Antenatal care in Indonesia: a nationwide study

One of the targets of the sustainable development goals is to reduce maternal mortality to less than 70 per 100 000 live births and neonatal mortality to less than 12 per 1000 live births by 2030 through optimisation of antenatal care (Lattof et al, 2020). Antenatal care includes screening for complications during early pregnancy to reduce morbidity and mortality (Moller et al, 2017). Mothers' and babies' quality of life can be optimised by integrating antenatal care services to prevent, detect and treat complications during pregnancy. In addition, antenatal care provides holistic care for and evaluation of the mother's and baby's health status, as well as lifestyle risks specific to pregnant women (World Health Organization (WHO), 2014).

Globally, high rates of maternal mortality and child health problems can be attributed to low antenatal care attendance (Barreix et al, 2020). Existing data on low- and middle-income countries show an increase in newborn mortality among women younger than 24 years old and those over 30 years old (Wu et al, 2021). Women aged 18–24 years have a higher risk of mortality during pregnancy as a result of immature reproductive organs, unstable psychological needs and a lack of experience (Peng et al, 2020; Akseer et al, 2022). Similarly, becoming pregnant at 30 or more years old carries greater risks. Thus, those aged 16–24 years and those older than 30 years are especially likely to benefit from an antenatal care programme.

Studies in western countries have shown that while the majority of women receive antenatal care at least once during their pregnancy (81%), only 55% attend the recommended eight antenatal care appointments. This recommendation is the basis of the global antenatal care policy framework (WHO, 2014; 2016). In southeast and east Asia, low attendance at antenatal care has primarily been attributed to a lack of education and economic difficulties, particularly in relation to transportation fees or buying essentials during pregnancy (Jiwani et al, 2020). In addition, having a large family, being a single mother, living in a rural area and preferring to give birth at home have been linked to low attendance (Jiwani et al, 2020). The Indonesian government has set a target of 85% implementation of antenatal care throughout the country (Kemenkes, 2022), recommending that women attend at least four appointments. The Indonesian Ministry of Health reported that the proportion of women attending the recommended minimum number of antenatal care visits increased from 70% in 2013 to 74.1% in 2018 (Ministry of Health, 2018).

The WHO (2016) developed the ‘every newborn: an action plan to end preventable death’ framework, which outlined guidelines to improve the quality of maternal and newborn care and provide a positive pregnancy experience for mothers. This framework is widely used as a reference to ensure high-quality services are provided for maternal and child health. In addition, the framework proposes evidence-based guidelines to develop the services provided to women antenatally through routine antenatal care. In this context, integrated antenatal care measurements assessing the quality of care are required to support implementation of the WHO framework (Lattof et al, 2020).

Antenatal care and the factors that affect attendance among pregnant women need to be explored. Studies in East Africa, South Africa and Bangladesh indicated that low attendance at antenatal care is associated with factors such as maternal and partner education, age, employment, marital status, wealth, birth order, contraceptive use, having a planned pregnancy and accessibility of health services (Tessema and Minyihun, 2021; Islam et al, 2022; Nxiweni et al, 2022; Rosnani and Mediarti, 2022). Studies in Indonesia have explored attendance at antenatal care attendance in regional settings (Denny et al, 2021; Andriani et al, 2022). This study's aim was to analyse the determinants of antenatal care attendance in two groups of women, those aged 18–25 years old, and those aged 26–44 years old. To fulfil this aim, the study used national data representative of women across the country. Ultimately, this study is intended to act as a foundation for developing a holistic programme to improve women's health in Indonesia during pregnancy.

Methods

This study used a cross-sectional design to explore data from the 2017 Indonesian demographic and health survey (National Population and Family Planning Board et al, 2018). The survey was funded by the Indonesian government and conducted in 34 provinces across Indonesia. It was carried out by Statistics Indonesia, the Ministry of Health and the National Population and Family Planning Board of the Republic of Indonesia. The International InnerCity Fund provided technical assistance for the surveys, funded by the United States Agency of International Development (Croft et al, 2018). Data collected from 24 July 2017 to 30 September 2017 were used in the present study.

