Utilization of Village Midwives and Other Trained Delivery Attendants for Home Deliveries in...

Utilization of Village Midwives and Other Trained DeliveryAttendants for Home Deliveries in Indonesia: Results of IndonesiaDemographic and Health Survey 2002/2003 and 2007

Christiana R. Titaley • Michael J. Dibley •

Christine L. Roberts

Published online: 10 October 2010

� Springer Science+Business Media, LLC 2010

Abstract This study aimed to examine factors associated

with utilization of village midwife and other trained delivery

attendants for home deliveries. Information from 14,672

cases of the most recent home deliveries of mothers in the

5 year-period prior to the Indonesia Demographic and

Health Survey 2002/2003 and 2007 were analysed. Multi-

nomial logistic regression analysis was performed. The

association between 26 factors categorised into external

environment, predisposing, enabling, need and previous

utilization of maternal health services, and utilization of

village midwife and other trained delivery attendants, such

as nurses, other midwives and doctors, for home deliveries

was examined. The population attributable risk of selected

significant predictors was calculated. The odds of using

village midwives and other trained delivery attendants at

childbirth for home deliveries increased with increasing

household wealth index and levels of parental education.

The odds increased among first birth, mothers who were

exposed to mass media, mothers with knowledge of delivery

complications, and mothers who had any delivery compli-

cations. However, mothers who attended less than four

antenatal care visits, who had high parity, or who reported

distance and transportation to health facilities was a major

problem, had significantly reduced odds for utilizing any

trained delivery attendants. Health promotion strategies to

raise community awareness about the importance of safe

delivery should target low educated parents, mothers from

low household economic status, as well as high parity

mothers. Efforts to promote antenatal care visits are likely to

increase utilization of trained delivery attendants for home

deliveries in Indonesia.

Keywords Midwives � Trained delivery attendants �Home deliveries � Indonesia

Introduction

Most of maternal and neonatal deaths occur outside health

facilities, without the assistance of trained delivery atten-

dants [1]. The rate of skilled attendance and institutional

delivery rates have been reported to be lowest in countries

with the highest rate of both maternal and neonatal mor-

tality [2, 3]. Approximately 35% of deliveries, worldwide,

are attended by untrained health workers [4]. This pro-

portion ranged from less than one percent in developed

regions to 65% in least developed countries [4]. Approxi-

mately 50 million mothers in developing countries have a

home delivery without any professional health care [5].

Interventions to reduce maternal and neonatal deaths

have included the provision of skilled birth attendants at

childbirth and the improvement of obstetric services in

health care facilities [1, 6]. It has been argued that 20–30%

of all-cause neonatal mortality rates could be reduced [7]

C. R. Titaley (&)

Sydney School of Public Health, University of Sydney,

Room 128C Edward Ford Building (A27), Sydney,

NSW 2006, Australia

e-mail: [email protected]

M. J. Dibley

Sydney School of Public Health, University of Sydney,

Room 307A Edward Ford Building (A27), Sydney,

NSW 2006, Australia


C. L. Roberts

The Kolling Institute of Medical Research, University of

Sydney, Royal North Shore Hospital, St Leonards,

NSW 2065, Australia


123

Matern Child Health J (2011) 15:1400–1415

DOI 10.1007/s10995-010-0697-1

and 74% of mothers lives could be saved [5] by imple-

menting skilled birth care. The proportion of deliveries

attended by skilled health personnel also has been included

as an indicator to monitor the progress towards the Mil-

lennium Development Goals 5 of maternal health [8].

A recent review on maternal survival reported the pro-

portion of deliveries assisted by health professionals has

been increasing [9]. This has likely contributed to the

global progress in reducing maternal mortality rates [10].

However, in some regions including Southeast Asia, a large

proportion of women are still left without professional care

at delivery [9]. The disparity in professional care at

delivery between urban and rural areas has also widened,

which is mainly due to the slower increase in professional

delivery care in rural areas [9, 11].

Several frameworks have been developed to analyze the

use of health care services. One of the most frequently used

is the behavioural model developed by Andersen in the late

1960 [12, 13]. The emerging model of this framework has

incorporated a range of factors categorized into some

groups of variables [12]. These groups include environ-

mental factors referring to the characteristics of health care

system and community; predisposing factors, the charac-

teristics that existed prior to the need to use health services;

enabling factors that allow an individual to use health

services; need factors which are reasons to use health

services; personal health practices and perceived health

status [12]. This framework was adapted in this study to

answer our research question.

Earlier studies have shown the relationship between

demographic, socio-economic factors and the uptake of

health care services. Maternal education, [14–19] parity

[19–21] and economic factors [19, 21–25] were shown to

be associated with health care seeking behaviour. Studies

have also reported an increased likelihood of the uptake of

delivery care services, which included the use of trained

attendants at childbirth and institutional deliveries, among

mothers attending antenatal care services [20, 26, 27]. The

positive influence of access to health care services have

also been reported [25, 28, 29]. An Indonesian study

reported distance and poor road conditions as part of the

reasons for mothers to prefer home delivery and to not use

trained delivery attendants at childbirth [30].

