Regional Disparities of Antenatal Care Utilization in Indonesia

Introduction The main strategy for decreasing maternal morbidity and mortality with antenatal care (ANC). ANC aims to monitor and maintain the health and safety of the mother and fetus, detect all complications of pregnancy and take the necessary actions, respond to complaints, prepare for birth, and promote healthy living behavior. The study aims to analyze inter-regional disparities in ≥4 ANC visits during pregnancy in Indonesia. Methods Data sources from 2017 Indonesian Demographic and Health Survey (IDHS). With an analysis unit of women aged 15-49 years old, a sample of 15,351 women was obtained. Besides ANC as the dependent variable, other variables analyzed were place of residence, age, husband/partner, education, parity, wealth status, and health insurance. Analysis using Binary Logistic Regression for the final test to determine disparity. Results All regions show a gap with the Papua region as a reference, except the Maluku region which was not significant shows differences in the use of ANC compared to the Papua. Women in the Nusa Tenggara have 4,365 chances of making ≥4 ANC visits compared to the Papua region. Women in Java-Bali have 3,607 times more chances to make ≥4 ANC visits than women in the Papua region. Women in Sumatra have 1,370 chances of making ≥4 ANC visits compared to women in the Papua region. Women in Kalimantan have 2.232 times made ≥4 ANC visits compared to women in the Papua region. Women in Sulawesi have 1,980 times more than AN4 ANC visits compared to women in the Papua region. In addition to the region category, other variables found to contribute to the predictor were age, husband/partner, education, parity, wealth and insurance. Conclusion There were disparities between regions in the ANC utilization in Indonesia.


Introduction
In health development, the target of increasing equal distribution and quality of health services is determined by three indicators, namely the number of sub-districts that have at least one accredited Puskesmas (Health Center) of 5,600, the number of regencies/cities that have at least one nationally accredited hospital of 481, and the percentage of regencies/cities that have up to 80% complete basic immunization in infants as much as 95%. Based on the Ministry of Health's report the target has been achieved, the target number of sub-districts that have at least one Health Center accredited in 2018 of 4900 sub-districts, has been realized as many as 5,385 Sub-districts (109.9%), or around 7,518 Health Centers. This achievement exceeded the target set because several regencies/cities used the Regional Revenue and Expenditure Budget purely for the accreditation process, not from the Non-Physical Allocation Fund. For the number of regencies/cities that have at least one nationally accredited hospital, the realization in 2018 was 440 (101.4%) of the target of 434. For the immunization target still not achieved, 2018 data shows complete basic immunization coverage for children aged 12-23 months in Indonesia is 57.9%, incomplete is 32.9% and not immunized is 9.2% [2]. 4 In the target of improving the community's health and nutrition status, several achievement targets have been set, namely the maternal mortality rate (MMR) of 306/100,000 live births, the infant mortality rate (IMR) which is targeted to reach 24/1000 live births, the prevalence of malnutrition in children under five 17/100,000, and the prevalence of stunting in children under two years 28 [7].
The main strategy for decreasing maternal morbidity and mortality with antenatal care (ANC). ANC aims to monitor and maintain the health and safety of the mother and fetus, detect 5 all complications of pregnancy and take the necessary actions, respond to complaints, prepare for birth, and promote healthy living behavior. ANC visits are very important to detect and prevent unwanted things that arise during pregnancy [8]. In developing countries, there has been an increase in the utilization of maternal health services but it still varies among population groups.
Disparities can occur due to geographical, demographic, socioeconomic, and cultural differences.
Gaps that occur result in decreased access to services, service quality, and service affordability [9][10].
In 2018 there has been an increase in the proportion of ANC visits to women aged 10-54 years ie first visit by 96.1% compared to 2013 by 95.2%, while for ANC fourth visits in 2018 amounted to 74.1% compared to 2013 by 70.0%, the coverage of ANC fourth visits is still below the target set in the 2017 Strategic Plan which is 76.0% [11]. However, the quality of services to ensure early diagnosis and appropriate care for pregnant women still needs to be improved.
Midwives spearheading to serve pregnancy checks including identification of complications or symptoms of complications, assist in labor and childbirth examination. If there are signs of complications that cannot be treated, the midwife must make a referral to a health facility that provides Basic Emergency Neonatal Obstetric Services, to obtain further treatment [12]. Data from the Ministry of Health in 2018 stated that the majority (62.7%) of deliveries were assisted by midwives and were carried out in independent midwife practices (29%), although there were still many at home (16%) [11].
This study was conducted to analyze interregional disparities in the utilization of ≥4 ANC visits during pregnancy in women aged 15-49 years who gave birth in the last five years in Indonesia. This study is important to do so that it can provide clear directions for the Ministry of Health to complete regional priority data in an effort to reduce maternal mortality.

Procedure
Ethical clearance has been obtained in the 2017 IDHS from the National Ethics Committee.
The respondents' identities have all been deleted from the dataset. Respondents have provided written approval for their involvement in the study. Through the website: https://dhsprogram.com/data/new-user-registration.cfm researchers have obtained permission to use data for the purposes of this study.

