Herwansyah

The high Maternal Mortality Ratio (MMR) remains one of the public health concerns facing the global health community. Several factors that lead to high MMR involve various aspects, and effective solutions are often multisector based. One of the factors contributing to the high MMR is the poor use of maternal health services at community-based healthcare facilities. Moreover, the lack of understanding regarding the importance of comprehensive service utilization is considered another determinant of high MMR. Therefore, maximizing the role of community health centre (CHC) and raising awareness of the significance of holistic maternal health services constitute effective and efficient actions. These solutions should be implemented simultaneously rather than on a standalone basis solution.

In the context of Indonesia, primary healthcare facilities play a critical role in the country’s health system. The CHC is the main entry point into the healthcare system, providing basic healthcare services to a larger community, and its utilization is essential to improving public health status, including maternal health. The CHC is also the foundation of initiatives to preserve and enhance community health at the most basic level, including maternal health service provision. The maximization of the utilization of maternal health services at the CHC optimize the pregnancy, delivery, and post-partum care condition of women. The improved outcomes will contribute significantly to the successful implementation of the maternal health program and, at a broader note, to the optimization of the existing health systems.

The Province of Jambi is one of the small provinces in Indonesia where the MMR remains high compared to other provinces in the country. Although the MMR is still below the national figure, the ratio is supposed to be low. Hence, this is still a major concern for the provincial government. Taking into consideration that there is scarce evidence in the field of the utilization of maternal health services at the CHC level in Indonesia generally and the Province of Jambi in particular. This dissertation explores how maternal health services are utilized at the primary healthcare level in the province of Jambi, Indonesia. This empirical study employed a mixed methods approach, combining in the several chapters methodologies, such as systematic literature review, interviews, and focus group discussions.

Chapter 1 provides a comprehensive overview of maternal health outcomes globally and specifically in Indonesia. The chapter also describes the concept of the community health centre, known as Puskesmas, in Indonesia and the maternal health services provided in this type of primary healthcare facility. Additionally, this chapter outlines the research objectives and methodology approaches applied throughout the dissertation.

Chapter 2 is a systematic literature review that identifies and discusses the evidence of published literature on the utilization of maternal health services in primary healthcare centre settings in Southeast Asian countries. The review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Electronic databases such as PubMed, Web of Science, and Google Scholar were searched for studies.

In total, 1876 studies were recorded, of which 27 studies on the utilization of maternal health services met the criteria and were selected for analysis. The seven Southeast Asian countries included Cambodia, Indonesia, Lao PDR, Myanmar, the Philippines, Timor-Leste, and Vietnam. The articles mainly focused on the use of maternal health services in primary healthcare settings. These services include antenatal care (ANC) visits, birth support, delivery location, and postnatal care (PNC). The primary factor for low service utilization across different countries has been attributed to socio-cultural differences and inequalities in the provision of healthcare services. This has been further studied and reported in Chapter 3, which explored socio-economic and demographic factors associated with the maternal health services at the CHC level with a focus on the Indonesian setting.

Chapter 3 investigated the socioeconomic and demographic factors related to the utilization of maternal health services at the primary healthcare level in the Province of Jambi, Indonesia. This cross-sectional study aimed to gain deeper insights on the potential gaps and room for improvement in the service use. The outcome variables included antenatal care visits to the CHC during pregnancy, delivery by skilled health professionals and in primary healthcare facilities, and postnatal care visits to the CHC within 42 days of delivery. Demographic characteristics (women’s age, ethnicity, parity and family type) were amongst the independent variables. The sociodemographic variables include household income, religion, educational status, occupation, health insurance and distance to health facilities. The analysis was completed using binary and logistic regression to examine the association between sociodemographic variables and maternal health services utilization.

The study findings show that sociodemographic factors, such as a woman's age, ethnicity, education level, parity, distance to health facilities, and health insurance ownership, had a positive correlation with the utilization of maternal health services at community health centres. Despite the overall progress in the utilization of maternal health services in general health facilities, it is crucial to focus on community health centre-based delivery and postnatal care. Interventions should focus on enhancing women's interests in using postnatal care services and the CHCs for delivery, as it was found that women were less likely to utilize the two services. Further improvement is required to develop a holistic maternal health program at the CHCs by considering the characteristics of the reproductive-aged women to meet the users’ expectations. Addressing the issues of low maternal health service utilization generally requires the support of healthcare providers at the CHC, particularly leaders and health professionals. The role and responsibilities of healthcare providers have been reported in Chapter 4.

Chapter 4 explored insights from the CHC leaders on better understanding how they communicate the roles and responsibilities in improving the utilization of maternal health services at the community health centre level. The findings in Chapter 5 are generated qualitatively using an exploratory-descriptive qualitative (EDQ) design. Twenty-five in-depth interviews (IDIs) were conducted with the CHC leaders in twenty-five CHCs across three regencies in the Province of Jambi. The three regencies were selected based on geographical reasons, representing three areas in the Province (Eastern, Central and Western Regencies). Inductive content analysis was used to examine the verbatim transcription in order to find emerging themes within the qualitative data. The interviews covered topics such as the participants' main duties as a leader, their biggest contributions, the difficulties they have faced while working at the CHCs, and how the leader perceived other staff duties.

