Women & Health

ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20

Determinants of utilization of antenatal care

services among adolescent girls and young women
in Indonesia

Ferry Efendi SKep.Ns, MSc, Ching-Min Chen RN, DNS, Anna Kurniati SKM, MA
& Sarni Maniar Berliana SST, MSi

To cite this article: Ferry Efendi SKep.Ns, MSc, Ching-Min Chen RN, DNS, Anna Kurniati SKM,
MA & Sarni Maniar Berliana SST, MSi (2016): Determinants of utilization of antenatal care
services among adolescent girls and young women in Indonesia, Women & Health, DOI:
10.1080/03630242.2016.1181136

To link to this article: http://dx.doi.org/10.1080/03630242.2016.1181136

Published online: 26 May 2016.

Submit your article to this journal

Article views: 16

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=wwah20

Download by: [University of Nebraska, Lincoln] Date: 03 June 2016, At: 18:49
 WOMEN & HEALTH
http://dx.doi.org/10.1080/03630242.2016.1181136

Determinants of utilization of antenatal care services

among adolescent girls and young women in Indonesia
Ferry Efendi, SKep.Ns, MSca,b, Ching-Min Chen, RN, DNSa,c, Anna Kurniati, SKM, MAa,d,
and Sarni Maniar Berliana, SST, MSie
a
Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan,
Taiwan, China; bFaculty of Nursing, Airlangga University, Surabaya, Indonesia; cDepartment of Nursing
and Institute of Gerontology, National Cheng Kung University, Tainan, Taiwan, China; dCenter for
Planning and Management of Human Resources for Health, The Board for Development and
Empowerment of Human Resources for Health (BPPSDMK), Ministry of Health, Jakarta, Indonesia;
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

e
Institute of Statistics (STIS), Statistics Indonesia (BPS), Jakarta, Indonesia

ABSTRACT ARTICLE HISTORY

Due to the high number of maternal deaths, provision of Received 9 July 2015
antenatal care services (ANC) in Indonesia is one of the key Revised 20 March 2016
aims of the post-Millennium Development Goals agenda. This Accepted 21 March 2016
study aimed to assess the key factors determining use of ANC KEYWORDS
by adolescent girls and young women in Indonesia. Data from Adolescent girls; antenatal
the Indonesia Demographic and Health Survey 2012 were care use; young women
used, with a focus on married adolescent girls (aged
15–19 years, n = 543) and young women (20–24 years,
n = 2,916) who were mothers. Bivariate and multiple logistic
regression analyses were performed to determine the factors
associated with ANC use. The findings indicated that adoles-
cents were less likely to make ANC visits than young women.
Richer women were more likely to make four ANC visits in both
groups compared to the poorer women. Living in urban areas,
higher educational attainment, and lower birth order were also
all associated with higher levels of receiving ANC among
young women. The results showed that socio-economic factors
were related to the use of ANC among adolescent girls and
young women. Ongoing health-care interventions should thus
put a priority on adolescent mothers coming from poor socio-
economic backgrounds.

Introduction
In 2015, Indonesia set a target to achieve a critical goal of reducing the
Maternal Mortality Rate (MMR) to 102 per 100,000 live births (Bappenas
2012; UNDP 2012). However, this target appears difficult to obtain, as the
latest data showed that the MMR was 359 per 100,000 live births (Statistics
Indonesia et al. 2013). A recent publication also showed that Indonesia failed
to reduce MMR to the level needed to reach the target included in the

CONTACT Ching-Min Chen, RN, DNS chingmin@mail.ncku.edu.tw Institute of Allied Health Sciences,
College of Medicine, National Cheng Kung University, No. 1, Daxue Rd., East Dist., Tainan City 70101, Taiwan, China.
© 2016 Taylor & Francis
 2 F. EFENDI ET AL.

Millennium Development Goals (MDGs), which was only a 0.6% decrease in

the MMR per year (Hogan et al. 2010).
Antenatal care (ANC) remains a frequently used intervention to reduce
MMR, particularly in developing countries (Ali and Adam 2011). The use
of ANC services has been significantly related to improving maternal and
neonatal outcomes (Rai, Singh, and Singh 2012; Ram and Singh 2006).
Recognizing this importance, the government of Indonesia launched the
Safe Motherhood program in 1990, based on the following four pillars:
family planning, antenatal care, safe delivery and essential obstetric ser-
vices (MoH 2011). This policy was also reflected in a strategic plan carried
out by the Ministry of Health from 2010–2014 to improve maternal and
child health, which put specific targets on the achievement of a number of
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

