THE ROLE OF HEALTH ACCESSIBILITY ON THE USE OF MATERNAL

HEALTH SERVICES IN ACHIEVING THE SUSTAINABLE

DEVELOPMENT GOALS-3 TARGET

THESIS SUMMARY

Submitted by:
Rahmi Budhy Fatmasari
16/407323/PEK/22558

DEPARTMENT OF MASTER IN ECONOMICS

FACULTY OF ECONOMICS AND BUSINESS
UNIVERSITAS GADJAH MADA
YOGYAKARTA
2019
 THE ROLE OF HEALTH ACCESSIBILITY ON THE USE OF MATERNAL
HEALTH SERVICES IN ACHIEVING THE SUSTAINABLE
DEVELOPMENT GOALS-3 TARGET

Rahmi Budhy Fatmasari

16/407323/PEK/22558

Abstract
One of the interventions that succeeded in reducing the maternal mortality ratio was
the use of antenatal care services. But the distance and travel time constraints are
often an obstacle for pregnant women in utilizing available health services. The
purpose of this study was to analyze trends in the development of health care
facilities in Indonesia, to analyze whether travel time to health facilities could be
categorized as an ideal travel time in supporting four or more prenatal activities and
analyzing pregnancy screening activities for pregnant women based on geographical
conditions. This study uses pooled cross section data from the Indonesia Family Life
Survey (IFLS) in 2000, 2007 and 2014 with the analysis method used is the
maximum probability with probit models. Overall, it can be concluded that the travel
time to health facilities did not significantly affect the number of antenatal visits in
this study.
Keywords: maternal mortality rates, maternal health services, sustainable
development, travel time
1. INTRODUCTION
One indicator of community health in a country is the ratio of maternal mortality
(Depkes, 2014). Maternal mortality rate (MMR) shows the ability and quality of
services that exist in an area/country. The MMR ratio is the number of women who
die from a cause of death related to pregnancy disorders or their handling (excluding
accident or incidental cases) during pregnancy, childbirth and during the puerperium
period (42 days after delivery) without taking into account the length of pregnancy
(Ministry of Health, 2015). Currently, the problems related to the process of
pregnancy and childbirth in several countries have not been controlled, where the
ratio of MMR is still relatively high. Maternal health which is one of the targets in the
Millennium Development Goals (MDGs) has not been able to be achieved by
Indonesia in 2015, because Indonesia's MMR ratio is still at 305 per 100.000 live
births (SUPAS, 2015). When compared with several ASEAN countries, the MMR
ratio in Indonesia ranks eighth out of nine countries after Philippines. This is certainly
a problem because Singapore, which ranks first with the lowest MMR ratio, has a
mortality rate far below the Indonesian MMR ratio of 70 per 100.000 live births
(ASEAN Secretariat, 2017).
Gay’s et al. (2003) stated that one of the interventions that succeeded in
reducing MMR was the use of appropriate antenatal care (ANC) services, such as
iron supplementation during pregnancy and professional medical personnel who
handled labor. The WHO report (2012) states that maternal mortality is more
prevalent among women living in rural areas and among the poor. The statement was
based on the existence of distance and transportation constraints which caused low
utilization of health facilities in rural areas. The same thing was mentioned by
Mpembeni, et al. (2007), Scott, et al. (2013), Hanson, et al. (2015) and Wilunda
(2017), where the main factor that dominates the low utilization of prenatal care
services is the distance to health facilities.
The distance constraints, travel time and transportation in utilizing health
services that occur a lot in rural areas are very different when compared to urban
areas. The existence of the industrialization phenomenon in urban areas encourages
much higher infrastructure development, such as the construction of roads, electricity
and public facilities and infrastructure. The results of Riskesdas Data in 2013 provide
an overview of the difference in travel time to government hospitals needed by rural
and urban communities.

minutes minutes minutes minutes

Urban Rural Lowest Lower-middle Middle Middle to upper Top

Figure 1.1 Travel time to characteristic government hospitals, Riskesdas (2013)

The graph above shows the difference in time taken to the government hospital by the
community with various characteristics. In the picture above, it is shown that the
majority of travel time needed by the lowest class of people to health facilities is
more than 60 minutes. This is contrary to the ideal travel time of 30 minutes. If
associated with BPS data (2018) regarding the number of rural poverties which is
higher than urban poverty in Indonesia, the majority of the lower classes of society
live in rural areas that still constrain distance and travel time in utilizing existing
health services. Another factor that causes the lowest class of people to have to take a
long time in utilizing health services is the absence of vehicles owned and inadequate
income. Unlike the case with the upper-class community, which only requires a travel
time of 16-30 minutes to go to a government hospital. The upper-class community on
average do not have problems in terms of transportation and costs that must be paid.
Likewise, if comparing the travel time of people living in rural and urban areas,
where the average community living in rural areas requires higher travel time than
people living in urban areas, the time needed to go to a government hospital is more
than one hour.
This study aims to analyze the trend of health infrastructure development in
Indonesia, analyze the effect of travel time on the number of antenatal visits and
analyze how geographical antenatal care activities are reviewed based on the area of
residence and location of residence, which will then be controlled by several variables
such as maternal characteristics, household characteristics, quality of health facilities
and community characteristics.

2. LITERATURE REVIEW
2.1 Maternal Mortality

Maternal mortality is a death during pregnancy or in a period of 42 days after the end
of a pregnancy caused by several factors related to pregnancy or it’s handling, but not
due to an accident or injury (Ministry of Health, 2014). Calculation of MMR is based
on two factors, namely the number of maternal deaths and the number of live births.
The indicator of the number of maternal deaths is the number of maternal deaths that
occur during pregnancy or childbirth. This refers to the definition of maternal
mortality from BPS (2018) which states that female deaths during pregnancy or for
42 days from termination of pregnancy regardless of duration and place of delivery,
are caused due to pregnancy or management, and not due to other reasons, per
100,000 live births.
D pregnant
MMR=
Number of Live Births
The above equation is the method used to calculate the number of MMR in
Indonesia. The amount of MMR is obtained by dividing the number of deaths of
mothers who are in the stage of pregnancy or childbirth to the number of live births.
Based on the explanation of Measure Evaluation (2018), information about maternal
mortality occurs in a period (generally one year) and information about the total
number of live births is also calculated in the same year. If data regarding the number
of live births are not available, we can use the value of the total estimated live birth
using census data for the total population and rough birth rates in a particular area.
The limits used in calculating the MMR are not related to age, calculated per
100.000 events and indicators of specific causes of death.
Number of maternal deaths
MMratio= ( Number of births )× 100.000
Another measurement used in the problem of maternal mortality is the maternal
mortality rate (MM Rate) which is the specific cause of death. The formula used to
calculate MM Rate is:

Number of maternal deaths

MMratio= ( Number of living productive women )
×1000

Maternal mortality is one of the targets that is still difficult to achieve in Indonesia,
where the 2015 MDG target is to reduce MMR to 102/100.000 live births, but until
2007 MMR in Indonesia is still 228/100.000 live births.