In 1989, the Indonesian Government embraced the

concept of the Safe Motherhood Initiative by implementing

the ‘‘village midwife’’ program which aimed at assigning a

midwife in every village [11, 31, 32]. By 1996, more than

50,000 village midwives had been placed in villages

around the country [11, 31, 32]. This intervention has

increased the proportion of deliveries attended by trained

attendants from 43% in 1997 [33] to 79% in 2007 [34].

Although this achievement is still below the national target

of 90% deliveries assisted by health professionals by 2010,

the village midwife program has successfully reduced the

socio-economic inequalities related to use of professional

attendants at delivery [35].

Despite numerous attempts made to increase utilization

of trained delivery attendants, the Indonesia Demographic

and Health Survey (IDHS) 2007 data reported a wide range

in the proportion of deliveries attended by trained health

professionals across provinces, from only 33% in Maluku

to 97% in DKI Jakarta Province [34]. Although the pro-

portion of home deliveries has declined, [33, 34] the 2007

IDHS reported more than half of all deliveries occurred at

home. This study aimed to determine factors associated

with utilization of village midwife and other trained

delivery attendants for home delivery.

Methods

Study Population

Data from two nationally representative surveys, the IDHS

2002/2003 and 2007 were used in this analysis. The IDHS

collects demographic and health-related information, such

as fertility, family planning and maternal and children

health [34]. The two surveys included information from

62,378 ever-married women aged 15–49 years, 29,483

from the IDHS 2002/2003 and 32,895 from the IDHS 2007

[33, 36]. Three questionnaires were used in these surveys—

the Household, Women’s, and Men’s questionnaires.

Variables included in this study were derived from the

Household and the Women’s questionnaires. The average

response rates of eligible households and women were 99

and 97%, respectively [33, 36]. The detailed sampling

method of the IDHS has been reported elsewhere [37].

Our study included information from 14,672 (7,457

from the IDHS 2002/2003 and 7,215 from the 2007 IDHS)

cases of the most recent home deliveries of mothers in the

5 year-period prior to each survey. By combining two

IDHS datasets, a large sample size could be obtained to

produce estimates with better precision. The demographic

information for study population is presented in Table 1.

We chose only the woman’s most recent delivery since the

most detailed health services information was available for

these births and to minimize recall bias of mothers about

their history of pregnancy and delivery.

Variables and Theoretical Framework

To identify factors associated with utilization of village

midwives and other trained delivery attendants for home

births, an outcome variable with three mutually exclusive

categories was constructed, (a) home deliveries without

any trained delivery attendants; (b) home deliveries with a

Matern Child Health J (2011) 15:1400–1415 1401

123

Table 1 Baseline characteristics of study population by different types of delivery attendants, IDHS 2002/2003 and 2007

Variable Home delivery assisted by

untrained delivery

attendants N (%)

Home delivery

assisted by village

midwife N (%)

Home delivery assisted

by other trained delivery

attendantsa N (%)

Year of survey

2002/2003 4,092 (53.6) 1,823 (52.8) 1,542 (43.1)

2007 3,550 (46.5) 1,631 (47.2) 2,034 (56.9)

External environment

Region and type of residence

Java-Bali region: urban 1,445 (18.9) 324 (9.4) 731 (20.4)

Java-Bali region: rural 2,832 (37.1) 1,198 (34.7) 827 (23.1)

Sumatera region: urban 145 (1.9) 158 (4.6) 424 (11.9)

Sumatera region: rural 1,102 (14.4) 930 (26.9) 634 (17.7)

Eastern Indonesia region: urban 302 (4.0) 91 (2.6) 367 (10.3)

Eastern Indonesia region: rural 1,815 (23.8) 753 (21.8) 593 (16.6)

Predisposing factors

Socio-demographic

Maternal age at childbirth Mean ± SE =

27.05 ± 0.14

Mean ± SE =

26.80 ± 0.18

Mean ± SE =

26.95 ± 0.15

Household wealth index

Poorest 2,349 (30.7) 594 (17.2) 342 (9.6)

Poorer 2,048 (26.8) 862 (24.9) 642 (17.9)

Middle 1,634 (21.4) 883 (25.6) 900 (25.2)

Wealthier 1,066 (13.9) 725 (21.0) 957 (26.8)

Wealthiest 341 (4.5) 279 (8.1) 623 (17.4)

Maternal education

Completed primary/incomplete secondary 4,600 (60.2) 2,277 (65.9) 2,138 (59.8)

