Traditional practices influencing the use of maternal health care services in Indonesia

Background Maternal Mortality Ratio (MMR) in Indonesia is still high, 305, compared to 240 deaths per 100,000 in South East Asian Region. The use of Traditional Birth Attendance (TBA) as a cascade for maternal health and delivery, suspected to be the pocket of the MMR problem. The study aimed to assess the influence of traditional practices on maternal health services in Indonesia. Methods We used two data sets of national surveys for this secondary data analysis. The samples included 14,798 mothers whose final delivery was between January 2005 and August 2010. The dependent variables were utilization of maternal healthcare, including receiving antenatal care (ANC≥4), attended by skilled birth attendance (SBA), and having a facility-based delivery (FBD). The independent variables were the use of traditional practices, type of family structure, and TBA density. We run a Multivariate logistic regression for the analysis by controlling all the covariates. Results Traditional practices and high TBA density have significantly inhibited the mother’s access to maternal health services. Mothers who completed antenatal care were 15.6% lost the cascade of facility-based delivery. The higher the TBA population, the lower cascade of the use of Maternal Health Services irrespective of the economic quintile. Mothers in villages with a high TBA density had significantly lower odds (AOR = 0.30; CI = 0.24–0.38; p<0.01) than mothers in towns with low TBA density. Moreover, mothers who lived in an extended family had positively significantly higher odds (AOR = 1.33, CI = 1.17–1.52; p<0.01) of using maternal health services. Discussion Not all mothers who have received proper antenatal delivered the baby in health care facilities or preferred a traditional birth attendance instead. Traditional practices influenced the ideal utilization of maternal health care. Maternal health care utilization can be improved by community empowerment through the maternal health policy to easier mothers get delivery in a health care facility.

was between January 2005 and August 2010. The independent variables were the use of traditional practices, type of family structure, and density of TBA. The dependent variables were utilization of maternal healthcare, including receiving antenatal care (ANC) and having a facility-based delivery. Multivariate logistic regression was conducted for the analysis by controlling all the covariates.

Results
Disregarding the costs for delivery, traditional practices and high TBA density signi cantly in uenced mother's access to maternal health utilization with a negative direction which is conversely to living in extended family structure. Mothers in villages with a high TBA density had signi cantly lower odds of receiving complete care and facility-based delivery compared to mothers in villages with low TBA density.
Moreover, mothers who lived in an extended family had higher odds of using maternal health services.

Conclusions
Traditional practices signi cantly in uenced the ideal utilization of maternal health care in Indonesia.
Higher TBA density in the villages signi cantly decreased mother's odds of using ANC, skilled birth attendance (SBA), and the complete of maternal health services. Maternal care utilization was positively in uenced by living with extended family.