2.2 Health Seeking Behavior

Health-seeking behavior begins with the decision-making process which is then
determined by the individual or household behavior, community norms, and
expectations and characteristics and behavior of health facility providers. Health
seeking behavior or care is defined as any action taken by an individual who
considers himself to have a health or illness problem for the purpose of finding the
right medicine. The model of belief in health (health belief model) can be used to
understand health seeking behavior. Health belief model was first proposed by
Resenstock 1966, then refined by Becker, et al. 1970 and 1980. The health belief
model is a concept that explains the reasons for individuals to want or not want to do
healthy behavior (Janz & Becker, 1984). The health belief model can also be
interpreted as a theoretical construct regarding individual beliefs in healthy behavior
(Conner, 2005). In general, health belief model is a model that is used to describe the
beliefs of individuals towards healthy behavior, so that individuals will carry out
healthy behaviors in the form of preventive actions and use of health facilities.
 Individual Perception Factors Affecting Possible Action

Age, Sex, Ethnicity, Benefit reduced

Personality, Socio- obstacles
economic,
Knowledge

Perceived level of Possible

vulnerability Perceived
Behavior
threat

Figure 2.1 Health Belief Model Signal to act

Source: Stretcher dan Rosenstock (1997)

In the health belief model chart above it is explained that the variables that
influence, the existence of cues to act and the belief of someone in themselves to be
able to do something, can affect perceptions of the level of perceived vulnerability,
seriousness, benefits, obstacles and also a person's behavior. Bedri (2001) states that
health seeking behavior is certainly clearly different for each individual and society
when faced with various types of diseases.
3. METHODOLOGY
3.1 Data
The data used in this study came from survey institutions, namely the Indonesia
Family Life Survey (IFLS) which is a household panel data in Indonesia since 1993
(first wave) until 2014 (wave five). In this study the data used were pooled cross-
section IFLS three-wave (2000), four (2007) and five (2014) data obtained from the
RAND IFLS. In order to analyze whether travel time to health facilities can be
categorized as the ideal travel time in supporting four times or more prenatal
activities, this study uses the maximum likelihood analysis with a probit model where
the dependent variable is the number of antenatal care visits four or more times. This
study also included several control variables such as maternal characteristics,
household characteristics, quality of health facilities and community characteristics.
The pooled cross-section data in this study consisted of 4.012 observations
where the level of observation used was individual. The number of antenatal visits
was the dependent variable in this study. The dependent variable in this study is a
dummy, dummy will be worth one if the number of inspection visits of pregnant
women is four or more, otherwise. The independent variable in this study is the travel
time needed by a mother to go to the location of a pregnancy examination in minutes.
Some control variables that will be used in this study include maternal characteristics,
household characteristics, quality of health facilities and community characteristics.
Tabel 3.1 Statistics Descriptive
Variable Obs Mean Std. Dev. Min Max
Number of ANC visits 4.012 0,92394 0.265127 0 1
Traveling time to public hospital 4.012 48,87556 133.2303 0 5400
Traveling time to private hospital 4.012 36,12195 73.27197 1 1800
Traveling time to health center 4.012 18,62219 67.04056 1 1800
Traveling time to private clinic 4.012 19,56135 32.06898 1 1800
Traveling time to doctor’s office 4.012 21,59776 55.24998 1 1800
Traveling time to midwife’s practice 4.012 15,09626 61.76913 0 1800
Age 4.012 28,34439 6.353073 15 52
Education 4.003 8,650762 3.764021 0 18
Job status (Dummy work) 4.008 0,468563 0.499073 0 1
Pregnancy order 4.012 1,457606 0.826309 1 10
Variable Obs Mean Std. Dev. Min Max
Per capita expenditure 3.946 467996,3 483165.8 11700 6222845
Vehicle in household (Dummy have
vehicle) 4.012 0,601995 0.489548 0 1
Location of residence (Dummy rural) 4.012 0,515461 0.499823 0 1
Weight (Dummy measured) 4.012 0,904239 0.294299 0 1
Height (Dummy measured) 4.012 0,467581 0.49901 0 1
Blood pressure (Dummy measured) 4.012 0,941895 0.233971 0 1
Blood tests (Dummy measured) 4.012 0,416958 0.493117 0 1
Uterine fundal height (Dummy
meausred) 4.012 0,525686 0.499402 0 1
Fetal heartbeat (Dummy measured) 4.012 0,844389 0.362531 0 1
TT imunization (Dummy obtain) 4.012 0,789277 0.407873 0 1
Iron suplement (Dummy obtain) 4.012 0,85212 0.355026 0 1
Road condition (Dummy paved) 4.012 0,85586 0.351275 0 1
Distance to the provincial capital 3.985 122,813 124.3699 0 998,98
Area of residence (Dummy Jawa-
Bali) 4.012 0,606234 0.488645 0 1
Existence of public hospital (Dummy
knowing) 4.012 0,779052 0.414937 0 1
Existence of private hospital (Dummy
knowing) 4.012 0,492768 0.50001 0 1
Existence of health center (Dummy
knowing) 4.012 0,956359 0.20432 0 1
Existence of private clinic (Dummy
knowing) 4.012 0,199252 0.399488 0 1
Existence of doctor’s office (Dummy
knowing) 4.012 0,473317 0.49935 0 1
Existence of midwife’s practice
(Dummy knowing) 4.012 0,849127 0.35797 0 1

Source: IFLS 3,4 dan 5 (data diolah)

3.2 Research Methods

The analysis technique used in this study is probit regression which is performed to
determine the marginal value of effect (mfx) of each independent variable on the
utilization of pregnancy examination services four or more times. Probit regression,
also called a probit model, is used to model dichotomous or binary outcome variables.
Basically probit regression is a regression model that can be used to determine the
effect of independent variables on the dependent variable that is binary. The probit
model can be written in the following equation:
probit ( EY )=Φ−1 ( p ) =Φ−1 ¿

In this study the dependent variable used is dummy, namely the number of
examination visits as many as four or more. The use of probit regression is based on
several previous studies which also analyzed the use of antenatal visits with the
dependent variable in the form of dummy. The equation model used in this study is:
Y it =α 0 + α 1 waktu tempuhit +α 2 karakteristik ibuit + α 2 karakteristik RT it + α 2 kualitas faskes+α 2 karakteristik

The estimation results of probit regression cannot be directly interpreted as in

the linear estimation model. In order to facilitate the interpretation of each variable in
the study, it is necessary to calculate the marginal effect value which is a change in
probability caused by a change in the value of the independent variable. The
calculation of the marginal effect value in this study uses the average marginal effect
because there are limitations to the calculation of the marginal effect at the mean,
which in general, rarely occurs when all variables are equal to the average value. In
addition to estimating the model using probit regression, in order to ensure there is no
sensitivity to various assumptions, a robustness test is carried out consisting of
goodness of fit tests through pseudo R 2, testing of Hosmer-Lemeshow and correctly
classified.
4. RESULT AND DISCUSSION
4.1 Trend of Health Infrastructure Development in Indonesia
The problem of access is still an obstacle for the community, especially those living
in rural areas to be able to take advantage of existing health services. In order to
analyze the accessibility of health facilities, travel time can be used as a measure of
the availability of health facilities to the location where people live. Laksono's
statement, et al (2016) states that the ideal travel time to the nearest health facility
such as a health center, practice of general practitioners / specialists and private
clinics is 30 minutes. The ideal travel time to go to a private midwife's house is 15
minutes. While the ideal travel time to the hospital is no more than 60 minutes.
 60

50 46 45 48

40 37 35
32
28 29
30 24
21 22 21
18 17 19 19
20 16 16

10

0
RS Pemerintah
Public Hospital RS Swasta
Private Puskesmas
Hospital Health Center Klinik
Private swasta
Clinic Praktik
Practicedokter
of Rumah bidan
Midwife’s
umum/spesialis
general swasta
Practice
practitioners
2000 2007 2014 / specialists

Figure 4.1 Travel time to health facilities in minutes, IFLS (2014)

Based on pooled-cross section data obtained from IFLS in 2000, 2007 and
2014, shown in Figure 4.1 regarding the comparison of travel time to health facilities
in Indonesia. In the picture above, it can be seen that on average the time needed by
the community to go to the government and private hospitals is in the ideal travel
time category. Likewise, for several other health facilities, the average travel time to
the available health facilities is in the ideal travel time category. What is of particular
concern is that the travel time to the practice of general practitioners / specialists in
2000 almost exceeded the ideal travel time of 30 minutes. However, in 2007 and
2014 it gradually dropped along with the facilities and the number of health workers
increasing every year.

