Understanding the determinants of prenatal care in Bali, Indonesia

BACKGROUND: Indonesia has the highest maternal mortality ratio (MMR) in south-east Asia (approximately 350 per 100,000 live births.) Studies show that the lack of prenatal care is an important risk factor for maternal death, particularly in rural settings. Reducing the MMR will require a better understanding of the determinants of prenatal care. The main objective of this study was to improve prenatal care rates among women in an isolated community in East Bali, Indonesa. The target community consists of 19 villages where poor pregnancy outcomes and infant mortality rates were high. Although women accessed formal health care for their children, they rarely utilized available maternal health services. Household surveys among women in this community showed less than one-quarter of pregnant women accessed formal prenatal care and more than 90% delivered at home without skilled delivery assistance. METHODS: To create a demand for prenatal care, we first had to better understand the reasons behind the under-utilization of formal maternal health services. We conducted structured interviews with mothers to determine perceptions of the benefits of and barriers to prenatal care. Surveys showed that the most important barriers were related to programmatic factors, including low perceived service quality and sporadic midwife availability at the government clinic. Other barriers included time constraints, traditional beliefs, unfamiliarity with formal health care providers, lack of knowledge about the benefits of prenatal care and lack of transport. We created a program that addressed and community leaders and health volunteers were recruited and trained to assist in the program promotion. RESULTS: During the first year, 324 prenatal care visits were conducted in the newly created mobile monthly health clinics, representing more than 100 women who likely would not have otherwise accessed such services. RECOMMENDATIONS/CONCLUSIONS: The provision of accessible maternal health care does not always guarantee its use. Services must be placed within a context acceptable to women and their families. It is vital to focus policy and programmatic interventions on the gaps in existing health care systems and in improving client satisfaction of health care services.