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Public Health

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Short Communication

Factors affecting the utilisation of maternal,

newborn, and child health services in Indonesia:
the role of the Maternal and Child Health Handbook

K. Osaki a,*, S. Kosen b, E. Indriasih b, K. Pritasari b, T. Hattori c

a
Japan International Cooperation Agency, Tokyo, Japan
b
Ministry of Health, Republic of Indonesia, Jakarta, Indonesia
c
Health and Development Service, Tokyo, Japan

article info
Article history:
Received 23 October 2013
Received in revised form
16 December 2014
Accepted 4 January 2015
Available online 9 March 2015
There are approximately 22 million children below the age of
five who currently reside in Indonesia (population 240
million).1 The infant mortality rate in Indonesia has decreased
from 49 per 1000 live births in 1998, to 27 in 2010.1 Further, the
maternal mortality ratio has decreased from 340 per 100,000
live births in 2000, to 220 in 2010,1 and the national coverage of
priority interventions has increased, including interventions
providing a maternal, newborn, and child health (MNCH)
continuum. However, the remaining coverage gaps in MNCH
care indicate the need for maternal and child care to continue
throughout the prenatal and postnatal periods2,3 to achieve
the country's UN Millennium Development Goals (MDGs).4
A 2004 ministerial decree declared the 48-page Maternal
and Child Health Handbook (MCHHB) the only home-based
record of MNCH in Indonesia. A following 2008 ministerial
decree identified it as a standard tool for minimum health
service provision in decentralized regional settings. Major
professional and non-governmental organisations and
development partners for the country have supported the
handbook's use for a range of services. The MCHHB includes a
home-based record, educational information, and communi-
cation material to increase awareness of the necessity of
MNCH service utilization by all women and children nation-
ally. The handbook is given to pregnant women during the
first antenatal care visit, referenced during times of need, and
brought to health service appointments. Health personnel
record details of delivered health care services in the hand-
book, assist clients in understanding its contents, and
encourage them to share information with their families. Like
other countries, Indonesia has used different types of parallel
records, although the MCHHB is gradually becoming the pre-
dominant home-based record. The MCHHB was piloted in
1993, and has been scaled up stepwise to accommodate the
country's diversity. While the Ministry of Health stopped
issuing an adapted version of the home-based maternal re-
cord to Indonesian women in 1997, they continued distrib-
uting the child growth monitoring/immunization card (KMS)
as a transitional measure.
In a prior study of a province where the MCHHB was
intensively promoted, relationships were observed between
MCHHB ownership and the utilization of various services such
as antenatal care, tetanus toxoid (TT) immunization, family
planning, and health personnel-assisted deliveries.5 Analyses
using the Indonesian Demographic Health Survey (IDHS)
indicated associations between record ownership both before
and after childbirth and health service utilization along the
MNCH continuum. Such services include increased maternal