2000 2007 2014

30%
39%

31%

Figure 4.2 Number of Indonesian Health Facilities in 2000, 2007 and 2014
(Indonesia Family Life Survey (IFLS))

The figure above shows the number of health facilities in a community in 2000, 2007
and 2014. Based on 2000 IFLS data, the number of health facilities that function well
in a community sample is 1,555 units. The number includes posyandu, health center
and auxiliary health centers, private clinics, traditional medical personnel as well as
government and private hospitals. In 2007 the coverage of health infrastructure
development expanded to the construction of posyandu for the elderly. The number of
health infrastructure in 2007 increased by 85 units, namely to 1,640 health facility
units. Seeing the increase in the number of health facilities, the government's efforts
to improve public welfare and health continue to be evaluated and improved.

4.2 Effects of Accessibility of Health Facilities on ANC Visits

The estimation in this study uses probit logistic regression method for pooled cross-
section data of IFLS in 2000, 2007 and 2014. The use of the estimation technique is
based on the value of the dependent variable in the form of qualitative variables,
which is worth 1 if the pregnancy check visit is at least four times or more during the
pregnancy period and otherwise. The coefficient value on the probit model can’t be
directly interpreted, it is necessary to calculate the marginal effect value in each
coefficient to be able to explain the effect of the independent variable on the
dependent variable.
Table 4.1 Estimastion Results
Marginal Probit
Number of ANC visits
Coeficient Marginal Effect
Traveling time to public hospital (Dummy ideal) -0,1059 -0,0128
Traveling time to private hospital (Dummy ideal) 0,1622 0,0196
Traveling time to health center (Dummy ideal) 0,1790 0,0217
Traveling time to private clinic (Dummy ideal) -0,1772 -0,0215
Traveling time to doctor’s office (Dummy ideal) -0,6904** -0,0836**
Traveling time to midwife’s practice (Dummy ideal) 0,0756 0,0092
Age 0,0058 0,0007
Education 0,0556** 0,0067**
Job status (Dummy work) -0,0191 -0,0023
Pregnancy order -0,0930** -0,0113**
Per capita expenditure 0,0000002** 0,0000003**
Vehicle in household (Dummy have vehicle) 0,1270** 0,0154**
Location of residence (Dummy rural) 0,0473 0,0057
Weight (Dummy measured) 0,2549** 0,0309**
Height (Dummy measured) 0,1627** 0,0197**
Blood pressure (Dummy measured) 0,2182* 0,0264*
Blood tests (Dummy measured) 0,1134 0,0137
Uterine fundal height (Dummy meausred) 0,1128 0,0137
Fetal heartbeat (Dummy measured) 0,0550 0,0067
TT imunization (Dummy obtain) 0,2610** 0,0316**
Iron suplement (Dummy obtain) 0,3927** 0,0475**
 Marginal Probit
Number of ANC visits
Coeficient Marginal Effect
Road condition (Dummy paved) 0,0664 0,0080
Distance to the provincial capital -0,0004* 0,00003*
Area of residence (Dummy Jawa-Bali) 0,2977** 0,0360**
Existence of public hospital (Dummy knowing) -0,0097 -0,0012
Existence of private hospital (Dummy knowing) 0,1298 0,0157
Existence of health center (Dummy knowing) -0,0470 -0,0057
Existence of private clinic (Dummy knowing) 0,0381 0,0046
Existence of doctor’s office (Dummy knowing) -0,0390 -0,0047
Existence of midwife’s practice (Dummy knowing) -0,2036** -0,0247**
Observasi (N) 3.915 3.915
2
Pseudo R 0,1660
Correctly classified 91,90%
Hosmer-Lemeshow 0,5947
Description: robust standard error is adjusted based on the level of significance *ρ
=0,1; **ρ=0,05
Source: IFLS 3, 4 dan 5

