Antenatal care and women's birthing decisions in an Indonesian setting: does location matter?

Poor maternal health outcome, still a major health problem in developing countries, is influenced by both women's personal characteristics and the characteristics of the place where they live. Identifying the spatial distribution and clusters of poor maternal health outcomes can assist in developing geographically specific interventions. This article examines the influence of urban and rural settings on antenatal care and birthing decisions in South Sulawesi, a province in Indonesia, and investigates the existence of geographical clusters of women's decision regarding antenatal care and birth assistance.

Data were derived from a survey of 485 women who recently gave birth. Household coordinates, midwives' location and hospital location were recorded using a handheld global positioning system (GPS). Logistic regression was used to examine the influence of place of residence on antenatal care and women's birthing decisions. SaTScan software was used to identify the location of geographical clusters. ArcGIS v9.3 was used to visualize and interpret the distribution of facilities and clusters.

Area of residence determines the likelihood of a woman presenting for antenatal care--care that pregnant women receive from skilled birth attendants. The likelihood of hospital delivery or delivery at home with the support of a skilled birth attendant (SBA), however, was not determined by residential area. Distance to nearest SBA, working as a village midwife, was associated with the likelihood to be assisted by her at home. Attendance of SBA at home, or delivery at a hospital, were clustered in urban areas at different geographical locations, but no similar clustering occurred in rural areas. In contrast, women with low numbers of antenatal care visits and a traditional birthing assistant (TBA) at home were clustered in particular rural areas, but low antenatal care visits and use of TBA were not clustered in urban areas.

Although area of residence did not appear to influence the likelihood of women delivering at hospital or with SBA at home, clusters of women follow particular patterns of behaviour in different geographic settings. This clustering highlights the heterogeneity of both urban and rural areas.