* Corresponding author. Japan International Cooperation Agency, 5-25 Niban-cho, Chiyoda-ku, 102-8012 Tokyo, Japan. Tel.: 81 3 5226
9348; fax: 81 3 3269 6992.
E-mail addresses: Osaki.Keiko@jica.go.jp (K. Osaki), soewarta.kosen7@gmail.com (S. Kosen), e_indriasih@yahoo.com (E. Indriasih),
kirana72012@gmail.com (K. Pritasari), ryoma.intl@gmail.com (T. Hattori).
http://dx.doi.org/10.1016/j.puhe.2015.01.001
0033-3506/ 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
 p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 5 8 2 e5 8 6
care (i.e. four antenatal care appointments, trained personnel-
assisted delivery, and care during the first postpartum week);
12 doses of child immunisations for seven diseases; and a
continuum of immunization before and after childbirth (i.e. 12
doses administered during childhood, and two maternal
doses of TT vaccine during pregnancy). However, the IDHS
data did not distinguish the MCHHB from parallel records, so
the implications regarding the association between MCHHB
ownership and service utilization are limited to provinces
where there is better access to services and MCHHB use is
promoted.6 Therefore, the present study aimed to identify the
direct contribution of the MCHHB toward MNCH service uti-
lization through the analysis of nationally representative
cross-sectional data from the Indonesia Basic Health Research
(RISKESDAS) collected in 2007 and 2010, which indicates
MCHHB ownership directly.7,8
The prevalence of home-based records and MCHHB usage
increased across the nation from 2007 (38.4%) to 2010 (55.2%)
in respondents with children under the age of two years.
Provincial prevalence ranged from 81.6% (Yogyakarta) to
23.1% (West Irian Jaya). The RISKESDAS 2010 showed that
18.4% of the respondents used the KMS only, while 26.5% did
not have any form of record. National MCHHB use may have
increased along with the estimated number of printed hand-
books from 2004 to 2006 (39.7%; 6,176,957) to 2007e2009 (54.5%;
8,590,446), according to data compiled by the Indonesian
government.
A comparison of respondents who used the MCHHB, the
KMS, or neither may reflect differences in socio-economic
factors. Wealth and education level were positively corre-
lated, while number of children, age of child(ren), and rural
residence were negatively correlated with MCHHB utilization.
MCHHB use and possible confounders for logistic regression
analysis as independent variables after controlling for
possible collinearity were employed. Further, communication
with health personnel was considered and indicated by the
obtainment of information regarding pregnancy-related
danger sings, as this may have influenced clients' service
receipt.5 To examine potentially distinct effects of the MCHHB
on women in different settings, an interaction term of the
MCHHB with a dummy variable for rural residence was
included.
First, given that pregnant women received the handbook
and health personnel used it for monitoring and communi-
cating with women throughout the antenatal care period, an
investigation was made whether MCHHB owners were more
likely to choose health personnel as delivery assistants (i.e.
physicians, midwives, and auxiliary nurses or midwives).
Table 1 shows that respondents who used the MCHHB (81.5%)
were more likely than those who did not (64.9%) to deliver
with health personnel assistance. Multivariate analysis indi-
cated that MCHHB use significantly predicted assisted delivery
[adjusted odds ratio (aOR), 1.94; 95% confidence interval (CI),
1.73e2.18], even when possible confounding factors,
communication with health personnel, and the interaction
term of the MCHHB with rural residence were included in the
regression equation.
Second, MCHHB users (90.6%) were significantly more
likely than non-users (73.1%) to obtain birth weight assess-
ments within 48 h postchildbirth. After controlling for
583
possible covariates, MCHHB use (aOR, 2.82; 95% CI, 2.46e3.23)
remained as a predictor of newborn care acquisition within
the initial 48 h.
The third variable was a continuum of care that included
four antenatal care visits (pregnancy), health personnel-
assisted birth (delivery), and measurement of birth weight
within the first 48 h (newborn). MCHHB users (66.6%) were
significantly more likely to have obtained the full care con-
tinuum than were non-users (45.4%). After controlling for
possible covariates, predictors of this variable included
MCHHB use (aOR, 1.67; 95% CI, 1.44e1.93).
The fourth and fifth variables pertained to immunisations.
Among respondents with a child who was 9e23 months old,
MCHHB users (1589; 52.4%) were more likely than non-users
(627; 23.9%) to have had their children fully immunized
(twelve doses). MCHHB users (744; 24.6%) were also signifi-
cantly more likely than non-users (308; 11.8%) to have ob-
tained full child immunization together with TT
immunization for the mother during pregnancy. Logistic
regression analysis indicated that MCHHB use predicted these
variables (aOR, 2.90; 95% CI, 2.46e3.41; aOR, 1.97; 95% CI,
1.66e2.35).
Authors controlled for possible selection bias by repeating
the comparison of MCHHB users and non-MCHHB users.
Comparisons both included and excluded respondents who
had received the MCHHB but no longer owned it by the time
of survey, to assess potential bias in the results. These
repeated analyses suggested the same trends; thus, bias
deriving from selection errors appeared minimal. Potential
recall bias resulting from the absence of health records
during survey completion was also tested. A recall-based
sample demonstrated the same trends as the whole sam-
ple, suggesting that bias deriving from recall errors was also
minimal.
The present results confirm and extend previous findings
indicating a positive relationship between home-based pre-
natal and postnatal record utilization and health service up-
take. Among MCHHB users, there was a higher prevalence of
health service reception; health personnel-assisted delivery;
birth weight measurement within 48 h; a continuum of
pregnancy, delivery, and newborn care; and completion of
measured child immunisations. As Bhutta and his colleagues
stated, the three priority coverage gaps across nations in
achieving MDGs four and five occur in family-planning ser-
vices, childbirth care, and the care of sick children.9 This study
addressed the second of these gaps, including newborn care.
Because MCHHBs are not distributed at immunization sites,
unlike KMS cards, which are often distributed to children
without another form of record, it is unlikely that immuni-
zation reception led to handbook ownership. MCHHB use
triggers an increase in service demand, standardises the to-
do list for efficient service provision, facilitates communica-
tion within and between services, and may have resulted in
the increased coverage of the studied services. Given that the
MCHHB is an efficient means of home-based health record-
keeping from pregnancy throughout childhood, it could
consequently promote continuous MNCH.
Similar to a previous study,6 this cross-sectional study
design enabled us to establish an associational relationship
between MCHHB ownership and health service utilization.
584 p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 5 8 2 e5 8 6