The main analysis in this study was to review the effect of travel time to health
facilities on the number of pregnancy check-ups of four or more times for mothers
who had completed their pregnancy. Based on the estimation results in table 4.1 only
travel time to the practice of general practitioners / specialists who have a significant
influence on the number of antenatal visits even though they have a negative
coefficient sign. A mother who has an ideal travel time to the practice of a general
practitioner / specialist has a tendency for the number of prenatal visits to be 0.0836
lower compared to mothers who travel more than 30 minutes to the general
practitioner / specialist practice site. This is possible because even though the practice
location of general practitioners / specialists tends to be close to the place of
residence, the costs that must be spent are far higher than checking with the
examination locations such as in the health center and the practice of private
midwives. The pattern of data from IFLS-3, IFLS-4 and IFLS-5 shows that the most
frequently visited pregnancy check-ups by pregnant women are health center,
although based on estimated values, the low travel time to the health center does not
affect the number of antenatal visits.
The analysis in this study also observed the influence of maternal characteristics
of pregnancy completion on the number of antenatal care visits. Based on the
estimation results in table 4.1, maternal education has a positive and significant
influence on the number of maternal examination visits. That is, the more the
education year of a mother increases, the higher the number of antenatal visit visits
will increase by 0.0067 compared to the number of examination visits for pregnant
women whose years of education are lower. This finding is in accordance with
Susuman (2015) regarding health care services and maternal education in South
Africa, which states that the education of a mother has a strong influence on the use
of antenatal care services. In general, the longer the education of a person, the more
knowledge and skills they have will also be broader, which of course can be applied
in the daily life of an individual. In some previous studies, the education variable was
the variable most often used as an explanation of the relationship to the utilization of
maternal health services. An educated mother is considered to have greater awareness
about the existence of maternal health services and benefits in using these services.
Bhattacherjee's research, et al. (2013) also revealed that educated women had better
opportunities in utilizing maternal health services.
Pregnancy order is also one of the factors affecting pregnancy examination
visits in several previous studies. Basically, a mother tends to pay more attention to
the health of her pregnancy in the first pregnancy than after her pregnancy. This is
because a mother in the first pregnancy has gained a lot of knowledge and experience
about pregnancy that can be applied in subsequent pregnancies. This theory is in line
with the results of the estimation in table 4.1, where the increasing number of mothers
with an increasing number of pregnancies has a tendency for the number of
pregnancy examinations to be 0.0013 lower compared to mothers whose pregnancies
are still low or mothers with the first pregnancy.
Based on the estimation results in table 4.1 it can be concluded that per capita
expenditure has a significant positive effect on the number of inspection visits. The
interpretation is that the number of mothers with high per capita expenditure has a
tendency for the number of inspection visits to be 0.0000003 higher than for mothers
with low per capita expenditure. This is based on the per capita expenditure of a
household showing financial capacity in consumption, including expenditure on
health. So the higher the per capita expenditure in a household, the better the
opportunity to be able to take advantage of health services by conducting inspection
visits to pregnant women, the higher compared to households with low per capita
expenditure. In addition to the variable per capita expenditure, vehicle ownership has
a positive influence on antenatal care visits. Based on the estimation results in table
4.1, a mother in a household with private vehicle ownership has a tendency to have a
higher pregnancy check-up of 0.0154 compared to a mother who does not have a
vehicle in her family. This finding is in line with the research of Sahito and Fatmi
(2018) that ownership of motorized vehicles has a significant positive effect on
examination visits of pregnant women in Pakistan. This is caused by the ownership of
motorized vehicles which will make it easier for someone to take the time and
distance to the location of available health facilities.
Gupta's research, et al. (2014) explained that the quality of a health facility can
be measured through the health services provided. Data available in the IFLS
regarding health services for pregnant women include measurements of body weight,
height, blood pressure, blood tests, measurement of fundal uterine height, infant heart
rate, administration of tetanus toxoid immunization and iron supplements. Based on
the results of the estimation in the table above, obtaining iron supplements from
health facilities has the greatest influence, which is 0.0475 and has a significant effect
on the number of antenatal care visits. This value means that mothers who get iron
supplements while undergoing antenatal care have a tendency for the number of
examination visits to be higher than 0.0475 compared to mothers who did not receive
iron supplements. Kiwanuka's research, et al. (2017) states that giving iron
supplements during pregnancy is an effective way to reduce anemia in pregnant
women in countries with limited resources.
Based on the estimation results in table 4.1, a mother who obtained health
services with measurements of body weight had a tendency for the number of
prenatal visits to be 0.0309 higher than for mothers who did not measure their weight.
Measurement of body weight in pregnant women aims to ensure that a mother who is
pregnant does not experience shortages or is overweight. Based on the
recommendations of the Ministry of Health of the Republic of Indonesia (2006), the
increase in normal weight for pregnant women is 7-12 kg which increases because of
the conception results, namely the fetus and placenta. The administration of tetanus
toxoid immunization also significantly affected the number of antenatal care visits.
Based on the estimation results in table 4.1, a mother who received tetanus toxoid
immunization had a tendency for the number of pregnancy checkups to be 0.0316
higher compared to mothers who did not receive tetanus toxoid immunization.
Basically, the provision of tetanus toxoid immunization plays an important role in
reducing maternal mortality. Early detection of eclampsia and pre-eclampsia can be
done by measuring blood pressure in pregnant women and ensuring that blood
pressure is in a normal size. The diagnosis of hypertension in pregnancy is of
particular concern if the systolic blood pressure is more than or equal to 140 mmHg
and the diastolic blood pressure is more than or equal to 90 mmHg (SOGC, 2008).
Based on the estimation results in table 4.1, a mother whose blood pressure was
measured when conducting a pregnancy examination had a tendency for the number
of examination visits to be 0.0264 higher than that of a mother who did not measure
her blood pressure. The benefits obtained from blood pressure checks, encourage
pregnant women to increase the number of inspection visits to control blood pressure
during pregnancy.
Anemia in pregnancy can cause prematurity, abortion, infection, hydatidiform
mole and hyperemesis gravidarum. The estimation results in table 4.1 show that
blood screening services do not have a significant effect on the number of antenatal
care visits. Based on the data used in this study, the number of mothers who received
blood examination services was lower compared to the number of mothers who
performed blood tests at the checkpoint location. In this study there were 58.33
percent of mothers who did not receive blood examination services. This makes it
possible to be a causal factor in the results of estimation of blood tests that have no
significant effect in increasing the number of prenatal care. In antenatal care services,
height measurement is one of the 10T service standards set by the Indonesian
Ministry of Health. Based on the estimation results, a mother who measures height
has a tendency for the number of pregnancy checkups to be higher than 0.0197
compared to mothers who did not take height measurements during antenatal care.
The importance of maintaining nutritional status during pregnancy has encouraged
pregnant women to take advantage of antenatal care services because one of the
services that will be obtained is measuring height, which through recording can be
known to the nutritional health of pregnant women.
 A city / district located close to the provincial capital, tends to be easier to use
health services because of the ease of access and the greater proportion of health
workers. This is different from the case with the community whose location is located
in a district / city far from the provincial capital. In terms of the completeness of
medical equipment, health workers and health facilities tend not to be the same as the
completeness of health facilities and infrastructure in urban areas. Based on the
estimation results in table 4.1, a mother whose location of residence is close to the
provincial capital tends to have a number of antenatal visits 0.00003 higher than the
number of prenatal examinations for mothers whose locations are far from the
provincial capital. This condition explains that through the estimation of this research,
it can be shown that the imbalance in the distribution of power and health facilities
still occurs in Indonesia. This is of particular concern for the central government and
regional governments to make efforts in equitable distribution of health facilities so
that the basic rights of public health can be fulfilled in all regions of Indonesia.
Titaley's (2010) states that a mother living in an area outside Java-Bali and
living in a rural area has a low rate of utilization of antenatal services. This was
caused by the lack of availability of health services and was exacerbated by the
limited access outside Java-Bali, especially in rural areas. Based on the estimation
results in table 4.1, a mother who lives in the Java-Bali region has a tendency for the
number of prenatal visits to be 0.0360 higher compared to mothers who live in areas
outside Java-Bali. This finding is in line with Nababan's (2018) which states that the
richest people living in urban areas precisely in Java and Bali use available health
facilities and have better access to basic services including health.
This study included the knowledge variable on the existence of health facilities
as a control in influencing the number of antenatal care visits. The estimation in this
study shows that only the knowledge variable on the existence of private midwife
practices has a significant influence even though the coefficient sign is negative. The
estimation results in table 4.1 show that a mother who knows the existence of the
location of the practice of a private midwife has a tendency for a prenatal visit to be
0.0247 lower than that of a woman who does not know the existence of a private
midwife practice.

