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Wenang S, Emilia O, Wahyuni A, Afdal A, Haier J. Obstetrics care in Indonesia: Determinants of maternal mortality and stillbirth rates. PLoS One 2024; 19:e0303590. [PMID: 38968281 PMCID: PMC11226051 DOI: 10.1371/journal.pone.0303590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 04/04/2024] [Indexed: 07/07/2024] Open
Abstract
PROBLEM The Indonesian Healthcare Program starting in 2014 enabled access to healthcare delivery for large population groups. Guidance of usage, infrastructure and healthcare process development were the most challenging tasks during the implementation period. Due to the high social impact obstetric care and related quality assurance require evidence-based developmental strategies. This study aims for analysis of outcome and maternal health care utilization, as well as differences related to demographic and economic subgroups. METHODS For univariate group comparison ANOVA method was applied and combined with Scheffé procedure and Bonferoni correction for post-hoc tests. Meanwhile, multivariate approaches through regression analysis based on insurance reimbursement data antenatal, perinatal and postnatal care were performed at the province level. Maternal mortality (MMR) and stillbirth rates were used for outcome. Demographic characteristics, availability of obstetricians (SPOG), midwifes and healthcare infrastructure were included for their determinants. RESULTS Specialized hospital facilities (type A/B) for advanced care covered a large part of uncomplicated cases (~35%). Differences between insurance membership groups (poor, non-poor) were not seen. Availability of human resources (SPOG, midwifes) (R2 = 0.728; p<0.001) and rural setting (R2 = 0.288; p = 0.001) are correlated with reduced insufficient referral. Their presence within provinces was related to lower occurrence of complicated cases (R2 = 0.294; p = 0.001). However, higher SPOG rates within provinces were also related to high C-section rates (p<0.001). MMR and stillbirth rates can be predicted by availability of human resources and C-section rates explaining 49.0% of variance. CONCLUSIONS Improvement of perinatal outcome should focus on sufficient referral processes, availability of SPOG in provinces dominated by rural/remote demography and avoidance of overtreatment by high C-section rates. It is very important to regulate the education of obstetricians and gynecologists in Indonesia as well as distribution arrangements regarding to solve the problems with pregnancy complications in remote and rural areas.
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Affiliation(s)
- Supriyatiningsih Wenang
- Faculty of Medicine and Health Sciences, Department of Obstetrics and Gynecology, Universitas Muhammadiyah Yogyakarta, Kasihan, Indonesia
| | - Ova Emilia
- Faculty of Medicine, Department of Obstetrics and Gynecology, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Alfaina Wahyuni
- Faculty of Medicine and Health Sciences, Department of Obstetrics and Gynecology, Universitas Muhammadiyah Yogyakarta, Kasihan, Indonesia
| | - Andi Afdal
- BPJS (Social Insurance Administration Organization), Jacarta, Indonesia
| | - Joerg Haier
- Faculty of Medicine and Health Sciences, Department of Obstetrics and Gynecology, Universitas Muhammadiyah Yogyakarta, Kasihan, Indonesia
- Comprehensive Cancer Center Hannover, Hannover Medical School, Hannover, Germany
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Ipa M, Laksono AD, Aggraeni YM, Rohmah N. Factors Associated with the Place of Delivery among Urban Poor Societies in Indonesia. Indian J Community Med 2023; 48:888-893. [PMID: 38249692 PMCID: PMC10795872 DOI: 10.4103/ijcm.ijcm_798_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 09/27/2023] [Indexed: 01/23/2024] Open
Abstract
Background Pregnant women in urban poor societies are vulnerable groups. Due to low financial capacity, there are obstacles to accessing delivery in an institution for poor women in urban areas. The study analyses factors associated with the delivery place among pregnant women in urban poor society in Indonesia. Materials and Methods The study analyzed secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 1,562 samples were childbearing-age women (15-49 years) who gave birth in an urban poor society in Indonesia in the last 5 years. The study examined some variables, such as delivery place, age, education, employment, marital status, parity, insurance, knowledge of pregnancy danger, antenatal care (ANC), the autonomy of health, and family finance autonomy. The study employed binary logistic regression in the final stage. Results The results show that age is associated with the place of delivery. The higher the education, the higher the possibility for delivery in an institution. Being employed and having partners are protective factors for women in institution delivery. The likelihood of giving birth in a medical facility decreases as more children are born alive. In addition, having health insurance, thorough ANC visits, knowledge of pregnancy danger symptoms, and health autonomy are protective factors for pregnant women having deliveries in medical facilities. On the contrary, pregnant women who rely solely on family financing have a higher chance of delivering in a medical facility. Conclusion The study concluded that 10 variables were associated with pregnant women's delivery in Indonesia's urban poor society: age, education, employment, marital, parity, insurance, pregnancy danger knowledge, ANC, health autonomy, and family finance autonomy.