Table 1 e Crude odds ratio (cOR), adjusted odds ratio (aOR), and 95% confidence intervals (CI) on maternal and newborn
services and ownership of MCHHB in the RISKESDAS 2010.
Respondents with 0e23-month-old children
N Attended birth by health personnel Birth weight measured in 48 h Continuum of care for MCH
% cOR aOR % cOR aOR % cOR aOR
(95% CI) (95% CI)a (95% CI) (95% CI)b (95% CI) (95% CI)c
Record use
MCHHB 4816 81.5 2.39*** 1.94*** 90.6 3.53*** 2.82*** 66.6 2.39*** 1.67***
(2.16e2.64) (1.73e2.18) (3.13e3.98) (2.46e3.23) (2.19e2.61) (1.44e1.93)
KMS only/no 3679 64.9 Ref Ref 73.1 Ref Ref 45.4 Ref Ref
record
Respondent's age (year)
<30 4646 73.4 Ref Ref 83.1 Ref Ref 58.4 Ref Ref
30e39 3248 76.9 1.20*** 1.84*** 83.9 1.06 1.61*** 60.2 1.08 1.57***
(1.09e1.34) (1.60e2.11) (.94e1.20) (1.38e1.89) (.98e1.18) (1.39e1.77)
40 448 67.6 .76** 1.88*** 78.3 .73* 1.98*** 46.4 .62*** 1.37*
(.61e.93) (1.43e2.47) (.58e.93) (1.45e2.71) (.51e.75) (1.07e1.77)
Respondent's education (years)
<6 995 47.1 Ref Ref 58.2 Ref Ref 29.2 Ref Ref
6e8 2319 59.0 1.61*** 1.30** 75.2 2.17*** 1.72*** 42.8 1.82*** 1.45***
(1.39e1.87) (1.11e1.53) (1.86e2.55) (1.45e2.05) (1.55e2.13) (1.22e1.72)
9e11 1926 78.9 4.20*** 2.79*** 87.3 4.95*** 2.99*** 62.0 3.96*** 2.49***
(3.56e4.96) (2.33e3.35) (4.12e5.95) (2.44e3.66) (3.36e4.68) (2.08e2.99)
12 3102 92.0 12.91*** 5.52*** 94.6 12.71*** 4.85*** 77.4 8.31*** 3.58***
(10.78e15.45) (4.52e6.75) (10.40e15.53) (3.86e6.09) (7.07e9.76) (2.99e4.30)
Wealth quintile
Poorest 2234 57.4 Ref Ref 70.1 Ref Ref 38.2 Ref Ref
Poorer 1938 70.7 1.79*** 1.26** 81.9 1.93*** 1.36*** 53.6 1.87*** 1.30***
(1.57e2.03) (1.08e1.45) (1.67e2.24) (1.15e1.60) (1.65e2.11) (1.13e1.50)
Middle 1725 79.5 2.87*** 1.51*** 87.3 2.93*** 1.54*** 62.6 2.71*** 1.56***
(2.49e3.32) (1.28e1.77) (2.47e3.46) (1.27e1.86) (2.38e3.08) (1.35e1.81)
Richer 1515 85.1 4.23*** 1.74*** 91.0 4.28*** 1.74*** 69.8 3.73*** 1.78***
(3.59e4.98) (1.44e2.10) (3.51e5.22) (1.39e2.19) (3.25e4.29) (1.51e2.09)
Richest 1083 92.2 8.70*** 2.86*** 93.6 6.26*** 2.04*** 78.3 5.83*** 2.37***
(6.87e11.03) (2.19e3.74) (4.82e8.11) (1.51e2.76) (4.93e6.90) (1.94e2.88)
Residential area
Urban 4201 86.6 Ref Ref 92.3 Ref Ref 70.5 Ref Ref
Rural 4294 62.2 .26*** .44*** 73.9 .24*** .38*** 44.6 .34*** .42***
(.23e.28) (.39e.50) (.21e.27) (.33e.44) (.31e.37) (.36e.50)
Number of children ever born .81*** .79*** .78***
(.77e.84) (.76e.83) (.75e.82)
Explained dangers
Yes 3122 83.6 2.31*** 1.58*** 91.4 2.96*** 1.89*** 74.0 3.10*** 2.24***
(2.07e2.58) (1.39e1.79) (2.57e3.41) (1.62e2.21) (2.82e3.42) (2.01e2.49)
No 5373 68.9 Ref Ref 78.2 Ref Ref 47.8 Ref Ref
MCHHB*Rural residence 1.40**
(1.14e1.71)
Child age in month

*P < .05, **P < .01, ***P < .001.

a Chi-squared test P < .001: HosmereLemeshow goodness-of-fit P .622.
b Chi-squared test P < .001: HosmereLemeshow goodness-of-fit P .349.
c Chi-squared test P < .001: HosmereLemeshow goodness-of-fit P .055.
d Chi-squared test P < .001: HosmereLemeshow goodness-of-fit P .208.
e Chi-squared test P < .001: HosmereLemeshow goodness-of-fit P .197.

