Childbirth decisions and outcomes in South Sulawesi Province, Indonesia

Maternal mortality remains a major public health problem in low and middle income countries. The decisions that women make regarding childbirth impact on maternal and foetal/neonatal outcomes, including maternal death. Although a range of barriers have been reported that influence access by pregnant women to skilled birth assistants and hospital, little is known about it in Indonesia in areas where there are high mortality rates. In this thesis, I examine the determinants of women's childbirth decisions and explore women’s access to skilled birth assistants either at home or hospital. This study was conducted in Bantaeng, a district in South Sulawesi Province, Indonesia. I adopted a mixed method approach; I conducted a survey with 485 women who recently delivered their babies, and followed this by in-depth interviews with women who had recently delivered, midwives, and men whose wives had died when they gave birth. First, as most women attended ANC, I examined the relationship between number of ANC visits and the likelihood of women being assisted by SBA at home and when delivering at hospital. I found that women who had at least four ANC visits were more likely to deliver at hospital and, if they delivered at home, they were likely to be assisted by SBA. Secondly, I explored the spatial patterns of women’s birthing decision. I found that although there were different types of decisions on antenatal care visits between women who resided in urban and rural areas, there was no difference in the likelihood of SBA assistance at home and hospital delivery. However, I found that there was a geographical cluster of women who did not present for ANC, and were assisted by TBA rather than by SBA at home or hospital delivery, suggesting that women’s decisions regarding childbirth within urban and rural area were not homogenous. Thirdly, I explored qualitatively barriers to the use of SBA and hospital. My qualitative data identified several factors influencing women’s decisions to deliver their babies at home with TBA or SBA, and their access to hospital when complications occurred. These factors included community characteristics such as availability of transportation, health system characteristics such as availability of midwife or obstetrician, cultural barriers, and attitudes toward pregnancy and toward SBA and toward delivery at hospital. Lastly, men’s involvement in maternal health was explored. Men are rarely involved in antenatal care, as antenatal care is perceived as women’s business and men do not necessarily accompany their wives. Men indicated that they were happy for the birth to be attended by a traditional birth assistant at home, but that they would seek help from a skilled birth assistant or take their wife to hospital if complications occurred. However, men could not recognize early signs of complications, particularly in the case of postpartum haemorrhage; this delayed transfer to hospital and appears to have contributed to maternal mortality.