goals, such as deliveries being assisted by a a qualified birth attendant (a

target of 90%), completing the first ANC visit (90%), and delivering a
normal weight infant (85%) (Kemenkes 2010). Indonesia’s MDGs include
the target that 95% of pregnant women will make their first ANC visit
during pregnancy, and that 90% will make at least four ANC visits
(Pritasari 2012). However, the latest national data showed that only 20
of 33 provinces had achieved the first target (≥95%), and only 12 provinces
achieved the second (MoH 2014).
Many studies have documented that getting pregnant at a young age decreases
the quality of health outcomes for women (Rai, Singh, and Singh 2012; Singh
et al. 2012). Despite a number of global strategies that have focused on repro-
ductive health, adolescent pregnancy remains a widespread problem, which is a
significant contributor in maternal and child mortality, especially in low- and
middle-income countries (World Health Organization 2014), with around 16
million adolescent females aged 15–19 years old giving birth every year (Word
Health Organization 2012). The importance of delaying marriage and pregnancy
in adolescent women is thus receiving increased attention. For Indonesia, a
country with 40.75 million adolescents, this issue is of particular importance
(Badan Pusat Statistik 2010). Data published by the Badan Kependudukan dan
Keluarga Berencana Nasional (BKKBN), or National Family Planning
Coordinating Board, in 2013 showed that adolescent pregnancies accounted for
48 of every 1,000 pregnancies, a 10% increase from the previous year (Jalal 2014).
The reduction of adolescent marriage and pregnancy has therefore become a
national goal to aid in Indonesia’s development (BKKBN 2012).
However, in spite of the urgent need to provide effective ANC services in
Indonesia, little attention has been given to analyzing the use of ANC, and
particularly the differences in such use between adolescent girls (15–19 years
old) and young women (20–24 years old). A nationwide quinquennial survey
conducted by the Indonesian Ministry of Health to capture details of com-
munity health at the district level (MoH 2010) found that the rate of infant
 WOMEN & HEALTH 3

death among adolescent mothers (15–19 years of age) was higher than that
seen with other age groups (Balitbangkes 2010).
To the best of our knowledge, few studies have been conducted on the use
of ANC in Indonesia. In particular, limited attention has been paid to
examining adolescent girls and young women who become mothers as a
separate population group, thus indicating a greater need to understand the
various factors related to the use of ANC among these individuals. In
addition, this study may also shed light on why, despite government efforts
to reduce the rate of adolescent pregnancies, this number actually increased
in recent years (Jalal 2014).
Therefore, this study was used to attempt to assess the determinants of the
differences in ANC use seen among adolescent girls and young women who
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

became mothers in Indonesia. It is anticipated that the results of this work would
not only help policy makers develop strategies to achieve the related national
targets and MDGs, but also provide insights into what the government can do in
the post-MDGs era as it aims to achieve its sustainable development goals (SDGs).

Materials and method

Setting
This study used data from the Demographic Health Survey of Indonesia.
Indonesia is the fourth most populous country in the world, with an esti-
mated population of 252 million (BPS 2014). The country has 34 provinces
and more than 17,504 islands, stretching from its east to west regions
(Kemendagri 2015). The poverty rate was 11.66% in 2012, with 28.59 million
people living below the poverty line (MoH 2013). Nationally, the percentage
of illiteracy rate was about 7.19%, with the highest rate in Papua province
(35.9%) and the lowest rate in Sulawesi province (1.1%) (MoH 2013). This
reflects the disparities between regions, which also exist in health outcomes,
such as the number of completed first and fourth ANC visits (MoH 2010;
Pritasari 2012). For example, the rates at which pregnant women make their
first and fourth ANC visits in DKI Jakarta province were 97.9% and 84.3%,
respectively, while in Papua Barat province the figures were only 71.3% and
34.7% (MoH 2010). In 2012, the Indonesian Demographic Health Survey
(IDHS) was thus conducted to gain a broader view of this issue. This survey
was carried out by Statistics Indonesia in collaboration with the Ministry of
Health and the National Population and Family Planning Board, with the
Inner City Fund (ICF) International and MEASURE (Monitoring and
Evaluation to Assess and Use Results) Demographic and Health Surveys
providing technical assistance in data analysis and report writing. The survey
process was initiated in 2011, followed by fieldwork in 2012, which was
completed a year later (Statistics Indonesia et al. 2013).
 4 F. EFENDI ET AL.

Data
A two-stage stratified sampling procedure was used in the 2012 IDHS. In
stage one, census blocks (CBs), which represented urban and rural areas of
each province in Indonesia, were determined. In stage two, households from
the CBs list were randomly selected. All women aged 15–49 years old were
eligible for an interview in the IDHS, and a total of 47,533 participated (a
response rate of 96%). Details of the sampling method of the IDHS 2012 have
been reported elsewhere (Statistics Indonesia et al. 2013).
Using the UN’s and WHO’s definition for adolescent age, two maternal
age categories, women aged between 15 and 19 years and women between 20
and 24 years were compared. To be included in the analysis, the women
needed to: (1) be married at the time of survey, (2) be aged 15–24 years old,
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

and (3) have had their most recent births within the 5 years preceding the
survey. A total of 3,459 women met these criteria and were included in the
analyses. Questionnaires were employed to gather data from the respondents,
and included items about their background, reproductive history, contra-
ceptive use, pregnancy and postnatal care, health and nutrition, immuniza-
tion history, fertility preferences, marriage and sexual activity, employment
status, partner’s background, HIV/AIDS, and other health issues (Statistics
Indonesia et al. 2013).

Outcome variables
The present study measured one health outcome variable, namely having had
at least four ANC visits (yes/no). The ANC policy in Indonesia follows the
World Health Organization’s guidelines and those prepared by the
Indonesian Ministry of Health (MoH). Under these guidelines, it is required
that every mother has at least four ANC visits (MoH 2013; World Health
Organization 1994).