4.3 Pregnancy Check-Up Activities based on Geographic Location

4.3.1 Prenatal care based on location of residence

The main analysis in this study is aimed more at discussing the influence of health
facility accessibility that is measured through the travel time in minutes, to the
number of antenatal visit visits of four or more. The health facilities used in the
analysis of this study are based on the location of antenatal care handled by the
availability of adequate health equipment and professional medical personnel such as
doctors, nurses and midwives. Some health facilities that are used are public /
government hospitals, private hospitals, health centers, private clinics, general /
specialist medical practices and private midwife homes. In the discussion on section
4.4, it is intended to examine the number of antenatal visits that are reviewed based
on geographical location.
 Based on pooled cross-section data obtained from IFLS-3, IFLS-4 and IFLS-5,
the number of inspection visits tended to be higher for mothers living in urban areas.
In addition, the average travel time to health facilities for mothers living in urban
areas has met the ideal travel time standard to the location of the antenatal care. This
is in line with the conditions of personnel and health facilities which are more
concentrated in urban areas than in rural areas. So that the implication is that people
in urban areas get more access to the available health services compared to rural
communities.
Table 4.2 Percentage of number of ANC visits based on location of antenatal
care in rural areas
Number of
Location Travel ANC visit
Time <4 ≥4 Total %
Public hospital > 60 mins 24 249 273 14,45%
Public hospital ≤ 60 mins 179 1.616 1.795 85,54%
Private hospital > 60 mins 10 100 110 5.3%
Private hospital ≤ 60 mins 193 1.765 1.958 94,7%
Health center > 30 mins 20 93 113 5,5%
Health center ≤ 30 mins 183 1.772 1.955 94,5%
Private health clinic > 30 mins 1 25 26 1,3%
Private health clinic ≤ 30 mins 202 1.840 2.043 98,7%
Practice of general practitioner/ sp > 30 mins 1 94 95 4,6%
Practice of general practitioner/ sp ≤ 30 mins 202 1.771 1.973 95,4%
Midwife’s practice > 15 mins 76 493 570 27,5%
Midwife’s practice ≤ 15 mins 127 1.372 1.499 72,5%
Observations (N) 2.068
Source: IFLS-3, 4 dan 5
Based on data from IFLS in 2000, 2007 and 2014, on average, people in
Indonesia have had ideal travel times to available health facilities. The percentage of
mothers in rural areas who have ideal travel time is 94 percent on average. While the
percentage of rural mothers who do not have the ideal travel time to the location of
the pregnancy check-up on average is 6 percent. The data in the table above shows
the percentage of mothers in rural areas who have the ideal travel time to practice
midwives is the smallest value compared to travel time to other health facilities.
In general, the location of public / government hospitals is located in the center
of the city / district. Unlike the case with the health center available in each sub-
district. This is in accordance with the data in the table above, where the number of
antenatal care visits that are in accordance with the ANC K4 standard with the ideal
travel time, tends to be more if the examination is done at the health center. Some of
the factors that cause this condition to occur are ease of access and administration
when conducting examinations at the health center compared to hospitals. But
overall, the highest percentage of mothers living in rural areas and having the ideal
travel time are mothers who do examinations in private clinics, which is 98 percent.
Private or individual clinics are working partners of government health facilities. For
example, in the city of Depok, the existence of private clinics is considered very
helpful for the Depok City Government in meeting the community's needs for quality
health facilities (Depok City Government, 2018). Given the need for health is a basic
right of society that must be met. The clinic is a health service facility that organizes
individual health services that provide basic and specialist medical services,
organized by more than one type of health worker and led by medical personnel
(Minister of Health, 2001). Based on the explanation, the existence of private clinics
is easier to reach for mothers in checking their pregnancies even though the costs of
medical treatment tend to be higher.
Table 4.3 Percentage of number of ANC visits based on location of antenatal care in
urban areas
Number of
Location Travel ANC visit
Time <4 ≥4 Total %
Public hospital > 60 mins 4 63 67 3,4%
Public hospital ≤ 60 mins 98 1.779 1.877 96,6%
Private hospital > 60 mins 1 36 37 1,9%
Private hospital ≤ 60 mins 101 1.806 1.907 98,1%
Health center > 30 mins 1 29 30 1,5%
Health center ≤ 30 mins 101 1.813 1.914 98%
Private health clinic > 30 mins 0 10 10 0,5%
Private health clinic ≤ 30 mins 102 1.832 1.934 99,5%
Practice of general practitioner/ sp > 30 mins 1 31 32 1,6%
Practice of general practitioner/ sp ≤ 30 mins 101 1.811 1.912 98,4%
Midwife’s practice > 15 mins 28 498 526 27,1%
Midwife’s practice ≤ 15 mins 74 1.344 1.418 72,9%
Observations (N) 1.944
Source: IFLS-3, 4 dan 5

The data in the table above shows mothers in urban areas who have the ideal
travel time to hospitals with a total of four or more pregnancies visits 96 percent. The
high percentage value is based on the location of public / government hospitals which
are generally located in urban areas. This makes it easier for pregnant women to get
their pregnancy checked because of its location close to the place of residence and
easy access to public transportation. Likewise, for private hospitals, urban
communities that have the ideal travel time to private hospitals with a total of four or
more pregnancy checkup visits are 98 percent. This is related to the number of private
hospitals which generally number more than one in each district / city.
The same is true for examinations to health centers, private clinics, general
practitioners / specialists and private midwives' homes. The majority of people living
in urban areas have ideal travel time to available health facilities, namely as many as
98 percent of pregnant women who have travel time to health centers, 99.5 percent of
pregnant women who have travel time to private clinics, 98.4 percent of pregnant
women who have travel time to practice general practitioners / specialists and 72.9
percent of pregnant women who have travel time to the homes of private midwives.
The number of mothers who have the ideal travel time to the homes of private
midwives tends to be lower compared to other health facilities, this is related to
conditions in Indonesia which in general the practice of private midwives is widely
opened in rural areas given the affordability of people to health facilities such as
adequate hospitals difficult.

4.3.2 Ante natal Care Visit based on Distance to The Provincial Capital
The territory of Indonesia is divided into several levels of administrative regions,
namely provinces, districts / cities, sub-districts and villages or what are referred to as
the smallest administrative regions (BPS, 2010 in Sari, et al (2014)). Rural areas
themselves have a definition as an administrative area at the village / kelurahan level
that does not meet certain conditions in terms of population density, percentage of
agricultural households, and a number of urban facilities, formal education facilities,
public health facilities and so on (BPS, 2010). In general, rural areas are located far
from the city center, so often people in rural areas experience obstacles in terms of
limited resources, accessibility to educational facilities, infrastructure and health and
the condition of isolated areas.
As a result of these constraints, especially in the health sector, many people in
rural areas cannot maximize the utilization of health services so that the percentage of
under-fives with poor nutrition, stunting problems to maternal deaths in rural and
remote areas of Indonesia tends to be higher. This condition is contrary to the
statement of Dwiyanto (2011) that health services are a basic right of society that
must be fulfilled in health development. This is an investment in improving the
quality of human resources and supporting economic development, and has an
important role in poverty reduction efforts. So, it can be concluded that basic rights
services in the health sector for the community, especially in rural areas, have not
been optimally fulfilled.
With regard to health facilities and infrastructure that have not been distributed
evenly, regions with high distances to the existence of a provincial capital can be
categorized as rural areas in accordance with BPS (2010). In this study the estimation
results show that a mother whose location of residence is farther away from the
provincial capital has a tendency for the number of pregnancy inspection visits to be
0.00004 lower than a mother whose location is not far from the capital city. The
proximity of the location of residence to the provincial capital city is quite influential
in terms of the utilization of maternal health services. As is well known, the
provincial capital is the center of government and the economy of a particular
province. The concentration of government and economic activities will certainly be
followed by the development of road infrastructure, education and health. So that it
can be said that the completeness and availability of health workers and health
facilities in areas close to the capital city tend to be superior compared to areas
located far from the provincial capital.
Based on the pooled cross-section data obtained from IFLS-3, IFLS-4 and
IFLS-5, the average distance from the location of the mother's residence to the
provincial capital is 122.71 kilometers. This shows that the majority of respondents in
this study reside in areas far enough from the provincial capital. If it is associated
with the estimation results, the pattern of data that shows the location where the
mother lives tends to be far from the provincial capital, it is acceptable to reason that
the number of inspection visits by pregnant women is influenced by the distance of
the location of the capital to the provincial capital. As mentioned earlier, the quality
of health facilities that can be utilized by people whose locations are far from the
provincial capital tends to be lower than the health facilities in the area around the
provincial capital.
4.3.3 Antenatal Care Visit based on Area of Residence

