In this analysis of the IDHS data in 2014–2017, fewer than four antenatal visits throughout pregnancy and the absence of postnatal care services had the most significant effects on increasing the odds of neonatal mortality. This result is in line with a study carried out by Laksono, which demonstrated that women with sufficient antenatal care (more than four visits) were at a lower odds of witnessing their newborn’s death (16). Our findings also support the results of the previous study using 2017 IDHS data, in which the authors found that attending more than four antenatal care visits during the pregnancy period had a protective effect on neonatal death. However, the study conducted by Masruroh et al. did not detect other significant factors that prevent a rise in the odds of neonatal mortality incidence (17). The use of antenatal care varies among regions in Indonesia, with a low coverage of antenatal care (fewer than four visits) observed in the Maluku and Papua regions (18). Antenatal care services were reported to be underserviced in rural areas outside the Java–Bali region, which consists of families with a low household wealth index and low maternal education level. The other associated factors reported were the distance between the mother’s residence and the health facility and the lack of obstetric complications before delivery (8). Based on a report by Suharmiati et al., this low utilisation of antenatal care visits in the remote and border islands with extreme topography was affected by the low availability of healthcare services and facilities, non-optimised health infrastructure and inappropriate reward for healthcare providers (19). Furthermore, in urban areas of Indonesia, the constraints of actualising efficient antenatal care services are made worse by several factors, including poor laboratory and management records during antenatal care services, inadequate monitoring documentation and the fact that less than 5% of women receive all the routine measurements, consisting of urine tests, blood screening tests, iron supplementation, tetanus vaccination and information on pregnancy complications (20). Meta-analyses conducted in African countries have also implied that the benefits of antenatal care visits facilitated by skilled providers can reduce the incidence of neonatal deaths (21, 22). Another meta-analysis that investigated the effect of antenatal care visits in various developing countries revealed that the risk of neonatal death could be reduced by adequate antenatal care visits (23). With regard to postnatal care, delivery facilities that supply postnatal care might attenuate the risks of neonatal mortality and therefore improve the lives of newborns (24, 25). A study conducted in Garut, Sukabumi and Ciamis found that women who attended antenatal and postnatal care services experienced financial difficulties related to the cost of health services or transportation, the distance to the nearest facilities and the lack of awareness, as indicated by the need to use the services only if obstetric complications had already occurred (26). Based on a report from Titaley, the non-participant group of mothers in postnatal care services was related mostly to the low household wealth index, lack of understanding of pregnancy complications and low education levels (27). Furthermore, similar to our finding that postnatal care plays a significant role in reducing the risk of neonatal deaths, a nationwide case–control study in India reported an increase in the odds of neonatal death among women undergoing childbirth in delivery facilities who did not attend a postnatal check-up (25). In general, this study supports the previous studies of the IDHS 2002–2003 that revealed the association between inadequate utilisation of perinatal health services, either antenatal care or postnatal care, and the increased odds of neonatal mortality. Clusters of deliveries that received assistance by TBAs had a significant reduction in the odds of neonatal death (13)].
Nevertheless, this study also revealed varying factors that induce neonatal deaths as perinatal outcomes. The delivery process facilitated by a TBA caused the odds to increase. The absence of education in mothers was found to increase the OR of neonatal deaths significantly. This finding suggests, in line with another report in Brazil, that a low level of maternal education has a significant effect on the increase in newborn death. In other words, low levels of education can induce a lack of discipline and adherence of women to a beneficial health curriculum (28). Analyses of the Indian National Family Health Survey in 1994 found that low education levels, regardless of age (i.e. adolescents or older women), increased the odds of neonatal death (29). In addition to the effect of low education levels of mothers, a study in Gaza, Palestine, reported that fathers who had an educational certificate at the highest level of secondary school was associated significantly with neonatal mortality. The difference between the groups with low and high educational levels (diploma or a university degree) was associated with the mothers’ adherence to antenatal visits and to breastfeeding their infants, whereby most parents with a lower educational level did not meet the required criteria (more than four antenatal care visits and exclusive breastfeeding) (30). Andriano et al. conducted a demographic study in Malawi to evaluate the effects of education system reform (i.e. free primary education for individuals during the 1990s) and found that education quality resulted in a lower probability of death in infants and children younger than 5 years (31). In general, these studies suggest that knowledge barriers between healthcare professionals and families, because of low educational levels, reflect the mothers’ attitudes to modern health services (28–31). However, after adjustment, the OR was not significant as compared with other covariates.