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Affiliation(s)
- Mara Ipa
- Research Centre for Public Health and Nutrition, Health Organization, The National Research and Innovation Agency, Indonesia
| | - Agung D. Laksono
- Research Centre for Public Health and Nutrition, Health Organization, The National Research and Innovation Agency, Indonesia
| | - Yusnita M. Aggraeni
- Research Centre for Public Health and Nutrition, Health Organization, The National Research and Innovation Agency, Indonesia
| | - Nikmatur Rohmah
- Faculty of Health Science, Universitas Muhammadiyah Jember, Indonesia
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Kusumawati N, Erlinawati E, Safitri Y, Nurman M, Erlin F. Exploring Women's Reasons for Choosing Home Birth with the Help of Their Untrained Family Members: A Qualitative Research. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2023; 11:72-84. [PMID: 37114100 PMCID: PMC10126444 DOI: 10.30476/ijcbnm.2023.97491.2186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Abstract
Background Home births with the help of untrained family members continue to be women's preference in Indonesia. However, the practice has received very little attention. The purpose of this study was to explore women's reasons for choosing home births with the help of their untrained family members. Methods This study used an exploratory-descriptive qualitative research approach and was conducted from April 2020 to March 2021 in Riau Province, Indonesia. A total of 22 respondents determined by data saturation was recruited using purposive and snowball samplings. The respondents consisted of 12 women who had at least one planned home birth with the help of their untrained family members, and 10 untrained relatives who had an experience in intentionally assisting their family member's home birth. Data were collected through semi-structured telephone interviews. Nvivo version 11 software was used for data analysis using the Graneheim and Lundman's content analysis. Results 13 categories and 4 themes emerged. The themes were living with fallacious beliefs in unassisted home childbirths, feeling of socially alienated from the surrounding communities, dealing with limited access to healthcare services, and escaping from childbirth-related stressors. Conclusion Home birth with the help of untrained family members takes place because of not only limited access to healthcare services, but also women's personal beliefs, values, and needs. Designing culturally sensitive health education, ensuring culturally competent healthcare workers and services, overcoming healthcare access barriers, and improving the community's pregnancy and childbirth literacies are fundamental in reducing unassisted home births and promoting facility childbirths.
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Affiliation(s)
- Nila Kusumawati
- Department of Nursing, Faculty of Health Sciences, Universitas Pahlawan Tuanku Tambusai, Riau Province, Indonesia
| | - Erlinawati Erlinawati
- Department of Midwifery, Faculty of Health Sciences, Universitas Pahlawan Tuanku Tambusai, Riau Province, Indonesia
| | - Yenny Safitri
- Department of Nursing, Faculty of Health Sciences, Universitas Pahlawan Tuanku Tambusai, Riau Province, Indonesia
| | - Muhammad Nurman
- Department of Nursing, Faculty of Health Sciences, Universitas Pahlawan Tuanku Tambusai, Riau Province, Indonesia
| | - Fitry Erlin
- Department of Nursing, STIKes Payung Negeri, Pekanbaru, Riau Province, Indonesia
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Aziz N, Liu T, Yang S, Zukiewicz-Sobczak W. Causal relationship between health insurance and overall health status of children: Insights from Pakistan. Front Public Health 2022; 10:934007. [PMID: 36568764 PMCID: PMC9768499 DOI: 10.3389/fpubh.2022.934007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
Evaluating the impact of health insurance always remains a methodologically challenging endeavor due to the absence of sample randomization. This paper evaluates the impact of health insurance on the health status of children in Pakistan using the data of the Multiple Indicator Cluster Survey (MICS) for Punjab, Pakistan, from 2017 to 2018. The study adopted the propensity score matching (PSM) method to address the sample selection bias. The sample is matched on potential covariates such as mother characteristics (education level), household head characteristics (gender, age, and education), and other household conditions (such as home dwelling, internet access, wealth index, migration member, number of children residing in the home, as child illness, etc.). The findings revealed that children with insurance have considerably better health than non-insured, at a 1% significance level. The results confirm that health insurance is not a luxury but a need that improves children's overall health. In this regard, governments should enhance and expand programs related to health insurance, especially for children. Health insurance programs will not only help poor people but also improve the overall infrastructure of health services in the country.
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Affiliation(s)
- Noshaba Aziz
- School of Economics, Shandong University of Technology, Zibo, China
| | - Tinghua Liu
- School of Economics, Shandong University of Technology, Zibo, China
| | - Shaoxiong Yang
- College of Economics and Management, Northwest A&F University, Xianyang, China
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Helmyati S, Wigati M, Hariawan MH, Safika EL, Dewi M, Yuniar CT, Mahmudiono T. Predictors of Poor Neonatal Outcomes among Pregnant Women in Indonesia: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14183740. [PMID: 36145116 PMCID: PMC9501636 DOI: 10.3390/nu14183740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: This study aimed to examine the association between maternal health behaviors and neonatal outcomes among the Indonesian population. Methods: Articles were collected from PubMed, EBSCO, ProQuest, DOAJ, and GARUDA. Funnel plots and Egger’s tests analyzed indications of publication bias. A Mantel–Haenszel random-effects model was used to see the overall effect size of exposures on outcomes. Heterogeneity was seen based on I2. Data collected from articles included the author, year of publication, location of the study, study design, number of samples, risk factors, and effect sizes. Results: We identified 24 relevant studies, including eight from the primary databases and 16 from an additional database. A total of 12 studies were included in the meta-analysis, examining the association between maternal health behaviors and neonatal outcomes. The pooled odds ratio (OR) for passive smoking and low-birth-weight (LBW) was 3.41 (95% CI: 1.75–6.63, I2 = 40%, four studies). The pooled OR for incomplete antenatal care (ANC) and LBW was 6.29 (95% CI: 2.11–18.82, I2 = 70%, four studies). The pooled OR for incomplete ANC and neonatal mortality was 2.59 (95% CI: 1.01–6.66, I2 = 93%, four studies). Conclusions: The results indicated that pregnant women with incomplete ANC had a higher risk of LBW and neonatal mortality, and those who were passively exposed to smoking had a higher risk of LBW. Further investigations are needed, considering the high heterogeneity found, and additional meta-analyses should be based on the variations of socio-demographic conditions.
