Background
Antenatal and postnatal care services are amongst the major interventions aimed at reducing maternal and newborn deaths worldwide [
1‐
3]. Antenatal care services help pregnant women by identifying complications associated with the pregnancy or diseases that might adversely affect the pregnancy [
2,
4]. Through antenatal visits, women benefit from various interventions, including counselling about healthy lifestyles, the provision of iron/folic acid supplements, and tetanus toxoid vaccinations reported to protect newborns against neonatal death [
1,
2,
4,
5]. In Indonesia, pregnant women are recommended to receive at least four antenatal care checks, one in the first trimester, one in the second and two in the last trimester [
6]. The minimum standard services provided include the measurement of body weight, blood pressure, symphysis-fundus height, Tetanus Toxoid (TT) vaccination, and iron/folic acid supplementation [
6].
The postnatal period, just after delivery and through the first six weeks of life [
4,
7], is recognized as a critical time for both mothers and newborns. The importance of postnatal care services has been reported in various studies worldwide [
8‐
10]. Postnatal care services enable health professionals to identify post-delivery problems, including potential complications, and to provide treatments promptly. In Indonesia, neonates are recommended to receive at least two adequate health care checks within the period of 0-7 days and 8-28 days after birth [
11].
Different health service delivery modes, from facility-based clinical care to outreach and family and community care, will benefit mothers' and children's health [
1]. In Indonesia, at the sub-district level, antenatal and postnatal care services are provided through the health centre, or
Puskesmas (
pusat kesehatan masyarakat), a primary health care level institution headed by a doctor or a public health officer [
6,
12].
Puskesmas is responsible for providing health services to the community within its service area. An inpatient care ward is available in some health centres, and is mostly used for delivery care services. Each
Puskesmas usually has between three and five sub-health centres, called
Pustu (puskesmas pembantu). At the village level, the available health facilities include the
Pustu, the integrated service post, called
Posyandu (
pos pelayanan terpadu), the village maternity post, called
Polindes (
Pondok bersalin desa), and village health posts, called
Poskesdes (
Pos Kesehatan Desa).
Posyandu is a form of outreach service available at an administrative ward of a village and run voluntarily by the community (cadres). It provides maternal and child health services, including health counselling, physical examinations of pregnant women, nutrition, immunizations, as well as weighing of children under five years of age, all conducted on a monthly basis [
12].
Polindes and
Poskesdes are also forms of community-based activities for antenatal care services, including delivery and postnatal care conducted by village midwives [
12]. As recommended by the WHO and UNICEF [
13], the Indonesian Government has also promoted postnatal care in the form of home visitations conducted by trained birth attendants, although its implementation varies widely across the country [
14].
There has been a series of attempts to improve the funding of health care, particularly for the poor. These efforts eventually resulted in the Health Insurance for the Poor scheme or
Asuransi Kesehatan Masyarakat Miskin (Askeskin) in 2004, which evolved into the Community Health Insurance program or
Jaminan Kesehatan Masyarakat (Jamkesmas) in 2008. These schemes aim to benefit disadvantaged citizens (identified from 14 criteria determined by Statistics Indonesia [
15]) by providing free health care services, including antenatal, delivery, or postnatal care services [
16,
17]. Furthermore, in 2007 a conditional cash transfer program called
Program Keluarga Harapan (PKH) was introduced and is currently being piloted in 40 districts throughout seven provinces, including some districts in West Java [
18]. The PKH is aimed at increasing the education level and health status of the poor [
18]. This means a cash allowance is provided to eligible recipients based on their compliance with certain conditions, such as the utilization of maternal and child health services.
Studies from developing countries [
19‐
25] have reported the influence of demographic and socio-economic factors on the utilization of maternal and child health care services. Women with higher economic status [
22,
23], higher educational levels [
19,
22,
24], and who live in urban areas [
22] with adequate health care services [
21,
22,
25] are more likely to utilize health care services. At the national level, previous analyses using various Indonesia Demographic and Health Survey (IDHS) data also confirmed the association of these factors with levels of antenatal or postnatal care service utilization [
26,
27].
Although the 2007 IDHS reported that 95% of pregnant women in Indonesia attended at least one antenatal visit, only 66% of mothers (58% in rural areas and 77% in urban areas) attended at least four antenatal care services as recommended. This figure was much lower than the national target of 90% antenatal care attendance [
28]. Moreover, approximately 16% of mothers did not receive any postnatal care services (17% in the rural areas and 15% in the urban areas) [
28]. The percentages of both antenatal and postnatal care uptake varied across provinces [
6,
28,
29]. In South Sumatera province, the rates for antenatal care and postnatal care attendance were 70% and 43%, respectively; whereas in DI Yogyakarta the attendance rates were 97% and 82%, respectively [
29].