Background
In 2015, the Indonesian maternal mortality ratio (MMR) was 305 per 100,000 live births, according to the Intercensus Population Survey (SUPAS) 2015 (1). Although it has remained high compared to neighboring countries (an average 240) in 2012, the Indonesian MMR dropped from 359 maternal deaths per 100,000 live births (2). The three common delays which adversely affect maternal mortality include: delays in family decision making due to mothers' inability to recognize danger signs in pregnancy; delays in accessing care at a healthcare facility related to geographic barriers and problems with transportation; and delays in receiving care because of the health service quality in healthcare facilities (3). These three types of delays together caused 85.7 percent of maternal deaths. An analysis in Aceh province, Indonesia found that vaginal bleeding (59.7%), eclampsia (25.5%), and other problems (14.8%) were signi cant factors in the increased risk of maternal mortality (4).
Traditional beliefs and practices are prevalent in Indonesia similarly to other Asian countries and are known to in uence maternal and child health (6, 7). Several studies, especially in Asia and Africa, have used quantitative and qualitative approaches to identify traditional beliefs and practices for pregnancy, which have included special dietary rules, personal hygiene, daily activities/isolation of pregnant women, taboo on informing about pregnancy, and prohibition of sexual intercourse (6,8-10). Traditional childbirth and postpartum practices include the choice of delivery place, fear of exposure to hospital equipment, rituals of cutting the umbilical cord and removing the placenta, breastfeeding and even the tradition of isolating the mother after childbirth and the baby (6,8, [10][11][12]. Previous studies found the key risk factors associated with reduced use of antenatal care (ANC) and facility-based deliveries (FBDs) included low household wealth index, inability to pay for services, low maternal education level, sociocultural factors, low involvement of mothers in the decision-making process, mothers' limited exposure to mass media, far distance to health facilities, and adequate access to and quality healthcare (13)(14)(15)(16). Other research examining factors that in uence the use of skilled birth attendants (SBAs) for delivery has found that Jaminan Kesehatan Nasional (JKN), Indonesia's national health insurance, has signi cantly increased the use of SBAs for poor pregnant women. This analysis also found that education and supply-side factors, including the ratio of primary health centers per 1,000 people, signi cantly in uenced SBA use in maternal health care utilization (17).
Indonesia's varied cultures and ethnic group practices underlie health-seeking behavior, particularly for maternal and neonatal health (MNH) services, whether or not these in uences are recognized (18). These include the number of TBA in population, the use of traditional practices, and family composition. A study in Uganda found that cultural factors inhibit mothers in using modern ANC. Beliefs and myths often enforce the mothers to give birth at home and implement the practice of traditional umbilical cord cutting (UCC) (19).
Childbirth at home remains prevalent in rural areas in Indonesia. It is related to the presence of and preference for TBAs at the village level. Data from several small qualitative studies in Jakarta, Banten, and West Java found that TBA use was a major sociocultural barrier to MNH utilization (20), and that the traditional beliefs underlying TBA preference were particularly pervasive among low-income families (21).
Research also showed that women tended to prefer TBAs because they believed it was easier to interact, have more experiences, are more accessible, and are more likely to encourage natural birth compared to midwives (22). Many types and styles of services performed by TBAs could result in unexpected maternal and newborn complications; such practices include ngolesi (to wet the vagina using coconut oil in the perception to ease the baby's delivery), kodok (the TBA inserting a hand into the uterus to take out mother's placenta), nyanda (having the mother sit in a straight-legged position for hours, with a consequent risk of bleeding and swelling) (23).
Traditional UCC using tools such as bamboo knives-sembilu-or unsterilized razors or scissors, is another traditional practice associated with maternal and newborn complications. It is widely practiced among the Dayak's ethnic group who mostly live in Senggau, West Kalimantan. Improper UCC may cause bleeding in the newborn. Similarly, cutting the placenta with the use of a bamboo knife may cause infection for the mother. Other risk factors associated with traditional UCC is the use of mixed kitchen dust or coffee and the saliva of a betel chewer as an antiseptic, also increase the risk of maternal and newborn complications (24).
Evidence of the in uence of family composition on the use of maternal health services is very limited in Indonesia. A small qualitative study in the Klaten district of Central Java found that the social in uences of the extended family were associated with increased use of postnatal care (25). Another study that used Indonesian Demographic and Health Survey data found that familial support was associated with a signi cant increase in the use of ANC services (13).
With regard to family planning methods, problems relating to unmet need are found in many countries. A number of cultural barriers exist, such as religious prohibitions, resistance from men, and misperceptions of the side effects of contraceptives (26)(27)(28)(29). This study aims to analyze the evidence of traditional practices that in uence the uptake of comprehensive maternal health service use in Indonesia. The Riskesdas (2010) sampling technique was a two-stage strati ed random sampling. The rst stage used neighborhood census blocks selected from each district/municipality in proportion to population size. In total, 2,800 census blocks were selected randomly from all possible census blocks. In the second stage, 25 households were randomly selected from each census block, yielding a total of 251,388 individuals from 70,000 households (30). The study sample focuses on mothers who had a live birth in the ve years before data collection (January 2005 to August 2010), for a total sample size of 14,798 mothers.

Study design and participants
The 2008 PODES was used to generate a variable on TBA density per 1,000 population. PODES 2008 is also nationally representative and conducted every three years by the Central Bureau of Statistics (31).
PODES collected data on the following topics: availability of human resources, natural resources, infrastructure, public facilities, and economic and social facilities at the village level.

Outcome variables
We examined the factors that in uence maternal healthcare use-speci cally, four outcome variables describing the maternal health continuum of care:

Explanatory variables
This study examines how the use of several traditional practices in uences the use of ANC, SBA, and FBD. Three variables were developed to measure cultural constraints that may in uence maternal healthcare use: (1) non-medical or traditional practices, (2) family composition, and (3) TBA density. The rst variable, "non-medical or traditional practices," refers to traditional beliefs or behaviors practiced by either the mother, her family, or her community. These beliefs and behaviors are proxied with a composite of two traditional practices: (a) use of traditional UCC care and (b) lack of family planning use for traditional reasons (20,25). We use a proximate approach to cultural factors to strengthen our argument regarding the impact of belief and tradition because using only one of these variables may not adequately represent cultural impact for the purposes of our analysis. "Non-medical or traditional practices" was coded as "yes" if the mother used either practice and "no" if the mother did not use either practice. Finally, for the purpose of the analysis we compare women who do not use family planning for traditional reasons to all other women (including women who are using family planning).
The second variable captures the mother's family composition, categorized as either nuclear or extended family (13,25,32). The third variable captures the availability of TBAs at the village level. Evidence shows that the more TBA in the community, the less likely the mother is to use modern MNH-seeking practices (20,21). We measure TBA density as the number of TBA per 1,000 population. TBA density is categorized in ve quintiles, from Q1 (low) to Q5 (highest).