Explanatory variables
Important demographic characteristics that were considered included mater-
nal age (15–19 and 20–24 years), place of residence (rural and urban),
mother’s education (no education, primary, secondary, and higher), hus-
band’s education (no education, primary, secondary, and higher), economic
status (low-income, middle-income, and high-income, with categories
defined as provided below), mother’s employment status (not working and
working), mass media (i.e., television) exposure (no exposure and some
exposure), and birth order of the infant (first, second, and third or more).
Exposure to mass media was assessed by asking how often the respondent
watched television (not at all versus ever). Economic status quintiles were
 WOMEN & HEALTH 5

calculated based on ownership of a standard set of assets, as outlined in the

Demographic Health Survey guidelines (Statistics Indonesia et al. 2013).
These assets included a television, car, flooring material, source of drinking
water, toilet facilities, and other items related to health (Statistics Indonesia
et al. 2013). The economic status quintiles were regrouped into three cate-
gories, low-income (lowest and second), middle-income (middle), high-
income (fourth and highest) for simplification and to achieve a better data
distribution.

Analytical approach
To determine ANC use among young mothers, both bivariate and multi-
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

variate analyses were performed. Bivariate analyses were used to examine the
associations between the use of ANC services and various socio-economic
and demographic characteristics. Factors significantly associated (p < .05)
with ANC use were included in the multiple logistic regression model.
Adjusted odds ratios (OR) with 95% confidence intervals (CI) were com-
puted. The analyses were conducted using SPSS version 17.0 (SPSS, Inc.,
Chicago, IL, USA). We tested our model with the Omnibus test of model
coefficients, with the results indicating that the model fit (p < .001). Further,
the results of Hosmer and Lemeshow’s goodness-of-fit test were p > .05,
which indicated model fit.

Ethics statement
The 2012 IDHS was conducted under the collaborative supervision of the
Board of Research and Health Development (Balitbangkes), part of the MoH
of Indonesia. The Balitbangkes conducted an independent ethics review of
the 2012 IDHS protocol. All respondent identifiers were removed from the
data, and the participants provided their written informed consent to be
included in the current study, with the signed consent forms being kept
under management of the MoH. Interviews for 2012 IDHS were then con-
ducted after obtaining the signed consent of each participant. Permission for
the use of the data in the current study was obtained from ICF International,
part of the DHS program (DHS 2013).

Results
The mean age at marriage was 15.9 years among adolescent girls, while it was
18.4 among young women (Table 1). The mean age at first birth was
16.9 years among adolescent girls, while for young women it was
19.6 years. Adolescent girls were more likely to come from families in the
low-income category compared to young women. The rate of present
 6 F. EFENDI ET AL.

Table 1. Comparison of selected characteristics of married women by age.

Age in years
Selected characteristics 15–19 20–24
Mean age at marriage 15.9 18.4
Mean age at first birth 16.9 19.6
Percent belonging to the low-income wealth quintile 43.3 34.5
Percent currently not using contraceptive 32.4 30.9
Percent experienced massive vaginal bleeding after birth 12.3 18.2
N 543 2,916

contraceptive use among both groups was around two-thirds, and more than
10% of all the respondents experienced heavy vaginal bleeding during and
after delivery.
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

Sample characteristics
The majority of the respondents resided in rural areas (Table 2), and more
than half had completed secondary high school, as had their husbands. The
majority of both groups had low socio-economic status, and most were
unemployed. A majority of the women often watched television, and in
both groups most of the women surveyed had recently given birth to their
first birth child.

Differences in antenatal care utilization

Out of the 3,459 eligible women who gave birth between the ages of 15–19
and 20–24, 70% and 80%, respectively, had had at least four ANC visits for
the period 2007–2012 (Table 3). Both early marriage (married before the age
of 18 years) and adolescent pregnancy had associations with ANC use among
Indonesian young women. All of the demographic variables examined in this
work, except for employment status, showed significant associations with the
use of ANC.

Factors associated with use of antenatal care

The use of ANC (at least four prenatal visits) increased with increasing socio-
economic status in our sample of young women (Table 4). In adjusted
analyses, place of residence, women’s education, economic status, mass
media exposure, and birth order all had significant associations with the
use of a minimum of four ANC visits among young women. Participants
living in urban areas were more likely to use ANC at least four times. Young
women who had less than a formal education were less likely to reach the
four visit minimum. The odds of completing four ANC visits was three times
higher among young women from the high-income category than among
 WOMEN & HEALTH 7

Table 2. Distribution of the percentage of women who had at least one live birth at a young age,
by age group.
15–19 years old 20–24 years old
Background characteristics n (%) n (%) X2
Place of residence
Rural 369 (68) 1,801 (61.8) 7.510**
Urban 174 (32) 1,115 (38.2)
Women’s education
No education 14 (2.6) 79 (2.7) 30.480***
Primary 173 (31.9) 856 (29.4)
Secondary 350 (64.5) 1,765 (60.5)
Higher 6 (1.1) 216 (7.4)
Husband’s education
No education 20 (3.7) 49 (1.7) 23.783***
Primary 191 (35.2) 925 (3.7)
Secondary 313 (57.6) 1,708 (58.6)
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

Higher 19 (3.5) 234 (8.0)

Wealth level
Low income 369 (68) 1,694 (58.1) 18.646***
Middle income 81 (14.9) 548 (18.8)
High income 93 (17.1) 674 (23.1)
Working status
Not working 401 (73.8) 1,790 (61.4) 30.624***
Working 142 (26.2) 1,126 (38.6)
Mass media exposure (TV)
No exposure 38 (7) 179 (6.1) 0.575
Some exposure 505 (93) 2,737 (93.9)
Birth order
Birth order, 1 504 (92.8) 2,192 (75.2) 83.168***
Birth order, 2 35 (6.4) 614 (21.1)
Birth order, 3+ 4 (0.7) 110 (3.8)
Total 543 2,916
*p < .05; **p < .01; ***p < .001.

