[Original Article]

Increased Utilization of Maternal Health Services by Mothers Using the Maternal

and Child Health Handbook in Indonesia

Agustin KUSUMAYATI1), Yasuhide NAKAMURA2)

1) Center for Reproductive Health Studies, Faculty of Public Health, University of Indonesia
2) Research Center for Civil Society, Graduate School of Human Sciences, Osaka University

Abstract
Objective
To assess the effects of the utilization of Maternal and Child Health Handbook (MCHH) in West Sumatra on the
utilization of maternal health services.
Methods
A repeated cross sectional study design was used. Three consecutive surveys were conducted in two districts, in
1999, 2001 and 2003, involving respectively 611, 621, and 630 mothers (pregnant and/or with one or more children
under age three) as respondents. Respondents for each survey were selected from the same sub-districts and villages,
using a multistage random sampling method. Data were collected primarily by using a pre-tested structured
questionnaire. Multiple logistic regression analyses were carried out to estimate the net effects of the MCHH on
mother’s use of maternal health services.
Results
After controlling for other influencing factors, utilization of MCHH was found to be associated with better
maternal knowledge regarding antenatal care (ANC), tetanus toxoid (TT) immunization and skilled birth attendance.
MCHH utilization was also associated with higher likelihood of mothers’ utilizing ANC, TT immunization and
family planning services, and of use or planned use of skilled birth attendance. Simply owning the handbook did not
affect maternal knowledge and was only associated with higher utilization of skilled birth attendance.
Discussion
The MCHH needs some modification, taking into account the educational level of the targeted mothers.
Appropriate health care provider training is needed to promote the use of the MCHH as a tool for encouraging and
focusing communication between mothers and health care providers, as well as to ensure that health care providers
are able to use the handbook.
Conclusion
Utilization of the MCHH has the potential both to improve maternal knowledge and to increase the utilization of
maternal health services. For maximum benefits, the handbook should be actively used by both mothers and health
care providers.

Keywords: MCH Handbook, health education, antenatal care, skilled birth attendance, Indonesia

Contact address: Faculty of Public Health University of Indonesia

Kampus Universitas Indonesia Depok
Depok 16424, Jawa Barat, Indonesia
Phone: 62-21-7874263 Fax: 62-21-7874265
Email: [email protected]
I. Introduction II. Conceptual Framework
Indonesia, the largest archipelago country in the The conceptual framework of this study (Figure-1)
world, has a total population of about 222,781,000.1) is based on Green and Kreuter’s framework for
Approximately 27.4% of the population are females determinants of health behavior6). The main dependent
15-49 years old, and 9.8% are children under five variable was a maternal health behavior, utilization of
years of age. This country still faces many health basic maternal health services. In the study area, and
problems as indicated by its high Infant Mortality Rate everywhere in Indonesia, each mother is expected to
(IMR) and Maternal Mortality Ratio (MMR). receive antenatal care (ANC) at least four times,
Although Indonesia’s IMR has decreased significantly, receive tetanus toxoid (TT) immunization at least
from 68 per 1000 live births in 1990 to 60 in 19952) twice, be attended by a skilled birth attendant during
and to 49 in 1998 3) , there has been much less delivery, and to use a modern family planning method.
improvement in the Neonatal Mortality Rate (NMR), Figure 1. Conceptual Framework for the Assessment of the Effect of
MCH Handbook Utilization on the Utilization of Maternal Health
which decreased from 28.4 per 1000 live births in Services in West Sumatra, Indonesia
1982-1987 to 21.8 in 1992-1997 and to 22 in 20014). Predisposing Factors Enabling Factors Reinforcing Factors
The latest Indonesian Health and Demography Survey Age Family size Support by voluntary
Education Economic status health worker
(IHDS) 2002-03 reveals an IMR of 35 per 1000 live Occupation Support by village
births and NMR of 20 per 1000 live births 5) . Reproductive status midwife

Considering the causes of infant deaths, Indonesia MCH Knowledge

needs to give special attention to perinatal health to

reduce its IMR. With adequate attention to and care
Utilization of MCH Handbook HEALTH BEHAVIOR
for pregnant mothers and their newborns, the MMR Utilization of Maternal Health Services
Ownership of MCHH
and IMR could be reduced simultaneously. Bringing MCHH to facility Antenatal care
Experience in receiving health Tetanus toxoid immunization
MMR in Indonesia decreased much more slowly information using MCHH Skilled birth attendance
Habit of reading MCHH Family planning
than IMR, from 404 per 100,000 live births in 1991 to Ease of understanding MCHH
373 in 19952) and to 307 in 20025). To speed up the This conceptual framework was developed based on the Green and Kreuter’s
reduction of MMR and IMR, Indonesians reviewed Precede-Proceed Model for health program planning and evaluation (Green,
L. W and Kreuter, M. W. Health Program Planning: an Educational and
measures implemented by other countries. In 1993 Ecological Approach. 4th Edition. New York: McGraw-Hill, 2005; Figure 1-2,
Japanese experts introduced the Japanese Boshi Kenko page 10).