Secondary or higher 415 (5.4) 615 (17.8) 1,016 (28.4)

No education/incomplete primary 2,627 (34.4) 561 (16.2) 422 (11.8)

Paternal education

Completed primary/incomplete secondary 4,482 (58.7) 2,014 (58.3) 1,895 (53.0)

Secondary or higher 832 (10.9) 806 (23.3) 1,243 (34.8)

No education/incomplete primary 2,294 (30.0) 624 (18.1) 430 (12.0)

Parental occupation

Unemployed mother and working father 3,833 (50.2) 1,834 (53.1) 1,922 (53.7)

Working mother and working father 3,600 (47.1) 1,550 (44.9) 1,568 (43.9)

Unemployed father 185 (2.4) 53 (1.5) 79 (2.2)

Maternal marital status

Currently married 7,417 (97.1) 3,385 (98.0) 3,477 (97.3)

Formerly married 225 (2.9) 69 (2.0) 98 (2.8)

Maternal final say on her own health care

Woman with partner/other 2,341 (30.6) 1,239 (35.9) 1,088 (30.4)

Woman alone 4,005 (52.4) 1,678 (48.6) 2,026 (56.7)

Partner alone/someone else/other 1,288 (16.9) 534 (15.5) 459 (12.8)

Birth rank and interval

2nd/3rd birth rank, [2 year interval 2,944 (38.5) 1,434 (41.5) 1,500 (42.0)

1st birth rank 2,009 (26.3) 1,145 (33.2) 1,174 (32.8)

2nd/3rd birth rank, B2 year interval 435 (5.7) 175 (5.1) 230 (6.4)

C4th birth rank, [2 year interval 1,937 (25.3) 605 (17.5) 578 (16.2)

C4th birth rank, B2 year interval 318 (4.2) 95 (2.8) 95 (2.6)

1402 Matern Child Health J (2011) 15:1400–1415

123

Table 1 continued


untrained delivery

attendants N (%)

Home delivery

assisted by village

midwife N (%)



attendantsa N (%)

Health knowledge

Frequency of reading newspaper

Never 5,460 (71.5) 1,899 (55.0) 1,701 (47.6)

Less than once a week 1,852 (24.2) 1,247 (36.1) 1,408 (39.4)

At least once a week 314 (4.1) 301 (8.7) 462 (12.9)

Frequency of listening to radio

Never 3,013 (39.4) 1,213 (35.1) 1,126 (31.5)

Less than once a week 2,463 (32.2) 1,156 (33.5) 1,230 (34.4)

At least once a week 2,151 (28.2) 1,077 (31.2) 1,207 (33.7)

Frequency of watching television

Never 1,283 (16.8) 345 (10.0) 201 (5.6)

Less than once a week 1,559 (20.4) 625 (18.1) 428 (12.0)

At least once a week 4,788 (62.7) 2,478 (71.7) 2,938 (82.2)

Knowledge on pregnancy complications

None 5,399 (70.7) 2,063 (59.7) 2,003 (56.0)

Yes 2,242 (29.3) 1,392 (40.3) 1,572 (44.0)

Knowledge on delivery complications

None 5,133 (67.2) 1,881 (54.5) 1,735 (48.5)

Yes 2,507 (32.8) 1,573 (45.5) 1,839 (51.4)

Knowledge on post-delivery complications

None 6,084 (79.6) 2,464 (71.3) 2,354 (65.8)

Yes 1,557 (20.4) 990 (28.7) 1,216 (34.0)

Enabling factors

Know where to go to seek health services

Small problem 7,002 (91.6) 3,236 (93.7) 3,424 (95.8)

Big problem 632 (8.3) 217 (6.3) 146 (4.1)

Permission to visit health services

Small problem 7,118 (93.2) 3,253 (94.2) 3,419 (95.6)

Big problem 516 (6.8) 199 (5.8) 151 (4.2)

Money to pay health services

Small problem 4,659 (61.0) 2,398 (69.4) 2,677 (74.9)

Big problem 2,978 (39.0) 1,055 (30.5) 893 (25.0)

Distance to health services

Small problem 5,632 (73.7) 2,809 (81.3) 3,137 (87.7)

Big problem 2,005 (26.2) 643 (18.6) 432 (12.1)

Transportation to health services

Small problem 5,778 (75.6) 2,875 (83.2) 3,205 (89.6)

Big problem 1,859 (24.3) 577 (16.7) 365 (10.2)

Presence of companion

Small problem 6,535 (85.5) 3,075 (89.0) 3,259 (91.2)

Big problem 1,099 (14.4) 377 (10.9) 311 (8.7)

Availability of care by female health workers

Small problem 6,898 (90.3) 3,156 (91.4) 3,254 (91.0)

Big problem 733 (9.6) 289 (8.4) 315 (8.8)

Need factors

Desire for pregnancy

Wanted then 6,085 (79.6) 2,888 (83.6) 2,899 (81.1)


123

village midwife as the delivery attendant, and (c) home

deliveries with other trained delivery attendant.