Covariates
Our analysis controlled for several demographic, household, and socioeconomic characteristics. Demographic characteristics included the following: mother's age; mother's education; parity; residence type; and region, based on ve groups of islands. We also controlled for household socioeconomic status, measured using average expenditure per capita per month, which we divided by ve quintiles, from Q1 (poorest) to Q5 (richest), with Q1 representing households spending less than Indonesia Rupiah (IDR) 190,000 per month and Q5 representing households spending more than IDR 1,500,000 per month.

Statistical analysis
Descriptive statistics were used to summarize sample characteristics (Table 1 and Table 2). Categorical variables were summarized using frequencies and their associated percentages.
The Cuzick's test for trend and Z-score were used to examine the outcome proportions for the dependent variables of ANC, SBA, FBD, and all maternal continuum services based on (across ordered groups) the independent variables of cultural barriers and the mother's characteristics (Table 3). Finally, multivariate logistic regression was used to quantify the relationship between potential explanatory variables for maternal health outcomes (Table 4). We analyzed data using STATA version 14.0. We conducted all analyses using the corresponding Riskesdas weights and accounting for the Riskesdas survey design, as published elsewhere (33,34). Plausible covariates for utilization of maternal care were the length of education, age, birth of rst child, socioeconomic status, urban-rural location, and region by island group that divided by the big islands.

Sample characteristics
A total of 14,798 mothers were involved in this analysis. Their individual characteristics can be seen at Table 1. The majority of mothers reported the use of non-traditional cultural practices (85.3%) and lived in a nuclear family structure (85.9%). Most mothers were ages 25-34 years at the time of their most recent live birth (53.5%) and had completed only primary school or less (43.1%); a signi cant proportion came from very poor or poor households (46.2%). The most recent birth was the second birth for most women in the study (33.3%), followed by rst birth (28.6%). Approximately half of the women lived in rural areas and half in urban areas; the majority resided in the Java-Bali and Sumatra regions.

Proportion of mothers who used maternal health services
The use of maternal health services by mothers is depicted in Table 2. The majority of mothers reported four or more antenatal visits (78.7%), but only 74.2 percent had their rst delivery contact with a health professional or SBA. However, the percentage for the last contact for delivery increased to 80.3 percent. Slightly more than half of mothers delivered at a health facility (54.9%).
A total of 63.6 percent of mothers used ANC ≥ 4 and SBA for their rst and last delivery contact. A smaller proportion of mothers (48%) used the ideal maternal health continuum of services, including four or more ANC visits, use of an SBA for their rst and last delivery contact, and use of an FBD. Our bivariate analysis (Table 3) shows there are difference in the proportion for the dependent variables of ANC, SBA, FBD and all maternal continuum services based on cross ordered groups the dependent variables of cultural barriers and the mother's characteristics. The use of ANC ≥ 4, SBAs for rst and last contact, and all maternal health continuum services was signi cantly higher among mothers who did not use non-medical traditional practices. The table also shows the outcome distribution of the continuum of care according to its characteristics. The proxy of traditional practices seems consistent and was lower in all uses of maternal healthcare. The ratio of TBAs was also consistent; the higher the TBA ratio, the lower the proportion of mothers accessing proper ANC. The pattern of the continuum of care goes down for ideal service use; ANC ≥ 4; SBA rst contact; SBA rst and last contact; and use of ANC ≥ 4, SBA rst and last contact, and FBD. The key outcome of the in uence of traditional practices is related to family patterns; mothers who lived in an extended family were more likely to be using maternal healthcare services continuously. The plausible covariates for increasing the use of maternal care were better education (i.e., higher level of mother's education), optimal age (25-34), birth of rst child, highest socioeconomic status, urban location, and region (Java-Bali). Signi cance (p) at *(< 0.1), **(< 0.05), ***(< 0.01) In uence of traditional practices and other factors on maternal health utilization Table 4 depicts the results of the logistic regression of traditional practices and other factors in uencing the continuum of maternal healthcare services utilization. The results indicate that traditional practices signi cantly in uence maternal healthcare utilization, even when controlling for demographic and socioeconomic characteristics. Mothers who used non-medical traditional practices experienced signi cantly lower odds of using all services in the maternal health continuum of care compared to women who used modern practices. Speci cally, the use of non-medical or traditional practices was associated with 2.1 times lower odds of using ANC ≥ 4 and 3.7 times lower odds of seeking an SBA for rst delivery contact (p < 0.01). Mothers living in an extended family experienced 1.3 times higher odds of receiving comprehensive maternal care compared to women living in a nuclear family (p < 0.01).
Traditional practices more than doubled the odds that a mother would not use maternal health services. As shown in Table 4, the odds ratio of ANC ≥ 4 was 0.5, rst contact with SBA (OR = 0.3); ANC ≥ 4 and skilled birth for the rst and last contact (OR = 0.4); and nally use of ideal care of ANC ≥ 4 times, SBA rst contact, and FBD (OR = 0.5).  Finally, the results show that higher TBA density in the village signi cantly decreases a mother's odds of using ANC, SBA, and the complete continuum of maternal health services. For example, mothers in villages with the highest TBA-to-population ratios experienced 3.2 times lower odds of receiving the complete maternal health continuum of services compared to mothers residing in villages with the lowest TBA density ratios (p < 0.01). It is important to note that the strength, signi cance, and direction of these relationships hold when analyzing the effects by rural/urban residence. This pattern of association was consistently signi cant for mothers in Java-Bali islands and was conversely associated with the extended family structure (see Table 1 in the appendix).
Of the demographic and socioeconomic characteristics included in this analysis, the results indicate that mothers' education and socioeconomic status were the two most important predictors of maternal health usage. Mothers who reported nishing high school or more were more likely to use any maternal health services than those who had nished primary school or less. Mothers in the richest socioeconomic status quintile experienced 2.8 times higher odds of using the continuum of maternal health services and 3.0 times higher odds of using ANC ≥ 4 and SBA for rst and last delivery contact compared to mothers in the poorest quintile (p < 0.01).