Techo (Maternal and Child Health Handbook Determinant variables of maternal health behavior
(MCHH)) as a measure to help reduce MMR and were classified into three groups, predisposing factors,
IMR. Initial assessment of a pilot project in Salatiga enabling factors and reinforcing factors. Predisposing
City, Central Java, showed some promising factors studied included maternal age7-9), maternal
advantages of using the MCHH. However, literacy and education7,8,10), maternal occupation7,8),
scientifically-sound evidence of the handbook’s paternal occupation7), maternal reproductive status7,11)
effectiveness is needed before countrywide expansion and maternal knowledge12,13). Maternal knowledge
of its use. Therefore, a larger-scale trial project was was a predisposing factor expected to be affected by
carried out in West Sumatra in 1997-2003, with the the use of the MCHH. Enabling factors considered
support from the Japan International Cooperation were economic status 14-16) and family size 17) .
Agency (JICA) through the `Ensuring Quality of MCH Economic status, indicated by the average family
Service through MCH Handbook“ Project. This monthly income and average family daily expenditure
study was carried out to assess the effects of the use of for food, was a proxy for resource availability in the
the MCHH on several aspects of maternal health family, while family size was a proxy for resource
behaviors, taking into account the influence of allocation for individual family members.
relevant predisposing, enabling and reinforcing Among the parties who could influence maternal
factors. This report describes one part of the study’s health behavior, health care provider are the only party
results, i.e. the MCHH’s effect on the utilization of who have clear and significant role in the utilization of
maternal health services. MCHH and to some extent determine the benefits of
the handbook for mothers. Moreover, utilization of the edited by the field supervisors in the field, and then re-
MCHH was also expected to affect the health care checked by the principal investigator before being
providers’ patterns of providing supports and services filed. The data were thoroughly cleaned before being
to mothers, which are reinforcing factors for the analyzed. Univariate analysis was done to provide
mothers’ behavior. In this study, health care providers descriptive information on the variables studied.
included voluntary health workers and village Multiple logistic regression tests with the backward
midwives, and their support was indicated by home (Wald) stepwise elimination method were executed on
visitations during pregnancy8,18,19). the three pooled data sets to assess the effects of the
Utilization of the MCHH was the intervention MCHH utilization on mothers, taking into account the
considered in the study. Utilization of the MCHH was influence of predisposing, enabling and reinforcing
indicated by (1) the mother’s ownership of the factors.
handbook, (2) the mother’s bringing the handbook Although this study did not involve invasive
with her when visiting a health facility or attending a interventions and did not deal with issues considered
health program, (3) the mother’s having received to be sensitive by the targeted population or by most
information from health care providers who used the Indonesians, ethical clearance was obtained from
handbook to provide such information, (4) the extent University of Indonesia. Formal permission to carry
to which the mother has read the handbook, and (5) out the research also was obtained from the central as
the ease with which the mother could understand the well as the local governments. Collective informed
content of the MCHH. Receiving health information consents were obtained from the Sub-district Heads
and/or health education has been found to be an and Village Heads and verbal informed consent was
important determinant of maternal knowledge10,20,21) obtained from each respondent.
and of health behavior8,22).