Home deliveries without any trained delivery attendants

refer to mothers delivering at home with the assistance of a

traditional birth attendant (TBA), relative, friend, or with-

out any attendants.

A village midwife in Indonesia is defined as ‘‘a midwife

assigned in a village to increase the quality and coverage of

the services of health centre. The service area of a village

midwife covers one to two villages. The roles of a village

midwife are to provide health care services based on their

competency, which include delivery care services, mater-

nal and child health, and oversee community involvement

in the five integrated health programs conducted through

the integrated health posts or Posyandu, which are maternal

and children health, family planning, nutrition and immu-

nization, diarrhoea and ARI management, as well as health

promotion activities’’ [38].

Other trained delivery attendants refer to skilled birth

attendants other than village midwives and is defined as

‘‘an accredited health professional—such as a midwife,

doctor or nurse—who has been educated and trained to

proficiency in the skills needed to manage normal

(uncomplicated) pregnancies, childbirth and the immediate

postnatal period, and in the identification, management and

referral of complications in women and newborns’’ [39].

Midwives included in ‘‘other trained delivery attendants’’

might be those working in public and private facilities who

have had more extensive training than the village midwife.

The behavioural model framework of Andersen [12] for

use of health care services was adapted in this study. Twenty-

six factors potentially associated with study outcomes were

identified and categorized into five main groups, external

environment, predisposing, enabling and need factors, as well

as previous utilization of maternal health services (Fig. 1).

A new household wealth index was constructed using a

Principal Component Analysis (PCA) method [40] to assign

weights for eleven variables consisting of four housing

characteristics, i.e. source of drinking water, type of toilet,

main material of floor, main material of wall, and seven

household assets i.e. availability of electricity, possession of

radio, television, fridge, bicycle, motorcycle, and car. These

variables were then aggregated to form an index functioning

as a proxy of the economic status of a household. According

to this index, all households across all IDHS datasets used in

this study were ranked into five categories, poorest (bottom

quintile), poor (second quintile), middle (third quintile),

wealthier (fourth quintile) and wealthiest (top quintile).

Statistical Analysis

Multinomial logistic regression analysis was performed to

determine factors significantly associated with utilization

of village midwives or other trained delivery attendants at

childbirth for home deliveries. In this analysis, home

deliveries without any trained delivery attendants was used

as the reference category, and the odds ratios presented in

this study were relative to this reference group.

Univariable multinomial logistic regression analyses

were conducted to estimate the crude Odds Ratio (OR) of

each potential predictor against the outcome. This was

followed by multivariable analyses to determine the

Table 1 continued


untrained delivery

attendants N (%)

Home delivery

assisted by village

midwife N (%)



attendantsa N (%)

Wanted later 836 (10.9) 354 (10.3) 416 (11.6)

Wanted no more 709 (9.3) 210 (6.1) 260 (7.3)

Pregnancy complications

No complications 7,251 (94.9) 3,186 (92.2) 3,320 (92.8)

With complications 389 (5.1) 264 (7.6) 256 (7.2)

Delivery complications

No complications 4,984 (65.2) 1,905 (55.1) 2,014 (56.3)

With complications 2,561 (33.5) 1,518 (43.9) 1,516 (42.4)

Previous experience with maternal health services

Use of antenatal care services

C4 antenatal service 4,286 (56.1) 2,865 (82.9) 3,023 (84.5)

\4 antenatal visit 3,293 (43.1) 563 (16.3) 537 (15.0)

All values are weighted by the sampling probabilities

The total number varies between categories due to missing valuesa Nurses, other midwives and doctors. Other midwives refer to midwives working in public and private facilities who have had more extensive

training than the village midwives


123

adjusted Odds Ratio (aOR) of factors significantly associ-

ated with each study outcome. Missing cases were exclu-

ded from all univariable and multivariable analyses.

In the multivariable method, a hierarchical modelling

strategy [41] were conducted by entering more distal fac-

tors—year of survey and the external environment factor

into the model. A backward elimination technique was then

employed to remove factors not significantly associated

with the study outcome using a significance level of 0.05.

The year of survey variable was selected a priori and

retained in the models irrespective of its significance level.

In the second model, all predisposing factors were entered

simultaneously, and backward elimination procedure was

conducted. Only factors significantly associated with the

study outcomes were retained in the model. This procedure

was repeated until all variables were entered into the model.

To calculate the population attributable risk (PAR), [24,

42, 43] binomial logistic regression models were per-

formed using selected factors retained in the final model.

