Maternal Health Care Utilisation in Indonesia: Regional Economic Status and Decomposing the Inequalities Tiara Marthias Center for Health Policy & Management Faculty of Medicine – Universitas Gadjah Mada INDONESIA
Indonesia
Background High MMR (228/100,000 live births) Inequalities Delivery assisted by skilled birth attendant 100 75 50 25 0 North Sumatra Riau Islands DKI Jakarta 97.3 Yogyakarta Bali West Kalimantan South Sulawesi Maluku 32.8 Papua ( DHS 2007) percentage delivery assisted by skilled birth attendant
Background Inequalities Inequality in maternal health care utilisation National aggregate does not reflect the true distribution Who are the most disadvantaged? Predisposing & enabling Supply: factors: External environment: Health resource availability, Income, Region, Distance to health care, Maternal education, Rural vs urban Availability of female health worker Maternal occupation, Health system financial Media exposure, investment/fiscal capacity Ability to pay, Women ’ s authority on health Well being status (HDI)
Indonesia Aim of the Study To explore the inequalities in the utilisation of skilled birth attendant (SBA) in Indonesia Objectives of the Study To quantify the extent of the inequalities in SBA utilisation in Indonesia To identify and quantify the factors contributing to the inequalities To assess the association between sub-national fiscal capacity and population status of well-being (HDI) with SBA utilisation in Indonesia
Methods (Data) Demographic Health Survey (DHS) 33 provinces; 32,895 respondents clustered-, 2-stage sampling 13,891 Most recent birth in the last 5-years births Income Regions and types of residence Antenatal care Maternal age Parity Health knowledge Education level Outcome: Occupational status Delivery assisted by skilled health Marital status professional Media exposure Religion Sub-national fiscal capacity Well being status (HDI)
Methods (Analysis) Regions of Indonesia: Java – Bali Urban Java – Bali Rural Sumatra Urban Sumatra Rural Eastern Indonesia Urban Eastern Indonesia Urban
Results
Socioeconomic Inequalities in Maternal Health Care Utilisation Concentra on� Curve� for� Skilled� Birth� A endant� U liza on� in� � Indonesia� and� Its� Regions� 1� a endant� 0.8� birth� Indonesia (0.319) skilled� Java-Bali Urban (0.252) by� Java-Bali Rural (0.273) 0.6� assisted� Sumatra Urban (0.045) births� Sumatra Rural (0.187) 0.319 Eastern Indonesia Urban (0.089) of� 0.4� percentage� Eastern Indonesia Rural (0.202) Line of equality Cumula ve� 0.2� 0� 0� 0.2� 0.4� 0.6� 0.8� 1� Cumula ve� percentage� of� births� ranked� by� their� economic� status�
Decomposition Analysis Decomposi on� Analysis� of� Skilled� Birth� A endance� U lisa on� � Inequality� in� Indonesia� Region� &� type� Wealth� Maternal� age� Antenatal� care� Pregnancy� complica on� knowledge� Maternal� educa on� Paternal� educa on� � Region� &� type� Wealth� Maternal� educa on� Indonesia� Maternal� occupa on� 9.54%� 13.80%� 36.77%� 14.93%� Paternal� occupa on� Frequency� of� listening� to� radio� Frequency� of� reading� newspaper� Frequency� of� watching� television� Religion� Maternal� say� on� own� healthcare� Marital� status� -5%� 15%� 35%� 55%� 75%� 95%� Parity�
Decomposition Analysis Decomposi on� Analysis� of� Skilled� Birth� A endance� U liza on� Inequality� for� Urban� Area� in� Indonesia� Region� &� type� Wealth� Maternal� age� East-Indo� urban� 0.00� Wealth,� 64.10%� 3.52%� Antenatal� care� Pregnancy� complica on� knowledge� Maternal� educa on� Paternal� educa on� � Maternal� occupa on� Sumatra� Urban� 0.00� Wealth,� 77.30%� 5.41%� Paternal� occupa on� Frequency� of� listening� to� radio� Frequency� of� reading� newspaper� Frequency� of� watching� television� Maternal Religion� Java-Bali� urban� Wealth,� 58.48%� 2.17%� 0.00� Religion education Maternal� say� on� own� healthcare� Marital� status� Parity� -5%� 15%� 35%� 55%� 75%� 95%� wealth: poorest (ref), maternal age: 25-35 (ref), ANC: <4 ANC visit (ref), pregnancy knowledge: no knowledge of pregnancy complications (ref), maternal/paternal education: primary school or less (ref), maternal/paternal occupation: unemployed (ref), frequency of media exposure: never exposed (ref), religion: Islam (ref), say on own health care: have no say (ref), marital status: currently married (ref), parity: 2-children or less (ref).
