Regional disparities in postnatal care among mothers aged 15-49 years old in Indonesia [version 1; peer review: 2 approved]

Background: In Indonesia, maternal mortality remains high, significantly 61.59% occur in the postnatal period. Postnatal care (PNC) provision is a critical intervention between six hours and 42 days after childbirth and is the primary strategy to reduce maternal mortality rates. However, underutilization of PNC in Indonesia still remains high, and limited studies have shown the regional disparities of PNC in Indonesia. Methods: This study aims to explore the gaps between regions in PNC service for mothers who have had live births during the last five years in Indonesia. This study was a secondary data analysis study using the Indonesian Demographic and Health Survey (IDHS) in 2017. A total of 13,901 mothers aged 15-49 years having had live births within five years were included. Chi-squared test and binary logistic regression were performed to determine regional disparities in PNC. Results: Results indicated that the prevalence of PNC service utilization among mothers aged 15-49 years was 70.94%. However, regional gaps in the utilization of PNC service were indicated. Mothers in the Middle of Indonesia have used PNC services 2.54 times compared to mothers in the East of Indonesia (OR = 2.54; 95% CI = 1.77-3.65, p<0.001). Apart from the region, other variables have a positive relationship with PNC service, including wealth quintile, accessibility health facilities, age of children, childbirth order, mother's education, maternal occupation, husband's age, and husband's education. Conclusion: Structured policies are needed to reduce gaps in areas with low service utilization. Developing innovative strategies to address PNC inequality in maternal services to improve maternal health is expected. Open Peer Review


Introduction
Maternal morbidity and mortality are a serious global health challenge. In 2019, the World Health Organization (WHO) revealed that 94% of maternal mortality occurred in low and middle-income countries, of which Indonesia is one (World Health Organization, 2019;World Health Organization et al., 2015). During 2000 and 2017, the maternal mortality ratio plunged by about 38% worldwide. Even with this decline, Sub-Saharan Africa and Southern Asia accounted for approximately 86% of maternal deaths worldwide. Southern Asia alone accounted for nearly one-fifth (58,000), which demonstrated the struggle to improve maternal health (World Health Organization, 2019;World Health Organization et al., 2015). In the Indonesia context, the government determined a target to reach an important goal of reducing maternal mortality rate to 102 per 100,000 live births in 2015 (Bappenas, 2015;Ministry of Health Republic of Indonesia, 2018). Despite the significant efforts to expand maternal health programmes, recent evidence showed that Indonesia was off-track to reach the Millenium Development Goals (MDGs) target by 2015. In 2015, maternal mortality deaths in Indonesia were three times higher than the MDGs target (Ministry of Health Republic of Indonesia, 2018;UNICEF & World Health Organization, 2015;World Health Organization et al., 2015). Hence, reducing maternal mortality ratio to less than 70 per 100,000 by 2030 as one of the Sustainable Development Goals (SDGs) target could be a critical challenge for Indonesia (UNICEF & World Health Organization, 2015;United Nations, 2017;World Health Organization, 2012).
Most maternal mortality deaths are preventable or treatable if skilled healthcare, such as midwives, is provided during the postnatal period. Critical interventions during the postnatal period must be delivered to prevent maternal mortality deaths (Lawn et al., 2016;World Health Organization et al., 2015). In the Indonesian setting, the cause of maternal mortality is predominantly due to postpartum haemorrhage, followed by indirect causes, such as heart disease, severe anaemia, malaria, HIV/ AIDS and hepatitis. Many factors have been linked to interventions of postpartum haemorrhage which cause emergency cases, and skilled health care required to respond effectively to emergencies (Adisasmita et al., 2015;Mahmood et al., 2018). However, PNC remains a critical intervention to reduce maternal deaths in Indonesia. A new health programme called EMAS (Expanding Maternal and Neonatal Survival), was implemented by the Indonesian government in 2012, focused on improving maternal health care. The programme aimed at ensuring that every woman has access to quality maternal healthcare, including childbirth assistance by skilled health personnel in healthcare facilities (a target of 2018 strategic plan: 82%), four visits of Antenatal care (ANC) (78% ), PNC, and providing ANC (87%). However, the national data revealed that utilization of PNC among 34 provinces in Indonesia remain varied and was considered lower compared to the childbirth assistance by skilled health personnel coverage. Socioeconomic, geographical, and demographic factors influence the underutilization of PNC. Current systematic reviews show that levels of education, poverty, and limitations of access to PNC services are common issues in low-and middle-income countries linked to inequities in the use of PNC services (Langlois et al., 2015).
In an Indonesia context, the national data in 2018 revealed that the average percentage of PNC visits for the first time in Indonesia was 93.3%. The highest percentage of visits occurred in Yogyakarta (99.6%) and the lowest percentage of visits was in Papua (56.3%). However, there were regional gaps in PNC visits across the provinces in Indonesia. Also, PNC utilization in rural areas was lower than urban areas in Indonesia (Kementerian Kesehatan Republik Indonesia, 2018;Ministry of Health Republic of Indonesia, 2018;Probandari et al., 2017). It is worth noting that 61.59 % of maternal mortality rates occurred during the postnatal period in Indonesia. Additionally, evidence shows that the quality of PNC is lower in most districts and cities among the Eastern Region in Indonesia. PNC must be performed a minimum of three times: within the first six hours to the third day after the delivery, from the fourth day to the 28th after the delivery and the 29th day to the 42nd day after childbirth. The standards of PNC including examination for vital signs; the apex of the uterus; lochia and other per vagina fluids; breasts and counselling for exclusive breastfeeding; provision of communication, information about and education of PNC, and family planning (Ministry of Health Republic of Indonesia, 2018;Probandari et al., 2017).
Several studies show that regional disparities in PNC occur in several countries. In Ethiopia, there were differences in each region and variations at regional levels at the utilization of PNC among women (Sisay et al., 2019). PNC service in Zambia was also reported to experience regional disparities (Jacobs et al., 2017). In the same vein, in Bangladesh, disparities in the utilization of maternal health services were also reported (Raheem et al., 2019). However, research focused on regional disparities on PNC among mothers aged 15-49 years old in Indonesia are not well investigated. This study was conducted to analyze the gap between regions in PNC service utilization among mothers aged 15 -49 years old who have had live births during the last five years in Indonesia. This study is significant because it can be a source of information and a reference regarding regional disparities in the utilization of PNC services in Indonesia. This research could complete a bigger picture for consideration in resolving disparities maternal services in Indonesia.