Sample

The antenatal care data were obtained from the Indonesian individual recode phase 7 dataset. A total of 49 627 individual surveys were taken from 1970 census blocks, composed of both urban and rural areas in 34 Indonesian provinces. For the survey, the provinces analysed were categorised according to three time zones: West Indonesia, Central Indonesia and East Indonesia. The survey used two-stage stratified sampling, first to select census blocks, followed by grouping households registered in the 2010 population census into urban and rural areas and then sorting by wealth index before using the data in systematic sampling. For the present study, 38 193 surveys were omitted as the respondent's age was outside the required range (18–44 years).

The inclusion criteria for the study were women aged 18–44 years in their last trimester of pregnancy. The sample was split into those aged 18–25 years and 26–44 years, with 14 405 surveys selected. However, 10 067 were ineligible for further analysis because of missing data. A total of 4338 surveys were identified as eligible for inclusion (Figure 1).

Variables

Independent variables

The independent variables were sociodemographic factors (region, marital status, age, age at first birth, education, husband's education, number of living children, parity), accessibility factors (residence, place of birth), affordability factors (wealth quintile, employment), health service characteristics (health insurance) and household factors (husband's support) (Simkhada et al, 2008).

For sociodemographic factors, regions were divided into West, Central and East Indonesia based on time zone. Marital status was defined as either ‘married’, meaning married or living with their partner at the time of the survey, or ‘unmarried’ (Senderowicz and Maloney, 2022). Women's ages were split into two categories: those aged 18–25 years old and those aged 26–44 years old (Peng et al, 2020). Age at first birth was categorised into three groups: 10–19 years, 20–35 years and 36–49 years. Number of living children was defined as children living in the household, with an additional child included if the woman was pregnant at the time of the survey, or in the case of women pregnant with the child of a man with more than one current wife. Parity was defined as the number of times a woman gave birth to a live or dead fetus at 24 weeks' gestation or more (Maraj and Kumari, 2021). Education was categorised based on level of learning development, learning goals achieved and skills developed. Education for both women and their partners was divided into high, middle, elementary and no education (Kemendikbud, 2003).

For accessibility and affordability factors, residence was based on the 2010 population census categorised into rural and urban areas (Statistics Indonesia, 2010). Place of birth was categorised as either at home or in a health facility (Campbell and Macfarlane, 1986). Wealth quintiles were expressed for individuals and described according to the household's socioeconomic status, divided into poorest, poor, middle, rich and richest. For employment, those who had participated in work other than housework in the 12 months before the survey were categorised as ‘employed’. Health insurance included both government and the private sector (Laksono et al, 2021). Husband's support was defined based on whether the husband accompanied his wife to antenatal care.

Dependent variable

Antenatal care was the dependent variable. The WHO state that women should attend at least four routine antenatal care visits during pregnancy, once during the first and second trimesters and twice in the third trimester (Barreix et al, 2020). Antenatal care was split into two categories: <4 and ≥4 visits (Kemenkes, 2022).

Data analysis

Univariate analysis was performed by considering distribution frequency. The data were analysed using STATA (version 16.1). As national data were used, multistage cluster random sampling was performed, with survey commands used in STATA to account for clustering effects and sample weight. A Chi-squared test was used to determine the relationship between the independent and dependent variables. Variables with P<0.25 were selected for binary logistic regression analysis. This study used an odds ratio with a 95% confidence interval and 5% significance.

Ethical considerations

The study was registered with The DHS Program and granted approval (no:171410) to download the required dataset. The study received ethical approval from the Institutional Review Board and the authors of the 2017 survey (ICF: FWA00000845). The survey respondents' informed consent was provided during the original survey.

Results

A sample of 4338 women from Indonesia aged 18–44 years were included. Table 1 outlines respondents' sociodemographic and antenatal care factors. Almost all women attended four or more antenatal care visits (93.0%) and were married (99.2%). The majority were from West Indonesia (78.4%), were aged 26–44 years old (74.5%) and had their first birth aged 20–35 years (64.7%). Most had middle education (53.6%), were para 2–4 (62.2%) and had 2–4 living children (63.2%).