The outcome variable was utilization of untrained delivery

attendants for home delivery. The PAR was used to esti-

mate the proportion of home deliveries without any trained

delivery attendants, which were attributable to the selected

risk factors. Using the adjusted odds ratio (aOR), the PAR

was calculated as follows:

PAR ¼ Proportion of home delivery with

untrained delivery attendants associated

with the factoraOR� 1ð Þ

aOR

All ORs, aORs and 95% confidence intervals (CI) were

weighted for the sampling probabilities. The STATA/MP

version 10.0 (2007) (Stata Corporation, College Station,

TX, USA) was used for all statistical analyses. Survey

commands were employed for all logistic regression

models to take into account the sampling weight and

cluster sampling design.

Results

Our study found that of 14,672 home deliveries included in

our analysis, 52% (n = 7,641) were attended by untrained

birth attendants including traditional birth attendants and

family relatives, 24% (n = 3,454) by a village midwife and

24% (n = 3,576) by other trained delivery attendants such

as nurses, other midwives and doctors. Approximately 94%

(n = 7,188) of mothers attended by untrained delivery

attendants were attended by a traditional birth attendant

(TBA); whereas 98% (n = 3,500) of mothers attended by

trained attendants were assisted by a nurse or midwife.

Amongst mothers with no education/incomplete pri-

mary, i.e. 25% of the entire sample, 73% (95% CI:

70.0–75.4%) delivered at home with untrained attendants.

Amongst 20% of mothers from poorest households, 72%

(95% CI: 68.7–74.2%) used untrained delivery attendants

at childbirth. For antenatal care use, of the 30% infants

whose mothers attended less than four antenatal services,

only 13% (95% CI: 11.3–14.5%) used village midwives

EXTERNAL ENVIRONMENT

PREDISPOSING FACTORS

ENABLING FACTORSUTILIZATION OF

DELIVERY ATTENDANT

Socio-demographic:- Maternal age at

childbirth- Household wealth index

- Maternal education

- Paternal education

- Parental occupation

- Maternal marital status

- Maternal final say on her own health care

- Birth rank and interval

Health knowledge:- Frequency of reading

newspapers- Frequency of listening to

radio- Frequency of watching

television- Knowledge on

pregnancy complications- Knowledge on delivery

complications- Knowledge on post

delivery complications

- Region and type of residence

- Know where to go to seek health services

- Permission to visit health services

- Money to pay health services

- Distance to health services

- Transportation to health services

- Presence of companion

- Availability of care by female health workers

PREVIOUS EXPERIENCE WITH

MATERNAL HEALTH SERVICES

- Use of antenatal care services

- Desire for pregnancy

- Pregnancy complications

- Delivery complications

NEED FACTORS

Fig. 1 Theoretical framework of factors associated with utilization of delivery attendants for home deliveries in Indonesia. Note: Framework

adapted from Andersen behavioural model [12]


123

and 12% (95% CI: 10.8–13.9%) used other trained atten-

dants. Figure 2 shows a decreasing trend of deliveries

attended by untrained birth attendants, from 63% in 1997

to 46% in 2007.

The detailed characteristics of variables used in these

analyses are presented in Table 1. A high proportion of

deliveries of mothers from poorest households (30.7%),

and/or mothers with low levels of education (34.4%) were

not assisted by trained delivery attendants. The proportion

of deliveries by the village midwife or other trained

attendants was higher in mothers from wealthier and

wealthiest households, with high education levels, having

first births, or attending four or more antenatal care visits.

Table 2 shows the results of bivariate and multivariable

analyses. As shown in Fig. 2, our analysis also found an

increased likelihood of using nurses, midwives and other

midwives rather than untrained attendants in the 2007

IDHS compared to the 2002/2003 IDHS (OR = 1.64,

P \ 0.001). The odds of using a village midwife versus the

untrained attendants, mainly the traditional birth atten-

dants, were generally higher among mothers living in rural

areas. In contrast, higher odds of using other types of

trained delivery attendants (i.e. nurses, other midwives, and

doctors) versus untrained delivery attendants were con-

stantly found in urban areas. Our study demonstrated that

the likelihood of using any type of trained delivery atten-

dants increased along with increasing household economic

status. Mothers from the wealthiest households were two

times and four times more likely to use a village midwife

and other type of trained delivery attendants, respectively,

compared to those from the poorest households. In the two

wealthiest groups, we found a higher increase of odds ratio

for using other types of trained attendants compared to the

increase of odds for using village midwife services.

A significant association between maternal and paternal

education and the use of delivery attendants was shown.

Parents with no/incomplete primary education had lower

odds of utilization of any trained birth attendants compared

to those with completed primary/incomplete secondary

education, whereas those with secondary or higher educa-

tion had the highest odds. The results also showed a

stronger relationship with maternal than paternal education.

Other predisposing factors that increased the likelihood of

using trained attendants included first born infants, mothers

with exposure to mass media, and mothers with knowledge

of any delivery complications.