Inequality in the distribution of health workers in a country is an old problem that

also occurs throughout the world and is a serious problem. Some developed and
developing countries state that the percentage of health workers in urban areas tends
to be higher than in rural areas. Dussault and Franceschini (2006) states that health
workers such as doctors and nurses tend to be unwilling if placed or moved to remote
and deepest areas. The geographical conditions in Indonesia itself pose many
challenges for health services and even distribution of health workers. The uneven
distribution of health workers often occurs especially in disadvantaged, remote areas,
prone to riots, natural disasters, regional expansion and border areas (Bambang,
2012).
Research Wisdom (2015) states that health centers in disadvantaged areas
tend to experience a shortage of skilled health workers. The consequences are in
addition to the financial capacity of the community which tends to be less due to
poverty, the health services received are also not optimal because of the large number
of health centers that lack health workers. Whereas based on Bappenas data (2005) it
was stated that the health facilities that were relatively widely used by residents for
outpatient treatment were Health center/Pustu (37.26 percent), doctor practices (24.39
percent) and health care practices (18.51 percent). Rural occupation more often
utilizes health center/pustu (42.40 percent) and health worker practices (23.42
percent).
Health workers in Indonesia in general are more concentrated in the Java-Bali
region, while the outer regions of Java-Bali tend to experience a shortage of skilled
health workers. Most regions of Eastern Indonesia have a low level of distribution of
health workers, which is still below the 40 percent figure. In addition, the BPS data in
2018 states that the maternal mortality rate in the Java-Bali region tends to be lower
compared to areas outside Java-Bali, especially in Eastern Indonesia such as the Nusa
Tenggara Islands, Maluku and Papua.
Based on the results of the estimation in this study, a mother who resides in
the Java-Bali region has a tendency for the number of prenatal examinations to be
0.0372 higher than for maternal antenatal visits in areas outside Java-Bali. The
estimation results are in line with the condition of the distribution of labor and health
facilities which are more concentrated in the Java-Bali region. This makes it easier
for mothers living in the Java-Bali region to take advantage of available health
services. Because the distribution of energy and health facilities is more evenly
distributed, people in the Java-Bali region have more access to health facilities. In
addition to analyzing the marginal value of the effect on the estimation results, the
antenatal visit activities based on the area of residence will be explained through data
descriptions, in order to analyze differences in antenatal care activities in mothers
residing in Java-Bali and outside Java-Bali. The data in the following table shows the
percentage value of the total visits from Java-Bali respondents, which totaled 2,433
individuals and respondents from outside Java-Bali totaling 1,582 individuals.
Table 4.4 Percentage of number of ANC visits based on the location of antenatal care
in the Java-Bali region
Number of
Location Travel Visit
Time <4 ≥4 Total %
Public hospital > 60 mins 14 163 177 7,3%
Public hospital ≤ 60 mins 117 2.137 2.254 92,7%
Private hospital > 60 mins 2 82 84 3,5%
Private hospital ≤ 60 mins 129 2.218 2.347 96,5%
Health center > 30 mins 10 70 80 3,3%
Health center ≤ 30 mins 121 2.230 2.353 96,7%
Private health clinic > 30 mins 1 19 20 0,8%
Private health clinic ≤ 30 mins 130 2.281 2.411 99,2%
Practice of general practitioner/ sp > 30 mins 1 83 84 3,5%
Practice of general practitioner/ sp ≤ 30 mins 130 2.217 2.347 96,5%
Midwife’s practice > 15 mins 44 564 608 25%
Midwife’s practice ≤ 15 mins 87 1.736 1.823 75%
Observations (N) 2.431
Source: IFLS-3, 4 dan 5

In the Java-Bali region, the percentage of visits of pregnant women who

conduct examinations in hospitals, private hospitals, health centers, private clinics
and the practice of general practitioners / specialists tends to be the same, which is
more than 92 percent. This shows that on average the number of mothers living in the
Java-Bali region has travel time to health facilities so that the number of antenatal
care visits that are in accordance with the ANC K4 standard amounts to more than 92
percent, except travel time to private midwife practice / home. These conditions
indicate that the distribution of power and health facilities in the Java-Bali region is
high, so that many mothers have easy access to using antenatal care services. As with
the outside of the Java-Bali region, the distribution of power and health facilities
tends to be uneven in several regions.
 Table 4.5 The percentage of ANC visits based on the location of pregnancy checks
outside the Java-Bali region
Jumlah
Location Travel kunjungan
Time ANC Total %
<4 ≥4
Public hospital > 60 mins 14 149 163 10,4%
Public hospital ≤ 60 mins 160 1.258 1.418 89,6%
Private hospital > 60 mins 9 54 63 3,9%
Private hospital ≤ 60 mins 165 1.353 1.518 96,1%
Health center > 30 mins 11 52 63 3,9%
Health center ≤ 30 mins 163 1.355 1.518 96,1%
Private health clinic > 30 mins 0 16 16 1%
Private health clinic ≤ 30 mins 174 1.391 1.565 99%
Practice of general practitioner/ sp > 30 mins 1 42 43 3%
Practice of general practitioner/ sp ≤ 30 mins 173 1.365 1.538 97%
Midwife’s practice > 15 mins 60 428 488 30,9%
Midwife’s practice ≤ 15 mins 114 979 1.093 69,1%
Observations (N) 1.581
Source: IFLS-3, 4 dan 5

The data in the table above, the percentage of mothers outside Java-Bali who
have the ideal travel time to health facilities and the number of antenatal visits
according to the ANC K4 standard, the value is more than 85 percent, except to the
practice / home of a private midwife. Although on average the percentage of pregnant
women who have the ideal travel time is quite large, the number of visits according to
the ANC K4 standard is not higher than that of women living in the Java-Bali region.
This further shows that the distribution of energy and health facilities in Indonesia is
still uneven and cannot be utilized by pregnant women in some regions.
5. CONCLUSION AND RECOMMENDATION
5.1 Conclusion
The trend of infrastructure development in the territory of Indonesia has increased
every year, but in the health sector itself is still experiencing some problems such as
the imbalance in the number of available health facilities and the uneven distribution
of health workers in each region, which indirectly can affect the high maternal
mortality rate in Indonesia. Overall it can be concluded that the travel time to health
facilities does not significantly affect the number of antenatal visits in this study, but
is more influenced by several other factors such as maternal education years, order of
pregnancy, vehicle ownership, household per capita expenditure, height measurement
mother, measurement of maternal weight, blood pressure measurements, iron
supplementation and tetanus toxoid immunization in the mother, distance to the
provincial capital, areas of residence in Java-Bali and outside Java-Bali and
knowledge of the existence of private midwife homes. Prenatal visits can be increased
by taking into account some of these influential factors. Thus the health condition of
pregnant women will increase along with the high rate of utilization of pregnancy
services, so that it can ultimately affect the decline in maternal mortality in Indonesia.