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Affiliation(s)
- Siti Helmyati
- Department of Nutrition and Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Center for Health and Human Nutrition, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Correspondence:
| | - Maria Wigati
- Department of Nutrition and Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
- Center for Health and Human Nutrition, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Muhammad Hafizh Hariawan
- Nutrition Study Program, Faculty of Health Sciences, Universitas ‘Aisyiyah Yogyakarta, Yogyakarta 55592, Indonesia
| | - Erri Larene Safika
- Faculty of Public Health, Mulawarman University, Samarinda 75242, Indonesia
| | - Mira Dewi
- Department of Community Nutrition, Faculty of Human Ecology, IPB University, Bogor 16680, Indonesia
| | - Cindra Tri Yuniar
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, Institut Teknologi Bandung, Bandung 40132, Indonesia
| | - Trias Mahmudiono
- Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya 60115, Indonesia
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Astuti RD, Nugrohowati RNI. Impact evaluation of subsidized health insurance programs on utilization of healthcare facilities: evidence from Indonesia. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:315-331. [PMID: 35028789 DOI: 10.1007/s10754-021-09321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/06/2021] [Indexed: 06/14/2023]
Abstract
Despite subsidized health insurance has long been proclaimed by many countries including Indonesia, the variety of evaluation results showing that the optimization of benefits obtained by recipients is still questionable. The objective of this study is to analyze the impact of subsidized health insurance programs (ASKESKIN and JAMKESMAS) on the utilization of healthcare facilities in Indonesia. Data from two waves longitudinal data, the Indonesian Family Life Survey (IFLS), were analyzed using the propensity score matching method. This study found that in general, ASKESKIN and JAMKESMAS had very small impacts on the utility of healthcare facilities measured by outpatient and inpatient visits by program's beneficiaries. It implies that being subsidized health insurance holders does not necessarily encourage them to visit formal healthcare facilities. In addition, the comparison of average treatment effect on the treated (ATT) between ASKESKIN and JAMKESMAS also did not show any significant improvement even though the program had tried to be improved. The results of this study provide the basis for advising policy makers that there needs to revisit the effectiveness of subsidized health insurance program implementation.
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Affiliation(s)
- Riska Dwi Astuti
- Economics Department, Faculty of Business and Economics, Universitas Islam Indonesia, Yogyakarta, Indonesia.
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Liyanto E, Nuryana D, Cahyani RA, Utomo B, Magnani R. How well are Indonesia's urban poor being provided access to quality reproductive health services? PLoS One 2022; 17:e0265843. [PMID: 35413051 PMCID: PMC9004760 DOI: 10.1371/journal.pone.0265843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Accommodating the needs of Indonesia’s rapidly growing urban population is essential to reaching national reproductive health goals and international commitments. As in other rapidly urbanizing low- and middle-income countries, satisfying the needs of Indonesia’s urban poor is both a high priority and a significant challenge. In this study, we assessed both how being from urban poor or near-poor households affects the quantity and quality of family planning and maternal health services received and the extent to which differentials had narrowed during the 2012–2017 period. This time interval is significant due to the introduction of a national social health insurance scheme in 2014, establishing the foundation for universal health care in the country. Data from the 2012 and 2017 Indonesian Demographic and Health Surveys were analyzed using logistic and multinomial logit regression. Poverty status was measured in terms of urban household wealth quintiles. For family planning, although urban poor and near-poor women made different method choices than non-poor women, no substantial 2017 differences in contraceptive prevalence, unmet need for family planning or informed choice were observed. However, urban poor women and to a lesser extent near-poor women systematically lagged non-poor urban women in both the quantity and quality of maternal health services received in connection with recent pregnancies. Significant maternal health service gains were observed for all urban women during the study reference period, with gains for poor and near poor urban women exceeding those for non-poor on several indicators. While the deployment of pro-poor interventions such as the national social health insurance scheme is likely to have contributed to these results, evidence suggesting that the scheme may not be influencing consumer health-seeking behaviors as had been anticipated along with continued limitations in public health sector supply-side readiness resulting in service quality issues suggest that more will have to be done.