Among the enabling factors, mothers reporting that

distance and transportation to health services were major

problems were less likely to use any trained delivery

attendants. Of the need factors, mothers with delivery

complications had an increased likelihood of using both

village midwife and any trained delivery attendants.

A significant association between antenatal care visits

and utilization of trained delivery attendants was confirmed

in our study. The odds of using a village midwife versus

untrained attendants was reduced by 70% for mothers who

had less than four antenatal visits compared to mothers

with four or more antenatal visits.

The PARs for selected significant predictors of utili-

zation of untrained delivery attendants are shown in

Table 3. The results showed that 45% (PAR = 0.45; 95%

CI: 0.36–0.53) of the total risk for utilizing untrained

attendants was attributable to low maternal education

level. The importance of antenatal care visits was also

reflected by its high PAR (30%) among mothers attending

less than four antenatal visits. The PAR values presented

in Table 3 should not be added, to avoid misinterpretation

[43].

0

10

20

30

40

50

60

70

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year of birthUntrained delivery attendant Village midwife as delivery attendant Other trained attendants as delivery attendant

Per

cent

Fig. 2 Trend of home deliveries assisted by untrained delivery

attendants, village midwives or other trained delivery attendants,

IDHS 2002/2003 and 2007. Note: Other trained delivery attendants

include nurses, other midwives and doctors. Other midwives refer to

midwives working in public and private facilities who have had more

extensive training than the village midwives; The information of

1997–2001 deliveries was derived from the 2002/2003 IDHS; 2002

and 2003 deliveries from both surveys, i.e. the 2002/2003 and 2007

IDHS, and 2004–2007 deliveries from the 2007 IDHS


123

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Ex

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Reg

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Jav

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Pre

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Ma

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edu

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Co

mp

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)0

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123

Ta

ble

2co

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me

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y

oth

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%C

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%C

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Ma

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Bir

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(Ref

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1.0

0

1st

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Hea

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Fre

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At

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to

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aw

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123

Ta

ble

2co

nti

nu

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Var

iab

leU

niv

aria

ble

anal

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sM

ult

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iab

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aly

sis

Ho

me

del

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by

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lag

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me

del

iver

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sist

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y

oth

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ain

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%C

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%C

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Kn

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ge

on

pre

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an

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mp

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tio

ns

No

ne

(Ref

)1

.00

1.0

0

Yes

1.6

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)\

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Kn

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No

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(Ref

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0

Yes

1.7

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Kn

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No

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(Ref

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0

Yes

1.5

8(1

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En

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1

Per

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0–

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0.0

2

Pre

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an

ion

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all

pro

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1.0

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Big

pro

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(0.6

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1)

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.56

(0.4

4–

0.7

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1

Ava

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(0.6

9–

1.1

8)

0.4

6


123

Ta

ble

2co

nti

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Nee

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Des

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Wan

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(Ref

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.00

1.0

0

Wan

ted

late

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Pre

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No

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Wit

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1.0

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123

Discussion

Main Findings

This study aimed to explore factors associated with utili-

zation of village midwives and other trained delivery

attendants for home delivery. Results of the study found a

significant association between utilization of trained

delivery attendants and the external environment, predis-

posing, enabling and need factors as well as previous

experience with maternal health care. The odds for using

village midwife services was generally higher in rural

areas; whereas for other type of delivery attendants the

odds were constantly higher in urban areas. Among pre-

disposing factors, the odds of using any trained delivery

attendants increased for mothers from wealthier house-

holds, mothers and fathers with higher education levels,

first birth rank infants, and mothers with knowledge about

delivery complications. Among enabling factors, mothers

reporting distance and transportation to health services as

major problems had a reduced likelihood of using trained

delivery attendants. Among need factors, the odds for using

any trained delivery attendants increased for mothers who

had delivery complications. A reduced likelihood of using

any trained delivery attendants was also observed among

mothers attending less than four antenatal care visits,

compared to those with four or more antenatal visits. The

likelihood of utilizing nurses, other midwives and doctors

at childbirth for home delivery services was significantly

higher in the 2007 IDHS than the 2002/2003 IDHS.

Utilization of Trained Delivery Attendants for Home

Deliveries

Our study found an increased use of nurses, other midwives

and doctors at childbirth in the 2007 survey compared to

2002/2003 survey. This finding reflects the improvement of

maternal and child health care in Indonesia, one of which is

the increased ratio of all midwives, including village

midwives and health centre midwives, from 29 in 2004

[44] to 43 per 100,000 populations in 2008 [45].

We found a significant association between both

maternal and paternal education on the use of trained

delivery attendants for home delivery, with a stronger

relationship for maternal compared to paternal education.

