Trends and inequities in use of maternal health care services in Indonesia, 1986−2012
Received 25 June 2017
Accepted for publication 29 September 2017
Published 29 December 2017 Volume 2018:10 Pages 11—24
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Colin Mak
Peer reviewer comments 2
Editor who approved publication: Professor Everett Magann
Herfina Y Nababan,1 Md Hasan,2 Tiara Marthias,1,3 Rolina Dhital,4 Aminur Rahman,2 Iqbal Anwar2
1Nossal Institute for Global Health, Melbourne School of Population and Global Health, the University of Melbourne, Parkville, Melbourne, VIC, Australia; 2Health Systems and Population Studies Division, icddr,b, Mohakhali, Dhaka, Bangladesh; 3Center for Health Policy and Management, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; 4FIGO Post-Partum IUD Initiative – Nepal, Nepal Society of Obstetrician and Gynaecologists (NESOG), Kathmandu, Nepal
Purpose: Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country’s maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths.
Methods: Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban–rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis.
Findings: Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth.
Conclusion: Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health.
Keywords: health inequity, health inequality, maternal health, health service utilization, universal health coverage, sustainable development goal
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