IV. Results
III. Materials and Methods 1. Utilization of the MCH Handbook, utilization of
This was a repeated cross sectional study. During maternal health services and its predisposing,
the preparatory phase of the project, the West Sumatra enabling and reinforcing factors
Provincial Health Office selected Padang Pariaman Table 1 summarizes the descriptions of
District as the intervention area and Tanah Datar predisposing, enabling and reinforcing factors,
District as the control area (the selection of those areas utilization of the MCHH, and utilization of maternal
was out of the principal investigator’s control). Three health services. The data showed that literacy rate was
consecutive surveys were conducted in 1999 (baseline quite high, but about 30%-40% of mothers only
survey, before introducing the handbook in either finished elementary school or lower. The mean scores
area), in 2001 (after 2 years’ utilization of the of maternal knowledge were not increased in either
handbook in Padang Pariaman only) and in 2003 (after district. Both monthly family income and daily family
4 years’ utilization of the handbook in Padang expenditure for food increased through the study
Pariaman and 2 years’ utilization of the handbook in period. Home visitation by the health care providers
Tanah Datar). Mothers who were pregnant or had did not change through the study period.
children under three years of age were eligible to be The MCHH utilization had increased the ownership
selected as respondents. Using a multistage random rate of home-based maternal health record. Before
sampling method, 611, 621, and 630 such mothers utilizing the handbook, only one fourth of pregnant
were selected as respondents, from the same sub- mothers had any type of home-based maternal health
districts and villages, for the three consecutive record, while at the end of the study 92.3% of mothers
surveys. Data were gathered using a pre-tested in Padang Pariaman and 85.8% of those in Tanah
structured questionnaire. Four field supervisors and Datar owned some type of home-based maternal
twenty well-trained data collectors were involved in health record. Utilization of the MCHH improved the
each survey. mothers’ habit to bring their home-based maternal
All completed questionnaires were checked and health records when taking a health service or
attending a health program. However, using MCHH throughout the study period. Improvement in the
instead of the previous home-based maternal health coverage of TT immunization was the most obvious
record did not improve the usage of the home-based change observed after implementing the MCHH
maternal health record by health care providers for program within the areas.
providing health information to mothers. At the end of 2. The Effect of the MCH Handbook on Maternal
the study 40% of mothers in Tanah Datar and 57% of Knowledge
those in Padang Pariaman had never read or had read Multiple logistic regression tests were used to
any part of the handbook or had read only s small part develop multivariate models for predicting certain
of it. Moreover, among mothers who had read at least aspects of maternal knowledge related to maternal
some part of the handbook, 22.4% in Tanah Datar and health services, i.e. knowledge on minimal adequate
27% in Padang Pariaman stated that they found it frequency of ANC, knowledge of the importance of
difficult to understand the handbook. TT immunization and the reason for its importance,
The data showed that the coverage of ANC, TT and knowledge of the safest birth attendant (Table 2).
immunization, skilled birth attendance and family Simply owning a MCHH was not associated with
planning services in both districts increased greater knowledge. However, mothers who reported
that they usually bring their home-based maternal
Table1. Utilization of the MCH Handbook and Utilization of Maternal
Health Services and Its Predisposing, Enabling and Reinforcing Factors in health record with them when visiting a health facility
Two Districts of West Sumatra, Indonesia,in 1999, 2001 and 2003 or attending a health program had a 2.5 times higher
Tanah Datar Padang Pariaman
Socio-demographic characteristics
1999 2001 2003 1999 2001 2003
likelihood of knowing the minimal adequate frequency
Predisposing Factors of ANC (95% CI 1.236-5.235), and self-report of
Maternal age (mean) 29.9 29.3 29.9 30.5 30.1 31.2
Maternal literacy (%) 97.4 98.7 99.1 94.8 95.3 97.1 having received health education involving use of the
% mothers finished Junior High School or 70.9 73.1 78.6 57.5 63.1 63.5 home-based maternal health record was associated
more
% working mothers 21.5 15.5 12.9 16.6 22.3 21.8
% mothers had >4 alive children 6.9 5.9 7.2 25.6 23.3 25.0 Table 2. Multivariate Models for Predicting Maternal Knowledge of