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Affiliation(s)
- Elvira Liyanto
- United Nations Population Fund, Indonesia Country Office, Central Jakarta, Indonesia
| | - Dewi Nuryana
- Knowledge Hub for Reproductive Health Indonesia, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Indonesia
| | - Restu Adya Cahyani
- Knowledge Hub for Reproductive Health Indonesia, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Indonesia
- * E-mail:
| | - Budi Utomo
- Knowledge Hub for Reproductive Health Indonesia, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Indonesia
| | - Robert Magnani
- Knowledge Hub for Reproductive Health Indonesia, Faculty of Public Health, Universitas Indonesia, Depok, West Java, Indonesia
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Seid A, Ahmed M. Association between health insurance enrolment and maternal health care service utilization among women in Ethiopia. BMC Public Health 2021; 21:2329. [PMID: 34969387 PMCID: PMC8719381 DOI: 10.1186/s12889-021-12105-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health insurance was considered as the third global health transition which can increase access to health care services by eliminating monetary obstacles to maternal health care use, particularly in emerging nations. Hence, this study aimed to assess the association between health insurance enrolment and maternal health care service utilization among women in Ethiopia. METHODS A cross-sectional study was conducted using the 2016 Ethiopia Demographic and Health Survey (EDHS) data set. About 4278 mothers who had delivered at least one child in the last five years of the survey were selected in the study. Multivariate logistic regression analysis was performed to measure the relationship between health insurance enrolment and maternal health care service utilization by controlling confounders An adjusted odds ratio with a 95% confidence interval and p-values < 0.05 were well-thought-out to state the imperative association. RESULTS The overall health insurance coverage among the women was 4.7%. About, 18.1% of women from households in the poorest wealth quantile had no health insurance coverage for maternal health care services. Moreover, 84% of women lived in a rural area did not enclose by health insurance. According to multivariate logistic regression, the likelihoods of ANC utilization were 1.54 times (AOR: 1.54; 95% CI: 1.06-2.25) higher among mothers who were enrolled in health insurance compared to their counterparts. In the same vein, the likelihoods of been attended by a skilled birth attendant were 1.84 times (AOR: 1.84; 95% CI: 1.1-3.08) higher among mothers who were enrolled in health insurance. CONCLUSIONS This study has shown that women enrolled in health insurance were associated with skilled delivery and recommended ANC utilization than women who did not enroll in health insurance. Health insurance enrolment enterprises must be available to all pregnant women, particularly those of poorer socioeconomic rank.
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Affiliation(s)
- Abdu Seid
- Department of Midwifery, Woldia University, Woldia, Ethiopia.
| | - Mohammed Ahmed
- Department of Public Health, Woldia University, Woldia, Ethiopia
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Pranata AK, Wahyudi AS, Handoyo L, Efendi F. Determinants of birthplace among middle-to lower-class women in Indonesia: A study using the Indonesian Demographic and Health Survey. PLoS One 2021; 16:e0259417. [PMID: 34714872 PMCID: PMC8555843 DOI: 10.1371/journal.pone.0259417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background One of the factors contributing to a high maternal mortality rate is the utilization of non-healthcare facilities as a birthplace for women. This study analyzed determinants affecting birthplace in middle-to lower-class women in Indonesia. Methods This study analyzed the 2017 Indonesian Demographic and Health Survey (IDHS) data. The total national sample size was 49,627 eligible women. Our sample included 11,104 women, aged 15–49, who had delivered babies and were of low-to-middle economic status. The type of survey dataset was individual record dataset. Data were analyzed with chi-square and multivariate logistic regression tests using Stata 16 software. Results About 64.99% middle to lower class women in Indonesia delivered in healthcare facilities. Women aged 45–49 (OR = 2.103; 95% CI = 1.13–3.93), who graduated from higher schools (OR = 2.885; 95% CI = 1.76–4.73), whose husbands had higher education (OR = 2.826; 95% CI = 1.69–4.74) and were employed (OR = 2.523; 95% CI = 1.23–5.17), who considered access to healthcare facilities was not a problem (OR = 1.528; 95% CI = 1.28–1.82), who had a single child (OR = 2.349; 95% CI = 1.97–2.80), and who lived in urban areas (OR = 2.930; 95% CI = 2.40–3.57) were determinants that significantly correlated with women giving birth in healthcare facilities. Conclusion This study provides insights for policymakers and healthcare centers in the community to strengthen access to healthcare services and devise health promotion strategies for pregnant mothers. Policy interventions designed for middle- to lower-class women should be implemented to support vulnerable groups.