Decomposition Analysis Decomposi on� Analysis� of� Skilled� Birth� A endance� U liza on� Inequality� for� Rural� Area� in� Indonesia� � Region� &� type� Wealth� Wealth� East-Indo� rural� 8.27%� 12.36%� 0.00� 47.30%� 4.42%� Maternal� age� Antenatal� care� Pregnancy� complica on� knowledge� Wealth� Maternal� educa on� Sumatra� rural� 0.00� 10.89%� 54.10%� 12.38%� 10.39%� Paternal� educa on� � Maternal� occupa on� Paternal� occupa on� Maternal education ANC Wealth� Frequency� of� listening� to� radio� Java-Bali� rural� 0.00� 21.65%� 44.35%� 16.62%� Frequency� of� reading� newspaper� -5%� 15%� 35%� 55%� 75%� 95%� wealth: poorest (ref), maternal age: 25-35 (ref), ANC: <4 ANC visit (ref), pregnancy knowledge: no knowledge of pregnancy complications (ref), maternal/paternal education: primary school or less (ref), maternal/paternal occupation: unemployed (ref), frequency of media exposure: never exposed (ref), religion: Islam (ref), say on own health care: have no say (ref), marital status: currently married (ref), parity: 2-children or less (ref).
Regional economic status & HDI Dependent variable: Skilled birth attendant utilisation linear regression Coef. 95% P-value Confidence Interval (2.60) – 4.20 Fiscal capacity 0.802 0.634 2.31 – 5.55 HDI 3.928 <0.001
Conclusion • Inequality in skilled birth attendant utilisation in Indonesia • Different levels of inequalities among regions • Contributions by socioeconomic level varies • Wealth as major contributor to SBA utilisation inequality • Other important determinants: maternal education, antenatal care • Increasing human well-being for better health care utilisation • The use of fiscal space is not always for health investment
Implications • Improve people ’ s daily living conditions • Distribution of resources, targeting poorer population • Improve other socioeconomic status: education, occupational status, cross-sectoral approach • Different levels of inequality and SES contribution - need for region-specific interventions • In the light of decentralization, better investment on health at sub-national level
References BPS, S. I. and M. International (2008). Indonesia Demographic and Health Survey 2007. Calverton, Maryland, USA, BPS and Macro International. Kakwani, N., A. Wagstaff, et al. (1997). "Socioeconomic inequalities in health: Measurement, computation and statistical inference." Journal of Econometrics 77 : 87-103. Koblinsky, M., Z. Matthews, et al. (2006). "Going to scale with professional skilled care." The Lancet 368 (9544): 1377-1386. Kruk, M. E., M. R. Prescott, et al. (2008). "Equity of skilled birth attendant utilization in developing countries: Financing and policy determinants." American Journal of Public Health 98 (1): 142-147. Pradhan, J. and P. Arokiasamy (In press). "Socio-economic inequalities in child survival in India: A decomposition analysis." Health policy doi:10.1016/j.healthpol.2010.05.010 . Titaley, C., M. Dibley, et al. (2010). "Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 2002/2003 and 2007." BMC Public Health 10 (1): 485. Vyas, S. and L. Kumaranayake (2006). "Constructing socio-economic status indices: how to use principal components analysis." Health Policy and Planning 21 (6): 459. Wagstaff, A., E. Van Doorslaer, et al. (2003). "On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam." Journal of Econometrics 112 (1): 207-223. WHO, W. H. O. (2010). Trends in maternal mortality: 1990 to 2008, Estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization.
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