those from the low-income category. The odds of ANC use also increased
with increased mass media exposure. Birth order was negatively associated
with ANC use, with young women whose most recent birth was their first
being more likely to have at least four ANC visits than those whose most
recent birth was their third or greater birth. Among the adolescents, those
from the high-income category were 1.9 times as likely to have four ANC
visits compared to those from the low-income category. Overall, for both age
groups only economic status was significantly related to ANC use, with those
individuals in the high and middle-income categories being more likely to
complete four ANC visits than those from the low-income category.

Discussion
A number of efforts have been made by the Indonesian government to
improve the use of ANC in recent years, including the Universal
Healthcare Delivery system, Integrated Health Posts in each village, and the
Expanding Maternal and Neonatal Survival program (MoH 2014). However,
 8 F. EFENDI ET AL.

Table 3. Background characteristics and ANC use of mother in Indonesia.

Frequency of ANC n (%)
Background characteristic Less than four times (n = 691) Four times and above (n = 2,768) X2
Marital age
<18 years 363 (26) 1,045 (74) 50.044***
≥18 years 328 (16) 1,723 (84)
Maternal age, years
15–19 147 (30) 396 (70) 20.282***
20–24 544 (20) 2,372 (80)
Place of residence
Rural 524 (20) 1,646 (80) 63.359***
Urban 167 (10) 1,122 (90)
Women’s education
No education 68 (70) 25 (30) 210.609***
Primary 258 (30) 771 (70)
Secondary 338 (20) 1,777 (80)
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

Higher 27 (10) 195 (90)

Husband’s education
No education 42 (60) 27 (40) 109.629***
Primary 277 (20) 839 (80)
Secondary 340 (20) 1,681 (80)
Higher 32 (10) 221 (90)
Wealth level
Low income 549 (30) 1,514 (70) 148.758***
Middle income 85 (10) 544 (90)
High income 57 (10) 710 (90)
Women’s work status
Not working 430 (20) 1,761 (80) 0.461
Working 261 (20) 1,007 (80)
Mass media exposure
(TV)
No exposure 110 (50) 107 (50) 136.627***
Some exposure 581 (20) 2,661 (80)
Birth order
Birth order, 1 447 (20) 2,249 (80) 110.396***
Birth order, 2 189 (30) 460 (70)
Birth order, 3+ 55 (30) 59 (50)
*p < .05; **p < .01; ***p < .001.

as reported in the Indonesia Health Profile in 2012, the country still needs to
increase its efforts to achieve the national and MDGs targets (MoH 2013).
Mounting evidence from developed and developing countries shows that
adolescent mothers are at high risk of suffering adverse health outcomes
for both their babies and themselves (Fatusi and Hindin 2010; Gortzak-Uzan
et al. 2001; Malamitsi-Puchner and Boutsikou 2006; UNICEF 2005).
Among both age groups examined in the current study, ANC use was
lower than the recommended national standards. Approximately 70% and
80% of the adolescent and young women mothers in this survey received at
least four ANC visits, respectively. Our analysis found a number of factors
that had a significant relation to the use of ANC for the different age groups.
For adolescent girls, only socio-economic status had a positive association
with four ANC visits. For the young women living in an urban area, mothers
 WOMEN & HEALTH 9

Table 4. Multiple logistic regression model based on the frequency of ANC received of both
groups.
At least four ANC received
Background characteristics 15–19 years old AOR (95% CI) 20–24 years old AOR (95% CI) Total sample
Marital age
<18 years 1 1 1,408
≥18 years 1.182 (0.634–2.201) 1.017 (0.807–1.282) 2,051
Place of residence
Rural (ref) 1 1 2,170
Urban 1.256 (0.787–2.006) 1.290 (1. 015–1.640)* 1,289
Women’s education
No education 0.238 (0.021–2.682) 0.246 (0.118–0.512)*** 93
Primary 2.060 (0.333–12.726) 0.899 (0.538–1.503) 1,029
Secondary 1.991 (0.335–11.838) 1.099 (0.680–1.776) 2,115
Higher (ref) 1 1 222
Husband’s education
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

No education 0.439 (0.082–2.365) 0.545 (0.237–1.256) 69

Primary 0.719 (0.194–2.665) 1.034 (0.630–1.695) 1,116
Secondary 0.682 (0.190–2.449) 1.133 (0.711–1.807) 2,021
Higher (ref) 1 1 253
Wealth level
Low income (ref) 1 1 2,063
Middle income 2.085 (1.077–4.039)* 1.587 (1.189–2.119)** 629
High income 1.925 (1.006–3.685)* 3.123 (2.164–4.507)*** 767
Mass media exposure (TV)
No exposure (ref) 1 1 217
Any exposure 1.172 (0.541–2.536) 2.532 (1.781–3.599)*** 3,242
Women’s working status
Not working (ref) 1 1 2,191
Working 0.810 (0.508–1.290) 1.094 (0.886–1.350) 1,268
Birth order
Birth order, 1 6.143 (0.607–62.167) 3.291 (2.106–5.144)*** 2,696
Birth order, 2 3.132 (0.285–34.481) 1.834 (1.167–2.881)** 649
Birth order, 3+ (ref) 1 1 114
Total 691 2,768 3,459
Nagelkerke R square 0.117 0.173
Note. AOR: Adjusted Odds Ratio; 95% CI: 95% Confidence Interval.
*p < .05; **p < .01; ***p < .001.