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Affiliation(s)
| | | | - Lukman Handoyo
- Department of Nursing, Sekolah Tinggi Ilmu Kesehatan Widya Dharma Husada Tangerang, Tangerang, Banten, Indonesia
| | - Ferry Efendi
- Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
- * E-mail:
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Aryastami NK, Mubasyiroh R. Traditional practices influencing the use of maternal health care services in Indonesia. PLoS One 2021; 16:e0257032. [PMID: 34506525 PMCID: PMC8432883 DOI: 10.1371/journal.pone.0257032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background Maternal Mortality Ratio (MMR) in Indonesia is still high, 305, compared to 240 deaths per 100,000 in South East Asian Region. The use of Traditional Birth Attendance (TBA) as a cascade for maternal health and delivery, suspected to be the pocket of the MMR problem. The study aimed to assess the influence of traditional practices on maternal health services in Indonesia. Methods We used two data sets of national surveys for this secondary data analysis. The samples included 14,798 mothers whose final delivery was between January 2005 and August 2010. The dependent variables were utilization of maternal healthcare, including receiving antenatal care (ANC≥4), attended by skilled birth attendance (SBA), and having a facility-based delivery (FBD). The independent variables were the use of traditional practices, type of family structure, and TBA density. We run a Multivariate logistic regression for the analysis by controlling all the covariates. Results Traditional practices and high TBA density have significantly inhibited the mother’s access to maternal health services. Mothers who completed antenatal care were 15.6% lost the cascade of facility-based delivery. The higher the TBA population, the lower cascade of the use of Maternal Health Services irrespective of the economic quintile. Mothers in villages with a high TBA density had significantly lower odds (AOR = 0.30; CI = 0.24–0.38; p<0.01) than mothers in towns with low TBA density. Moreover, mothers who lived in an extended family had positively significantly higher odds (AOR = 1.33, CI = 1.17–1.52; p<0.01) of using maternal health services. Discussion Not all mothers who have received proper antenatal delivered the baby in health care facilities or preferred a traditional birth attendance instead. Traditional practices influenced the ideal utilization of maternal health care. Maternal health care utilization can be improved by community empowerment through the maternal health policy to easier mothers get delivery in a health care facility.
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Affiliation(s)
- Ni Ketut Aryastami
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Republic of Indonesia
- * E-mail:
| | - Rofingatul Mubasyiroh
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Republic of Indonesia
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Watson J, Yazbeck AS, Hartel L. Making Health Insurance Pro-poor: Lessons from 20 Developing Countries. Health Syst Reform 2021; 7:e1917092. [PMID: 34402399 DOI: 10.1080/23288604.2021.1917092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.
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Affiliation(s)
- Julia Watson
- International Development Division, Abt Associates Inc, Rockville, Maryland, USA
| | - Abdo S Yazbeck
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lauren Hartel
- International Development Division, Abt Associates Inc, Rockville, Maryland, USA
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Zahroh RI, Disney G, Betrán AP, Bohren MA. Trends and sociodemographic inequalities in the use of caesarean section in Indonesia, 1987-2017. BMJ Glob Health 2021; 5:bmjgh-2020-003844. [PMID: 33380412 PMCID: PMC7780721 DOI: 10.1136/bmjgh-2020-003844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Caesarean section (CS) rates are increasing globally. CS can be a live-saving procedure when medically indicated, but it comes with higher risks for women and newborns when done without medical indication. Crucially, inequalities in who receives CS exist, both within and across countries. Understanding factors driving increasing rates and inequalities of CS is imperative to optimise the use of this life-saving intervention. This study aimed to investigate trends of CS use and inequalities across sociodemographic characteristics in Indonesia over a 30-year period. METHODS Seven waves of the Indonesia Demographic and Health Survey were used to estimate trends and inequalities in CS from 1987 to 2017. Relative and absolute inequalities across a range of sociodemographic characteristics were estimated and trends in inequalities were assessed through changes in rate ratio and rate difference. RESULTS The proportion of facility-based births in Indonesia has increased in the past 30 years, coinciding with an increase in CS rate (CSR) (1991 CSR: 1.6% (95% CI 1.3 to 1.9); 2017 CSR: 17.6% (95% CI 16.7 to 18.5)). Higher rates of CS are observed mostly in Western Indonesia, while lower CSRs are observed in Eastern Indonesia. Inequalities of CSRs in Indonesia are observed across type of health facility (public/private), regions, places of residence, wealth quintiles and maternal education, with the highest CSRs in more affluent and educated groups. Widening absolute inequalities of CS are observed across all sociodemographic characteristics, except facility type, where CSR gaps between public and private facilities have closed on both relative and absolute scales. CONCLUSION This study provides evidence of increasing trends in CSRs and widening absolute inequalities in CSRs across different sociodemographic groups of women in Indonesia. The context of increasing CSRs across society, however, may have resulted in more stable relative inequalities. Improving understanding of the drivers of these trends in Indonesia and, particularly, of women's and providers' perspectives and preferences for childbirth, should be prioritised to optimise the use of CS.
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Affiliation(s)
- Rana Islamiah Zahroh
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - George Disney
- Disability and Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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13
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Widayanti AW, Green JA, Heydon S, Norris P. Health-Seeking Behavior of People in Indonesia: A Narrative Review. J Epidemiol Glob Health 2021; 10:6-15. [PMID: 32175705 PMCID: PMC7310809 DOI: 10.2991/jegh.k.200102.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 12/21/2019] [Indexed: 11/01/2022] Open
Abstract
This review aims to locate existing studies on health-seeking behavior of people in Indonesia, identify gaps, and highlight important findings. Articles were retrieved from Medline, Scopus, Web of Science, Academic Search Complete (via Ebsco), and ProQuest with a number of key words and various combinations. Articles from Indonesian journals were also searched for with Google Scholar. A total of 56 articles from peer-reviewed journal databases and 19 articles from Indonesian journals were reviewed. Quantitative designs were applied more frequently than qualitative, and mixed methods designs were used in some studies. The majority gathered retrospective information about people's behaviors. Communicable diseases and maternity care were the most frequently studied conditions, in contrast to noncommunicable diseases. In terms of geographical distribution, most research was conducted on Java island, with very few in outside Java. Important findings are a model of Indonesian care-seeking pathways, an understanding of determinants of people's care choices, and the role of sociocultural beliefs. The findings from this narrative review provide insight to what and how Indonesians make decisions to manage their illness and why. This makes an important contribution to understanding the problem of underutilization of medical services despite the government's extensive efforts to improve accessibility.