Maternal knowledge of maternal health 52.0 39.8 42.1 50.1 38.9 39.3 Maternal Health Services
services (mean score ) 95% CI for Exp (B)
Predictor variable B SE Sig. Exp (B)
Enabling Factors Lower Upper
Family size (mean) 4.1 3.9 4.1 4.7 4.5 4.8 Knowledge of adequate minimal
Average monthly income (mean in 365.1 551.3 663.6 350.5 567.6 656.6 frequency of ANC
thousands IDR) Parity .595 .279 .033 1.813 1.048 3.136
Average daily food expenditure (mean in 10.1 11.1 14.0 12.8 12.8 15.6 Survey time .458 .203 .024 1.580 1.061 2.353
thousands IDR) Home visitation by village midwife .408 .202 .043 1.505 1.013 2.234
Reinforcing Factors Habit in bringing MCHH .934 .368 .011 2.544 1.236 5.235
% mothers home-visited by voluntary 19.5 24.0 24.8 14.3 42.3 18.9 Constant -3.321 .446 .000 .036
health workers during the last pregnancy Knowledge of the importance of TT
% mothers home-visited by village 16.2 81.3 21.4 20.5 63.7 27.6 immunization 1.782 4.022
midwives during the last pregnancy Maternal education .985 .208 .000 2.677 .280 .779
Utilization of MCHH District -.762 .261 .004 .467 1.740 4.139
% mothers owned home-based maternal 25.1 36.8 85.8 24.4 84.9 92.3 Mother had received health education .987 .221 .000 2.684
health record using MCHH
% mothers had always brought home- 19.7 60.7 61.2 29.3 49.2 47.2 Ease of understanding MCHH .725 .232 .002 2.064 1.310 3.252
based maternal health record when taking Constant .744 .324 .022 2.104
health service or attending health program Knowledge of the reason of the
% mothers had read most or all part of NA NA 60.3 NA 48.5 43.0 importance of TT immunization
MCHH Maternal literacy 2.069 1.047 .048 7.918 1.018 61.617
% mothers could understand MCHH NA NA 77.6 NA 70.2 73.0 Maternal education .890 .188 .000 2.436 1.685 3.522
easily Parity -.742 .243 .002 .476 .296 .766
% mothers received information from 51.3 53.6 48.4 38.7 55.7 38.5 Family size .465 .184 .012 1.592 1.109 2.284
health care providers using home-based Survey time .567 .160 .000 1.763 1.289 2.411
maternal health record Practice in reading MCHH .490 .165 .003 1.632 1.180 2.256
Utilization of Maternal Health Services Ease of understanding MCHH .867 .250 .001 2.380 1.457 3.887
% mothers received ANC 4 times 75.9 80.9 86.6 64.3 75.1 76.2 Constant -3.902 1.054 .000 .020
during the last pregnancy Knowledge of the safest birth attendant
% mothers received TT 2 times during 56.4 58.9 70.8 9.4 49.8 56.1 Maternal education 1.677 .541 .002 5.349 1.853 15.436
the last pregnancy Survey time 1.678 .511 .001 5.355 1.968 14.568
% mothers used (or planned to use) skilled 98.0 98.7 98.7 89.3 92.4 93.3 Experience of receiving health 2.156 .762 .005 8.638 1.938 38.490
birth attendant in most recent (or next education using MCHH
expected) delivery Easiness to understand MCHH 1.005 .487 .039 2.731 1.052 7.090
% mothers practiced family planning 52.1 49.7 59.1 29.2 33.4 40.7 Constant 1.692 .386 .000 5.430
with a 2.7 times higher chance that the mothers would attendance and family planning (Table 3). Owning a
know the importance of TT immunization (95% CI home-based maternal health record was associated
1.740-4.139) and a more than 8 times higher chance with a 3 times higher probability that the mother
that they would know the safest birth attendant (95% would use a skilled birth attendant (95% CI 1.031-
CI 1.938-38.490). 9.477). Mothers’ reporting that they usually bring the
Active usage of the MCHH by the mothers was home-based maternal health record with them to
found to be strongly associated with maternal health facilities or programs was associated with a 2.5
knowledge. Having read most or all part of the MCHH times higher probability of their practicing family
was found to be associated with higher probability that planning (95% CI 1.520-4.184). Receiving health
the mother would know the reason why TT education involving use of the home-based maternal
immunization for pregnant mothers is important health record was not associated with mothers’
(OR=1.925; 95% CI 1.180-2.256). Being able to utilization of any of the maternal health services
understand the handbook easily was associated with a studied. However, having read most or all part of the
higher probability that the mother would know about MCHH was found to be associated with mothers’
the importance of TT immunization (OR=2.064; 95% receiving ANC at least 4 times (OR=1.736; 95% CI
CI 1.310-3.252) and the reason for that importance 1.194-2.522) and with their receiving at least two TT
(OR=2.380; 95% CI 1.457-3.887) and could identify immunizations (OR=1.576; 95% CI 1.146-2.166).
the safest birth attendant (OR=2.731; 95% CI 1.052- Being able to understand the MCHH easily was found
7.090). to be associated with a higher likelihood of using a
3. The Effect of the MCHH on Utilization of skilled birth attendant (OR=2.627; 95% CI 1.260-
Maternal Health Services 5.475).