The research findings demonstrate that various participants have a clear understanding of the duties and responsibilities of a leader to improve the use of maternal health services at healthcare facilities. One of the key components to enhance the utilization of maternal health services is through the active engagement of CHC leaders in their primary duties and responsibilities. Participants described different roles and responsibilities in improving the services utilization at the CHC including the operational plan development, managerial and human resources duties, performance management, quality assurance and professional development.

A number of factors, such as the availability of adequate human resources in the healthcare facilities, the availability of supporting infrastructure, healthcare financing, and the management of healthcare organizations, affect the CHCs' ability to provide appropriate services. All these factors require a trustworthy and reliable leadership role, which is necessary for the CHCs to function as a public health institution providing basic maternal health services at the primary healthcare level. In order to meet the predefined objectives, the CHC leader is crucial in motivating all available resources, especially when it comes to enhancing the standard of maternal health through optimal use of maternal health services.

Further, the study showed that interpersonal determinants are associated with service utilization. The household perspectives of the socio-demographic characteristics of household members in light of support for the use of maternal health services have been further explored in the next chapter. Chapter 5 explored how influential relationships lead to the preference for maternal health service utilization at either the CHC or other healthcare facilities. Based on a mixed-methods study using explanatory sequential design, this study aims to provide a more comprehensive knowledge of the interpersonal variables associated with to the use of maternal health services.

The quantitative study was conducted through a survey of 432 respondents, focusing on the characteristics of women and their husbands and their association with maternal health service preference. In addition, a qualitative approach was employed to explore how family members perceive their role in supporting maternal health service use and the steps they take to overcome interpersonal barriers to the utilization of these services. The survey instrument used in the quantitative study consisted of questions that aimed to capture important characteristics of the targeted respondents, including their demographic information, utilization of antenatal care, and delivery services. The study's outcome variables focused on the willingness of respondents to visit the CHC for the first ANC, subsequent ANC visits, and utilization of delivery services at the CHC. Meanwhile, the independent variables included the socio-demographic characteristics of the woman, her husband, and the family's residency status. In addition to the survey, we also conducted a qualitative research phase where we gathered valuable insights on social phenomena through focus group discussions (FGDs) with family members. The participants for the FGDs were selected purposefully, with the assistance of CHC staff.

The findings of the study indicate that factors such as knowledge, positive attitudes from family members, and experiences play a crucial role in women's decision to use maternal health services holistically at primary healthcare centres. On the other hand, sociodemographic characteristics have a relatively less impact on service utilization. Taking into account these interpersonal factors, healthcare providers and policymakers can develop targeted interventions that can help improving maternal health service utilization and enhance the well-being of women across Indonesia. However, most of the public health services at the primary healthcare level, including maternal health service provision, were suspended and overlooked, which potentially led to an increase in maternal mortality during the COVID-19 pandemic. This phenomenon has been further studied and reported in Chapter 6.

Chapter 6 provides perspectives from midwives in Indonesia on the provision of maternal health services during the pandemic. The main purpose of this study was to identify potential barriers and facilitators to the services provided by midwives at primary healthcare facilities. This qualitative study intended to understand the experiences of the informants through in-depth and intense discussions. The study was carried out in three municipalities in the Province of Jambi at five CHCs, which were classified as emergency obstetric and neonatal community health centre (PONED). Five FGDs were conducted with three to six midwives in each discussion. The duration of each session varied based on the informants’ working hours and activities on the appointed days. Each FGD typically lasted between 60 and 90 minutes.

The transcripts were analysed using conventional content analysis. The findings resulted the explicit and implicit meaning from the text data analysis and reflected the opinions of the informants. The two primary themes were constructed based on the qualitative analysis of the data, which included the condition of maternal health services at the CHC during the pandemic as well as barriers and facilitators related to the healthcare provider, community-level circumstances, and organizational health sector-level. Despite the fact that the COVID-19 pandemic has resulted in a significant change in the maternal health service provision at the CHC level, the healthcare workers continued to serve the service under strict health protocols. The identified barriers and facilitators to the service provision included fear of being infected, a lack of personal protective equipment, extended working hours, the implementation of strict health protocols, and service delivery limitations.

Urgent strategies are needed to reduce critical challenges in maternal health service provision in particular during uncertain conditions. Strengthening the quality of services can be achieved by increasing the number of human resources, providing essential protective personal equipment, and developing new comprehensive policies to improve the standard-based of maternal health services. The community's involvement in adhering to COVID-19 preventive program and control measures will greatly benefit midwives who are facing the challenges of the pandemic.

In Chapter 7, the key findings of Chapters 2–6 were interpreted within the context of maternal health service utilization, supported by various evidences and contexts. The results interpretations were followed by various policy and research implications at different levels.

To conclude, this dissertation has provided valuable insights into the use of maternal health services at the primary healthcare facilities in the Province of Jambi Indonesia. The utilization of maternal health services is influenced by several factors, including sociodemographic factors, interpersonal supports, healthcare professionals, and the leadership role in enhancing service utilization. To improve the service use and lower the MMR in the Province of Jambi, the outlined factors may be considered as enablers and have to be prioritized at decision and policy makers.