Determinants of maternal healthcare service utilisation among Indonesian mothers: A population-based study

Study design

This population-based, cross-sectional study used nationally representative data from the IDHS in 2017. This survey is part of the International Demographic and Health Survey (DHS) program, and its details can be found on the DHS program website (see the data availability statement for more detail).

Study setting and population

The population in this study was households from 34 provinces (comprised of 12033 residential areas) in Indonesia. The IDHS collected data from July 24^th to September 30^th, 2017, using a two-stage stratified sampling method. The first stage was selecting census blocks based on the wealth index that resulted in 1,970 blocks. In the second stage, 25 ordinary households were chosen from each block with systematic sampling from the list. A total of 49,627 women of childbearing age met the 2017 IDHS criteria to be interviewed. In the present study, the inclusion criteria of respondents included mothers aged 15 to 49 years who had a live birth in the five years preceding the survey. The exclusion criteria were whether the variables incomplete or missing. Of these, a sample of 12,033 mothers from 34 provinces in Indonesia was analysed.

Variables

The outcome variable in this study comprised the three key MHC components, namely ANC visits, institutionalised INC, and PNC after delivery obtained from participants self-reportedly. The ANC visit was categorised under two levels: adequate (4 times or more) and inadequate (fewer than 4 times). Institutionalised INC defined as a delivery that occurred at a healthcare facility regardless of its types (clinic, public health centre, and hospital) and ownership (government-owned and private sector). The use of PNC refers to a health check for the mother after delivery. According to the Ministry of Health Republic of Indonesia, PNC has to be carried out at least three times within the first six hours to the third day after delivery, on the fourth day to 28^th after delivery, and the 29^th day to the 42^nd day after childbirth.

The explanatory variable in this study consisted of three categories that include mother’s sociodemographic factors, husband’s sociodemographic factors, and household-related factors. Under the category of mother’s sociodemographic factors, there were three variables, namely mother’s age in years (19-24, 25-34, and 35-49), mother’s occupational status (employed and not employed), mother’s educational level (primary, secondary, and higher). Three variables were under the category of husband’s sociodemographic factors consisted of an age gap with husband (younger/older than their husband), husband’s occupational status (employed and not employed), husband’s educational level (primary, secondary, and higher). In regard to household-related factors, in this category, there were three variables comprised the number of children (0, 1-3, and more than 3), household wealth index (richest, rich, middle, poor, and poorest), residential area (urban and rural), and access to a healthcare facility (problem and not), which refers to percentage of women who reported that they have serious problems in accessing health care for themselves when they are sick.

Statistical analysis

Data obtained from the DHS dataset were analysed using STATA version 16.0 (Stata Corp, College Station, TX, USA). Data were analysed using the descriptive statistics method, and results were presented as weighted frequencies and percentages. The adjusted odds ratios (OR; AOR) with 95% confidence interval (CI) of factors associated with MHC (ANC, INC, and PNC) were estimated by multivariate logistic regressions.

Ethical consideration

The DHS program provided approval to use the 2017 IDHS data, and the data set is publicly available on DHS’s website. The 2017 IDHS study protocol has been approved for ethical clearance from the national board review of the Ministry of Health of Republic Indonesia and Inner City Fund (ICF) Macro institutional review board (number 45 CFR 46). Before participants were interviewed, informed consent was sought by each interviewer.

Population characteristics

A total of 12,033 mothers were eligible for data analyses in this study. Table 1 presents the descriptive characteristics of the study population. A high proportion of mothers were aged from 25 to 34 years (55.26%), employed (50.08%), had secondary education (61.36%), and were predominantly younger than their husbands (81.45%). The majority of husbands were working (99.48%) and had received their secondary education (60.19%). In this study, the mothers had predominantly had 1 to 3 children (95.73%) in their household, considered themselves as rich (21.68%), mostly did not have a problem (89.83%) when accessing health facilities, and resided in the rural area (50.44%).

The proportion of maternal healthcare services utilization among Indonesian mothers

Figure 1 displays the proportion of Indonesian mothers’ maternal healthcare service utilisation in ANC, INC, and PNC. About 93.44% of mothers had adequate ANC visits (≥4 visits), while only 6.56% had inadequate ANC visits (<4 visits). Regarding institutionalised INC, 83.73% of mothers had delivered at the healthcare facility, whereas about 16.27% did not receive the delivery at the healthcare facility. In terms of the use of PNC, only 71.64% of mothers had the PNC after delivery.

Figure 1. The proportion of maternal healthcare services utilization.