Discussion
As expected, the ndings of this study con rmed that various factors associated with traditional practices in uence use of maternal health services. Mothers who adhered to traditional practices were less likely to use maternal health services, compared to their counterparts who used more modern practices. These results apply to all types of maternal health services and are shown to be a barrier to mothers' use of such services in Indonesia. Research in Uganda and sub-Saharan Africa on the in uence of traditional practices such as UCC (speci cally using the practice of tying and disposing the placenta as a proxy for cultural barriers) has also found a negative in uence on maternal health services use (20).
The use of family planning as part of this study's composite variable has been studied in other countries.
From the beginning, the assumption was that the use of contraceptive devices may be in uenced by cultural issues and thus could be used as a cultural proxy. Our study's ndings are in line with those presented by a study in Mexico where cultural barriers related to family planning were attributable to religious reasons, prohibition by husbands, and fear of side effects. Moreover, this study showed that gender roles and religious objections acted intergenerationally to in uence the refusal to use modern methods of contraception. In addition, a low education level resulted in lack of information and misconceptions about the long-term fertility risks due to hormonal exposure from using modern methods (26,28).
The study results also indicate that family structure is an important factor that in uences mothers use of ANC ≥ 4, SBA, and FBD. Extended family structure has a positive in uence on the use of MNH services as a whole. These ndings are consistent with a study in central Java that found that the extended family is signi cantly associated with the use of antenatal and postnatal care (13,32). Our study's ndings are also consistent with one United States-based study which found no signi cant in uence on MNH utilization for mothers within an extended family comprising other adult members or coparents (35). In addition, a study from Madhya Pradesh, India found that women living in an extended family and who had good family relationships were more likely to receive antenatal services (36); nevertheless, after controlling for sociodemographic characteristics, women living in extended households were less likely to receive either ANC services or an FBD (37). Results from qualitative studies in Egypt, Nepal, and China have also been inconclusive (38-40).
Finally, this study found that the presence of TBAs was also associated with decreased utilization of the full cascade of maternal health services. Mothers who live in an area with a high prevalence of TBAs were less likely to use any maternal health services. In general, mothers may view TBAs as being familiar and of known competence. Indeed, other studies in Indonesia have con rmed the phenomenon of TBAs assisting mothers completely throughout the maternal healthcare continuum, from pregnancy up to delivery and postanatal care hence up to 40 days after birth (41). In some ethnic groups in Indonesia, a TBA, known as a dukun, is considered to be someone with supernatural power without formal learning, gained through cultural tradition (42). Moreover, mothers who use TBAs receive mantras and herbs believed to make the delivery process more confortable (22). A study in Bogor district found that using a TBA for delivery was inexpensive and more convenient because TBAs were perceived to be friendlier and have more patience regarding the mother's condition (41). Nevertheless, a study in Cirebon, West Java found, some mothers prefered to delivery with a TBA even though she paid more than SBA (43).
Use of maternal healthcare was also in uenced by the mother's age and educational attainment. Study results show that the older and better educated the mother, the greater the odds of using maternal health services. These ndings are consistent with those from a study in a Midwestern city in the United States, in which years of education were signi cantly associated with use of adequate prenatal care (44). Conversely, a study in South Jakarta found that mothers' age, education, occupation, and number of pregnancies had no in uence on antenatal care seeking at the appropriate time (45). This contradiction may be due to the different studies' criteria for choosing their subjects and those subjects' socioeconomics background; the rst study chose low-income women in a developed country, whereas the latter chose women in a middle-income country with free antenatal services provided by the government. Nevertheless, these free services are not necessarily inexpensive, as geographical access and transportation barriers remain. As a large country with great socioeconomic diversity, the gaps between poor and rich remain very wide, as was found by a study conducted in three districts in West Java (13).
Urban and rural residence and region were two demographic variables signify the difference of maternal health utilization. In Indonesia, economic development has occurred more extensively in the western part of the country, such as in Java-Bali, compared to Nusa Tenggara, Maluku, and Papua in the eastern part. Similarly, the distribution of healthcare facilities is greater in urban areas and the western part of the country. Access to a health facility depends not only on free service provision and distribution of facilities, but also the availability of transportation. Again, a study in West Java showed that distances from health facilities and poor road conditions constrained mothers' access to antenatal care, particularly for those living in the remote areas (13,46).
This study used 2010 Riskesdas data to analyze quantitative evidence on the in uence of cultural factors or traditional practices on the utilization of maternal health services in Indonesia. One limitation is that the 2010 Riskesdas is an older dataset. However, it provides the only available data that allow us to anlyze the in uence of traditional practices at a nationally representative level. As cross-sectional data, this analysis can measure only association, not causation; however, the ndings clearly indicate that traditonal beliefs and cultural issues are associated with maternal health.