5.2 Recommendation
The trend of infrastructure development in rural areas, especially outside Java-Bali is
still very low, especially in the Nusa Tenggara Islands, Maluku and Papua regions.
This is related to the number of low pregnancy visits and high maternal mortality. So,
the advice given is more equal distribution of health and health facilities, especially in
Eastern Indonesia, with the aim of making it easier for pregnant women to check their
health and pregnancy, which in turn has implications for increasing maternal health
and reducing maternal mortality. The number of inspection visits for pregnant women
in the Java-Bali region tends to be higher than the number of inspection visits outside
Java-Bali. The existence of these differences shows that the availability of personnel
and health facilities in the outer islands of Java-Bali is relatively low. So that the
steps that can be taken in overcoming the differences in the number of antenatal visits
are to increase the distribution of labor and health facilities in the outer islands of
Java-Bali.
 BIBLIOGRAPHY

Arthur, E. 2012. Wealth and Antenatal Care Use: Implications for Maternal Health
Care Utilisation in Ghana. Health Economics Review, no. 2 (Agustus), 1–18.
Badan Pusat Statistik (BPS). 2015. Survei Penduduk Antar Sensus 2015. Jakarta :
BPS.
Badan Pusat Statistik (BPS). 2015. Profil Penduduk Indonesia Hasil Supas 2015.
Jakarta : BPS.

Bedri N. 2001. Health-Seeking Behaviour for Vaginal Discharge: Pathways, Factors

and Processes Influencing Early Modern Care Use for Abnormal Vaginal
Discharge in the Sudan. Disertasi. Manchester: University of Manchester, U.K.

Bhattacherjee, S., dkk. 2013. Maternal Health Care Services Utilization in Tea
Gardens of Darjeeling, India. Journal of Basic and Clinical Reproductive
Sciences, no. 2 (Desember):2.
Buor, D. 2003. “Analysing The Primacy of Distance in The Utilization of Health
Services in the Ahafo-Ano South District, Ghana”. The International Journal of
Health Planning and Management, no. 18 (April): 293- 311.

Chakraborty, N, Islam, M. A, Chowdury, R. I, dan Bari, W. 2003. “Analysis of Ante‐

Partum Maternal Morbidity in Rural Bangladesh”. The Australian Journal of
Rural Health, no. 11 (Februari): 22-27.
Das, A.C. 2017. “Does Antenatal Care Reduce Maternal Mortality?”. Mediscope,
no.4 (Januari). 1-3.
Depkes RI. 2006. Pedoman Umum Gizi Seimbang (Panduan Untuk Petugas). Jakarta:
Departemen Kesehatan.
Dussault, G. dan Franceschini, M.C. 2006. “Not Enough There, Too Many Here:
Understanding Geographical Imbalances in The Distribution of The Health
Workforce”. Human Resources for Health, no.4 (Mei): 12.
Dwiyanto, Agus. 2011. Manajemen Pelayanan Publik. Yogyakarta: Gadjah Mada
University Press.
Figueiredo, K. M. S., dkk. 2018. “Actions of Primary Health Care Professionals to
Reduce Maternal Mortality in The Brazilian Northeast”. International Journal
for Equity in Health. 17:104: 1-8.
Frankenberg, E., Butt.enheim, A., Sikoki, B., dan Suriastini, W. 2009. Do Women
Increase Their Use of Reproductive Health Care When It Becomes More
Available? Evidence from Indonesia. Stud Fam Plann, no. 40 (Januari): 27–38.
Gay, J., dkk. 2003. What Works: A Policy and Program Guide to the Evidence on
Family Planning, Safe Motherhood, and STI/HIV/AIDS Interventions: POLICY
Project. Diakses pada 8 Oketober 2018.
http://www.postabortioncare.org/sites/pac/files/Compendium.pdf.
Gething, P.W., dkk. 2012. “Geographical Access to Care at Birth in Ghana: A Barrier
to Safe Motherhood”. BMC Public Health, no. 991 (Desember). 1-13.
Greenaway, E.S., dkk. 2012. Understanding the Association Between Maternal
Education and Use of Health Services in Ghana: Exploring the Role of Health
Knowledge. Journal of Biosocial Science, no. 44 (November):733-747.
Gujarati, D. 2003. Basic Econometrics 4th Edition. New York: Mc Graw-Hill.
Gupta, S. dkk. 2014. “Factors Associated with Four or More Antenatal Care Visits
and Its Decline among Pregnant Women in Tanzania between 1999 and 2010”.
PLOS One. 9(7).
Hanson, C., dkk. 2015. “Maternal Mortality and Distance to Facility-Based Obstetric
Care in Rural Southern Tanzania: A Secondary Analysis of Cross-Sectional
Census Data in 226000 Households”. Lancet Glob Health, no.385 (Mei): 387-
395.
Heru, R., dkk. 2012. “Konseling Ibu Hamil Pada Bidan Praktik Swasta Dan
Puskesmas Di Kabupaten Bantul”. Jurnal Kebijakan Kesehatan Indonesia, no.1
(September). 168-172.
Hikmah, N. 2015 Kesenjangan Distribusi Tenaga Kesehatan Di Puskesmas Wilayah
Indonesia Timur Analisis Data IFLS East 2012.
Hodin, Sarah. 2016. “Too Far to Walk”: 20 Years Later, Distance Remains a Barrier
to Maternal Health-MHTF Blog. 14 Oktober 2016. Diakses pada 3 Oktober
2018, https://www.mhtf.org/2016/10/14/too-far-to-walk-20-years-later-distance-
remains-a-barrier-to-maternal-health/.
Hosmer, D. W., dan Lemeshow, S. 2000. Applied Logistic Regression. New York:
John Wiley & Sons, Inc.
Idris, S.H., dkk. Barriers to Utilisation of Maternal Health Services in A Semi-Urban
Community in Northern Nigeria: The Clients' Perspective. Nigerian Medical
Journal, no. 54 (Januari): 27-32.
Jowett, Matthew. 2000. “Safe Motherhood Interventions in Low-Income Countries:
An Economic Justification and Evidence of Cost-Effectiveness”. Health Policy,
no. 53 (Maret):201–228.
Kebijakan Kesehatan Indonesia. 2014. “Simposium Perencanaan Berbasis Bukti dan
Pengenalan Perencanaan untuk Bidang Kesehatan Ibu dan Anak”. Diakses pada 8
Oktober 2018. http://www.kebijakankesehatanindonesia.net/23-agenda/372-
kelompok-kia-2.
Kementerian Kesehatan RI. 2012. Buletin Jendela data dan Informasi Kesehatan,
volume 1, September 2012. Eliminasi Tetanus Maternal dan Neonatal.
Kementerian Kesehatan RI. INFODATIN Pusat Data dan Informasi Kemeterian
Kesehatan RI. Mother’s Day. 2014.
Kementerian Kesehatan RI. Profil Kesehatan Indonesia. 2015.
Kiwanuka, T. S., dkk. 2017. “Adherence to Iron Supplements Among Women
Receiving Antenatal Care at Mulago National Referral Hospital,
Uganda-cross-sectional Study”. BMC Research Notes, no. 10: 510.
Laksono, A. D., dkk. 2016. Aksesibilitas Pelayanan Kesehatan di Indonesia. Sleman:
PT. Kanisius.
Long, J.S. dan Freese, J. 2014. Regression Models for Categorical Dependent
Variables Using Stata, Third Edition. Stata Press.
Mackian, Sara. 2002. A Review of Health Seeking Behaviour: Problems and
Prospects. Health System Developmen Program. University of Manchaster.
Makate, M. dan Makate, C. 2017. Prenatal Care Utilization in Zimbabwe: Examining
the Role of Community-Level Factors. Journal of Epidemiology and Global
Health, no.7 (Agustus): 255-262.
Manang, F. 2015. Build and they will come? Access to Health Facilities and
Maternal Care Usage in Rural Ethiopia. University of Dodoma. Tanzania.