Factors associated with maternal healthcare services utilization

The multivariate logistic regressions analysis revealed five determinant variables of ANC visits (Table 2). A higher odds of adequate ANC visits was found for mothers aged 35-49 years (AOR = 2.14; 95%CI = 1.55–2.94) and those aged 25-34 years (AOR = 1.48; 95%CI = 1.19–1.84) compared to mothers aged 15-24 years. Mothers who had employed husbands had a 2.91 (95%CI = 1.39–6.09) increased likelihood of having adequate ANC visits than those who were not working. Mothers with 1 to 3 children had 1.66 times (95%CI = 1.12–2.4) greater in having adequate ANC visits than mothers who do not have children. Compared to mothers who were in the poorest category, those who were in richest, rich, middle, and poor had 5.93 (95%CI= 3.81–9.20), 3.04 (95%CI= 2.18–4.25), 2.07 (95%CI = 1.56–2.75), and 1.87 (95%CI = 1.44–2.42) times likely to have adequate ANC visits respectively. Mothers who considered that access to the healthcare facility was not a problem had a 1.55 greater odds (95%CI = 1.20–2.02) of having adequate ANC visits than those who had problem accessing the healthcare facility.

Regarding institutionalised INC, five determinant variables were identified as statistically significant (Table 2). A higher odds of delivering at a healthcare facility was found for mothers who aged 35-49 years (AOR = 1.92; 95%CI = 1.52–2.43) and aged 25-34 years (AOR = 1.19; 95%CI = 1.01–1.41) compared to mothers aged 15-24 years. Mothers who had secondary education had 1.57 times higher chances of delivering at healthcare facilities (95%CI = 1.33–1.85) than those with primary education. Also, mothers who had husbands with secondary education had 1.20 times more chances to deliver at healthcare facilities (95%CI= 1.02–1.40) than those with primary education. Compared to mothers who were in the poorest category, those who were in richest, rich, middle, and poor were 9.22 (95%CI = 6.54–13.00), 3.44 (95%CI = 2.71 4.37), 2.57 (95%CI = 2.07–3.20), and 2.14 (95%CI = 1.79–2.56) times likely to deliver at a healthcare facility respectively. Moreover, mothers who resided in urban areas had a 2.44 greater odds (95%CI = 1.96–3.03) of delivering at a healthcare facility than those living in the rural area.

With regard to the use of PNC, seven determinant variables were identified as statistically significant (Table 2). A higher odds of PNC utilisation was found for mothers aged 35-49 years (AOR = 1.31; 95%CI = 1.09–1.58) and aged 25-34 years (AOR = 1.23; 95%CI = 1.06–1.43) compared to mothers aged 15-24 years. Mothers who were employed had 1.15 (95%CI = 1.03–1.27) times increased likelihood of utilising PNC after delivery than those who were not employed. Mothers who had husbands with secondary education had 1.20 times more chances to utilise PNC (95%CI = 1.05–1.37) than those with primary education. For mothers who had 1 to 3 children had 1.64 times (95%CI = 1.31–2.05) to use PNC than mothers who do not have children. Compared to mothers in the poorest category, those in the middle and rich categories were 1.30 (95%CI = 1.08–1.55) and 1.29 (95%CI = 1.07–1.56) times likely to use PNC. Also, mothers who considered that access to the healthcare facility was not a problem had a 1.23 greater odds (95%CI = 1.03–1.46) utilise PNC than those who thought that access to the healthcare facility had a problem. Moreover, mothers who resided in urban areas had 0.81 times (95%CI = 0.70–0.90) less chances of having PNC after delivery than those in rural areas.

Socio-structural determinant

The present study observed that numerous socio-structural factors were identified as determinants of MHC use. Socio-structural factors are those that generate or reinforce social stratification in the society and that define the individual socio-economic position.¹⁶ First, the household wealth index was identified to play a crucial role in determining utilisation of ANC visits, institutionalised delivery, and the use of PNC, which corresponded to other studies.^14,17 Well known as a structural factor, the wealth index influences mothers’ ability to seek healthcare services through multiple mechanisms, including commute, financial capacity, geographic accessibility, and ability to comprehend the context of such services.¹⁹ In doing so, those who are living in poverty condition are at risk for underutilised maternal health services. This finding warrants attention because 16.88% of mothers are in the poorest category, and 20.15% are in the poor at the present study. In order to improve the utilisation of MHC, health professionals need to reach and facilitate mothers who live in poverty.

Next, husband’s educational level emerged as the determinant factor for institutionalised delivery and the use of PNC after delivery. Husband’s education level may linked with better health awareness that may make the family aware and utilise healthcare services better.²⁰ Also, since the Indonesian culture adopted the patriarchy concept, the husband plays a major role in family decision-making. Subsequently, a husband with better education may lead the family to utilise MHC properly. Besides, husbands’ occupational status also determine the utilisation of ANC service. Husbands’ occupational status is thought to be linked with family income, which may later influence mothers’ ability to access ANC service.^21,22 The husbands who are working are probably relatively more economically prepared to face the mother’s needs during the pregnancy period.

