418(57.4) 509(52) 707(45.9) 193(36.6) 216(45.3)

Rural 1785(43.2) 711(43.5) 472(34.6) 522(35.7) 851(28.9) 213(20.4) 221(20.3)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 30(18.2) 9(14.5) 24(26.1) 13(13.1) 19(8.1) 4(10) 31(7.8)

Primary 753(34.1) 569(33.5) 239(28.2) 293(31) 378(20.7) 61(11.9) 92(19.6)

Secondary 1972(53.8) 1469(59.7) 475(50.4) 578(49.1) 857(43.7) 256(30) 228(39.9)

Higher 532(67.4) 415(69.1) 152(72) 147(67.1) 304(65.4) 85(51.2) 86(66.2)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


No education 33(29.2) 16(29.1) 13(26.5) 13(17.3) 26(14.1) 3(8.3) 9(4.3)

Primary 817(35.87) 556(35.3) 253(31.9) 265(29.3) 454(24.8) 48(10.8) 66(16.4)

Secondary 2027(53.7) 1470(57.7) 463(47.3) 592(49.2) 814(40.7) 264(29.4) 272(36.1)

Higher 408(62.7) 418(65.9) 160(59) 161(62.4) 260(55.8) 88(46.8) 84(46.9)

P value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not working outside

home

1622(53) 1271(49.2) 353(46.5) 543(45.7) 849(36.5) 227(27.5) 241(36.1)

Skilled 998(51.8) 800(57.4) 283(53.8) 315(49.7) 508(44.4) 138(35.7) 138(47.3)

Agriculture 343(33.5) 66(30.6) 111(26.1) 107(25.7) 81(13.1) 26(10.6) 37(8.8)


P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Continued

Sumatra

region


Islands Region

Kalimanta

Region

Sulawesi

Region

Maluku

islands Region

Western New

Guinea Region


(3287)

Safe delivery

(2462)

Safe delivery

(890)

Safe delivery

(1031)

Safe delivery

(1558)

Safe delivery

(406)

Safe delivery

(437)


Not working 41(50.6) 31(44.9) 17(54.8) 10(40) 31(40.8) 23(42.6) 21(23.6)

Skilled work 1148(58.8) 1199(56.8) 321(54.4) 411(54.2) 572(46.7) 165(37.7) 199(42.6)

Agriculture 859(39.2) 211(39.8) 200(28.4) 200(27.4) 352(21.4) 84(13.5) 67(10.2)


P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Wealth Quintile

Poorest 662(35.4) 160(30.8) 265(28.9) 287(30.9) 499(22.6) 112(14.2) 162(16.2)

Poorer 757(48.9) 348(45.2) 196(45) 270(42) 339(40) 91(26.4) 79(39.7)

Middle 724(53.4) 480(50.7) 155(54.4) 204(53.1) 301(45.5) 95(42.6) 89(49.7)

Richer 655(54.8) 663(54.6) 138(60) 140(54.9) 262(56) 75(50.3) 71(61.2)

Richest 489(56.5) 811(59.3) 136(60.4) 130(57) 157(52.5) 33(49.3) 36(48.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001


Not at all 259(35.2) 137(33.9) 208(29.7) 65(28.3) 131(17.7) 90(18.2) 120(14.7)



P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Birth order

1st 1295(43.6) 1084(45.7) 387(43.1) 439(39.8) 598(34.6) 159(28.5) 153(28.2)

2nd

955(49.6) 820(59.1) 244(43.2) 292(44) 425(36.4) 99(25.4) 108(28.2)

3rd

565(55.9) 350(58.9) 142(45.2) 157(45.6) 250(36.1) 69(26.3) 74(29.5)

4th 263(55.6) 106(45.9) 63(40.9) 77(45.8) 147(36.9) 36(24) 48(30.6)

5Th

& above 210(45.9) 102(43.6) 54(33.3) 66(40.7) 138(27.8) 43(20.2) 54(23.1)

P-value 0.001 0.001 0.14 0.18 0.01 0.20 0.46

Child status

Dead 86(23.2) 80(35.1) 32(20.8) 31(20.8) 51(14.3) 12(9.4) 24(14)

Alive 3201(49.5) 2382(51.9) 858(44.2) 1000(43.6) 1567(36.5) 394(27.3) 413(29.6)

P-value 0.001 0.001 0.001 0.001 0.001 0.001 0.001

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Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku islands

Region

Western New

Guinea region


Age (Years)

15-19 1 1 1 1 1 1 1

20-24 1.2(0.8-1.9) 1.1(0.7-1.9) 0.5(0.2-1.2) 0.7(0.4-1.2) 0.8(0.5-1.2) 2.0(0.9-4.4) 0.7(0.4-1.4)

25-29 0.5(0.3-0.7) 0.5(0.3-0.8) 0.3(0.1-0.6) 0.3(0.2-0.6) 0.5(0.3-0.7) 1.1(0.5-2.5) 0.6(0.3-1.3)