Manzoor, I, Hashmi, NR dan Mukhtar, F. 2009. “Determinants and Pattern of Health

Care Services Utilisation in Post Graduate Students”. J Ayub Med Coll
Abbottabad, no. 21 (Maret): 100-105.
Mathole T, Lindmark G, Majoko F, Ahlberg BM. 2004. “A Qualitative Study of
Women’s Perspectives of Antenatal Care in A Rural Area of Zimbabwe”.
Midwifery 20: 122–132.
Mikrajab, M.A. dan Rachmawati, T. 2016. “Analisis Kebijakan Implementasi
Antenatal Care Terpadu Puskesmas di Kota Blitar”. Buletin Penelitian Sistem
Kesehatan, no. 19 (Januari). 42-53.
Mpembeni, R.NM., dkk. 2007. “Use Pattern of Maternal Health Services and
Determinants of Skilled Care During Delivery in Southern Tanzania:
Implications for Achievement of MDG-5 Targets”. BMC Pregnancy and
Childbirth. 7:29.
Nababan, H.Y., Hasan, Md., Marthias, T., Dhital, R., Rahman, A., dan Anwar, I.
2018. Trends and Inequities in Use of Maternal Health Care Services in
Indonesia, 1986-2012. International Journal of Women’s Health. 2018(10): 1-24.
Noerdin, E. 2014. “Transport, Health Services and Budget Allocation to Address
Maternal Mortality in Rural Indonesia”. Transport and Communications Bulletin
for Asia and the Pacific. Jakarta.
Olivares, A.M. dan Forero, C.G. 2010. “Goodness-of-Fit-Testing”. International
Encyclopedia of Education, no. 7: 190-196.

Onah, H, Ikeako, L, dan Iloabachie, G. 2009. “Factors Associated with The Use of
Maternity Services in Enugu, Southeastern Nigeria”. Social Science and
Medicine, no. 63 (Juli):1870-1878.
Oyerinde, K. 2013. “Can Antenatal Care Result in Significant Maternal Mortality
Reduction in Developing Countries?”. Community Medicine and Health
Education, no. 3 (Februari): 1-2.
Peraturan Pemerintah No. 47 Tahun 2016 tentang Fasilitas Pelayanan Kesehatan.
Preeclmpsia Foundation. 2013. “Preeclampsia and Maternal Mortality: a Global
Burden”. Preeclmpsia Foundation, 1 Mei 2013. Diakses pada 10 Desemeber
2018. https://www.preeclampsia.org/health-information/149-advocacy
awareness/332-preeclampsia-and-maternal-mortality-a-global-burden.
Putra, D.S. 2017. Logistic Regression. Diakses pada 1 Maret 2019.
https://kudo.co.id/engineering/2017/03/23/logistic-regression.
Rooney, Cleone., dkk. 1993. “Antenatal Care and Maternal Health: How Effective is
It?”. World Health Organization. Diakses pada 3 Oktober 2018.
http://apps.who.int/iris/handle/10665/59954.
Sakinah, V. dan Fibriana, A.I. 2015. “Upaya Peningkatan Pengetahuan, Sikap dan
Kunjungan Antenatal Care (Anc) Ibu Hamil melalui Pemberdayaan Kader
ANC”. Unnes Journal of Public Health, no. 1 (Januari). 54-60.
Sahoto, A dan Fatmi, Z. 2018. Inequities in Antenatal Care, and Individual and
Environmental Determinants of Utilization at National and Sub-national Level in
Pakistan: A Multilevel Analysis. International Journal of Health Policy and
Management, no. 10 (Januari): 1-12.
Scott, S., dkk. 2013. “Maternal Mortality, Birth with A Health Professional and
Distance to Obstetric Care in Indonesia and Bangladesh”. Tropical Medicine and
International Health, no.10 (Oktober): 1193-1201.
Shariff, A dan Singh, G. 2007. Determinants of Maternal Health Care Utilisation in
India: Evidence from a Recent Household Survey. New Delhi: National Council
of Applied Economic Research.
Simkhada, B., dkk. 2008. Factors Affecting the Utilization of Antenatal Care in
Developing Countries: Systematic Review of the Literature. Journal of
Advanced Nursing, no. 61 (Maret): 244-260.

Stretcher, V. Dan Rosenstock, I.M. 1997. The Health Belief Model. San Francisco:
Jossey-Bass. Diakses pada 7 Desember 2018.
http://www.jblearning.com/samples/0763743836/chapter%204.pdf.

Srivastava, A., dkk. 2014. Correlates of Maternal Health Care Utilization in

Rohilkhand Region, India. Annals of Medical and Health Sciences Research, no.
4 (Maret): 417-425.

Susuman, A.S. 2015. Health care services and maternal education in South Africa.
Scandinavian Journal of Public Health, no. 43 (Juni): 673-676

Takeda, Yuko. 2010. “Understanding The Life Style of Women to Enhance Your
Practice”. Journal of the Japan Medical Association, no.5 (Oktober): 273-278.
The ASEAN Secretariat. 2017. ASEAN Statistical Report on Millenium
Development Goals 2017. Jakarta: ASEAN A Community of Opportunities.
The Society of Obstetricians and Gynaecologists of Canada (SOGC). 2008.
Diagnosis, Evaluation, and Management of the Hypertensive. Diakses pada 28
Februari 2019. https://www.sogc.org/wp-
content/uploads/2014/05/gui307CPG1405Erev.pdf
Titaley, C.R., Dibley, M.J., Roberts, C.L. 2010. “Factors associated with
underutilization of antenatal care services in Indonesia: results of Indonesia
Demographic and Health Survey 2002/2003 and 2007”. BMC Public Health.
10:485.
Tran, T.K., dkk. 2012. Factors Associated with Antenatal Care Adequacy in Rural
and Urban Contexts-Results from Two Health and Demographic Surveillance
Sites in Vietnam. BMC Health Services Research, 12:40.
Turner, J.A. 2010. Diagnosis and Management of Pre-eclampsia: An Update.
International Journal of Women’s Health, no.2 (September):327-337.
Villar, J. Dan Bergsjo, P. 1997. “Scientific Basis for The Content of Routine
Antenatal Care. I. Philosophy, Recent Studies, and Power to Eliminate or
 Alleviate Adverse Maternal Outcomes”. Acta Obstetrica et Gynecologica
Scandinavica, no.76 (Januari):1–14.
Wilunda, C., dkk. 2017. “Barriers to Utilisation of Antenatal Care Services in South
Sudan: A Qualitative Study in Rumbek North County”. Reproductive Health.
14:65.
Women Research Institute. 2011. Mencari Ujung Tombak Penurunan Angka
Kematian Ibu di Indonesia. WRI: Jakarta.
World Health Organization. 2016. WHO Recommendation on Antenatal Care
Contact Schedules. The WHO Reproductive Health Library; Geneva: World
Health Organization. Diakses pada 27 Desember 2018.
https://extranet.who.int/rhl/topics/improving-health-system-performance/who-
recommendation-antenatal-care-contact-schedules.
World Health Organization. 2015. WHO Recommendations for Prevention and
Treatment of Pre-eclampsia and Eclampsia

Zwi, A. dan Brugha, R.F. 2001. “Private Health Care in Developing Countries: If It is
to Work, It Must Start from What Users Need”. BMJ Clinical Research, no. 323
(September): 463-464.