Insurance in Indonesia Linked to Better Maternal Care
Low-income women in Indonesia who have health insurance coverage are more likely to deliver their babies in health facilities or with the aid of skilled birth attendants, reducing the risks of maternal mortality, according to a study led by School of Public Health researchers.
The study, in the journal BMC Health Services Research, found that poor women who have government-financed health insurance (Jamkesmas), which covers comprehensive maternity benefits, including prenatal care, institutional delivery, and postnatal care, were 19 percent more likely to deliver in a health facility and 17 percent more likely to deliver with a skilled birth attendant compared to poor women without insurance. Higher educational attainment and lower levels of poverty also were associated with a higher likelihood of skilled care, while unemployment, living in households with five or more family members, and living in rural areas were associated with a lower likelihood.
“These findings support the economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake,” the authors said. “As part of the causal chain of events to reduce maternal mortality, health insurance can be a key component that encourages women to deliver their babies at health facilities or with the aid of skilled birth attendants.”
The research team highlighted a recommendation that insurance access be accompanied by other measures to reduce maternal mortality, including addressing socio-cultural barriers, making health facilities more accessible, and easing enrollment in the insurance plan. Cultural barriers they cited include a preference to deliver at the parental village, where access to maternal health services might be limited; a preference for the use of traditional birth attendants (TBAs); and “fatalistic views” among women that they had little control over whether they would survive their pregnancies. Study participants identified problems with the distances to health facilities; poor referral systems for higher levels of care; and expenditures such as transportation, food, and accommodation for family members.
The researchers also called for health-promotion strategies that increase community awareness about pregnancy-related risks and the importance of skilled birth attendants and health facility deliveries.
The study cited quality of care as a key barrier to maternal health care, with issues involving a shortage of qualified health providers, overcrowded health facilities, and a lack of health facility accreditation. The unequal distribution of experienced midwives and OB-GYNs in Indonesia means that rural and remote areas lack adequate numbers of health care providers to provide high-quality maternal health services, the authors said. In addition to not having enough skilled birth attendants, variability in their “clinical competence” also is a concern, according to the study.
“Health facilities must be fully equipped, and health providers sufficiently trained, in order to save the life of a woman in the event of an obstetric emergency,” the researchers said.
The study was led by Mohamad (Bram) Brooks, a 2016 graduate of the SPH DrPH program who is now with Pathfinder International in Watertown.
Co-authors include: Hasbullah Thabrany, chair of the Center for Health Economics and Policy Studies, University of Indonesia School of Public Health; Matthew Fox, professor of epidemiology and global health; and Veronika Wirtz, Frank (Rich) Feeley, and Lora Sabin, associate professors of global health.