30+ 0.2(0.1-0.3) 0.2(0.1-0.3) 0.1(0.04-0.2) 0.1(0.09-0.2) 0.2(0.1-0.3) 0.4(0.2-0.9) 0.3(0.1-0.5)

Place of Residence

Urban 1 1 1 1 1 1 1

Rural 0.6(0.5-0.7) 0.6(0.56-0.71) 0.4(0.3-0.5) 0.5(0.4-0.6) 0.5(0.4-0.5) 0.4(0.3-0.6) 0.3(0.2-0.47)



Primary 2.3(1.6-3.5) 3.0(1.5-6.0) 1.1(0.7-1.8) 3.0(1.6-5.4) 3.0(1.8-4.8) 1.2(0.4-3.5) 2.9(1.9-4.4)

Secondary 5.2(3.5-7.8) 8.7(4.0-17.7) 2.9(1.8-4.7) 6.4(3.5-11.6) 8.9(5.5-14.3) 3.9(1.4-11.0) 7.8(5.2-11.7)

Higher 9.3(6.1-14.2) 13.0(6.0-27.0) 7.3(4.0-12.7) 13.5(7.0-25.8) 21.6(13-35.8) 9.4(3.2-27.7) 23.0(13.7-38.7)



Primary 1.4(0.9-2.0) 1.3(0.7-2.4) 1.3(0.7-2.5) 2.0(1.1-3.7) 2.0(1.3-3.0) 1.3(0.4-4.5) 4.4(2.0-8.9)

Secondary 2.8(1.9-4.2) 3.3(1.8-5.9) 2.5(1.3-4.8) 4.6(2.5-8.5) 4.0(2.7-6.4) 4.6(1.4-15) 12.5(6.0-24.9)

Higher 4.0(2.6-6.3) 4.7(2.6-8.6) 4.0(2.0-7.9) 8.0(4.1-15.1) 7.7(4.9-12.0) 9.7(3.0-32) 20.0(9.0-40.8)



Skilled 1.0(0.9-1.1) 1.4(0.3-0.6) 1.3(1.1-1.7) 1.2(1.0-1.4) 1.4(1.2-1.6) 1.5(1.1-1.9) 1.6(1.2-2.0)

Agriculture 0.95(0.40-0.5) 0.5(0.3-0.6) 0.4(0.3-0.5) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.3(0.2-0.5) 0.2(0.1-0.2)

Unskilled/

others

0.60(0.5-0.7) 1.1(0.9-1.3) 0.7(0.5-0.9) 0.5(0.4-0.8) 0.7(0.6-0.9) 0.4(0.2-0.7) 0.2(0.1-0.3)

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Continued….

Sumatra

region


Islands Region

Kalimantan

Region

Sulawesi

Region

Maluku

islands Region

Western New

Guinea region




Skilled work 1.4(0.9-2.2) 1.6(1.0-2.6) 1.0(0.5-2.3) 1.2(1.0-1.4) 1.4(1.2-1.6) 0.8(0.5-1.4) 2.4(1.4-4.0)

Agriculture 0.6(0.4-0.9) 0.8(0.5-1.3) 0.3(0.2-0.7) 0.4(0.3-0.5) 0.3(0.2-0.3) 0.2(0.1-0.4) 0.4(0.2-0.6)


Wealth Quintile

Poorest 1 1 1 1 1 1 1

Poorer 1.7(1.5-2.0) 1.9(1.5-2.3) 2.0(1.6-2.5) 1.6(1.3-2.0) 2.3(1.9-2.7) 2.2(1.6-3.0) 3.4(2.4-4.7)

Middle 2.1(1.8-2.4) 2.3(1.8-2.9) 2.9(2.2-3.9) 2.5(2.0-3.0) 2.9(2.4-3.4) 4.5(3.0-6.3) 5.1(3.6-7.2)

Richer 2.2(1.9-2.6) 2.7(2.2-3.4) 3.7(2.7-5.0) 2.7(2.0-3.6) 4.4(3.5-5.4) 6.1(4.2-8.9) 8.2(5.4-12.2)

Richest 2.4(2.0-2.8) 3.3(2.6-4.0) 3.8(2.8-5.1) 3.0(2.2-4.0) 3.8(3.0-4.8) 5.9(3.5-10.0) 4.9(3.0-7.9)


Not at all 1 1 1 1 1 1 1

Less than once a

week

1.0(0.7-1.5) 2.6(1.7-3.9) 1.8(1.1-2.9) 2.5(1.2-5.3) 1.9(1.2-2.8) 5.6(2.2-14.6) 5.8(2.4-14.2)


Birth order

1st 1 1 1 1 1 1 1

2nd 1.3(1.1-1.4) 1.7(1.5-2.0) 1.0(0.8-1.2) 1.2(0.9-1.4) 1.1(0.9-1.3) 0.8(0.6-1.1) 1.0(0.7-1.3)

