The mean age of pregnant women that participated in the questionnaire survey was 27 years. The characteristics of the study participants for the questionnaire survey are shown in Table 1. A total of 151 participants completed their antenatal care consultations more than or equal to 4 times (46.3%) and 175 participants did not complete (53.7%). The percentage of participants that graduated from primary school was 60%, and the women that their husband graduated from primary school was 63 %. The higher percentage of participants that received an additional physical examination and vital signs at each consultation (82.2%) and received obstetric physician examination and vital signs at the first consultations (89.6%) were observed. In contrast, the percentage of participants that received an additional obstetric physical examination and vital signs at each consultation was low (11%). Regarding the postpartum consultations, most of the participants had received examination services 6–8 hours after delivery (before returning home) (96.9%), but 40.2 % and 27.6% of participants had not visited the primary care/health service after six days and after two weeks of delivery, respectively. More than a quarter of participants (27.6%) had not visited the primary care/health service after six weeks of delivery.
The characteristics of study participants and association between each characteristic of pregnant women and completion of antenatal care visit for the questioner survey (n = 326)
Characteristics and type of examination
Total N (%)
Antenatal care visit N (%)
Adjusted OR* (95% CI)
Complete (4 visits or more) N = 151
(< 4 visits) N = 175
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<20 or ≥ 35 yrs.
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The highest educational level
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The highest educational level of Husband
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Did you get a physical examination and vital signs at the first consultation?
Did you get an additional physical examination and vital signs at each consultation?
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Did you get an obstetric physical examination at the first consultation?
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Did you get an additional obstetric physical examination at each consultation?
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Did you go through the registration counter for consultation?
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Did you wait for examinations was quite a long time?
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Did you receive examination services 6–8 hours after delivery?
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Did you receive the primary care/health service after six (6) days of delivery?
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Did you receive the primary care/health service after two (2) weeks of delivery?
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Did you receive the primary care/health service after six (6) weeks of delivery?
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|OR, odd ratio; CI, confidence intervals|
|* Adjusted for age, parity, and educational level of respondent.|
The estimated relationship between each factor and the completion of antenatal care are also shown in Table 1. It was discovered that women that their characteristics were classified into higher risks for delivery are more likely to complete antenatal care consultations than women with lower risks of delivery. Particularly, women with high parity (≥ 4 times) were more likely to complete antenatal care consultations [OR:1.92 (95% CI: 1.04–3.55] compared to women with lower parity (≤ 3 times). After adjusting for potential confounders, the relationship between parity and antenatal consultation completion was weakened, but the positive relationship was observed [adjusted OR: 1.73 (95% CI: 0.90–3.34)]. Regarding the educational level, women with higher educational levels (graduated secondary school or more) tend to have more extensive antenatal care consultations [OR: 1.45 (95% CI: 0.93–2.27)] compared to women with a lower educational level (graduated primary school or less). In addition, women that their husbands had higher educational levels were more likely to complete antenatal care consultations [OR: 2.70 (95% CI: 1.70–4.31]. This relationship was observed even after adjusting to potential confounders [adjusted OR: 3.02 (95% CI: 1.69–5.41)].
This quantitative analysis also shows the positive relationship between accessing accurate and prompt services and the completion of antenatal care consultations (Table 1). Indeed, women that receive an additional physical examination and vital sign or additional obstetric physical examination at each consultation, were more likely to complete antenatal care consultations than the women that did not receive the services [OR for additional physical examination:1.99 (95% CI: 1.10–3.62); and OR for additional obstetric physical examination: 8.78 (95% CI: 3.32–23.24)]. These significant relationships were observed even after adjusting for potential confounders [Adjusted OR for additional physical examination:1.90 (95% CI: 1.03–3.48); and adjusted OR for additional obstetric physical examination: 9.10 (95% CI: 3.42–24.23)]. These significant relationships did not observe in the analysis with access to the normal physical examination or normal obstetric physical examination at the first consultations. In addition, women that have access to the examination without waiting for a long time, were more likely to complete their antenatal care consultations than the women waiting for a long time [OR: 1.64 (95% CI: 1.06–2.54)] and this positive relationship remained after adjusting for potential confounders [Adjusted OR: 1.64 (95% CI: 0.99–2.41)].