This was also reflected by the high PAR value of parental

education, particularly maternal education. The relation-

ship between education and maternal and children health

has been long recognized [14–18, 21, 29]. A recent

review of maternal mortality stated that the increase of

maternal educational attainment was one of the main

drivers for the global reduction in maternal mortality rates

[10]. Education provides a greater understanding about

the importance of health, [16, 18] and a greater decision

making power for women about their own, and other

family members’ health [14, 15]. Education also leads to

better health seeking behaviour, [14] and higher socio-

economic status [15]. In the present study, the importance

of education was also reflected by an increased utilization

of trained delivery attendants among mothers with

knowledge on delivery complications. Community-based

participatory interventions, such as women’s groups or

community facilitators, have been shown to increase uti-

lization of maternal health services [46, 47] and could be

Table 3 Population attributable risk (PAR) for utilization of

untrained delivery attendants for home deliveries in Indonesia, IDHS

2002/2003 and 2007

Variable % aORa PAR (95% CI)

Household wealth index

Wealthiest (Refb) 0.32 1.00

Wealthier 0.28 1.37 0.07 (0.01–0.13)

Middle 0.22 1.84 0.10 (0.05–0.14)

Poorer 0.14 2.50 0.09 (0.06–0.11)

Poorest 0.05 3.93 0.03 (0.02–0.05)

Combined risk 0.26 (0.14–0.37)

Maternal education

Secondary or higher (Ref) 0.05 1.00

Completed primary/

incomplete secondary

0.60 1.83 0.27 (0.20–0.34)

No education/incomplete primary 0.34 3.40 0.24 (0.20–0.28)


Paternal education

Secondary or higher (Ref) 0.11 1.00

Completed primary/

incomplete secondary

0.59 1.46 0.17 (0.11–0.25)

No education/incomplete primary 0.30 1.67 0.11 (0.07–0.17)


Knowledge on delivery complications

Yes (Ref) 0.33 1.00

None 0.67 1.35 0.18 (0.10–0.24)

Distance to health services

Small problem (Ref) 0.74 1.00

Big problem 0.26 1.27 0.06 (0.00–0.11)

Transportation to health services

Small problem (Ref) 0.76 1.00

Big problem 0.24 1.27 0.05 (0.00–0.10)

Use of antenatal care services

C4 antenatal visits (Ref) 0.57 1.00

\4 antenatal visits 0.43 3.12 0.30 (0.26–0.33)

a aOR = adjusted Odds Ratio. All aORs were obtained from a

binomial logistic regression of the final model with utilization of

untrained delivery attendant as the outcome variableb (Ref) = reference group

All values are weighted for the sampling probability


123

used to increase awareness about safe delivery services in

Indonesia.

Significant associations between antenatal care visits

and the use of trained delivery attendants have been

reported in previous studies [20, 26, 27]. Our results

demonstrated that mothers who attended four or more

antenatal care visits [34, 45] had an increased likelihood to

use trained delivery attendants than mothers with less than

four antenatal care visits. Several factors have been sug-

gested for this association. Health education messages

delivered during antenatal care visits increase women’s

awareness about the importance of safe delivery care as

well as the potential risks that might be associated with not

having this type of delivery care [26, 27]. Frequent contact

between health professionals and expectant mothers usu-

ally facilitates good rapport between women and health

workers [27]. This evidence suggests that efforts to

increase utilization of antenatal care services in Indonesia

will be beneficial and likely led to an increased use of

trained birth attendants. Our previous study using the IDHS

2002/2003 and 2007 demonstrated that women from rural

areas, households of low economic status and low maternal

education level were more likely to underutilize antenatal

care services [19]. Public health interventions, such as

community-based education using women’s groups or

traditional birth attendants, to promote antenatal and

delivery services targeting these vulnerable groups should

be a priority. The outreach health services currently

implemented in Indonesia, such as the integrated health

post or Pusat Pelayanan Terpadu (Posyandu) play a vital

role in providing basic maternal and child care including

antenatal care services [48]. These outreach services are

beneficial in reaching communities residing in rural and

remote areas. However, careful planning about the location

of the Posyandu is important to improve access and cov-

erage of health services especially among those commu-

nities reporting distance and geographical constraints as

major barriers.

Access to health services emerged as significant pre-

dictor of utilization of delivery attendants, shown by

reduced odds among mothers reporting distance and

transportation to health services as major problems. The

relationship between access to health services, either due to

the distance to health services or lack of transportation, and

utilization of health services have been demonstrated in

other studies [25, 28, 29]. In Indonesia a policy of bringing

maternal health care services closer to the community has

been implemented through the village midwife program.