The effect of MCHH on utilization of maternal Maternal knowledge was found to be strongly
health services was assessed with regard to four associated with a mother’s utilization of maternal
services, i.e. ANC, TT immunization, skilled birth health services. Significant positive knowledge -
practice associations were found for TT immunization
Table 3. Multivariate Models for Predicting the Utilization of Maternal (OR=6.015; 95% CI 3.779-9.573) and skilled birth
Health Services
95% CI for Exp (B)
attendance (OR=30.540; 95% CI 10.472-89.070).
Predictor variable B SE Sig. Exp (B)
Lower Upper 4. The Influence of Predisposing, Enabling and
Utilization of ANC
Maternal education .423 .201 .036 1.526 1.028 2.265 Reinforcing Factors
Parity .661 .215 .002 1.936 1.269 2.954 Results of multiple logistic regression tests showed
District -.426 .216 .048 .653 .428 .997
Practice in reading MCHH .551 .191 .004 1.736 1.194 2.522 that maternal literacy and paternal occupation had
Knowledge of minimal adequate -.553 .232 .017 .575 .365 .905 little influence on the main outcomes. This is due to
frequency of ANC
Constant .759 .271 .005 2.136 the fact that there was little variation in these
Utilization of TT immunization variables. To analyze the influence of maternal
Parity .899 .241 .000 2.457 1.531 3.942
Family size -.506 .200 .012 .603 .407 .893 education, comparison was made between mothers
District -.396 .175 .023 .673 .478 .948
who had not finished Junior High School and those
Knowledge of the adequate 1.794 .237 .000 6.015 3.779 9.573
frequency of TT immunization who had. Mothers who had finished Junior High
Practice in reading MCHH .455 .162 .005 1.576 1.146 2.166
School were more likely to recognize the importance
Constant -1.424 .310 .000 .241
Utilization of skilled birth attendance of TT immunization (OR=2.677; 95% CI 1.782-4.022)
Maternal education .847 .401 .035 2.333 1.063 5.117
and to know the reasons for its importance
Parity .850 .395 .031 2.340 1.079 5.072
Ownership of MCHH 1.140 .566 .044 3.126 1.031 9.477 (OR=2.436; 95% CI 1.685-3.522) and to be able to
Ease of understanding MCHH .966 .375 .010 2.627 1.260 5.475
indicate the safest birth attendant (OR=5.349; 95% CI
Knowledge of the safest birth 3.419 .546 .000 30.540 10.472 89.070
attendant 1.853-15.436). Moreover, mothers who had completed
Constant -2.968 .784 .000 .051
Junior High School were more likely to receive ANC
Utilization of family planning
District -.914 .153 .000 .401 .297 .541 at least four times (OR=1.526; 95% CI 1.0288-2.265)
Ownership of MCHH -.757 .384 .049 .469 .221 .995
and to use a skilled birth attendance (OR=2.333; 95%
Habit in bringing MCHH .925 .258 .000 2.522 1.520 4.184
Constant .318 .353 .367 1.374 CI 1.063-5.117). Parity (number of pregnancies) - as
a proxy for reproductive status - was significantly the importance of considering maternal education
associated with mothers’ receiving ANC at least 4 when implementing health education programs. When
times (OR=1.936; 95% CI 1.269-2.954), receiving TT developing health education materials and programs, it
immunization at least twice (OR=2.457; 95% CI should be taken into consideration that about 30%-
1.531-3.942), and selecting medical professional such 40% of the targeted mothers in the study area (and in
as midwife, nurse, or doctor as birth attendant most other areas in Indonesia) have never completed
(OR=2.340; 95% CI 1.079-5.072). elementary school. Mothers’ low educational levels
Economic status as measured by financial limit their ability to understand messages delivered
availability has been found factoring other studies to through health education materials and/or sessions and
be strongly associated with various aspects of maternal to follow the advice they are given.