Conclusion
The ideal utilization of maternal care so called continuum maternal health care in Indonesia were signi cantly in uenced by traditional practices after controlling for demographic and socioeconomic characteristics. Most mothers access incomplete maternal health services from pregnancy to delivery as recommended by the program. Some mothers who have received proper antenatal care preferred to deliver outside of health care facilities or without SBA. We conclude that the traditional practices to the use of maternal health services in Indonesia present a problem that may lead to a high prevalence of maternal mortality. Disregarding costs for delivery, traditional practices and high TBA density signi cantly in uenced mother's access to maternal health utilization with a negative direction conversely to living in extended family structure.
Higher TBA density in the village signi cantly decreases mother's odds of using ANC, SBA, and the complete continuum of maternal health services. It is important to note that the strength, signi cance, and direction of these relationships hold when analyzing the effects by rural/urban residence. Mothers' education and socioeconomic status were the two most important predictors of maternal health usage.
The pattern of association was consistently signi cant for mothers in Java-Bali islands and was conversely associated with the extended family structure.
Extended family structures frequently exist in Sulawesi and Eastern Indonesia, and traditional UCC practices occur more often in Eastern Indonesia and Kalimantan. Moreover, Sulawesi and Java-Bali have the highest occurrence of traditional beliefs and practices regarding contraceptive use as a family planning method.

Recommendation
An innovative SBA-TBA partnership could be developed in villages with a high number of TBAs. Such partnerships may provide a "win-win solution." The TBA, in addition to providing some traditional services, may encourage the pregnant women to visit a midwife. The TBA could also report to the SBA so the SBA could follow up the pregnant mothers to have antenatal care and so on. Incentives to foster this prospective solution may need to be considered.
Maternal health is not merely a responsibility of a mother's family, as the community and government also needs to play a role. Due to the decentralization, the involvement of other sectors need to be considered regarding their function. For example, district health o ces could help improve the number and quality of health services points; the Ministry of Education could add curricula on reproductive health; and the Ministry of Public Works could ease access of transportation to the health facilities. A comprehensive strategy to increase maternal health services utilization would be the responsibility of the Ministry of Health; such a strategy would include providing quali ed health personnel and empowering health providers to implement the standard of basic and comprehensive obstetric neonatal services (PONED/PONEK) at health centers and hospitals.
Finally, future research is needed on the SBA-TBA partnership by taking into account the local tradition in the decentralization era.