Table 2 outlines factors related to accessibility, affordability and household. Most women had given birth at home (78.3%), belonged to the poorest or poor wealth quintiles (54.7%) and were employed (59.3%). The majority did not have insurance (83.0%) and had been accompanied by their husbands during antenatal care (73.2%).

The results of bivariate analysis, shown in Table 3, showed a significant relationship between antenatal care visits and all variables except employment and age. These variables were not included in multivariate analysis, also presented in Table 3. Based on binary logistic regression, age at first birth, place of birth, wealth quintile and insurance were significantly associated with antenatal care visits. Women who were younger when they first gave birth were more likely to attend the recommended number of visits than older women (adjusted odds ratio: 1.49; P<0.001). Women who gave birth at home were less likely to attend the recommended number of visits than those who gave birth at health facilities (adjusted odds ratio: 0.52; P<0.001). Women in the middle wealth quintile were more likely to attend the recommended number of visits than those in the poorest quintiles (adjusted odds ratio: 1.78; P=0.002), and women with insurance were more likely to attend the recommended number of visits than those who did not (adjusted odds ratio: 1.54; P=0.004).

Discussion

This study analysed the determinants of attended the recommended number of antenatal care visits during pregnancy in Indonesia, and found that age at first birth, place of birth, wealth quintile and insurance were significantly associated with attending four or more visits.

Access to quality antenatal services helps prevent maternal mortality resulting from pregnancy complications (Kumar and Singh, 2017). The WHO recommend that antenatal care should be initiated immediately after conception and continued until the last term of pregnancy (Barreix et al, 2020). In Indonesia, it is recommended that women attend at least four antenatal care visits during pregnancy, although the WHO target suggests at least eight visits (Barreix et al, 2020; Kemenkes, 2022). In the present study, over one in 20 women did not attend four or more visits. This may be related to several factors, such as sociodemographics or the availability and accessibility of healthcare services, especially in remote areas (Mathole et al, 2004; Nketiah-Amponsah et al, 2013; Kumar and Singh, 2017). In addition, a lack of insurance or health facilities that do not accept government-based insurance affect a woman's ability to attend antenatal care (Simkhada et al, 2008). It has also been reported that several ethnic groups in Indonesia prefer a traditional approach to prenatal care (Titaley et al, 2010; Azuh et al, 2015; Bhandari and Chan, 2017).

Women who first gave birth at the age of 20–35 years were significantly more likely to attend the recommended number of antenatal visits. A study in Turkey that reported that a positive and memorable antenatal care experience can increase the desire to attend regular antenatal care (Karabulut et al, 2013). As women aged 20–35 years are at lower risk of complications during pregnancy, they may be more likely to have a positive experience. Consequently, this may mean they are more likely to attend antenatal care in future pregnancies. Younger adults may also be more motivated to learn about the importance of fetal development and mothers' wellbeing (Mathole et al, 2004). Studies have shown that knowledge of reproductive health affects women's sexual habits, positively influencing their readiness for pregnancy and birth, and providing psychological stability and reproductive maturity (Laopaiboon et al, 2014; Murdiningsih and St Hindun, 2020; Łada-Maśko and Kaźmierczak, 2021).

Women who gave birth at a healthcare facility were more likely to have attended the recommended number of antenatal care visits than those who gave birth at home. Healthcare in Indonesia can reach even remote areas where sub-health centres have been set up with standard facilities to help with birth. Most respondents in the present study lived in rural areas, which may have limited transportation facilities, limiting choice of service to that closest to their residence (Mahendradhata et al, 2017). The service provided by healthcare professionals can give women information on the progress of their pregnancy. Studies have shown that good service at healthcare centres can increase pregnant women's confidence and encourage them to attend regular antenatal care (Lapierre et al, 2020; Moucheraud et al, 2021; Klankhajhon and Sthien, 2022).