Methods
This study analyzed and reported unit data from the 2017 Indonesian Demographic Data Survey (IDHS) collected by the Inner City Fund (ICF). This study is part of the International Demographic and Health Survey (DHS) program. In this study, unit data consist of women aged 15-49 years old having had live births in the last five years preceding the survey.
The purpose of the cross-sectional study of the IDHS conducted by the ICF from July 24 to September 30, 2017 was to offer up-to-date projections of basic demographic and health indicators. The IDHS study demonstrates a broad overview of population problems in Indonesia.
We utilized the data conducted by the national and provincial representatives. This cross-sectional study represents 1,970 census blocks urban and rural areas in Indonesia. The census block obtained 59,100 female respondents aged 15-49 years old. The survey employed a two-stage stratified cluster sampling method. The first stage was the selection of several census blocks by systematic sampling proportional size. In the second stage, 25 ordinary households were selected with systematic sampling from the listing. In this study, a sample of 13,901 women aged 15-49 years from 34 provinces in Indonesia was analyzed. The inclusion criteria were taken from IDHS that included all women aged 15-49 years who had given birth in the last five years. The exclusion criteria were whether the variables incomplete or not available.

Ethical consideration
Ethical review boards approved ethical clearance for the Inner City Fund OCR Macro (number 45 CFR 46) and the national board review from the Ministry of Health of Republic Indonesia.
Before the survey, an informed consent was obtained from the respondents based on voluntary participation.

Variables
The dependent variable of this study was PNC visits. According to the recommendation of the Ministry of Health Republic of Indonesia, PNC must be performed at minimum three times: at the first six hours to the third day after the delivery, on the fourth day to the 28th after the delivery and the 29th day to the 42nd day after childbirth (Ministry of Health Republic of Indonesia, 2018). This data was based on the mother's perception of PNC utilization during the postnatal period. Independent variables analyzed in this study were the related geographic and socioeconomic factors, including a region of residence, the place of residence, wealth quintile, health insurance, access to health facility, age, gender, birth rank, education, and occupation.
The residence region was grouped as six regions, namely Sumatera, Jawa, Bali & Nusa Tenggara, Kalimantan, Sulawesi, Maluku & Papua, and of which were also categorized as West Indonesia, Middle Indonesia and East Indonesia. The place of residence was determined as rural and urban areas. The wealth quintile of households was set into five categories: poorest, poorer, middle, richer, and richest. The wealth quintile of households was scored based on wealth criteria (DHSProgram, 2016). Health insurance was divided into two categories, namely yes and no. Access to the health facility was categorized into two, namely difficult and not. Children's age was divided into five categories: less than one month, one month, two months, three months, four months. The gender of the child, namely female and male. Birth rank was categorized as first child, second, third, fourth and so on. Mother's age divided into six categories: 15-24, 25-29, 30-34, 35-39, 40-49, and 45-49, while husband's age divided into seven categories: 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80. Mother's and husbands' education levels were grouped into no education, primary, secondary, and higher education. Mother's and husband's occupation was divided into two categories: not working and working.

