Health inequities occur when health services are not accessible or utilized by certain people due to their gender, socio-economic status, ethnicity, geographic residence, or other characteristic. Because of this lack of access, disadvantaged populations are at much higher risk of adverse health outcomes. For example, the maternal mortality rate was 104 per 100,000 live births in Yogyakarta province, and was more than double that (216 per 100,000 live births) in the poor rural province of East Nusa Tenggara. In order to improve equity and reduce maternal, newborn, and child mortality, disadvantaged or high risk groups must be targeted for services and interventions
In 2009, the Indonesian government initiated a strategy to reduce maternal and child mortality. The strategy, called Revolusi KIA, seeks to improve the quality of healthcare facilities and encourage women to deliver in facilities. In the Nusa Tenggara Timur (NTT) province, the number of women delivering in facilities has increased. However, many women continue to deliver at home despite the availability of local health centers, called Puskesmas. TRAction is supporting the development of a case study to identify factors that influence whether women deliver in a Puskesmas or not.
The aim of this case study was to identify factors that influence the use of available facilities for delivery, within the context of the Revolusi KIA program. Research questions included:
The study used both qualitative and quantitative methods to 1) identify factors influencing use or non-use of Puskesmas for delivery and 2) determine the impact of current programs implemented as part of the Revolusi KIA strategy on coverage of maternity services and equitable access to those services.
Two villages were included in the study: one located close to the Puskesmas Wae Nakeng, and one located within a 1 hour drive. In both villages, in-depth interviews were conducted with women who delivered in a facility and women who delivered at home, birth decision influencers (such as the husband or mother-in-law), the village midwife, traditional birth attendants, and village leaders. Questions investigated facilitators and barriers to Puskesmas delivery, and factors influencing birth decisions. Group interviews were conducted with Revolusi KIA implementers, nurses, and midwives to understand provider perspectives on factors related to facility delivery.
To determine if the health facility is serving the poorest women in the community, quantitative data on each woman who was pregnant within the last year was collected from the Puskesmas and village midwives. The data was analyzed to determine how geographic residence, education, and other equity-related characteristics affect place of delivery.
Statistically, the health facility-based birth program achieved variable results in different areas within NTT province. The quantitative analysis revealed that several factors including age of mother, living in urban areas, higher socioeconomic level, owning insurance, regular ANC visits, and knowledge of ovulation positively affected the likelihood of a woman delivering in a health facility. The qualitative findings indicated several barriers to health facility delivery including low awareness of program benefits, perceived financial costs, cultural practices, and environmental disparities. Most families still perceive that home births are less disruptive and that cost of delivery is expensive, leading to a preference for home delivery. Traditional birth attendants (TBAs) emerged as valued and influential members of the community and important players in the delivery process.
Maternal mortality will decrease when women are able to plan their pregnancies, give birth under the supervision of a skilled attendant, and have access to high-quality treatment if complications occur. These improvements are feasible even in low-income settings, but require continuous and focused strengthening of health systems. Improving maternal health outcomes requires commitment at all levels. This study revealed that increased community engagement can lead to better maternal and child health through the effective use of health promotion materials endorsed by the village leaders and involved fathers. In addition, it is important to increase the availability and capacity of midwives at the village level and strengthen the partnership between TBAs and midwives.
This case study identified contextual factors surrounding the decision to use available health facilities for delivery, and explore how well the Puskesmas are serving the poorest women in the community. The Provincial Health Office implementing the study will use the results to inform future programming. The results will also be shared with the Indonesian Ministry of Health to inform national Revolusi KIA activities. In addition, TRAction will synthesize the findings from this and four other equity studies to gain a global understanding of factors influencing access and utilization of facilities for delivery. Experience from this study and other TRAction projects will also be used to develop qualitative research training tools.