This study assessed the influence of mothers’ participation in the pregnancy class (KIH) program on utilization of MNH services along continuum of care, including adequate ANC, SBA and delivery in health facility. Our results indicate that complete participation in pregnancy classes is associated with higher utilization of adequate ANC, use of SBA as the last contact, and delivery in health center. Thus, effective implementation of the KIH program can support safer pregnancy and delivery.
Our study found that geographical factors also influence the utilization of maternal health services, which may be due to easier access related to distance, number of facilities, and availability of transportation. Our analysis of 2016 Sirkesnas data revealed that the utilization of adequate ANC by mothers was quite low at 29.3%. One possible explanation of low levels of adequate ANC use may be related to some components of the ANC program. For example, case management and examination for sexually transmitted diseases is not conducted systematically among all pregnant women, but rather, only conducted for pregnant women if there is an indication observed beforehand. Similarly, laboratory tests are conducted only when the health facility has the required medical equipment and infrastructure. One study found that the three main reasons for mothers not receiving ANC were: (1) cost/money to pay health services (45.4%), (2) far distance (42.1%), and (3) the mother did not feel a need to check the pregnancy via an ANC visit (34.7%) . Although distance and cost may hinder a mother from accessing ANC, these factors are external and cannot necessarily be controlled by mother. Two approaches may be implemented to improve use of adequate ANC: (1) ensuring the health facilities have high service readiness to deliver ANC services and (2) improving mother’s knowledge on the importance of ANC visits, which can be achieved by improving KIH program implementation.
Our study also shows that the proportion of deliveries assisted by SBA was quite high in Indonesia (77.1%), and most women gave birth in a health facility. Nevertheless, a notable proportion of mothers still used a non-health facility for delivery (24.3%). The possible explanation that such health-seeking patterns persist may be due to the social influences on the mother’s choice of facility for delivery. Research from 2012 indicated that pregnant women generally wished to give birth in health facilities, however, some delivered in non-health facilities because of the influences of parents, husbands, and/or the community . This research also indicates that several other social influences may be important: (1) lack of support from parents or husbands for delivery in health facilities; (2) local cultural norms that consider delivery in health facilities as only for those mothers who experience complications, viewing such births as inconvenient for others in the community. In addition, difficulties in accessing health facilities because of geographical conditions and inadequate transportation may also influence mothers’ decision to deliver in non-health facilities . Other research in Indonesia has shown other reasons mothers choose to give birth with a dukun (a traditional healer), namely, as a result of fewer health workers in the community or less intense interaction with the local community because they live in another village. Cost is also a factor in using a traditional healer, as it costs less to give birth using a traditional birth attendant (called “paraji”) and they are viewed by the community as always ready when needed. Moreover, pregnant women with lower education levels and those from a lower economic level may have limited access to health information, leading to preferences to use a traditional healer .
We found that mothers who took KIH classes used adequate ANC at higher rates compared to those who did not take the classes. Based on the 2016 Sirkesnas report, 49.8% of mothers did not know about the KIH program, which may explain the low levels of participation . Pregnancy classes are designed as a means for mothers to improve their knowledge and skills regarding pregnancy, childbirth, and newborns. Before the existence of the KIH program, the problems and complications experienced by pregnant women were handled only on a case-by-case basis through individual consultation. The weaknesses of this process were possibly due to the limited ability of mothers to understand information of ANC, which may be related to low formal education of mothers. However, through the KIH program, mothers’ awareness of the importance of prenatal care increased.
KIH program materials were designed to provide mothers with knowledge of pregnancy problems through discussion of written material on maternal and child health in the form of face-to-face discussions and exchanges of experience. The results of our study confirm that mothers who participate more fully in the KIH program preferred a health facility for giving birth.
In addition, most mothers gave birth with SBA (more than 80%), meaning that they received ANC from health workers in health facilities, so any labor complications could be prevented early on. This result is supported by the analysis from this study showing that mothers involved in KIH had higher odds of obtaining complete ANC services. This result is in line with the results of the study of Juana (2016), which found a meaningful relationship between ANC continuity, maternal education, and parity, with the selection of dukuns as birth attendants. Mothers who did not adhere to ANC, had a low education level, and high parity preferred to use dukuns as the main helpers .
Along with increasing mothers’ knowledge about pregnancy, childbirth, and healthy children, the KIH program encourages mothers gain independence decision-making and choosing to give birth using health workers. In addition, they may also provide new insight to their husband and family so that the decision on utilizing the MNH services could be accepted more easily among all family members. Furthermore, full support of family members might increase mothers’ confidence regarding safety, ease, and comfort during labor in health facilities. One study has found lower levels of postpartum depression among mothers involved in KIH compared to mothers not involved in the program .
The analysis from this study shows that mothers with complete participation in KIH utilized birth attendants at health facilities, both in the health center and the hospital (51.90 and 33.50% respectively). In other words, our study indicates that the KIH program helped prevent the first delay in the decision to seek care. Thus, it seems that the KIH program as provides many benefits. Even though the observed KIH coverage is low, our analysis shows that increased KIH participation is associated with increased use of MNH services. Our results show us that the difference in the odds between incomplete participation and complete is around 33%, illustrating the significant influence of the KIH program. Thus, the KIH program seems essential to improving the safe utilization of maternal health services. Therefore, the sustainability of the KIH program certainly needs to be balanced with an increase in the quality of facilitators who provide KIH material, especially in terms of effective communication skills and knowledge about the health of pregnancy and childbirth.
One limitation of this research is that it describes conditions only for 2016 or earlier. Despite this limitation, this analysis is the last condition that can be obtained from a national survey specifically relating to ANC and KIH. Also, the Sirkesnas questionnaire had a limited number of questions and lacking some data on several socioeconomic characteristics. Another limitation was that the survey presentation could have resulted in recall bias because of the time elapsed between when the survey was conducted and when women delivered. In addition, there might be issues related to the timing of the ANC. As stated before, the KIH program is introduced to mothers during their second or third trimester of pregnancy. One component of four adequate ANC visits is mothers’ visits during the first, second, and third trimester of pregnancy. We cannot separate the ANC visit in the first trimester to preserve the outcome of ideal ANC as defined by government of Indonesia. We tried to account for this limitation by controlling for factors such as geography, region, and number of ANC visits, however, some omitted variable bias may still exist.