Our demographic study found that childbirths assisted by a TBA increased the risk of neonatal death significantly. With regard to the person assisting the childbirth, Titaley et al. analysed the effects of trained delivery attendance and place of delivery on early neonatal deaths. The results of that study further support our analyses by elucidating that women living in rural areas and experiencing home delivery with appropriate assistance from skilled healthcare professionals had a significantly reduced chance of having their newborns die. In addition, delivering in a healthcare facility or in the home without the assistance of trained delivery attendants could increase the risk of neonatal death (32). In another study on the IDHS data sets conducted by Badriah et al., labour facilitated by a skilled birth attendant was correlated with a higher risk of labour complications, namely, prolonged labour and postpartum fever. Besides this, there were no differences in stillbirths or neonatal deaths between women assisted by trained birth attendants and those assisted by untrained attendants (33). The use of services provided by TBAs among pregnant women in Indonesia is still inevitable, because of the traditional beliefs and recommendations from families that convince women in achieving a satisfying pregnancy and perinatal care (34, 35). Proximity to institutional healthcare, transportation problems and low financing within the family units are major constraints to accessing sufficient healthcare services, including delivery assistance from TBAs (34, 36). Ironically, based on reports in Bangladesh, some communities did not access a health facility because no proper facility was available in their area or the care available was of poor quality. Thus, women who do not want to attend a healthcare facility to manage their pregnancy and who prefer untrained birth attendants may fail to recognise early the alarming signs of dangers in pregnancy (36). In Indonesia, traditional beliefs affect women’s preference between midwives and TBAs and therefore influence their adherence to antenatal care visits in several rural areas. Based on trends among communities in Indonesia, women believe that pregnancy is a part of their ordinary life cycle and is not a complexity that can appear as a risk factor for comorbidities and complications. This trend then influences women to be more active in seeking appropriate health facilities, including sufficient antenatal care services and delivery assistance from TBAs (35).
Our study found that delivering in public hospitals could increase the odds of neonatal death, although it was not significant. A meta-analysis assessing the effect of delivery at healthcare facilities on neonatal deaths showed that delivering in a health facility was effective in reducing the odds of neonatal death, especially in low- to middle-income countries (37). Our finding is in line with Titaley’s report, which elucidated higher odds of women experiencing the death of their neonates in public hospitals than in private hospitals (32). Based on a report in Ethiopia, the rate of neonatal deaths in public hospitals was influenced mostly by preterm birth, birth asphyxia and neonatal infection (38). In addition, Adams et al. suggested that a disparity exists between the ability to alleviate the burden of the neonatal mortality rate in public hospitals and private hospitals, in which public hospitals demonstrated a higher rate of neonatal deaths. This disparity was probably affected by different clinical practices, obstetrician-led care models and congenital anomalies experienced by babies born in public hospitals (39). Occasionally, the number of neonates died outside of hospitals could be higher that than in hospitals because communities cannot recognize the various life-threatening conditions in young babies, namely, birth asphyxia, prematurity and birth injuries. However, this phenomenon led to the late detection and treatment of babies whose condition was commonly complicated. For instance, a few reports from countries in the Middle East and South Asia found that prematurity with complications and sepsis were the most frequent contributing factors causing neonatal deaths in the hospital setting (40–42).
Proximate determinants including male gender and birthweight < 2.5 kg also increased the odds of neonatal deaths. This finding is in line with previous demographic studies, which indicated that the risk of neonatal death was higher in male infants and newborns who were smaller in size (32, 43, 44). Mostly, the disadvantage of the rising number of male infant deaths was attributed to perinatal conditions in the decades before improvements in obstetric practices. However, the innate biological differences between both gender groups turned out to be more significant in developing the risk of male newborn deaths (45). Reports from other countries indicated various trends. Based on multilevel analyses carried out in Brazil to determine the factors associated with neonatal mortality, maternal characteristics were not associated with neonatal deaths. Instead, neonatal characteristics, including foetal congenital anomaly, low Apgar score at 1 minute and low birthweight, presented a significant association (46). In Ethiopia, a few regions including Tigray, Omhara and Benishangul Gumz showed a significant association with neonatal deaths as the study outcome. Maternal age < 18 years was significant to the study outcome, whereas in terms of neonatal aspects, male gender and being born in the winter or rainy season were correlated significantly with the outcome (47).
Despite the strength of this study, which is related to its capability of forming a nationwide representation based on a survey and multilevel analyses to clarify the association between tested determinants and the outcomes specifically, this survey did not cover data on maternal deaths or all variables specific to neonatal aspects, such as genetic and environmental factors. In terms of maternal aspects, other complications, including vaginal bleeding, fever and convulsions, were not specified to minimise data distribution.
As a result of the disparities in perinatal care services, including antenatal care and postnatal care utilisation over various regions in Indonesia, healthcare providers and policymakers must refer to the findings of the IDHS to make a decision to maximise the utilisation of such services. Healthcare providers should implement a few interventions, such as education targeting mothers regarding the importance of antenatal care programmes for their condition, composed of screening, detection, management and monitoring, because these interventions can be effective in increasing mothers’ awareness and can provide integrated care starting from the pregnancy process to childbirth and the postnatal period. In the other words, mothers’ awareness should not be limited to worrying about obstetric complications but should be focused on every second of the pregnancy period. To equalise the quality of antenatal care services in Indonesia, policymakers must establish a policy of implementing funding reallocation to improve the health infrastructure in regions with a low coverage of perinatal care services; otherwise, the standardised reward for healthcare workers should be guaranteed.
In addition, facilities and delivery attendants in public hospitals should be trained effectively to ensure that the delivery practice is safe. Traditional delivery attendants deemed to be unskilled must be encouraged to undergo training in perinatal self-care skills. In other words, to improve maternal and newborn care, public hospitals must be used efficiently by every pregnant woman who needs perinatal care and childbirth services, by establishing training for midwives and physicians working at such health facilities. In addition, TBAs must be empowered to work collaboratively with healthcare providers. An integrated system is needed that provides training for unskilled birth attendants, including midwives and TBAs, in every region of Indonesia that is still isolated from healthcare centres.