The 2007 IDHS reported that in West Java province only 84% of mothers attended at least four antenatal services (tabulation was performed using the 2007 IDHS dataset [
30]) and only 65% of mothers attended a postnatal service within two days of delivery [
28]. Any evaluation of community perceptions about antenatal and postnatal care services, as well as the constraints of accessing those services, has the potential to improve maternal and neonatal health. This paper presents an analysis of community members' perspectives on antenatal and postnatal care services, including reasons for using or not using these services, and the health services received during antenatal and postnatal care in West Java province. Cultural practices (based on shared concepts, values, and ideals of a group) during antenatal and postnatal period were also explored. An analysis of the use of delivery care services in these study areas is presented elsewhere [
31].
Results
Issues regarding antenatal and postnatal care services are classified into five major topics, which are (1) Reasons for attending antenatal and postnatal care services; (2) Reasons for not attending antenatal or postnatal care services; (3) The practice of antenatal and postnatal care services; (4) Traditional practices during pregnancy and postnatal period; and (5) Community perceptions about midwives and traditional birth attendants.
Reasons for attending antenatal and postnatal care services
The main reason for attending antenatal and postnatal care services was to ensure the safe health of mothers and infants. Some participants also mentioned other reasons such as problems during pregnancy or to follow other family members' experiences.
We feel safe by attending antenatal services. We may know problems related to pregnancies. If we had never had our pregnancy checked, we would not be able to know any [problems]. (A mother, 26 years, in-depth interview, Batu Nunggal, Sukabumi District)
I went to see the village midwife because I had some bleeding in the 4th month [of the pregnancy]. I was afraid I might miscarry. (A mother, 26 years, focus group discussion, Limus Nunggal, Sukabumi District)
I went to the midwife because my mother also used her service. (A mother, 23 years, in-depth interview, Batu Nunggal, Sukabumi District)
Another reason for attending postnatal care services mentioned by the participants was immunization for the newborns.
Reasons for not attending antenatal or postnatal care services
Economic and pragmatic reasons
Our study found that the perceived cost of health services emerged as a major issue hindering community members from utilizing antenatal and postnatal care services.
I went to traditional birth attendants. It is cheaper. I think you have to pay [to have your pregnancy checked] in Posyandu [integrated service post]. I will go there if I do not need to pay anything. (A mother, 22 years, in-depth interview, Panyutran, Ciamis District)
They said they did not want to have their pregnancy checked because they did not have any money. Some said they needed more money to use a midwife's services. It is different from traditional birth attendants. You do not need much money to pay them. (A cadre, in-depth interview, Limus Nunggal, Sukabumi District)
Additionally, transportation costs added to the burden. Some participants mentioned the reason of practicality for using the services of traditional birth attendants as they lived closer than health care providers.
The problem is I did not have any money to pay the transport. I want to have my pregnancy checked by the doctor or the midwife every month, but their places are so far away. I needed transport to get there. Instead, I went and sought traditional birth attendants. (A mother, 22 years, in-depth interview, Sukarame, Garut District)
Although Jamkesmas cards had been provided to some poor and near poor communities to enable them to use health services for free, misconceptions about its eligibility were found in the villages. Some participants stated that Jamkesmas cards could be used only for particular health care providers, such as the village midwife; or health care services, such as delivery services; some did not think they could be used for antenatal and postnatal services.
Jamkesmas does not cover health care services after delivery; it is only for delivery services. (A mother, 29 years, in-depth interview, Sukarame, Garut District)
You can only use Jamkesmas with the village midwife and nothing other than that. (A cadre, in-depth interview, Batu Nunggal, Sukabumi District)
Jamkesmas... sometimes you can, but sometimes you cannot use it... They said Jamkesmas was useless... when you bring it to the doctor it [the service] is still expensive. (A father, focus group discussion, Panyutran, Ciamis District)
Moreover, our study found that free health services were assumed to be associated with a lesser quality of both health services and medications compared to health services that required some payments.
I do not have any money. For you to have your pregnancy checked, you need much money. It is free in the health centre, but it is better to go to the services where you can pay. They will give you better medication. (A mother, 34 years, focus group discussion, Sukarame, Garut District)
Knowledge about maternal and child health
Some participants did not feel the need to have antenatal or postnatal care services as they did not experience any problems during pregnancy and after delivery.
