Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey

Background: Antenatal care aims to prevent maternal and perinatal mortality and morbidity. In Indonesia, at least four antenatal visits are recommended during pregnancy. However, this service has been underutilized. This study aimed to examine factors associated with underutilization of antenatal care services in Indonesia. Methods: We used data from Indonesia Demographic and Health Survey (IDHS) 2002/2003 and 2007. Information of 26,591 singleton live-born infants of the mothers’ most recent birth within five years preceding each survey was examined. Twenty-three potential risk factors were identified and categorized into four main groups, external environment, predisposing, enabling, and need factors. Logistic regression models were used to examine the association between all potential risk factors and underutilization of antenatal services. The Population Attributable Risk (PAR) was calculated for selected significant factors associated with the outcome. Results: Factors strongly associated with underutilization of antenatal care services were infants from rural areas and from outer Java-Bali region, infants from low household wealth index and with low maternal education level, and high birth rank infants with short birth interval of less than two years. Other associated factors identified included mothers reporting distance to health facilities as a major problem, mothers less exposed to mass media, and mothers reporting no obstetric complications during pregnancy. The PAR showed that 55% of the total risks for underutilization of antenatal care services were attributable to the combined low household wealth index and low maternal education level. Conclusions: Strategies to increase the accessibility and availability of health care services are important particularly for communities in rural areas. Financial support that enables mothers from poor households to use health services will be beneficial. Health promotion programs targeting mothers with low education are vital to increase their awareness about the importance of antenatal services. Background The proportion of child deaths occurring in the neonatal period-the first four weeks of an infants’ life, has been increasing worldwide [1,2]. Antenatal care, a pregnancy-related service provided to pregnant women by health professionals, is among the major interventions which aim to prevent neonatal deaths and maintain the health of women during pregnancy [3,4]. A review on interventions for neonatal survival demonstrated that up to 12% of neonatal deaths could be averted by the provision of antenatal care services at 90% coverage [3]. Antenatal care enables health professionals to identify potential risks for the pregnancy or for the delivery and to provide prompt treatment for women experiencing health problems during pregnancy [4]. Through this service, women will receive assistance in developing a birth plan and be prepared for parenting after the childbirth [4]. Other services provided include the provision of * Correspondence: [email protected] Sydney School of Public Health, Edward Ford Building (A27), University of Sydney, NSW 2006, Australia Full list of author information is available at the end of the article Titaley et al. BMC Public Health 2010, 10:485 http://www.biomedcentral.com/1471-2458/10/485 © 2010 Titaley et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tetanus Toxoid vaccinations, iron/folic acid supplements and control of nutritional deficiencies [3,5]. Observational studies from both developed and developing countries have shown a protective effect of antenatal care services on neonatal deaths [6-10]. Inadequate antenatal care has been associated with adverse pregnancy outcomes [6,8,11]. Furthermore, studies from India have shown that women who attended antenatal care services had an increased likelihood of using trained delivery attendants during childbirth, or having an institutional delivery [12,13]. In Indonesia, at least four antenatal visits are recommended during pregnancy [14,15]. Antenatal care is provided by health personnel through different modes of service delivery, including the facility based and outreach services. Descriptive data from the 2007 Indonesia Demographic and Health Survey (IDHS) [14] has shown that, as in other developing countries [16-19], antenatal care services in Indonesia are still underutilized. Approximately 95% of pregnant women in Indonesia attended at least one antenatal care visit; however only 66% of women had four antenatal visits as recommended, which is lower than the national target of 90% of women having at least four antenatal care visits [14]. The proportion of non-attendance at antenatal care services varied widely across provinces, ranging from 31% in Papua to less than 0.5% in DKI Jakarta [14]. This study therefore aimed to examine factors associated with underutilization of antenatal care services in Indonesia. The results should provide insights to policy makers about potential public health strategies to increase the uptake of antenatal care services. Methods Data sources We used data from the Indonesia Demographic and Health Survey (IDHS) 2002/2003 and 2007, which are openly available from the Measure DHS website [20]. The IDHS is a five-year periodic survey used to collect information from ever-married women aged 15-49 years and ever-married men 15-54 years about demographic and health status. Three types of questionnaires used were the Household, Women’s, and Men’s Questionnaire [20]. The Women’s questionnaire included questions about women’s demographic characteristics, their reproductive history, pregnancy, postnatal care, as well as immunization and nutrition. The sampling method of the IDHS has been reported in detail elsewhere [21]. A total of 62,378 eligible women were interviewed for these two surveys; 29,483 in the 2002/2003 survey [22] and 32,895 women in the 2007 survey [14]. The response rate of eligible women in the 2002/2003 and 2007 IDHS was 98% [22] and 96% [14], respectively. In the present study, information of 26,591 singleton live-born infants of the mothers’ most recent birth within five years preceding each survey was used. The most detailed health services information is available for a woman’s most recent birth. Furthermore, this restriction aimed to reduce recall bias of mothers about their pregnancies. Variables The primary outcome of this study was underutilization of antenatal care services which included infants whose mothers never attended antenatal care services and mothers attending less than the four recommended antenatal services [14,15]. Antenatal service referred to any pregnancy-related services provided by skilled health personnel, such as doctors, midwives, or village midwives. We excluded those antenatal care services provided by non-health professionals such as traditional birth attendants. A sensitivity analysis was also performed for infants whose mothers never attended any antenatal service for her last pregnancy within five years preceding each survey. We adapted the behavioural model framework of Andersen [23] for use of health services, to group the factors potentially associated with not attending antenatal care services (Figure 1). Twenty-three potential risk factors were identified and categorized into four main groups, external environment, predisposing, enabling and need factors. The variables included in the study are presented in Figure 1. A new household wealth index variable was constructed to rank households across the pooled IDHS data. Using a Principle Component Analysis method [24], weights were assigned to four housing characteristics (source of drinking water, type of toilet, main material of floor, main material of wall), and seven household assets (availability of electricity, possession of radio, television, fridge, bicycle, motorcycle, and car). A composite threecategory variable of household wealth index, i.e. rich, middle and poor, and maternal education level, was constructed to assess their association with the outcome. Statistical analysis Frequency tabulations were performed to describe the characteristics of infants included in this study. Logistic regression was used to determine factors associated with the outcome. Bivariate and multivariable analyses were conducted to assess the crude Odds Ratio (OR) and adjusted Odds Ratio (aOR), respectively. Using a hierarchical modelling strategy [25], the more distal factors were first entered into the model to assess their associations with the study outcome. Backward elimination procedure was then employed to remove factors which were not significantly associated with underutilization of antenatal services, using a significance level of 0.05. A variable that represented year of survey was retained in all models regardless of its significance level. Titaley et al. 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