Data Analysis
The Ministry of Health of the Republic of Indonesia recommends that the ANC during pregnancy be done at least 4 times, namely in the first trimester 1 time, in the second trimester 1 time, and in the third trimester 2 times [13]. Other variables analyzed as independent variables are the place of residence, age, husband/partner, education level, parity, wealth status, and health 7 insurance. Because all variables are categorical, the Chi-square test was used to select variables related to the frequency of ANC utilization during pregnancy. Because of the nature of the dependent variable, Binary Logistic Regression is used for the final test to determine disparity. SPSS 21 software is used for all stages of statistical analysis.  Table 1. Table 1 shows that there are statistically significant differences between regions. Each region was seen dominated by the use of ANC which had ≥4 visits. Note: * p < 0.05; * * p < 0.01; * * * p < 0.001. Table 2 shows the results of the binary logistic regression test which shows disparities between regions in the use of ANC in Indonesia. At this stage <4 ANC visits during pregnancy are used as a reference. Table 3 shows that all regions show gaps with the Papua region as a reference, except the Maluku region which is not significant shows differences in the use of ANC with the Papua region.   Note: * p < 0.05; * * p < 0.01; * * * p < 0.001.

Results
In addition to the region category, other variables found to contribute to the predictor are age group, husband/partner, education level, parity, wealth status, and health insurance. Table 2 shows that women in the 15

Discussion
The results showed that disparity between regions in the use of ANC is still ongoing. The disparity is also clearly seen between the East and West regions. The results of this analysis are in line with several studies in Indonesia which show that the Eastern region is lagging behind the Western region [14][15][16]. Especially when compared to the Java-Bali region as the center of government.
Geographically, conditions in Eastern Indonesia also show more extreme variability than Western regions. This condition makes some parts of the East in the category of isolated or remote area [17][18], and some other areas are quite difficult to reach because of the limited means of roads and public transportation available [19].
Qualitatively, some research also shows that in the Eastern region having more health beliefs is a challenge for health workers to strive for better maternal health [20][21]. Not only applies to the community, but the health belief also encompasses health workers, because they are an inseparable part of the community itself [22].
The analysis shows that there is no difference between urban and rural areas in ANC utilization in Indonesia. This condition is different from the findings in Nigeria [23], Ethiopia [24], Pakistan [25] and several other countries [26], which found disparities between urban and rural areas.
The age group was found to be a predictor of ANC utilization. The youngest age group has a lower probability of making ≥4 ANC visits. This is likely due to the lack of experience, so knowledge about health risks is lower [27][28]. A study in India that analyzed the relationship 14 between child marriage and the utilization of maternal healthcare services concluded that many challenges were found so that more effort was needed so that child marriage could have a positive impact on the use of maternal healthcare services [29].
The analysis shows that women who have husbands/partners are likely to be better at using ANC. This is in line with the conclusions in several studies that show the role of husband/partner in providing support for a woman's health behavior [30--33]. Some other studies actually involve a husband to be able to improve a woman's health status through actively better health behaviors [34][35].
Analysis of this study proves that education is one of the determining factors for women in Indonesia to make ≥4 ANC visits. In general, it can be explained that the more educated a person is, the easier it is to receive new health information, while at the same time being able to understand the dangers or risks of behaviors that have an impact on health [36][37][38]. Education has also been shown to play a role in one's perception of the quality of health services [39,40]. Furthermore, improving education is generally accepted as one of the determinants of life expectancy [41].
This study found that parity is a determinant of the use of ANC. The lower the parity, the more likely it is to make ≥4 ANC visits. Parity as one of the determinants of ANC utilization is also found in several recent studies in several countries [42][43][44].
In line with the level of education, wealth status was also found to be directly proportional to the behavior of ≥4 ANC visits. This result is in accordance with several studies which found that wealth status is one of the positive determinants of ANC utilization, namely in Ethiopia [45], Pakistan [46], Nigeria [47], and Uganda [48]. The better the wealth status of a woman, the more likely it is to make ≥4 ANC visits. 15 Women covered by health insurance were found to have better use of ANC. Women who do not have health insurance have lower ANC utilization. This finding is in line with the goal of the National Health Insurance released by the Indonesian government to provide universal access to health care facilities [49,50]. Social insurance policies to increase public access to health care facilities have also been adopted by other countries. The results of studies evaluating this matter show positive results [51][52][53], although also in the implementation there were still some obstacles encountered [54][55].
Disparities found and detected in this study are still limited to superficial. Researchers suggest further research in order to detect the causes of disparity in more depth.

Conclusions
Based on the results of the study it can be concluded that there are 10 variables that become a barrier for Indonesian women to make AN4 ANC visits during pregnancy. The barriers consisted of variables of young age, low education, high parity, poverty, not having health insurance, not being able to read, not being exposed to the media, never using the internet, not knowing the danger signs of pregnancy, and belief in traditional birth attendants. Thus, maternal health programs need to address barriers to things for effective health care utilization.