Statistical analysis
Data were analyzed using STATA version 16.0. The descriptive statistics method was also utilized for showing what kinds of data. Due to variables, the chi-square test was performed to determine variables correlated to the PNC utilization. Binary logistic regression was utilized to determine disparity in this study. Measurement of associations among variables was expressed as Odds Ratio (OR) and 95% Confidence Interval (CI). Significant variables were tested with a p-value of 0.05 and 95% CI, which are considered the disparity in PNC among mothers aged 15-49 years in Indonesia.

Results
A total of 13,901 women aged 15-49 years old with live births in the last five years preceding the survey were interviewed. Table 1 shows the bivariate analysis that there were ten categories among some variables associated with the utilization of PNC visits (p-value < 0.05). These variables include geographic factors, region, socio-economy (wealth quintile and access to the health facility), children (age of child and birth rank), mother factors (age, education and occupation), husband factors (age, education, and occupation). Residence, socioeconomic (health insurance ownership), child gender, mother's age and husband's occupation did not show associations with the utilization of PNC visits among mothers aged 15-49 years old in Indonesia (Table 1). More detail results can be found in Table 1. Table 2 shows that the least distribution of respondents is in the East of Indonesia. Nearly half of participants who live in the East of Indonesia did not use the PNC services. More than half of participants who live in the East of Indonesia was classified as lowest. Interestingly, most participants who live in the East of Indonesia stated that there was no problem with access to the health facility. More detail characteristics of participants can be found in Table 2. Table 3 reveals that nearly half of participants who live in Sumatera, Kalimantan, Maluku and Papua did not use the PNC service. The highest number of participants classified as lowest was found in Maluku & Papua. For health insurance ownership, more participants who live in Kalimantan did not have health insurance. The highest number participants having four and more children per household were found in Maluku & Papua (Table 3).
In multivariate analysis, the participants who live in the Middle of Indonesia utilized PNC services 2.54 times more than the participants who live in the West of Indonesia (OR = 2.54; 95% CI = 1.77-3.65). The participants who live in the East of Indonesia had 0.71 fewer odds than participants in Indonesia's West (OR = 0.71; 95% CI = 0.52-0.96). The participants who live in Java were 1.46 times more likely to use PNC services (OR = 1.46; 95% CI = 1.26-1.69) compared to participants living in Sulawesi (OR = 0.53; 95% CI = 0.35-0.80).   (Table 4). Details of the results of a multivariate analysis shown in Table 4.    Table 5.