health. In this study the use of financial availability The findings of this study provide additional
became inappropriate due to sharp changes and evidence in support of health sector leaders who want
instability in the Indonesian overall macro-economic to assure or promote adequate education for girls and
and monetary situation. In multivariate analysis it was women. Referring to the McCarty and Maine model26),
found that family size was significantly associated education is among the contextual determinants of
with maternal knowledge as to why TT immunization maternal mortality. Other factors include women’s
is important and also with mothers’ receiving TT status and family status in the community, which are
immunization at least twice. Home visitation during very much affected by educational levels and
pregnancy by voluntary health workers or village economic status of the women and the family. In
midwives was not significantly associated with Indonesia, the impacts of many health-related efforts
utilization of maternal health services by mothers. to reduce MMR are slowed by the very slow rates of
improvement in these beyond-health determinants of
V. Discussion MMR, especially in the wake of the severe multi-
The importance of maternal education and parity dimensional crises that Indonesia experienced in 1997-
Maternal literacy and paternal occupation was 1998. To accelerate the reduction of MMR,
found to have less influence to the main outcomes, i.e. Indonesia’s development efforts should consistently
utilization of ANC, TT immunization, skilled birth focus on improving health and education.
attendance and family planning services. Maternal In line with the results of other studies11,17), this study
education and parity were found to be the factors most found that lower parity is associated with better
strongly associated with those main outcomes. maternal knowledge (i.e. knowledge of adequate
Mothers’ education was positively associated with minimal frequency of ANC and of the importance of
mothers’ knowledge of the safest birth attendant, TT immunization) and with better maternal health
utilization of ANC and utilization of skilled birth behavior (i.e. utilization of ANC, TT immunization
attendance. Mother’s education was also associated and skilled birth attendance). It seems that mothers
with mother’s knowledge of TT immunization, which who have higher parity are less aware of specific
was positively related to utilization of TT needs for health care during pregnancy. This finding
immunization. These findings are similar to those of suggests that when designing and providing maternal
many previous studies, which revealed that maternal health services, including health education services,
education has close association with various aspects of health care providers should pay more attention to the
maternal knowledge and behaviors.10,11,23) Maternal needs of mothers with higher parity.17,24,25)
education cannot be modified by any brief health The MCHH effect on maternal knowledge and
education program intended to improve the mothers’ utilization of maternal health services
knowledge and behavior, and in fact maternal Taking into account of other influencing factors,
education influences mothers’ attendance to antenatal utilization of MCHH was found to be associated with
education24,25) as well as mothers’ ability to absorb and better maternal knowledge of the maternal health
understand information provided during the services studied. Simply owning a copy of the MCHH
educational sessions.10,23) This findings re-emphasize was not associated with better maternal knowledge. To
acquire better knowledge, mothers need to be aware of showed that literacy did not lead the mothers to read
the handbook, to read it, to be able to easily the whole parts of the handbook. Moreover, due to at
understand its contents, to make use of it (as indicated least some mothers’ reported difficulties in
by bringing it with them when visiting health facilities understanding the handbook’s contents, there is no
or attending health program), and to be given health assurance that even mothers who do read the
information by health care providers who use the handbook will acquire adequate knowledge. Specific
handbook in providing such information. efforts should be made to allow mothers to understand
Utilization of the MCHH had both direct and the handbook’s messages. Utilizing the MCHH during
indirect effects on the utilization of maternal health health education sessions could be an effective
services. After controlling for other relevant measure as well as an opportunity to learn what
influencing factors, the study indicated that mothers’ messages and what parts of the handbook mothers do
utilization of the MCHH increased the likelihood that and do not understand. The full advantages of MCHH
they would utilize maternal health services directly. will only be attained when its utilization is supported
However, it also affected the utilization of maternal by an effective health care delivery system,27) which
health services indirectly by affecting maternal must include effective health education programs.
knowledge. Owning the MCHH had only little Previous studies have demonstrated that health
influence on the utilization of maternal health services. education can effectively improve both maternal
To improve maternal health behavior, the MCHH knowledge28,29) and behavior.22,30) In the study area, as
should be used properly not only by the targeted in most areas of Indonesia, several community-based
mothers, but also by their health care providers. activities such as Dasa Wisma (a group of ten
Furthermore, multivariate modeling indicated that in households, through which mothers can share, discuss
most cases improvements in maternal health service and solve various health problems) and Posyandu
utilization were attributable in part to improvements in (Integrated Health Post which operates once a month
maternal knowledge. Therefore, utilization of the and provides basic maternal and child health services)
handbook within the health care system should be are available and provide opportunities to improve
designed and carried out in such a way as to ensure maternal knowledge and maternal health behavior.
improvement of maternal knowledge. Utilizing the MCHH during health education sessions
Evidence from this study supports the idea that the involving these community-based activities could help
MCHH can be used as a tool in maternal education, encourage communication between mothers and health
particularly in antenatal education. However, care providers and could also help improve the
utilization of the MCHH will be effective only if the functioning of the activities.
