A multilevel analysis of village and local health systems factors affecting maternal health service delivery and use in rural Indonesia.

摘要

Background. At the core of the Government of Indonesia's strategy to improve maternal health is the village midwife program placing one midwife in every village. Although the program has improved access to basic health services over the past two decades, Indonesia's maternal mortality continues to remain high and large disparities persist between the main island of Java and the outer islands.;Objectives. The objectives of this study are threefold. First, to study how individual, village, and health facility characteristics influence the use of three key maternal services: antenatal care; safe delivery; and, institutional delivery. Second, to analyze the extent to which the use of these services differs by villages and health facility areas, and to identify factors that explain these differences. Lastly, to assess the effectiveness of the village midwife program in providing these maternal services.;Methods. Three-level random effects logistic models corresponding to individual, village, and health facility area-levels are applied to analyze the data from a survey conducted in 2007, representing the poorest 80 percent of rural districts in five provinces. Data included 3,425 live births in 1,953 villages in 297 health facility areas.;Findings. Maternal service use remains low with large disparities between provinces on-Java and off-Java. Large village and health facility-level random intercepts remained in all three outcomes even after controlling for individual, village and health facility characteristics, suggesting that the implementation of the centrally designed service delivery systems vary widely among villages and health facility areas. Placement of village midwives mitigates the negative effects of distance to health facilities on use of antenatal care and safe delivery, even reversing it off-Java.;Conclusions. Although village midwives are effective particularly in remote villages, distinct policies are required including: quality improvement of services at the health facilities on-Java and geographic redistribution of existing midwives off-Java while assessing alternative deployment arrangements. Gaining community support for maternal services off-Java is also a priority.