Discussion
This study aimed to examine the gap across the region in Indonesia for PNC utilization among mothers aged 15-49 years old using the 2017 IDHS data sets. PNC has been the primary strategy to improve maternal health outcomes to reduce the high maternal mortality deaths in Indonesia. Therefore, assessing the regional disparities in PNC may provide evidence for the government to resolve discrepancies in maternal services in Indonesia. This study demonstrated that the prevalence of PNC service utilization among mothers aged 15-49 years was 70.94%. This finding was higher than other research in Sub-Saharan Africa, and Ethiopia with Abebo & Tesfaye (2018) and Tessema et al. (2020), respectively finding that 47.9% and 52.48% of women had used PNC service. An intertwined complex factor, such as the health system, maternal health policies, and socio-cultural variations across countries, may hinder women's use of the PNC service.
The findings in this study revealed the geographic influence on mothers for utilization of PNC service. Mothers who settled in the Middle of Indonesia had increased odds of using PNC service, while those which lived in the East of Indonesia had decreased odds. This result is congruent with previous research carried out in Ethiopia (Sisay et al., 2019). In Ethiopia, the geographic factor is correlated to the utilization of PNC service due to the region's level of development and location. Evidence in Indonesia shows that the socio-economic development, such as industrial, housing, public transportation, road facilities and health facilities in the East of Indonesia, lagged compared to the West of Indonesia (Ministry of Health Republic of Indonesia, 2018;Soewondo et al., 2019;Suparmi et al., 2018). Therefore, it is a call of action to provide equality in developing human resources and infrastructure to reduce the possibility of gaps.
Additionally, mothers who live in Java are 1.46 times more likely to use PNC services than mothers who live in Sulawesi where they are 0.53 less likely to utilize PNC services. Consistent with previous studies performed in Indonesia, Java has dominance development compared to other islands because this island is the centre of the Indonesian government (Laksono et al., 2020). The Java island oriented and centred development model has harmed maternal health outcomes in Indonesia (Bappenas, 2018). Natural resources, human resources and facilities must be equal throughout Indonesia, so the gap between islands could be minimized.  Mohan et al., 2017;Yunus et al., 2013). However, in this study we have found that, statistically, the odds ratio was quite similar between middle and richer households. Additionally, the previous study in other parts of Ethiopia demonstrated that sociodemographic factors, such as income, did not correlate with the use of PNC services (Angore et al., 2018). Mothers from richer households were more likely to access the PNC services. Ownerships of consumer goods at home, such as motorcycles and cars, may increase the risk at ease transportation, making them have no strain to access the health facility.
The present study showed that access to the health facility was correlated to PNC service in Indonesia. With mothers who thought that access to the health facility was not a problem, they had an odds ratio of 1.29 greater in using PNC service than mothers who considered access to the health facility difficult. Previous research conducted in Malawi has found a significant association between the health facility and the utilization of PNC services. Other Ethiopia studies have demonstrated that physical accessibility plays an essential variable in health service utilization (Kim et al., 2019;Tarekegn et al., 2014). Access to the health facility is related to the costs incurred, which is influenced by having transportation to the health facility, which is considered expensive. Long and shorter distances, better roads, and better public transportation may increase access to the health facility, primarily in Indonesia, with its massive gaps in development across the country (Bappenas, 2018).
In this study, mothers having children aged three months increased the likelihood to use PNC services about 1.43 times (OR = 1.43; 95% CI = 1.23-1.66) more than mothers with children aged four months (OR = 1.30; 95% CI = 1.12-1.51). A similar study in Nepal showed that PNC service utilization in the early postnatal period was most likely due to the motherhood transition period (Sanjel et al., 2019). The possible reason could be that mothers with fewer children, and younger children, may want information and petrified of complications during the postnatal period. In the Indonesia setting, the first neonatal examination (KN1) is carried out at 6-48 hours after baby is born, which is at the same time for the first PNC visit (KF1 To the best of our knowledge, this is the first study to examine the gaps across the region in utilization PNC service among mothers aged 15-49 years old in Indonesia, which is one of a country in Southeast Asia that contribute to the global burden of maternal mortality rates in the world. The strengths of our study that we utilized the national and provincial data representatives, which internationally standardized. However, we also note some limitations. The IDHS data analyzed in this study was collected using the cross-sectional method and mother's recall preceding survey prone to the possibility bias information.

Conclusion
This study reveals the gap across the region for PNC utilization among mothers aged 15-49 years old in Indonesia. This study's findings provide evidence to complete the bigger picture for the government to resolve discrepancies in maternal services in Indonesia. Structured policies are needed to reduce gaps in areas with low service utilization. Developing innovative strategies to address inequality in maternal services to improve maternal health is inescapable. Future research should explore the interregional gaps and factors that cause maternal health service utilization by using a different platform.

Data availability
Data used in this study is available online from the Indonesian 2017 Demographic and Health Survey (DHS) website under the DHS VII recode column. Access to the dataset requires registration and is granted only for legitimate research purposes. A guide for how to apply for dataset access is available at: https://dhsprogram.com/data/Access-Instructions. cfm. This is a very interesting study providing information of the utilization of PNC services in Indonesia. The authors have described the gaps across the region clearly. We can see which regions in Indonesia utilized more PNC service as well as other factors contributing to this utilization.

Open Peer Review
As this study using secondary data from Indonesian DHS in 2017, this situation might have changed now, perhaps it is good to add in the title the year of the survey.
In the method section, it is not very clear whether the authors explain the method used by the IDHS or the method for this study. The information provided in this section hinders the possibility of others to replicate this study. Need more detailed information, step-by-step of what the authors did in this method section. 1 In the variable, for example, the authors categorized the mothers' age into six groups however there is no reference of this categorizing whether using WHO definition or else. Need to provide more information regarding this section.
Statistical analysis is already clear and can be replicated. The description of the result also has been clear.
In the discussion part, the authors' explanation is very repetitive. Every paragraph has a similar pattern where it started from the finding, comparing with previous study and additional explanation. Although this pattern can be accepted, however somehow make this part very boring. The authors tend to start the statement with: this study inline with.... the result congruent with...consistent with previous study... If it's possible to change the pattern in every paragraph not only the word that is used. expertise to confirm that it is of an acceptable scientific standard.
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