who had a higher level of educational attainment, higher income status, and
greater mass media exposure were more likely to have adequate ANC use,
while higher parity of young women was negatively associated with the use of
four ANC visits. Adolescent girls with middle-income status were two times
as likely to have the recommended number of ANC visits than those with
low-income status. Meanwhile, young women in the high-income group
were three times as likely to have four ANC visits compared to those in
the low-income group. Similarly, Singh et al. (2012) found that women in
rural India aged 15–19 years old with higher socio-economic status were
more likely to use full ANC services than those in the poorest category.
The government of Indonesia is now seriously addressing the issue of
health inequality between provinces. The results of the current study clearly
illustrate the importance of geographical factors in determining adequate use
 10 F. EFENDI ET AL.

of ANC, with women in urban areas much more likely to achieve this than
those in rural areas. This may be linked with the accessibility of ANC services
in different areas, with women in urban areas finding these easier to access
than those in rural areas. For example, data from the Ministry of Villages,
Disadvantaged Regions and Transmigration noted that the average distance
to a midwife practice within rural areas was 34 km, while nationally it was
only 16 km (Kemendesa-PDT 2015). Moreover, Indonesia has about 74,405
rural villages with 52.97% categorized as underdeveloped and the majority
located in the eastern part of Indonesia (Kemendesa-PDT 2015). In 1989, the
Indonesian government launched a village-based midwife program in
response to high mother and infant death rates. Within 7 years every village
in Indonesia thus had a skilled birth attendant or midwife (MoH 2013). In
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

addition, community initiatives undertaken with the establishment of

Integrated Health Post (Posyandu) program further enhanced accessibility
to such care (MoH 2013). However, despite these efforts inequalities between
various regions still remain, and thus policy makers should focus on devel-
oping innovative or non-standard approaches to address this issue, based on
the actual situations in various areas, with the current study providing
findings to inform these approaches.
The findings of this study indicated a significant association between
maternal education and adequate use of ANC, which is supported by pre-
vious research (Ciceklioglu, Soyer, and Öcek 2005; Navaneetham and
Dharmalingam 2002; Titaley, Dibley, and Roberts 2010). This may be
because women who have higher educational attainment may have acquired
more knowledge about maternal and child health and the potential benefits
of ANC, thus resulting in a higher level of ANC use (Titaley, Dibley, and
Roberts 2010). In this context it should be noted that Indonesia is on track to
increase access to education among women across the nation. As reported in
a recent study, the school participation rate increased from 55% in 2009 to
61% in 2012 among girls aged 16–18 (Badan Pusat Statistik 2014). However,
even though Indonesia has a 9-year compulsory education system, 2.6% and
2.7% of adolescent girls and young women in this study, respectively,
remained uneducated. It is thus suggested that by further working to improve
the education level of its citizens, and meeting the specific needs of target
populations, the government can get closer to achieving its goals with regard
to reducing adolescent pregnancy, as well as maternal and infant death rates.
Mass media exposure was found to be significantly associated with the use
of ANC among young women, consistent with previous studies
(Navaneetham and Dharmalingam 2002; Pallikadavath, Foss, and Stones
2004), as the communication channel used to convey health-related messages
plays an important role in the decision to use health-care services (Grilli et al.
2000). Television is an especially good medium, because it persuades the
audience in a visual and auditory manner and is likely to influence
 WOMEN & HEALTH 11

significantly more people than other forms of media. Moreover, health

messages need to be tailored to the target populations, particularly when
these are illiterate women in Indonesia.
The current study found that young women who had their first birth
between ages 20–24 years were more likely to have four ANC visits than
women who had more births by this age. Earlier research showed that
women were significantly more likely to use antenatal health-care services
for their first deliveries (Chakraborty et al. 2003; Rai, Singh, and Singh 2012),
as these are seen by the mothers as riskier than subsequent deliveries. The
time and resource constraints faced by women with higher parity have also
been reported to have an association with the low use of ANC in larger
families (Elo 1992; Wong et al. 1987), and thus messages about the impor-
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

tance of ANC during pregnancy should be targeted at this group.