Given that the existence of respondents who owned the KMS
may have influenced the relationships observed in the present
study, a similar analysis of future MCHHB data is suggested, as
the results of a later analysis would presumably be free of the
transition effects.
The benefit of this analysis is its basis in nationwide data,
which enables confirmation of the association between
MCHHB use and the consistent reception of MNCH services, a
relationship that has been minimally explored. Despite
limited resources, the government and its development
partners have an important role in providing an efficient
range of MNCH care through service integration. Such an
integration requires a common tool that is used by various
programmes and health personnel engaged in MNCH care.6,10
The MCHHB can facilitate integration to ensure mothers and
children are central to the country's health system.
 p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 5 8 2 e5 8 6 585

Respondents with 9e23-month-old children

N Child immunization completion Child immunization with TT completion
% cOR (95% CI) aOR (95% CI)d % cOR (95% CI) aOR (95% CI)e

3032 52.4 3.50*** 2.90*** 24.6 2.44*** 1.97***

(3.12e3.93) (2.46e3.41) (2.11e2.82) (1.66e2.35)
2622 23.9 1.00 Ref 11.8 Ref Ref

2998 39.4 Ref Ref 20.0 Ref Ref

2215 41.4 1.09 1.44*** 19.4 .97 1.09
(.97e1.22) (1.25e1.65) (.84e1.11) (.92e1.28)
316 25.9 .54*** .97 8.9 .39*** .52**
(.42e.70) (.71e1.32) (.26e.58) (.34e.81)

678 22.6 Ref Ref 10.1 Ref Ref

1543 29.4 1.43** 1.15 14.2 1.48** 1.25
(1.16e1.77) (.92e1.44) (1.11e1.97) (.93e1.68)
1257 42.0 2.49*** 1.68*** 20.8 2.34*** 1.68**
(2.01e3.07) (1.33e2.11) (1.76e3.12) (1.25e2.26)
2051 50.9 3.55*** 1.97*** 24.7 2.92*** 1.88***
(2.91e4.34) (1.57e2.48) (2.23e3.82) (1.41e2.52)

1502 29.4 Ref Ref 13.4 Ref Ref

1289 36.5 1.38*** 1.07 16.2 1.25* 1.04
(1.18e1.62) (.90e1.27) (1.01e1.54) (.84e1.30)
1139 42.5 1.78*** 1.17 21.2 1.74*** 1.31*
(1.51e2.09) (.98e1.41) (1.41e2.14) (1.05e1.63)
1011 44.3 1.91*** 1.20 23.1 1.94*** 1.43**
(1.62e2.26) (.99e1.45) (1.58e2.39) (1.14e1.81)
713 52.3 2.64*** 1.44** 24.1 2.05*** 1.38*
(2.20e3.17) (1.16e1.78) (1.63e2.57) (1.07e1.78)

2805 45.5 Ref Ref 20.1 Ref

2849 33.0 .59*** .68*** 17.3 .83**
(.53e.66) (.56e.83) (.73e.95)
.82*** .93*
(.77e.87) (.87e1.00)

2031 49.2 1.92*** 1.47*** 27.5 2.39*** 1.91***

(1.72e2.15) (1.31e1.66) (2.08e2.73) (1.66e2.20)
3623 33.6 Ref Ref 13.7 Ref Ref
1.26 1.19
(.99e1.61) (1.00e1.43)
1.03*** 1.02*
(1.01e1.04) (1.00e1.03)

Provincial Health Office of Central Java Province; Dr Eliz-

Author statements
Acknowledgements
The authors gratefully acknowledge Dr Anung Sugihantono,
Director General, Nutrition, Mother and Child Health, Ministry
of Health; Ms. Wahiyu Setianingsih, Head, Sub-directorate,
abeth Jane Soepardi, MPH, Dsc, Director, Directorate of Child
Health; Dr Gita Maya, Director, Directorate of Maternal Health,
Ministry of Health, Indonesia; Yasuhide Nakamura, MD, MPH,
PhD, Professor, Graduate School of Human Sciences, Osaka
University; and Jennifer Bryce, EdD, MEd, Institute for Inter-
national Programs, Johns Hopkins Bloomberg School of Public
586 p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 5 8 2 e5 8 6
Health. They also express special thanks to Dr Azrul Azwar,
MD, MPH, PhD.
Ethical approval
None sought.
Funding
None declared.
Competing interests
The authors declare no conflict of interest.
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