content is appropriate for the targeted community and Implications for future application of MCHH
if the community is concerned with maternal and child To reap the advantages of the MCHH, simply
health and aware that it can be improved27). There is distributing the handbook is not enough. Ideally, the
need to review and modify the contents of the handbook should be carefully read by the mothers and
Indonesian MCHH, to guarantee its appropriateness they should understand its contents. Furthermore, the
for the targeted population. Particular attention should MCHH should be used by health providers when
be paid to its manner of presenting its messages, since conducting health education sessions. Health
about one fourth of mothers who had read at least authorities should ensure the availability of adequate
some parts of the handbook stated that they found it inputs and resources to review and modify the MCHH,
difficult to understand its contents. The MCHH should as well as assuring its availability and distribution.
incorporate attractive, interesting, and easy-to- Availability of adequate inputs has to be ensured to
understand ways to deliver its messages. carry out related training for health care providers.
The low rates of active usage of the MCHH by Such training is crucial in order to promote the use of
mothers need to be increased. The literacy rate was MCHH in health education sessions, as well as to
high in both districts and literacy is a prerequisite to a assure the health provider’s capability to utilize the
mother’s reading the handbook. However this study handbook effectively, including its use in such
sessions. The Indonesian Government at the central, McGraw Hill, 2005.
provincial and district levels should take adequate 7) Onah, H. E., Ikeako, L. C., Iloabachie, G. C.
initiatives to activate all relevant stakeholders to Factors Associated with the Use of Maternity
support appropriate and sustainable utilization of the Services in Enugu, Southeastern Nigeria. Soc Sci
MCHH. Med 2006; 63(7): 1870-1878.
8) Sunil, T. S., Rajaram, S. and Zottarelli, L. K. Do
VI. Conclusion Individual and Program Factors Matter in the
Utilization of the MCHH in West Sumatra, Utilization of Maternal Care Services in Rural
Indonesia, has a potential to improve both maternal India? A Theoretical Approach. Soc Sci Med
knowledge and the utilization of maternal health 2006; 62(8): 1943-1957.
services. However, to reap these benefits the handbook 9) Seiber, E. E., Hotchkiss, D. R., Rous, J. J., and
should be actively used both by the mothers and by Berruti, A. A. Maternal and Child Health and
health care providers. The MCHH needs to be Family Planning Service Utilization in Guatemala:
modified, particularly in terms of incorporating Implications for Service Integration. Soc Sci Med
attractive, interesting, and easy-to-understand ways to 2005; 61(2): 279-291.
deliver its messages, taking into account the 10) Nuraini, E. and Parker, E. Improving Knowledge
educational levels of the targeted populations. The of Antenatal Care (ANC) Among Pregnant
effectiveness of existing community-based activities in Women: a Field Trial in Central Java, Indonesia.
promoting maternal knowledge and behavior can be Asia Pac J Public Health 2005; 17(1): 3-8.
improved by utilizing the MCHH during their health 11) Fujita, N., Matsui, M., Srey, S., Po, C. S., Uong,
education sessions. Utilization of the MCHH in health S. and Koum, K. Antenatal Care in the Capital
education sessions will encourage and focus City of Cambodia: Current Situation and Impact
communication between mothers and health care on Obstetric Outcome. J Obstet Gynaecol Res
providers. The Indonesian Government needs to assure 2005; 31(2): 133-139.
adequate availability of the various inputs necessary to 12) Paredes, I., Hidalgo, L., Chedraui, P., Palma, J.
support appropriate and sustainable utilization of the and Eugenio, J. Factors Associated with
MCHH. Inadequate Prenatal Care in Ecuadorian Women.
Int J Gynaecol Obstet 2005; 88(2): 168-172.
References 13) Phoxay, C., Okumura, J., Nakamura, Y. and
1) www3.who.int/whosis/core/core_select_process. Wakai, S. Influence of Women’s Knowledge on
cfm accessed in January 24th 2007. Core Health Maternal Health Care Utilization in Southern
Indicator: Indonesia Laos. Asia Pac J Public Health 2001; 13(1): 13-
2) National Statistical Bureau of Indonesia. 19.
National Socio-Economy Survey 1995. Jakarta: 14) Almeida, S. D. and Barros, M. B. Equity and
Balai Pustaka; 1996. Access to Health Care for Pregnant Women in
3) National Statistical Bureau of Indonesia. Campinas (SP), Brazil. Rev Panam Salud Publica
National Socio-Economy Survey 1998. Jakarta: 2005; 17(1): 15-25.