The results of the present study showed that the income status of mothers
was significantly associated with the use of ANC for both age groups. Similarly,
other studies have found that high-income status is positively related to greater
use of maternal health-care services (Målqvist et al. 2013; Matijasevich et al.
2010). Low economic status is generally a barrier to accessing health-care
services (Celik and Hotchkiss 2000; Overbosch et al. 2004). This issue is
especially important in Indonesia, which has around 28 million people living
in poverty, or 11.47% of the total population (BPS 2013). To address this issue,
the government launched a Universal Delivery Care (Jampersal) plan, which
allows pregnant women to deliver their children in a health-care facility for
free (MoH 2013). This plan also covers ANC services for up to four visits, with
more visits available to those women who have complications during preg-
nancy. However, as noted in an earlier study, not all women who are able to
use this plan, due to the mother’s preferences, additional costs that can be
incurred during labor, distance to the health facility, and administrative pro-
blems (Trisnantoro 2011). One of the solutions that has been suggested to
address this issue is to rely on the initiative of the local communities. One of
the unique aspects of Indonesia’s health system is the concept of community
empowerment (MoH 2009), and the main goal of health development is
independence. To achieve this, however, each community needs sufficient
knowledge, and the health workers who are on the frontline of such efforts,
for instance, nurses, midwives, and other health workers, need to be empow-
ered to convey health messages to the community.
The results of this study call for a deeper debate on early marriage and
pregnancy, and the negative outcomes of these life events on every level of
the community. In Indonesia, the minimum age of marriage for girls is
16 years, and for boys it is 19 years (Government of Indonesia 1974). This
study showed that the mean age at marriage was 15.9 years for the adolescent
girls, and this young age is an issue that requires special attention from a
reproductive health perspective. In addition, some studies showed that early
 12 F. EFENDI ET AL.

sexual activity and childbearing can harm the health of both the mother and
infant, and this should be highlighted in the related educational efforts
(Hampton 2010; Raj et al. 2010).
The Indonesian government has claimed that, with the current population
make-up, the nation is expected to have a demographic dividend in the near
future (Kemenkokesra 2012). As stated by Tirtosudarmo (2013), “A demo-
graphic dividend is when the proportion of people in the productive age group
(15–64 years) reaches a maximum, and the dependency ratio is at its lowest
level.” Preparation for this golden period should thus be made in advance. In
this regard, it is time to invest in young women’s health, particularly adolescents
and young mothers, who play a great role in determining the well-being of the
next generation. Taking into account the results of this study, future policies
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

and programs must address adolescents and young mothers to meet their needs
better for accessible, reliable, and affordable ANC.
The present study, makes several noteworthy contributions to the issue of
ANC use among adolescent girls and young women in Indonesia. The ANC
use rates for both age groups were found to be below the national standard,
and this issue needs to be urgently addressed. Current government policies
and programs should thus target low-income households, with an emphasis
on the sexual and reproductive rights of adolescent girls.

Limitations
The Indonesia Demographic Health Survey (IDHS) provided limited infor-
mation on certain topics, and this restricted available detailed data and may
have resulted in certain uncontrolled factors confounding the results.
Moreover, the data were all self-reported, which might have resulted in recall
and/or social acceptability bias. In addition, all variables were assumed to be
fixed over a period of 5 years prior to the survey (ceteris paribus).
A further limitation was that the use of secondary data may have resulted
in misclassification of information and/or a lack of comparability with regard
to the results from earlier works that used standard instruments. In addition,
this study used a cross-sectional design, which prohibited the assessment of
the temporal and thus potentially cauasal relations among the variables.

Conclusion
The results of this study suggest that any strategy created to improve
antenatal care services should take into account the socio-economic context
of adolescent and young mothers to achieve the maximum impact. In
particular, vulnerable individuals who have low socio-economic status, low
education levels, and higher parity should be the focus of efforts to increase
access to the Universal Health Coverage plan. In addition, raising awareness
 WOMEN & HEALTH 13

of the problems associated with early marriage and adolescent pregnancy

should be initiated at the national level. Moreover, in the long term a petition
to change the marriage law to increase the minimum age of marriage may be
useful to protect the sexual and reproductive health of adolescents and young
women.

References
Ali, A. A. A., and I. Adam. 2011. Lack of antenatal care, education, and high maternal
mortality in Kassala hospital, eastern Sudan during 2005–2009. Journal of Maternal-Fetal
and Neonatal Medicine 24 (8):1077–78. doi:10.3109/14767058.2010.545908.
Badan Pusat Statistik. 2010. Hasil sensus penduduk 2010 [Results of population census 2010].
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

Jakarta, Indonesia: BPS.

Badan Pusat Statistik. 2014. Angka Partisipasi Sekolah (APS) [School Participation Rate].
Badan Pusat Statistik. http://www.bps.go.id/tab_sub/view.php?tabel=1&daftar=1&id_sub
yek=40&notab=13 (accessed May 22, 2015).
Balitbangkes. 2010. Laporan Nasional Riskesdas 2010 [Report of basic national health research
2010]. Jakarta, Indonesia: Badan Litbangkes Kemenkes RI.
Bappenas. 2012. Laporan Pencapaian Tujuan Pembangunan Millenium di Indonesia 2011
[Report on Millenium Development Goals in Indonesia 2011]. Jakarta, Indonesia:
Bappenas.
BKKBN. 2012. Policy Brief Remaja Pernikahan Dini [Policy brief on adolescent marriage].
Jakarta, Indonesia: BKKBN.
BPS. 2013. Jumlah dan Persentase Penduduk Miskin, Garis Kemiskinan, Indeks Kedalaman
Kemiskinan (P1), dan Indeks Keparahan Kemiskinan (P2) Menurut Provinsi, September
2013 [Number and Percentage of Poor Population, Poverty Line, Poverty Gap Index (P1),
and Poverty Severity Index (P2) by Province, September 2013]. BPS. http://www.bps.go.id/
tab_sub/view.php?tabel=1&id_subyek=23&notab=1 (accessed January 10, 2015).
BPS. 2014. Tabel Dinamis Kependudukan [Table Dynamic of Population]. BPS. http://www.
bps.go.id/site/pilihdata (accessed December 20, 2014).
Celik, Y., and D. R. Hotchkiss. 2000. The socio-economic determinants of maternal health
care utilization in Turkey. Social Science & Medicine 50 (12):1797–806. doi:10.1016/S0277-
9536(99)00418-9.
Chakraborty, N., M. A. Islam, R. I. Chowdhury, W. Bari, and H. H. Akhter. 2003.
Determinants of the use of maternal health services in rural Bangladesh. Health
Promotion International 18 (4):327–37. doi:10.1093/heapro/dag414.
Ciceklioglu, M., M. T. Soyer, and Z. A. Öcek. 2005. Factors associated with the utilization and
content of prenatal care in a western urban district of Turkey. International Journal for
Quality in Health Care 17 (6):533–39. doi:10.1093/intqhc/mzi076.
DHS. 2013. Demographic and health surveys. ICF International. measuredhs.com (accessed
October 4, 2015).
Elo, I. T. 1992. Utilization of maternal health-care services in Peru: The role of women’s
education. Health Transition Review 2 (1):49–69.
Fatusi, A. O., and M. J. Hindin. 2010. Adolescents and youth in developing countries: Health
and development issues in context. Journal of Adolescence 33 (4):499–508. doi:10.1016/j.
adolescence.2010.05.019.
 14 F. EFENDI ET AL.