I did not go to the midwife anymore [within 40 days after delivery]. I felt healthy. (A mother, 20 years, focus group discussion, Limus Nunggal, Sukabumi District)
I feel healthy. Nothing happened. You need money to go the midwife. If I am not sick why should I go to the midwife [after delivery]? I do not want to waste my money. (A mother, 22 years, in-depth interview, Panyutran, Ciamis District)
They do not want to come usually because they feel healthy and there is no complication with the pregnancy. If they have some problems, usually they will come. (A health centre midwife, in-depth interview, Sukarame, Garut District)
Furthermore, negative attitudes towards child immunization were mentioned as a reason for not attending postnatal care services.
Someone told me to bring my child for immunization. But you know, after immunization children usually have some swelling on their hands. Sometimes it is like an abscess. The child will cry, and get sick. I do not want it. I am afraid. (A mother, 22 years, in-depth interview, Panyutran, Ciamis District)
I was afraid my child would have a fever if we brought him to the midwife. They said usually children will suffer from fever after immunization. I do not want him to get sick. (A cadre, in-depth interview, Sukarame, Garut District)
Access to services
Physical proximity to health services was a major problem, especially in rural villages with poor road conditions. Some participants complained that they needed to walk for up to two hours to reach the nearest health centre. The situation became worse during the rainy season when the road was slippery.
It is really hard when it is raining. We are afraid we will fall over because the road is so slippery and we are pregnant. The health centre is far and you can see that the road condition is so poor. (A mother, 36 years, focus group discussion, Limus Nunggal, Sukabumi District)
Another constraint was the limited availability of health services, particularly in remote areas, where the village midwife either did not live there or frequently travelled out of the village.
To be honest, there are new midwives who do not live in the village; some of them are also doing further study in midwifery [in the city]. (A health centre midwife, in-depth interview, Sukarame, Garut District)
The village midwife is currently studying in the capital city. So she is not available from Friday to Sunday. (A mother, 26 years, focus group discussion, Limus Nunggal, Sukabumi District)
Most women in these villages are agricultural workers during daylight hours. This means attending health care services during the daytime, compounded by long waiting periods, might lead to loss of income.
The practice of antenatal and postnatal care services
The Government's guidelines for antenatal and postnatal care services had been implemented in all villages. The minimum of four antenatal care visits and two postnatal visits were encouraged.
In these study areas, antenatal services were mainly provided at Puskesmas and monthly in Posyandu. Antenatal care services included physical examinations, weight measurements, counselling, Tetanus Toxoid vaccinations, as well as iron/folic acid supplements. Ninety tablets of iron/folic acid supplements are recommended for pregnant women. However, not all women in the villages reported receiving 90 tablets during pregnancy. Some participants mentioned that the supplements were received every time they visited antenatal care services. The number of supplements women received varied between 15 and 30 tables. Consequently, women attending antenatal care less than four times received a fewer number of supplements. The experience of adverse effects, such as nausea, and traditional beliefs about the effect of supplements became reasons for failing to comply with the national guidelines.
I was afraid I would have a large baby. It [the iron/folic acid supplement] also has a bad smell; I could not stand it, so I did not take it. Sometimes I finished the whole package in a month, sometimes I did not. (A mother, 37 years, focus group discussion, Benteng, Ciamis District)
Although postnatal care services in the form of home visitations have been endorsed, the practice varied widely across villages. Some participants reported that they were never visited by the midwife within the first month after delivery. Postnatal services were also provided by Posyandu and Puskesmas. According to study participants who attended postnatal care services, they received such services as BCG, Hepatitis B and Polio immunization for the baby, cord care, physical examination, as well as counselling about breastfeeding and infant health care.
Three days after delivery, the village midwife visited and examined my body as well as the baby's. She examined the baby's navel, gave immunization, and vitamin A. (A mother, 30 years, focus group discussion, Batu Nunggal, Sukabumi District)
Participants raised concerns about the availability of newborn immunization vaccines, particularly the BCG vaccine that was not always available, leading to a delayed immunization schedule. Community understanding about immunizations was still lacking, as some study participants did not know the type and benefit of immunization received by their infants.
Traditional practices during pregnancy and postnatal period
The services of traditional birth attendants were commonly used in all villages during antenatal and postnatal periods. Traditional birth attendants massaged mothers, usually in the fourth and eighth month of pregnancy, using traditional herbal medicine such as coconut oil, and holy water.
The traditional birth attendant massaged me when I was four, seven and eight or nine months pregnant... you know sometimes it was a breech position. They know the baby's position. (A mother, 25 years, in-depth interview, Batu Nunggal, Sukabumi District)
Usually in the fourth month of pregnancy, there will be a traditional ritual held. We will be called to massage the pregnant mother using coconut oil. (A traditional birth attendant, focus group discussion, Sukajaya, Garut District)
After delivery, traditional birth attendants provided a regular service to newly-delivered mothers and newborns. Daily visits were conducted to bath the newborn and to treat the newborns' umbilical cord until it fell off. Mothers would be massaged to hasten the return of the uterus to its normal size. Additional visits occurred to check both the mother's and infant's condition until the 40th day after delivery.