Affordability factors, such as wealth quintile, can affect antenatal care attendance. In the present study, women in the middle to upper levels were more likely to have attended the recommended number of antenatal care visits than those in the poorest quintile. Women in higher wealth quintiles are more likely to have both the knowledge and the ability to attend care at a facility (Silva-Perez et al, 2019). It has also been found that higher wealth quintile is linked to more comprehensive knowledge and understanding of health and wellbeing, making these women more likely to prioritise regular attendance at antenatal care (Dhagavkar et al, 2021). Studies have shown that women in developed countries who attend an average of four antenatal care visits are more likely to report good-quality care (Arsenault et al, 2018).

Women with insurance were more likely to attend the recommended number of antenatal care visits. This finding is similar to other studies in developing countries (Celik and Hotchkiss, 2000; Kabir et al, 2005; Nketiah-Amponsah et al, 2013; Laksono et al, 2021). This is likely in part because of government policies that have been established to make it easier to purchase health insurance for antenatal, childbirth, newborn and postpartum care (Rokx, 2009; Titaley et al, 2010). Antenatal care services provided by the Indonesian national health insurance system were integrated into the design of all health sectors (Agustina et al, 2019) and insurance provisions were designed specifically to help pregnant women easily reach relevant services, such as antenatal care. However, some private health service providers have continued to impose charges for antenatal care.

Receiving support from a partner has previously been reported to be a significant factor for use of antenatal care (Tesfaye et al, 2018). A woman's partner can provide support during pregnancy by showing care, expressing love and affection, paying attention to women's rights and responding to socioeconomic difficulties (Kashaija et al, 2020). However, the present study found that husband's support was not significantly linked to the number of antenatal care visits. However, despite the possible absence of husbands, the majority of women attended antenatal care, a finding that is consistent with Sehrish et al's (2021) findings. Cultural factors in Indonesia play a crucial role in regulating women's behaviour in regards to antenatal care, influencing the use of maternal health services and traditional treatments (Arsenault et al, 2018; Setyowati and Rosnani, 2019; Rosnani et al, 2022).

Strengths and limitations

The use of a nationwide survey as the data source for analysis means that the findings are likely to be representative of women in Indonesia. The study's findings provide valuable information that can be used to support the Indonesian government to optimise antenatal care and improve the wellbeing of mothers and their children.

However, the study's cross-sectional design means that it cannot provide a cause and effect explanation for the findings. Additionally, as husband support was presented without proper classification in the original survey, detailed discussion of this factor is beyond the scope of this study. Further research should be carried out to explore the type of support expected and received by women during pregnancy care. Home birth should also be explored in relation to antenatal care, to estbalish if this is a preventative factor.

Conclusions

Antenatal care attendance among women in Indonesia is linked to their age at first birth, wealth quintile, giving birth at a health facility and having insurance. These findings can be used to educate maternity nurses, midwives, health workers and the government on the need for interventions that encourage antenatal care attendance. This will help to increase awareness of complications during pregnancy and birth, potentially lowering the morbidity and mortality rates for women and their babies. This study also emphasises that investigations need to be carried out to explore the role of partner support and cultural beliefs in antenatal care in Indonesia.

Key points

• Antenatal care is important for the wellbeing of both mother and fetus.
• In Indonesia, it is recommended that women attend a minimum of four antenatal care appointments, lower than the target of eight appointments set by the World Health Organization.
• Based on data from the 2017 demographic and health survey in Indonesia, age at first birth, place of birth, insurance and wealth quintile are significantly related to attending the recommended four visits to antenatal care.
• Further research is needed to explore the types of support offered by women's husbands in Indonesia, and the role of cultural beliefs in influencing antenatal care attendance.

CPD reflective questions

• How can women at greater risk of complications be encouraged to attend antenatal care?
• What impact does living in a remote area have on attendance at antenatal care in your practice?
• What programme could be implemented to promote antenatal care attendance among women in the upper and lower age range?