Gortzak-Uzan, L., M. Hallak, F. Press, M. Katz, and I. Shoham-Vardi. 2001. Teenage

pregnancy: Risk factors for adverse perinatal outcome. Journal of Maternal-Fetal and
Neonatal Medicine 10 (6):393–97. doi:10.1080/jmf.10.6.393.397.
Government of Indonesia. 1974. Undang-undang Republik Indonesia Nomor 1 Tahun 1974
Tentang Perkawinan [Law of the Republic of Indonesia Number 1 Year 1974 on Marriage],
Jakarta, Indonesia, 1–12.
Grilli, R., N. Freemantle, S. Minozzi, G. Domenighetti, and D. Finer. 2000. Mass media
interventions: Effects on health services utilisation. Cochrane Database of Systematic
Reviews (2):CD000389. doi:10.1002/14651858.cd000389.
Hampton, T. 2010. Child marriage threatens girls’ health. JAMA 304 (5):509–10. doi:10.1001/
jama.2010.1009.
Hogan, M. C., K. J. Foreman, M. Naghavi, S. Y. Ahn, M. Wang, S. M. Makela, A. D. Lopez, R.
Lozano, and C. J. L. Murray. 2010. Maternal mortality for 181 countries, 1980–2008: A
systematic analysis of progress towards millennium development goal 5. The Lancet 375
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

(9726):1609–23. doi:10.1016/S0140-6736(10)60518-1.
Jalal, F. 2014. Paparan Kepala BKKBN Pada Konferensi Pers Rakernas Program
Kependudukan dan Keluarga Berencana Tahun 2014 [Statement head of BKKBN at a
Press-conference of National Meeting on Population and Family Planning Program 2014].
Jakarta, Indonesia: BKKBN.
Kemendagri. 2015. Kode dan Data Wilayah Administrasi Pemerintahan (Permendagri No.
56-2015). Kementerian Dalam Negeri. http://www.kemendagri.go.id/pages/data-wilayah
(accessed January 11, 2015).
Kemendesa-PDT. 2015. Program Pengembangan Desa dan Daerah Tertinggal Tahun
2015–2019 [Program development of Village and Disadvantaged Region in 2015–2019].
Jakarta, Indonesia: Kemendesa, PDT.
Kemenkes. 2010. Rencana Strategis Kementerian Kesehatan Tahun 2010–2014 [Strategic Plan
of Ministry of Health year 2010–2014]. Jakarta, Indonesia: Kemenkes.
Kemenkokesra. 2012. 2017–2019 Puncak Bonus Demografi. Kemenkokesra. http://menko
kesra.go.id/content/2017-2019-puncak-bonus-demografi (accessed January 10, 2014).
Malamitsi-Puchner, A., and T. Boutsikou. 2006. Adolescent pregnancy and perinatal out-
come. Pediatric Endocrinology Reviews 3 (Suppl 1):170–71.
Målqvist, M., O. Lincetto, N. H. Du, C. Burgess, and D. T. P. Hoa. 2013. Maternal health care
utilization in Viet Nam: Increasing ethnic inequity. Bulletin of the World Health
Organization 91 (4):254–61. doi:10.2471/BLT.12.112425.
Matijasevich, A., C. G. Victora, D. A. Lawlor, J. Golding, A. M. B. Menezes, C. L. Araújo, A. J.
D. Barros, I. S. Santos, F. C. Barros, and G. Davey Smith. 2010. Association of socio-
economic position with maternal pregnancy and infant health outcomes in birth cohort
studies from Brazil and the UK. Journal of Epidemiology and Community Health
2010:108605.
MoH. 2009. Sistem Kesehatan Nasional [National health system]. Jakarta, Indonesia:
Kemenkes.
MoH. 2010. Laporan Nasional Riskesdas 2010 [National report on basic health Research 2010].
Jakarta, Indonesia: Badan Litbangkes Kemenkes RI.
MoH. 2011. Pedoman Pelaksanaan Kemitraan Bidan dan Dukun [Guideline of partnership
between midwife and traditional birth attendant]. Jakarta, Indonesia: Kemenkes.
MoH. 2013. Profil Kesehatan Indonesia 2012 [Indonesia Health Profile Year 2012]. Jakarta,
Indonesia: Kemenkes.
MoH. 2014. Profil Kesehatan Indonesia 2013 [Indonesia Health Profile Year 2013]. Jakarta,
Indonesia: Kemenkes.
 WOMEN & HEALTH 15

