25 Feb 2016

Neonatal Mortality in Indonesia: the Protective Role of Antenatal, Delivery and Postnatal Care Services

Christiana Rialine Titaley, March 2011
The University of Sydney

Abstract
The aim of this body of research is to examine factors associated with neonatal mortality and the role of antenatal, delivery and postnatal care services in preventing 
neonatal deaths in Indonesia. The specific aims include examining the associations between socio-economic and demographic factors and neonatal mortality, and the extent to which antenatal care services, including iron/folic acid supplementation, delivery and postnatal care services, are associated with improved neonatal survival. It also examines factors associated with utilization of antenatal, delivery and postnatal care services.

This research uses both quantitative and qualitative methods. For the quantitative analyses, data are derived from the Indonesia Demographic and Health Surveys 
(IDHS). The four IDHS used are from 1994, 1997, 2002/2003 and 2007. The quantitative methods consist of multilevel modelling (Chapter 3), Cox proportional 
hazards models (Chapter 4, and 6), and logistic regression analysis (Chapter 5, 7 and 9). The STATA/MP version 10.0 (2007) was used for all statistical analyses.
Data for the qualitative analyses are taken from a study conducted in West Java Province, Indonesia, which involved 295 participants. All the 20 focus group 
discussions and 165 in-depth interviews were recorded and transcribed. The transcriptions were managed and coded using the NVivo 8 software, followed by a 
content and thematic analysis. The qualitative methods data are used in two manuscripts (Chapter 8 and 10).

Chapter 3 analyses the determinants of neonatal mortality in Indonesia. The findings show a reduced level of risk of neonatal death is associated with the increased mean number of antenatal and postnatal visits, and the percentage of deliveries assisted by trained delivery attendants in the cluster. The risk reduced 
significantly amongst mothers who attended postnatal care services.

Chapter 4 demonstrates that amongst the components of antenatal care services, the use of iron/folic acid supplements during pregnancy is the main protective effect against early neonatal deaths. Chapter 5 shows that underutilization of antenatal care services in Indonesia is more frequent among mothers living in rural areas of the outer Java-Bali region, from households with low economic status, and with a low educational level, high birth rank infant, and who experience no obstetric complications during pregnancy.

Chapter 6 examines the role of delivery care services in preventing early neonatal deaths. This analysis failed to demonstrate that having trained delivery attendants at home deliveries reduces the risk of early neonatal deaths. The benefit of institutional deliveries is only shown amongst urban mothers who had delivery complications. Chapter 7 shows that amongst home deliveries, there is an increased use of trained delivery attendants among mothers from wealthier, educated households, with knowledge about delivery complications, and those with obstetric complications at delivery and first birth rank infants. In Chapter 8, data from the qualitative study reveals that the primary reasons for having home deliveries, or using the services of traditional birth attendants at childbirth, are financial constraints, issues relating to trust, and traditional beliefs about the roles of traditional birth attendants during pregnancy, delivery and post-partum. Health services are perceived by some community members as necessary only when obstetric complications occur. Home delivery is considered the most suitable option for some women, since they are required to take care of other family members at home.

Chapter 9 assesses factors associated with non-utilization of postnatal care services. The use of postnatal care services is reduced amongst mothers from rural areas, from households with a low wealth index, with low educational level, who are less exposed to mass media, and with high birth rank infants. In Chapter 10, data from the qualitative study shows that financial difficulties, physical distance, poor road infrastructure, shortage of health personnel and lack of community awareness about maternal and child health, limit the utilization of antenatal and postnatal care services.

Together, the findings highlight the importance of implementing comprehensive strategies to improve neonatal health and the coverage of maternal and newborn health services in Indonesia. Public health interventions that target specific high-risk groups are essential. Efforts to improve the availability, accessibility and quality of antenatal, delivery and postnatal care services will benefit both mothers and newborns. The protective role of iron/folic acid supplements during pregnancy against neonatal deaths confirms the importance of the provision of this supplement in routine antenatal care services. Initiatives to promote utilization of maternal and newborn health care services should be considered, such as increasing community awareness about the importance of maternal and newborn health services, strengthening community participation in health programs, and providing financial support for women from economically disadvantaged households.

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