Although this strategy has minimized the issue of access to

health care, studies showed that maternal health services

were still underutilized for those residing in rural and

remote areas [11, 19, 23, 30]. This is partly due to the

shortage of health professionals, particularly when the

village midwife is the solo health provider in the village,

and the absenteeism if she frequently travels out of the

village or prefers to reside outside the village in a nearby

town [11, 19, 49]. The provision of adequate supports,

protection, opportunities for career development as well as

incentives to the village midwives will be beneficial to

retain them in rural areas [5].

The role of economic factors on utilization of maternal

health care services has been reported in several studies

[19, 21–23, 25, 29]. Although a study using pooled IDHS

data from 1986 to 2002/2003 [35] showed that the village

midwife program had reduced socio-economic inequalities

in utilizing health professionals at delivery, the present

study still found a reduced likelihood for using both village

midwife and other trained delivery attendants for home

delivery amongst women from poorer households. Another

Indonesian study reported that maternal mortality rate was

the highest for women in the lowest household wealth

index, among which only 10% were assisted by health

professionals at childbirth [50]. Our results also have been

confirmed by a qualitative study from West Java Province,

Indonesia, that reported financial difficulties as one of the

major reasons for community members to utilize the ser-

vices of TBA at childbirth, as the services of village

midwives were perceived to be costly [30]. Although

the health insurance scheme for the poor and near poor

population, called the Health Insurance Scheme for the

Population or Jaminan Kesehatan Masyarakat, has been

developed by the Indonesia Government [51] to enable

financially deprived populations to access health services

for free, misconceptions about its eligibility have also been

reported by some women [19, 30]. A regular monitoring

and evaluation system should be established to ensure its

effectiveness for the target population. The conditional

cash transfer program reported to have a positive impact on

the uptake of health care services in low and middle

income countries [52, 53] has been piloted in seven prov-

inces in Indonesia [54]. This scheme could be expanded to

increase delivery service utilization among financially

disadvantaged mothers. Additionally, strengthening com-

munity-based finance mechanisms such as the pregnant

mother saving scheme or social funds for pregnant women

may benefit women. In Indonesia, these communal

financing schemes are available through the Village Alert

program as part of the Safe Motherhood Initiative and aim

at helping mothers access safe delivery care services [55].

Another significant predictor found in this study was the

birth rank of infants. An increased likelihood of using

trained attendants at childbirth was found among firstborn

infants; whereas a reduced likelihood was observed among

high rank infants. This has also been reported in other

studies [20, 21]. Women maybe more anxious about their

first birth and seek assistance from a trained attendant [21].


123

They might also not be aware of the increased risks asso-

ciated with higher rank births and they may mainly rely on

their experiences with their previous pregnancies [20, 21].

Health promotion strategies should be developed to reach

these women, particularly since they have also been found

to underutilize antenatal care services [19]. Mass media

such as television that was found in our study to be highly

utilized by the community can also be used to convey

health information including messages about the impor-

tance of maternal and child health services.

Strengths and Limitations

The data used in this study were derived from two

nationally representative surveys, with a high individual

and household response rate [34, 36]. The large sample size

used in this analysis allowed the examination of different

potential predictors, covering external environment, pre-

disposing, enabling, need and previous utilization of health

services. Furthermore, the restriction of the samples to the

most recent birth of mothers within the last 5 years of each

survey minimized the potential of recall bias and maxi-

mised the amount of available information.

Several limitations should be noted. Since the data used

in this analysis were derived from a cross-sectional study,

it is not possible to infer causality for the factors associ-

ated with the use of birth attendant. All the information is

also self-reported. Possible misclassification of health

centre facilities and village midwives might have occurred.

Furthermore, some potential predictors, such as cultural

factors, which were not available in the survey question-

naires, were not included in the analysis. However, these

limitations are unlikely to impact on the validity of the

analyses.

Conclusion

Our study showed a significant association between

external environment, predisposing, enabling and need

factors, as well as previous utilization of maternal health

services and utilization of village midwives and other

trained delivery attendants for home delivery in Indonesia.

Health promotion strategies to raise community awareness

about the importance of safe delivery will be beneficial to

increase utilization of trained delivery attendants for home

delivery. This strategy should target parents with low levels

of education, high parity mothers, and those from poorer

households. The importance of an adequate attendance at

antenatal care indicates the need to promote utilization of

antenatal care services among those women who are least

likely to use them. Strengthening current health financing

through health insurance, conditional cash transfer, or

communal financing schemes will help women from

financially disadvantaged families to utilize delivery health

services. This should be accompanied by a regular moni-

toring system to evaluate its effectiveness in reaching poor

populations. Improving availability and accessibility of

maternal health services should also be considered.

Acknowledgments We thank the Australian Agency for Interna-

tional Development (AusAID) for funding Christiana R Titaley PhD

scholarship in International Public Health at the Sydney School of

Public Health, University of Sydney, Australia. Christine L Roberts is

supported by a NHMRC Research Fellowship.

Conflict of interests None declared.

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