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Affiliation(s)
- Anna Wahyuni Widayanti
- School of Pharmacy, University of Otago, Dunedin, New Zealand.,Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - James A Green
- School of Pharmacy, University of Otago, Dunedin, New Zealand.,School of Allied Health and Physical Activity for Health, Health Research Institute (HRI), University of Limerick, Limerick, Ireland
| | - Susan Heydon
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Pauline Norris
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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14
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Anindya K, Lee JT, McPake B, Wilopo SA, Millett C, Carvalho N. Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis. J Glob Health 2021; 10:010429. [PMID: 32566167 PMCID: PMC7298736 DOI: 10.7189/jogh.10.010429] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Reducing inequality in maternal, neonatal and infant mortality are key targets in the Sustainable Development Goals. This study is the first to evaluate the impact of Indonesia’s national health insurance scheme, Jaminan Kesehatan Nasional (JKN), on access to maternal health services by sociodemographic status. Methods Using data from the 2017 Indonesia Demographic and Health Survey (IDHS) on women with live births in 2016-2017, we conducted propensity score matching (PSM) analysis to evaluate the association of JKN enrollment on the following maternal health care utilisation outcomes: (1) at least four antenatal care (ANC4+) visits; (2) ANC4+ visits and received essential components of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the national level and by economic subgroup and region of residence. Additionally, we investigated the potential negative impact of JKN on access to maternal health services among the uninsured population by looking at trends over time using data from the 2012 and 2017 IDHS. Results Of the 5429 women who had recently given birth, 61% were insured by JKN in 2017. After matching treated and untreated women on key sociodemographic characteristics, enrollment in JKN was associated with a higher prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI) = 4.8-9.39); ANC4+ visits and received essential components of ANC (5.6%, 95% CI = 3.3-7.9); skilled birth attendance (3.0%, 95% CI = 1.5-4.5; facility-based delivery (10.2%, 95% CI = 7.5-12.7); PNC (4.0%, 95% CI = 2.2-5.7); PNC with skilled provider (4.5%, 95% CI = 2.6-6.5). Effect sizes were larger among the poor and those living in less-developed areas, such as Eastern Indonesia and Sulawesi, except for at least ANC4+ and received clinical components. Conclusions Expansion of health insurance coverage was associated with reductions in sociodemographic inequalities in access to maternal health services in Indonesia. However, large differences in utilisation persist across regions and by economic subgroup. Accelerating progress toward universal health coverage may reduce health inequalities in other low and middle-income countries.
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Affiliation(s)
- Kanya Anindya
- School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Tayu Lee
- Nossal Institute for Global Health, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Siswanto Agus Wilopo
- Center for Reproductive Health and Department of Biostatistics, Epidemiology and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Christopher Millett
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Natalie Carvalho
- Centre for Health Policy & Global Burden of Disease Group, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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15
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Solanke BL. Do the determinants of institutional delivery among childbearing women differ by health insurance enrolment? Findings from a population-based study in Nigeria. Int J Health Plann Manage 2021; 36:668-688. [PMID: 33438771 DOI: 10.1002/hpm.3112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/24/2020] [Accepted: 12/22/2020] [Indexed: 11/12/2022] Open
Abstract
Studies in Nigeria have identified several individual and contextual determinants of institutional delivery among childbearing women. However, it is not clear in literature whether these determinants are peculiar to women who enrolled or do not enrolled in health insurance schemes. This study compares the determinants of institutional delivery among childbearing women who either enrolled or do not enrolled in health insurance schemes in Nigeria. The study was based on women's data from the 2018 Nigeria Demographic and Health Survey. A weighted sample size of 17,465 women was analysed. Stata 14 was used to perform data analysis. Three binary logistic regression models were estimated. Results show higher prevalence of institutional delivery among women who enrolled in health insurance (39.3% vs. 70.5%). Result further reveal differences in the determinants of institutional delivery among the women with sex of head of household (adjusted odds ratio [AOR] = 1.340, p < 0.05; 95% CI: 1.121-1.602), type of marriage (AOR = 0.817, p < 0.05; 95% CI: 0.727-0.918) and status of most recent delivery (AOR = 0.703, p < 0.001; 95% 95% CI: 0.631-0.781) showing significance among women not enrolled in health insurance but insignificant among women enrolled in health insurance. Differences in determinants of institutional delivery among the women may be attributed to differences in their socio-demographic condition.