Balai Pustaka; 1999. 15) Heaman, M. I., Gupton, A. L. and Moffatt, M. E.
4) National Statistical Bureau of Indonesia. Prevalence and Predictors of Inadequate Prenatal
National Socio-Economy Survey — Household Care: A Comparison of Aboriginal and Non-
Health Survey 2001. Jakarta: Balai Pustaka; 2002. Aboriginal Women in Manitoba. J Obstet
5) National Statistical Bureau of Indonesia. Gynaecol Can 2005; 27(3): 237-246.
Indonesian Health and Demography Survey 2002- 16) Kenney, G., Sommers, A. S. and Dubay, L.
2003. Jakarta: Balai Pustaka; 2003. Moving to Mandatory Medicaid Managed Care in
6) Green, L. W. and Kreuter, M. W. Health Ohio: Impacts on Pregnant Women and Infants.
Promotion Planning: An Educational and Med Care 2005; 43(7): 683-690.
Ecological Approach. 4th Edition. New York: 17) Atiyeh, G. N. and El-Mohandes, A. Preventive
 Healthcare of Infants in a Region of Lebanon: 25) Fabian, H. M., Radestad, I. J., and Waldenstrom,
Parental Beliefs, Attitudes and Behaviors. Matern U. Characteristics of Swedish Women Who Do
Child Health J 2005; 9(1): 83-90. Not Attend Childbirth and Parenthood Education
18) Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. Classes During Pregnancy. Midwifery 2004; 20:
W., Holmberg, J., Ng, R. K., Isacks, K., Sheff, K. 226-235.
and Henderson Jr., C. R. Effects of Home Visits 26) Maine D., Akalin, M. Z., Ward, V. M. and
by Paraprofessionals and by Nurses: Age 4 Kamara, A. The Design and Evaluation of
Follow-up Results of a Randomized Trial. Maternal Mortality Programs. Center for
Pediatrics 2004; 114(6): 1560-1568. Population and Family Health, School of Public
19) Olds, D. L. and Kitzman, H. Can Home Health, Columbia University; 1997.
Visitation Improve the Health of Women and 27) Nakamura, Y. Maternal and Child Health
Children at Environmental Risk? Pediatrics 1990; Handbook Program. In the Proceeding of the 4th
86(1): 108-116. International Symposium on Maternal and Child
20) Soliman, M. H. Impact of Antenatal Counselling Health Handbook, 11th-13th December 2004,
on Couples’ Knowledge and Practice of Bangkok, Thailand.
Contraception in Mansoura, Egypt. East Mediterr 28) Ohnishi, M., Nakamura, K., and Takano, T.
Health J 1999; 5(5): 1002-1013. Improvement in Maternal Health Literacy Among
21) Belizan, J. M., Barros, F., Langer, A., Farnot, U., Pregnant Women Who Did Not Complete
Victora, C. and Villar, J. Impact of Health Compulsory Education: Policy Implications for
Education During Pregnancy on Behavior and Community Care Services. Health Policy 2005;
Utilization of Health Resources. Latin American 72: 157-164.
Network for Perinatal and Reproductive Research. 29) Renkert, S. and Nutbeam, D. Opportunities to
Am J Obstet Gynecol 1995; 173(3 Pt 1): 894-899. Improve Maternal Health Literacy through
22) Turan, J. M. and Say, L. Community-based Antenatal Education: An Exploratory Study.
Antenatal Education in Istanbul, Turkey: Effects Health Promotion International 2001; 16(4): 381-
on Health Behaviors. Health Policy Plan 2003; 388.
18(4): 391-398. 30) Pearson, C. and Thurston, M. Understanding
23) Fabian, H. M., Radestad, I. J. and Waldenstrom, Mothers’ Engagement with Antenatal Parent
U. Childbirth and Parenthood Education Classes Education Services: A Critical Analysis of a Local
in Sweden. Women’s Opinion and Possible Sure Start Service. Children & Society Volume
Outcomes. Acta Obstet Gynecol Scand 2005; 2006; 20: 348-359.
84(5): 436-443.
24) Spinelli, A., Baglio, G, Donati, S., Grandolfo, M.
E. and Osborn, J. Do Antenatal Classes Benefit
the Mother and Her Baby? J Matern Fetal
Neonatal Med 2003; 13(2): 94-101.