In contrast, the positive relationship between accessing postpartum examinations and the completion of antenatal care consultations was not observed, but some inverse relationships were observed (Table 1). For example, women that received the primary care/health service after six days or two weeks of delivery were less likely to complete antenatal care consultations compared to women that did not receive the services [adjusted OR for visiting after six days of delivery: 0.60 (95% CI: 0.38–0.95); and adjusted OR for visiting after two weeks: 0.34 (95% CI: 0.21–0.55)]. On the other hand, this inverse relationship was not observed in women that visited the primary health care center after 6 weeks of delivery, and the women tend to complete their antenatal care consultations than the women that did not visit the centers [adjusted OR: 1.15 (95% CI: 0.70–1.89)].
Focus group discussion
Focus group discussions were conducted with 26 sub-sample of pregnant women, 6 maternity and pediatric staff, 4 head of community health center, 7 public health officer, 7 cross-sector health officer, and 9 community working groups (cadres) to explore about their background and feeling about individual motivation on examination of pregnant women and completion of antenatal care consultations.
Completion of antenatal care visits
The questionnaire survey discovered that more than half of the respondents did not complete their antenatal care consultations. According to the focus group discussion, it revealed that women preferred to check their pregnancy at a Posyandu than community health center. Posyandu is an integrated health post and support the delivery of health programs to the residents of the community by village health workers. The routine activity is twice a month. Visiting Posyandu might be related to low consultations during the first period by pregnant women as described by two respondents:
I only had a checkup at the community health center once, because every month there was a Posyandu near the house. (Responder #1, age 30, 7 months gestational age).
I often went for a checkup in the private clinic and Posyandu for about 8 visits, except once when I went for a checkup at the community health center for the pregnancy class program. (Responder #2, age 23, 9 months gestational age, second pregnancy).
According to the questionnaire survey, it was revealed that 82.2% of respondents received additional physical examinations and vital sign checkups during each consultation, but only 11% of respondents received an additional obstetric physical examination during the consultation and 89% of respondents did not receive those services. These queries are important to obtain a detailed understanding about the type and timing of the proper examinations needed by pregnant women, and being explored in the focus discussion:
I went to this community health center last month, and on each consultation, the nurse said I had symptoms of hypertension, but I was not given any medication. (Responder #3, age 20, 5 months gestational age, third child).
My gestational age is 7 months, but I have never had any ultrasonography (USG) examinations. According to the other moms, the doctor is fierce. (Responder #4, age 19, 7 months gestational age).
My gestational age is 9 months. I only had one USG and the examination took a very long time. When we asked about the condition of the fetus, the doctor did not want to tell us the results, and the doctor just said “you do not need to know the results, the important thing is to know the gender and that the fetus is in good condition,” but we as the mother want to know the condition of our fetus. Finally, I decided to give birth at the Maternity Hospital. (Responder #5, age 22).
In the questionnaire survey, half of the participants answered that they had waited quite a long time for an examination. The promptness of actions was based on the service path; generally, pregnant women that attended the registration counter for their consultations received the opportunity to attend an examination based on their number on the queue. However, respondents stated that there was a very long waiting time for examinations. Prompt actions were still constrained by the limited availability of health-care workers and inadequate facilities; therefore, the registration counter queue becomes backed up with the waiting patients. The examination and counseling ideally need to take fifteen (15) minutes, but the check-up schedule coincides with holidays, the number of patients automatically accumulate in the schedule for the next day. Participants in the focus group discussion described the current situation and their feeling:
I do not understand why the waiting time feels quite long every time I visit the health-care center, although the number of health-care personnel and the available facilities seem sufficient. (Responder #6, age 19, 7 months gestational age).
I hesitate to go to the community health center because every time I get a checkup, I only had practicing medical students that examined me as part of their working experience. When these students could not handle my case, a midwife will take over. I think that a midwife should accompany these practicing students or doctors and do not engage in other routine practices when we enter the examination room. We hope that we can have a USG examination at each consultation and that the queuing time is not too long. (Responder #7, age 35, 6 months gestational age).
Over 96.9% of respondents were examined 6–8 hours after delivery (before returning home). This proportion is decreasing after six days of delivery and increased again with the number of weeks after delivery. The background of these trends was related to the cultural background of some community and is explained by the health officer and other staffs:
The very low number of postpartum consultations in this community health center is influenced by strong traditions; e.g., mothers that have given birth are forbidden to leave their house before 40 days. Community health center (midwives) anticipates this tradition by visiting them directly in their home. (Responder #8 Midwife Coordinator at Puskesmas Area A).
The most important function is to always socialize with midwives and mothers to take directly in order to take over birth control after delivery. The birth control device is strongly recommended to be inserted before leaving the health-care center or returning home (e.g., intrauterine or implanted devices), especially for mothers following their second labor. (Responder #9 Cross Sector Health Officer at Puskesmas Area C).