3rd 1.6(1.4-1.9) 1.7(1.4-2.1) 1.1(0.8-1.4) 1.3(0.9-1.6) 1.1(0.9-1.3) 0.9(0.7-1.2) 1.1(0.8-1.5)

4th 1.6(1.3-2.0) 1.0(0.8-1.3) 0.9(0.6-1.3) 1.3(0.9-1.8) 1.1(0.9-1.4) 0.8(0.5-1.2) 1.1(0.8-1.7)

5Th

& above 1.1(0.9-1.3) 0.9(0.7-1.2) 0.7(0.5-0.9) 1.0(0.7-1.5) 0.7(0.6-0.9) 0.6(0.4-0.9) 0.8(0.5-1.1)

Child status

Dead 1 1 1 1 1 1 1

Alive 3.3(2.5-4.2) 2.0(1.5-2.6) 3.0(2.0-4.5) 3.0(2.0-4.4) 3.5(2.6-4.7) 3.6(2.0-6.6 2.6(1.6-4.6)

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Table 5: Multivariate Analyses of selected socioeconomic predictors for complete ANC

coverage and safe delivery services in Indonesia.


Variable OR


Place of residence

Urban 1.0 1.0

Rural 1.02 0.95-1.10 0.58 0.86 0.80-0.92 0.001

Region

Sumatra 1 - - 1 - -

Java 1.50 1.32-1.59 0.001 0.99 0.90-1.08 0.80


Kalimantan 1.07 0.96-1.20 0.23 0.79 0.71-0.08 0.001

Sulawesi 0.76 0.70-0.83 0.001 0.56 0.51-0.61 0.001

Maluku Islands 0.56 0.49-0.64 0.001 0.30 0.26-0.35 0.001

Western New Guinea 0.46 0.40-0.54 0.001 0.44 0.38-0.51 0.001

Wealth quintile

Poorest 1 - - 1 -

Poorer 1.45 1.32-1.60 0.001 1.64 1.50-1.80 0.001

Middle 1.57 1.42-1.74 0.001 1.89 1.70-2.10 0.001

Richer 1.75 1.56-1.96 0.001 2.02 1.81-2.26 0.001

Richest 1.52 1.33-1.73 0.001 1.72 1.51-1.96 0.001



Primary 1.85 1.51-2.27 0.001 2.06 1.65-2.56 0.001

Secondary 2.94 2.40-3.63 0.001 3.98 3.19-4.97 0.001

Higher 6.20 4.87-7.85 0.001 10.37 8.06-13.3 0.001

Father’s education


Primary 1.50 1.18-1.90 0.001 1.16 0.91-1.47 0.24

Secondary 1.81 1.43-2.31 0.001 1.61 1.26-2.05 0.001

Higher 1.79 1.37-2.33 0.001 1.68 1.28-2.20 0.001

Frequency of listening to radio/reading news paper/magazine

Not all 1 1



• Mother’s age at childbirth, mother’s occupation, father’s occupation, birth order, and child

status are controlled in multivariate analyses.

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Figure 1. Flow chart of the process of selection of mothers' sample available for analyses of

ANC and Safe delivery services.

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Flow chart of the process of selection of mothers' sample available for analyses of ANC and Safe delivery services Figure 1

215x279mm (300 x 300 DPI)

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation

Reported on page

#

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 1

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 4-5

Objectives 3 State specific objectives, including any prespecified hypotheses 4-5

Methods

Study design 4 Present key elements of study design early in the paper 5

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

5

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 5-6

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic

criteria, if applicable

5-6

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

5-6

Bias 9 Describe any efforts to address potential sources of bias 5-6

Study size 10 Explain how the study size was arrived at 5-7

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen

and why

6

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 7

(b) Describe any methods used to examine subgroups and interactions N/A

(c) Explain how missing data were addressed 5-7

(d) If applicable, describe analytical methods taking account of sampling strategy N/A

(e) Describe any sensitivity analyses N/A

Results

Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, 7, See Figure 1

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confirmed eligible, included in the study, completing follow-up, and analysed

(b) Give reasons for non-participation at each stage 7, Figure 1

(c) Consider use of a flow diagram Figure 1

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and

potential confounders

7, 10-11

(b) Indicate number of participants with missing data for each variable of interest N/A

Outcome data 15* Report numbers of outcome events or summary measures 8-10, 11-13

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95%

confidence interval). Make clear which confounders were adjusted for and why they were included

Tables 2, 4 and 5

(b) Report category boundaries when continuous variables were categorized 6

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period N/A

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses N/A

Discussion

Key results 18 Summarise key results with reference to study objectives 14-16

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction

and magnitude of any potential bias

3

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results

from similar studies, and other relevant evidence

14-16

Generalisability 21 Discuss the generalisability (external validity) of the study results 16

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

16

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional

studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting.

The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of

Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-

statement.org.

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