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      Regional disparities in antenatal care utilization in Indonesia

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          Abstract

          Introduction

          The main strategy for decreasing maternal morbidity and mortality has been antenatal care (ANC). ANC aims to monitor and maintain the health and safety of the mother and the fetus, detect all complications of pregnancy and take the necessary actions, respond to complaints, prepare for birth, and promote a healthy lifestyle. This study aims to analyze interregional disparities in ≥4 ANC visits during pregnancy in Indonesia.

          Methods

          Data was acquired from the 2017 Indonesian Demographic and Health Survey (IDHS). The unit of analysis was women aged 15–49 years old, and a sample of 15,351 women was obtained. In addition to ANC as the dependent variable, the other variables analyzed in this study were a place of residence, age, husband/partner, education, parity, wealth status, and health insurance. For the final analysis, binary logistic regression was used to determine disparity.

          Results

          With the Papua region as a reference, all regions showed a gap except for the Maluku region, which was not significantly different in the use of ANC compared to the Papua region. Women in the Nusa Tenggara have 4.365 times the chance of making ≥4 ANC visits compared to those in the Papua region (95% CI 3.229–5.899). Women in Java-Bali have 3.607 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 2.741–4.746). Women in Sumatra have 1.370 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 1.066–1.761). Women in Kalimantan have 2.232 times the chance of making ≥4 ANC visits compared to women in the Papua region (1.664–2.994). Women in Sulawesi have 1.980 times more chance of making ≥4 ANC visits compared to women in the Papua region (1.523–2.574). In addition to the region category, other variables that contributed to the predictor were age, husband/partner, education, parity, wealth and insurance.

          Conclusion

          There were disparities in ANC utilization between the various regions of Indonesia. The structured policy is needed to reach regions that have low coverage of ≥4 ANC. Policymakers need to use the results of this study to take the necessary policies. Policies that focus on service equality to reduce disparities.

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          Most cited references43

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          Universal health coverage in Indonesia: concept, progress, and challenges

          Indonesia is a rapidly growing middle-income country with 262 million inhabitants from more than 300 ethnic and 730 language groups spread over 17 744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20 900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 livebirths to 23 per 1000, and the total fertility rate decreased from 5·61 to 2·11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 livebirths, and minimal change in neonatal mortality. The centralised one size fits all approach did not address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. Decentralisation of governance to 354 districts in 2001, and currently 514 districts, further increased health system heterogeneity and exacerbated equity gaps. The novel UHC system introduced in 2014 focused on accommodating diversity with flexible and adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. With early success, challenges have emerged, such as the so-called missing-middle group, a term used to designate the smaller number of people who have enrolled in UHC in wealth quintiles Q2-Q3 than in other quintiles, and the low UHC coverage of children from birth to age 4 years. Moreover, high costs for non-communicable diseases warrant new features for prevention and promotion of healthy lifestyles, and investment in a robust integrated digital health-information system for front-line health workers is crucial for impact and sustainability. This Review describes the innovative UHC initiative of Indonesia along with the future roadmap required to meet sustainable development goals by 2030.
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            Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey

            Introduction Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in Nigeria. Methods We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for the sampling weight and the cluster design of the survey. The prevalence of underutilization of ANC was assessed using frequency tabulation while associated factors were examined using Chi-Square test and multivariable logistic regression analysis. Results The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence and 22.4% in urban residence. The North-West region had the highest prevalence of ANC underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences respectively. Factors associated with greater odds of ANC underuse in rural residence were maternal non-working status, birth interval < 24 months, single birth type, not listening to radio at all, lack of companionship to health facility and not getting money for health services. In urban residence, mothers professing Islam, those who did not read newspaper at all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural and urban residence, maternal and husband’s education level, region of residence, wealth index, maternal age, frequency of watching television, distance to- and permission to visit health facility were significantly associated with ANC underuse. Conclusions Rural-urban differences exist in the use of ANC services, and to varying degrees, factors associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors identified in this study may help to improve the utilization of ANC services both in rural and urban Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and regional disparities in access to ANC in Nigeria.
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              Inequities in utilization of reproductive and maternal health services in Ethiopia

              Background Disparities in health services utilization within and between regional states of countries with diverse socio-cultural and economic conditions such as Ethiopia is a frequent encounter. Understanding and taking measures to address unnecessary and avoidable differences in the use of reproductive and maternal health services is a key concern in Ethiopia. The aim of the study was to examine degree of equity in reproductive and maternal health services utilization in Ethiopia. Method Data from Ethiopia demographic health survey 2014 was analyzed. We assessed inequities in utilization of modern contraceptive methods, antenatal care, facility based delivery and postnatal checkup. Four standard equity measurement methods were used; equity gaps, rate-ratios, concertation curve and concentration index. Results Inequities in service utilization were exhibited favoring women in developed regions, urban residents, most educated and the wealthy. Antenatal care by skilled provider was three times higher among women with post-secondary education than mothers with no education. Women in the highest wealth quantile had about 12 times higher skilled birth attendance than those in lowest wealth quantile. The rate of postnatal care use among urban resident was about 6 times that of women in rural area. Use of modern contraceptive methods was more equitably utilized service while, birth at health facility was less equitable across all economic levels, favoring the wealthy. Conclusion Considerable inequity between and within regions of Ethiopia in the use of maternal health services was demonstrated. Strategically targeting social determinants of health with special emphasis to women education and economic empowerment will substantially contribute for altering the current situation favorably.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Project administrationRole: ResourcesRole: SoftwareRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: Funding acquisitionRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 February 2020
                2020
                : 15
                : 2
                : e0224006
                Affiliations
                [1 ] National Institute of Health Research and Development, The Ministry of Health, Jakarta, The Republic of Indonesia
                [2 ] Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia
                University of Gondar, ETHIOPIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-4365-5747
                Article
                PONE-D-19-27564
                10.1371/journal.pone.0224006
                7018075
                32053621
                b1cd5839-76dd-47c3-9bff-2b567ef0acc6
                © 2020 Laksono et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 15 October 2019
                : 11 January 2020
                Page count
                Figures: 1, Tables: 3, Pages: 13
                Funding
                The author(s) received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Antenatal Care
                People and Places
                Geographical Locations
                Asia
                Indonesia
                People and Places
                Geographical Locations
                Oceania
                Indonesia
                Social Sciences
                Economics
                Health Economics
                Health Insurance
                Medicine and Health Sciences
                Health Care
                Health Economics
                Health Insurance
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                People and Places
                Population Groupings
                Age Groups
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Birth
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Birth
                Social Sciences
                Sociology
                Education
                Educational Attainment
                Research and Analysis Methods
                Research Design
                Survey Research
                Census
                Custom metadata
                Data cannot be shared publicly because of ethical restrictions prohibit public sharing of a data set. Data is available from the https://dhsprogram.com/data/new-user-registration.cfm by submitting an application to the ICF via the website. Other researchers will be able to access the data set in the same way as the authors, and the authors do not have special access rights that others do not have. Interested researchers can replicate the findings in this study as a whole by directly obtaining data from IDHS by following the protocol in the manuscript method section. The IDHS data set that I use is a data set of "women of childbearing age" in Indonesia.

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