Navaneetham, K., and A. Dharmalingam. 2002. Utilization of maternal health care services in
Southern India. Social Science & Medicine 55 (10):1849–69. doi:10.1016/S0277-9536(01)
00313-6.
Overbosch, G. B., N. N. N. Nsowah-Nuamah, G. J. M. Van Den Boom, and L. Damnyag.
2004. Determinants of antenatal care use in Ghana. Journal of African Economies 13
(2):277–301. doi:10.1093/jae/ejh008.
Pallikadavath, S., M. Foss, and R. William Stones. 2004. Antenatal care: Provision and
inequality in rural north India. Social Science & Medicine 59 (6):1147–58. doi:10.1016/j.
socscimed.2003.11.045.
Pritasari, K. 2012. Kebijakan dan Strategi Percepatan Sasaran 5 MDGs Dan Pelayanan
Kesehatan Yang Mendukung Revitalisasi KB. Kementerian Kesehatan [Policy and accel-
eration strategy of goal 5 of the MDGs and health services that support revitalization of
family planning]. http://www.bkkbn.go.id/materi/Documents/Materi%20Rakernas%
202012/KEMENKES%20DIRJEN%20GIZI%20[Compatibility%20Mode].pdf (accessed
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016

May 28, 2014).

Rai, R. K., P. K. Singh, and L. Singh. 2012. Utilization of maternal health care services among
married adolescent women: Insights from the Nigeria demographic and health survey,
2008. Women’s Health Issues 22 (4):e407–14. doi:10.1016/j.whi.2012.05.001.
Raj, A., N. Saggurti, M. Winter, A. Labonte, M. R. Decker, D. Balaiah, and J. G. Silverman.
2010. The effect of maternal child marriage on morbidity and mortality of children under 5
in India: Cross sectional study of a nationally representative sample. The British Medical
Journal 340. doi:10.1136/bmj.b4258.
Ram, F., and A. Singh. 2006. Is antenatal care effective in improving maternal health in rural
Uttar Pradesh? Evidence from a district level household survey. Journal of Biosocial Science
38 (04):433–48. doi:10.1017/S0021932005026453.
Singh, P. K., R. K. Rai, M. Alagarajan, and L. Singh. 2012. Determinants of maternity care
services utilization among married adolescents in rural India. Plos One 7 (2):e31666.
doi:10.1371/journal.pone.0031666.
Statistics Indonesia, National Population and Family Planning Board, Kementerian
Kesehatan, and ICF International. 2013. Indonesia demographic and health survey 2012.
Jakarta, Indonesia: BPS, BKKBN, Kemenkes, and ICF International.
Tirtosudarmo, R. 2013. The politics of a ‘demographic bonus’. The Jakarta Post. www.
thejakartapost.com/news/2013/09/24/the-politics-a-demographic-bonus.html (accessed
January 12, 2014).
Titaley, C., M. Dibley, and C. Roberts. 2010. Factors associated with underutilization of
antenatal care services in Indonesia: Results of Indonesia demographic and health survey
2002/2003 and 2007. BMC Public Health 10 (1):485. doi:10.1186/1471-2458-10-485.
Trisnantoro, L. 2011. Pemantauan Pelaksanaan Kebijakan Jampersal dan BOK Untuk
Pelayanan Kesehatan Ibu dan Bayi Di Papua Barat, Yogyakarta, dan NTT [Monitoring
Implementation of Jampersal and BOK Policy for Maternal and Infant Health Services in
West Papua, Yogyakarta and NTT]. Kemenkes. http://www.kesehatanibu.depkes.go.id/wp-
content/uploads/downloads/2012/08/Hasil-Studi-Jampersal-2011_Laksono-Trisnantoro.
pdf (accessed January 10, 2014).
UNDP. 2012. MDG acceleration framework: Saving the lives of mothers in central Java,
Indonesia. UNDP. http://www.undp.org/content/dam/undp/library/MDG/MDG%
20Acceleration%20Framework/MAF%20Reports/MDG%20Indonesia%20sep-24.pdf
(accessed January 2, 2014).
UNICEF. 2005. Early marriage a harmful traditional practice a statistical exploration 2005.
New York, NY: UNICEF.
 16 F. EFENDI ET AL.

Wong, E. L., B. M. Popkin, D. K. Guilkey, and J. S. Akin. 1987. Accessibility, quality of care
and prenatal care use in the Philippines. Social Science & Medicine 24 (11):927–44.
doi:10.1016/0277-9536(87)90286-3.
Word Health Organization. 1994. Mother-baby package: Implementing safe motherhood in
countries. Geneva, Switzerland: Author.
World Health Organization. 2012. Adolescent pregnancy. http://www.who.int/mediacentre/
factsheets/fs364/en/ (accessed January 12, 2015).
World Health Organization. 2014. Adolescent pregnancy. http://www.who.int/mediacentre/
factsheets/fs364/en/ (accessed January 28, 2015).
Downloaded by [University of Nebraska, Lincoln] at 18:49 03 June 2016