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Affiliation(s)
- Bola Lukman Solanke
- Department of Demography and Social Statistics, Faculty of Social Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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16
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Do justice and trust affect acceptability of Indonesian social health insurance policy? INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2020. [DOI: 10.1108/ijhg-05-2019-0028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to investigate whether justice, trust in healthcare services, the confidence level of the health system and institutions, political party support and evaluation of healthcare services post-Jaminan Kesehatan Nasional (JKN) affected policy acceptability (PA) in the health workers (n=95) and laypeople (n=308) sample.Design/methodology/approachThe authors performed a two-level, linear mixed-effects model to test the hypothesis that trust, perceived justice, confidence in healthcare services and national health system evaluation could impact PA in the health workers and laypeople sample. The authors calculated the effect sizes by comparing Level 2 variances and residuals of the null model and the random intercept model.FindingsThe findings suggested that healthcare workers with high concern for justice would be more likely to hold negative acceptability to JKN. The findings implied that health workers tend to associate JKN with unfairness. Also, JKN acceptability in laypeople sample was found to be positively associated with the evaluation of healthcare service post-JKN, whereas justice or political party support did not affect JKN acceptability. It might indicate that laypeople motives for joining JKN scheme could be essentially pragmatic.Research limitations/implicationsThe authors administered the questionnaire using an online platform and circulated it through social media and IMS, so that this research poses a problem of self-selection bias, which potentially leads to biased estimates. The authors also oversampled female participants, especially in laypeople sample.Originality/valueAiming at universal health coverage in 2019, JKN will cover almost 300m Indonesians and be one of the biggest single-payer national health insurance scheme in the world. The research might offer insight into how health workers and laypeople respond to the policy.
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17
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Diba F, Ichsan I, Muhsin M, Marthoenis M, Sofyan H, Andalas M, Monfared I, Richert K, Kaplan L, Rogge L, Doria S, Samadi S, Vollmer S. Healthcare providers' perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study. BMJ Open 2019; 9:e031484. [PMID: 31818837 PMCID: PMC6924809 DOI: 10.1136/bmjopen-2019-031484] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia. DESIGN With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility. SETTING In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered. PARTICIPANTS Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys. PRIMARY AND SECONDARY OUTCOME MEASURES The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district. RESULTS Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities. CONCLUSIONS The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.
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Affiliation(s)
- Farah Diba
- Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
| | - Ichsan Ichsan
- Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
| | - Muhsin Muhsin
- Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
| | | | - Hizir Sofyan
- Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
| | | | - Ida Monfared
- Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Katharina Richert
- Centre for Evaluation and Development, Mannheim, Germany
- Department of Economics, University of Mannheim, Mannheim, Baden-Württemberg, Germany
| | - Lennart Kaplan
- Deutsches Institut für Entwicklungspolitik, Bonn, Nordrhein-Westfalen, Germany
| | - Lisa Rogge
- Leibniz University Hanover, Hannover, Niedersachsen, Germany
| | - Siobhan Doria
- Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Samadi Samadi
- Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
| | - Sebastian Vollmer
- Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
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18
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Rizal MF, van Doorslaer E. Explaining the fall of socioeconomic inequality in childhood stunting in Indonesia. SSM Popul Health 2019; 9:100469. [PMID: 31485478 PMCID: PMC6715956 DOI: 10.1016/j.ssmph.2019.100469] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 08/11/2019] [Accepted: 08/14/2019] [Indexed: 11/27/2022] Open
Abstract
In spite of the enormous economic progress and development witnessed in Indonesia in the last few decades, still more than 30% of Indonesian children under the age of five suffer from stunting, or low height for age. This concern is exacerbated by the fact that stunting remains more concentrated among the poorer households, leading to further intergenerational transmission of poverty and ill health. We examine recent trends in the evolution of the prevalence of childhood stunting and severe stunting, its socioeconomic inequality and the factors that appear to have contributed to these developments. Using the two most recent waves of the Indonesia Family Life Survey (IFLS), we study the changes in the prevalence of (severe) stunting between 2007 and 2014 for children aged 0-59 months and their socioeconomic-inequality using the Erreygers Concentration Index (EI) and its regression-based decomposition. We find a significant drop in the rate of severe stunting but not in stunting, as well as a significant reduction in the degree of absolute inequality of stunting. A decomposition analysis shows that household wealth, maternal education, institutional delivery, and availability of adequate sanitation contribute most to socioeconomic inequality in under-five stunting. Further analysis of the change in inequality over time indicates that the reduction in the association of wealth with stunting and a substantial improvement of health care access of the poor (as proxied by immunizations and institutional deliveries) play the most important role in narrowing the stunting gap between richer and poorer kids. General economic growth, poverty reduction, and implementation of pro-poor health and social programs during the studied period such as the expansion of health insurance coverage for the poor (Jamkesmas) and Conditional Cash Transfer program (Program Keluarga Harapan, PKH) are some plausible explanations of the observed result.