I come every day until the umbilical cord falls off. I put Betadine and usually after three days it falls off. Before that I only wipe the newborn... I will give him/her a bath after the umbilical cord falls off. (A traditional birth attendant, in-depth interview, Sukarame, Garut District)
In remote areas where one village midwife was available, traditional birth attendants were more capable of reaching the community. Their role was also perceived to be important by the community.
Some people said traditional birth attendants are more patient and careful. They could visit the mother and infant until 40 days after delivery. For seven days after delivery, the traditional birth attendants will come to bath the baby until the umbilical cord falls off. The mother will be massaged as well. And some said that the traditional birth attendants were still preferable, because they were cheaper. (Staff of district health office, in-depth interview, Ciamis District)
However, we also found some women preferred using the service of health professionals, such as the village midwife, over the traditional birth attendants due to better equipment or more thorough examinations.
Traditional birth attendants had an incomplete set of equipment, while for the village midwife they already have a complete one. To be safe. (A mother, 36 years, focus group discussion, Limus Nunggal, Sukabumi District)
I sought the midwife's service because she checked us more carefully, not like the traditional birth attendants who only touched us. (A mother, 28 years, focus group discussion, Limus Nunggal, Sukabumi District)
From the traditional birth attendants, we found a positive response about working together with the village midwife.
I told them [the women] if you want to stay healthy, you need to be examined by the midwife. You need to be treated and examined during the Posyandu service. (A traditional birth attendant, in-depth interview, Sukajaya, Garut District)
The roles of both traditional birth attendants and village midwives were also considered to be important in the community.
We need both the traditional birth attendant and the midwife. The traditional birth attendant can massage, fix the baby's position and the stomach muscles of a pregnant woman...I haven't encountered a midwife that could do that. Midwives usually give medications. So, both of them are still needed. (A community leader, in-depth interview, Panyutran, Ciamis District)
Conclusions
Antenatal and postnatal services were still under-utilized, despite community members' positive attitudes regarding these services. The factors that hindered utilization of antenatal and postnatal care services in our study included financial difficulties, physical distance to health facilities aggravated by poor road infrastructure, a limited availability of health services, and perceived need for health services. Misunderstanding about the eligibility of Jamkesmas has also prevented poor communities from fully benefitting from this insurance scheme. For some women who perceived pregnancy and delivery as a natural process in life's events, the services of the traditional birth attendants were part of their cultural practices. Unless obstetrics complications arose, there was no perceived necessity in using health professional services.
No 'magic bullet' solution is available to overcome the constraints; instead, comprehensive public health approaches are required. Poverty alleviation strategies will help financially deprived communities to access and use maternal and child health services. Appropriate socialization programs about Jamkesmas are important to ensure its optimum utilization among poor and near poor communities. In addition, evaluation and monitoring programs about its benefit and effectiveness should be conducted regularly.
Strategies that address problems related to the limited availability of health services should be a priority. This includes efforts to retain village midwives in isolated areas, as well as the use of a team of providers, such as a midwife and midwife assistants, to increase the coverage of their services. The involvement of traditional birth attendants might be an alternative solution for providing basic antenatal and postnatal services under the supervision of health professionals.
Health programs aimed at increasing community awareness about the importance of antenatal and postnatal services should be considered. Strengthening community-based participatory programs to actively engage in overcoming constraints will be beneficial. Local community members should also be involved to encourage pregnant women and newly delivered mothers to use health services.
Acknowledgements
This project received funding from the Ford Foundation Indonesia and the Australian Health Policy Institute, University of Sydney, Australia. This analysis forms part of CRT's PhD thesis. We are indebted to community members and health workers in six villages, particularly our respondents, and those involved in our study. We are grateful to our local collaborators, Dr Nida P. Harahap and the staff of District Health Offices in Garut, Sukabumi and Ciamis districts. We would like to thank researchers from the National Institute of Health Research and Development, Ministry of Health, Indonesia, in alphabetical order, Ms Ida, SKM, Mr Meda Permana, SSos., Dra Soenanti Zalbawi, MM, Ms Tin Afifah, SKM, and Ms Oster Suriani, SKM, and all field assistants helping us during the study. We thank staff from the Sydney School of Public Health who supported this study. The funding source had no role in the study design, data collection, data analysis, data interpretation or writing this paper.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors designed the study. CRT conducted data collection. Under the supervision of CLH, CRT conducted data analysis and wrote the first draft of the manuscript. MJD and PH provided data analysis advice and revision of the final manuscript. All authors read, commented on and approved the final manuscript.