This study identified the mother’s educational level associated with institutionalised delivery that was also supported by other studies.^17,23 Mothers who hold secondary education are prone to having delivery at the healthcare facility. This result is plausible since education is a marker for various factors that affect health-seeking behaviours. Compared to those with lower education levels, women with higher levels of education possess the level of health literacy required to make the right choices about their health and are better placed to overcome the cultural barriers to maternal health care use.^24,25 Moreover, low education can create a social distance between pregnant women and service providers, leading to poor quality client-provider interactions and discouraging services among women with low education.²⁶ Last, mother’s occupational status also has a role in determining PNC utilisation. This result aligns with previous studies, where the risk for underutilised PNC among working mothers was lower than mothers who were not employed.^14,17 The possible explanation is that working mothers can control their earnings, preventing them from suffering from financial hardship and increasing their independence to seek healthcare services.²⁷ However, it should be noted that attending PNC requires mothers to spare their time from work which could cost working mothers loss of their incomes. Thus, providing flexible service hours and the availability of maternity leave would help working mothers remove their barriers to accessing health services.

Intermediary determinant

The current study demonstrates that several intermediary factors determined the MHC utilisation among mothers. These factors directly shape individual health choices and outcomes through which the structural determinants operate. They span material circumstances, psychosocial circumstances, behavioral factors, and the health system.¹⁶ Age was an essential determinant factor for utilising ANC, institutional delivery, and PNC use among Indonesian mothers. Older mothers tend to utilised MHC correctly than younger mothers. This was thought because older mothers are more mature in appraising the benefit of using MHC. They know that ANC visit was necessary during pregnancy, delivery at a healthcare facility relative safe, and receiving PNC will be essential for mothers and babies.^28,29 This finding is important because Kurniati et al. found that about 32% of mothers give birth for the first time when they are younger than 19 years old.¹⁴ Therefore, developing effective policies for improving MHC among younger mothers is necessary.

The residential area was found as the determinant of institutionalised delivery and the use of PNC services. Mothers who settled in the urban area were more likely to give birth at healthcare facilities and unlikely to utilised PNC services. Regarding institutionalised delivery, those who resided in urban areas had the privilege of a broad range of choices and had better access to the facility that provides delivery care. Unlike the urban area, mothers who settled in the rural or countryside often face difficulties finding and reaching healthcare facilities because their residence area was relatively least developed.^23,30 Apart from that, we discovered that mothers who settled in urban areas were unlikely to utilise PNC services. This might be attributed to mothers’ misconceptions about insurance coverage. For instance, a previous qualitative study in Indonesia reported that some mothers thought national insurance could be used only for particular health care providers, such as the village midwife, and insurance cannot be used for PNC.³¹ This finding is not exclusive to Indonesia, as studies from other countries also demonstrated similar findings.^17,18,32 Thus, providing equal services for mothers who settle in urban and rural areas is warranted. In favour of access to the healthcare facility, mothers who thought there was no problem tend to have adequate ANC visits and used the PNC service. Mothers may perceive numerous aspects could be causes of accessibility problems to a healthcare facility. However, a few elements that often become problems are transportation, distance, medication, and treatment. More importantly, transportation and distance are classical problems in Indonesia, where infrastructures developed disproportionately across the country.³³ Such issues significantly hinder mothers from initiating ANC and receiving PNC.^34,35 Although approximately 89% of mothers thought there was no problem accessing healthcare facilities in the present study, we thought this remains important because mothers do not often speak up about this matter to the local health authority. Another possibility is related to the lack of awareness on the important of PNC services for the mother and baby. However, further scrutiny need to be done as low PNC services in urban area may be related to many barriers. Thus, more effort from the health professional to explore the unseen problem in utilizing healthcare facilities among mothers is necessary.

With regard to the number of children, we found it was a determinant of ANC and PNC among Indonesian mothers. Compared to mothers who do not have children, those who had 1 to 3 children were more likely to have adequate ANC visits and PNC use, which was aligned with past works.^15,17 This was thought that as mothers became more experienced in motherhood and had appropriate knowledge from previous maternal experiences, they were encouraged to use those services.^36,37 In other words, those who were in their first-time pregnancy or delivery were at risk for underutilised ANC and PNC. We recognised that this finding might become an opportunity for health professionals to empower experienced mothers to encourage first-time mothers to use MHC correctly. However, experimental studies are required to prove this idea.

The data of this population-based study were collected by government bodies that have authority in maternal health surveys, namely the Central of Statistics Agency and the National Population and Family Planning Board, Indonesia. Also, study’s findings are generated from a large sample size that tends to provide high statistical power. However, despite the strength of this study, the present study also has some limitations that should be considered. To begin with, the cross-sectional nature adopted in this study cannot be over-interpreted for implying causality. In addition, the answer given by mothers were self-reported and based on their recall preceding survey that has the potential to result in bias. Furthermore, this study used data from a nationally representative sample; hence, this finding may be generalised to Indonesian mothers only.