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Affiliation(s)
- Muhammad Fikru Rizal
- Center for Health Financing Policy and Health Insurance Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Eddy van Doorslaer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Applied Economics, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
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19
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Pedrana A, Qomariyah SN, Tholandi M, Wijayanto B, Gandawidjaja T, Amelia D, Apriatni M, Sudirman S, Zazri A, Sethi R, Emerson M, Ahmed S. Assessing the effect of the Expanding Maternal and Neonatal Survival program on improving stabilization and referral for maternal and newborn complications in Indonesia. Int J Gynaecol Obstet 2019; 144 Suppl 1:30-41. [DOI: 10.1002/ijgo.12733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alisa Pedrana
- Disease Elimination Program; Burnet Institute; Melbourne Vic. Australia
| | | | | | | | | | - Dwirani Amelia
- Research and Development Unit; Budi Kemuliaan Health Institute; Jakarta Indonesia
| | | | | | - Ali Zazri
- Jhpiego Indonesia; Jakarta Indonesia
| | | | - Mark Emerson
- Bloomberg School of Public Health; Johns Hopkins University; Baltimore MD USA
| | - Saifuddin Ahmed
- Bloomberg School of Public Health; Johns Hopkins University; Baltimore MD USA
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20
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Harahap NC, Handayani PW, Hidayanto AN. Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.100184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Widyaningsih V, Khotijah, Balgis. Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia. Glob Health Action 2018. [PMID: 28649930 PMCID: PMC5496086 DOI: 10.1080/16549716.2017.1339534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem. Objective: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity. Methods: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762). Results: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia. Conclusion: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.
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Affiliation(s)
- Vitri Widyaningsih
- a Faculty of Medicine , Universitas Sebelas Maret , Surakarta , Indonesia
| | - Khotijah
- a Faculty of Medicine , Universitas Sebelas Maret , Surakarta , Indonesia
| | - Balgis
- a Faculty of Medicine , Universitas Sebelas Maret , Surakarta , Indonesia
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22
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Jacobs C, Michelo C, Moshabela M. Why do rural women in the most remote and poorest areas of Zambia predominantly attend only one antenatal care visit with a skilled provider? A qualitative inquiry. BMC Health Serv Res 2018; 18:409. [PMID: 29871624 PMCID: PMC5989442 DOI: 10.1186/s12913-018-3212-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While focused antenatal care (ANC) has served as an entry point in the continuum of care for both mothers and children, fewer than a third of pregnant women in the most remote and poorest communities of Zambia achieve the four ANC visits recommended by the World Health Organization. Current evidence suggests that attending ANC provided by a skilled healthcare worker at least once is common and associated with skilled birth attendance. The aim of this study was to explain why one ANC visit with a skilled provider seemed more common than four ANC visits among women in the remote and poorest districts of Zambia. METHODS A qualitative case study design was conducted in 2012 among 84 participants in the selected remote and poorest districts of Zambia. Focus group discussions were conducted with mothers and community health volunteers, while key informant interviews were conducted with healthcare providers. Thematic analysis was conducted. RESULTS Most women delayed starting antenatal care visits due to uncertainties about the timing for initiation of ANC and due to waiting for confirmation of the pregnancy by an elderly woman. Attendance of ANC once with a skilled provider was due to the need to assess their health status and that of their baby. In some facilities, attendance of ANC at least once was enforced by financial charges imposed on women for late ANC initiation, and/or incentives provided by nongovernmental organisations. Unavailability of services at health posts closest to these remote communities led to failure to return for subsequent ANC visits. Women's livelihoods such as nomadic lifestyles made it harder for them to initiate and make additional ANC visits. CONCLUSION The popularity of ANC attendance once by a skilled provider among the remote and poorest women of Zambia was explained through perceived unavoidable social and economic barriers to care, and the punitive and incentive procedures implemented by health services. Maximising comprehensive care by skilled healthcare workers in the one visit a woman makes at the health facility, may lead to optimal utilisation of quality focused ANC. Enhancing community-based interventions may increase the potential to reach the vulnerable populations.
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Affiliation(s)
- Choolwe Jacobs
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa. .,School of Public Health, Department of Epidemiology & Biostatistics, Section for Surveillance & Disease Control, University of Zambia, Lusaka, Zambia. .,Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia.
| | - Charles Michelo
- School of Public Health, Department of Epidemiology & Biostatistics, Section for Surveillance & Disease Control, University of Zambia, Lusaka, Zambia.,Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
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23
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Boatin AA, Schlotheuber A, Betran AP, Moller AB, Barros AJD, Boerma T, Torloni MR, Victora CG, Hosseinpoor AR. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 2018; 360:k55. [PMID: 29367432 PMCID: PMC5782376 DOI: 10.1136/bmj.k55] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide an update on economic related inequalities in caesarean section rates within countries. DESIGN Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. SETTING 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time. PARTICIPANTS Women aged 15-49 years with a live birth during the two or three years preceding the survey. MAIN OUTCOME MEASURES Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change. RESULTS National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries. CONCLUSIONS Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.
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Affiliation(s)
- Adeline Adwoa Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Schlotheuber
- Department of Information, Evidence and Research, World Health Organization, Geneva, 1211, Switzerland
| | - Ana Pilar Betran
- HRP-UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ann-Beth Moller
- HRP-UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ties Boerma
- Countdown to 2030 for Women's, Children's and Adolescents' Health; and Center for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Maria Regina Torloni
- Evidence Based Healthcare Post Graduate Program, São Paulo Federal University, São Paulo, Brazil
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ahmad Reza Hosseinpoor
- Department of Information, Evidence and Research, World Health Organization, Geneva, 1211, Switzerland
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