in indonesia services among adolescent girls and...

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Women amp Health

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Determinants of utilization of antenatal careservices among adolescent girls and young womenin Indonesia

Ferry Efendi SKepNs MSc Ching-Min Chen RN DNS Anna Kurniati SKM MAamp Sarni Maniar Berliana SST MSi

To cite this article Ferry Efendi SKepNs MSc Ching-Min Chen RN DNS Anna Kurniati SKMMA amp Sarni Maniar Berliana SST MSi (2016) Determinants of utilization of antenatal careservices among adolescent girls and young women in Indonesia Women amp Health DOI1010800363024220161181136

To link to this article httpdxdoiorg1010800363024220161181136

Published online 26 May 2016

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Determinants of utilization of antenatal care servicesamong adolescent girls and young women in IndonesiaFerry Efendi SKepNs MScab Ching-Min Chen RN DNSac Anna Kurniati SKM MAadand Sarni Maniar Berliana SST MSie

aInstitute of Allied Health Sciences College of Medicine National Cheng Kung University TainanTaiwan China bFaculty of Nursing Airlangga University Surabaya Indonesia cDepartment of Nursingand Institute of Gerontology National Cheng Kung University Tainan Taiwan China dCenter forPlanning and Management of Human Resources for Health The Board for Development andEmpowerment of Human Resources for Health (BPPSDMK) Ministry of Health Jakarta IndonesiaeInstitute of Statistics (STIS) Statistics Indonesia (BPS) Jakarta Indonesia

ABSTRACTDue to the high number of maternal deaths provision ofantenatal care services (ANC) in Indonesia is one of the keyaims of the post-Millennium Development Goals agenda Thisstudy aimed to assess the key factors determining use of ANCby adolescent girls and young women in Indonesia Data fromthe Indonesia Demographic and Health Survey 2012 wereused with a focus on married adolescent girls (aged15ndash19 years n = 543) and young women (20ndash24 yearsn = 2916) who were mothers Bivariate and multiple logisticregression analyses were performed to determine the factorsassociated with ANC use The findings indicated that adoles-cents were less likely to make ANC visits than young womenRicher women were more likely to make four ANC visits in bothgroups compared to the poorer women Living in urban areashigher educational attainment and lower birth order were alsoall associated with higher levels of receiving ANC amongyoung women The results showed that socio-economic factorswere related to the use of ANC among adolescent girls andyoung women Ongoing health-care interventions should thusput a priority on adolescent mothers coming from poor socio-economic backgrounds

ARTICLE HISTORYReceived 9 July 2015Revised 20 March 2016Accepted 21 March 2016

KEYWORDSAdolescent girls antenatalcare use young women

Introduction

In 2015 Indonesia set a target to achieve a critical goal of reducing theMaternal Mortality Rate (MMR) to 102 per 100000 live births (Bappenas2012 UNDP 2012) However this target appears difficult to obtain as thelatest data showed that the MMR was 359 per 100000 live births (StatisticsIndonesia et al 2013) A recent publication also showed that Indonesia failedto reduce MMR to the level needed to reach the target included in the

CONTACT Ching-Min Chen RN DNS chingminmailnckuedutw Institute of Allied Health SciencesCollege of Medicine National Cheng Kung University No 1 Daxue Rd East Dist Tainan City 70101 Taiwan China

WOMEN amp HEALTHhttpdxdoiorg1010800363024220161181136

copy 2016 Taylor amp Francis

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Millennium Development Goals (MDGs) which was only a 06 decrease inthe MMR per year (Hogan et al 2010)

Antenatal care (ANC) remains a frequently used intervention to reduceMMR particularly in developing countries (Ali and Adam 2011) The useof ANC services has been significantly related to improving maternal andneonatal outcomes (Rai Singh and Singh 2012 Ram and Singh 2006)Recognizing this importance the government of Indonesia launched theSafe Motherhood program in 1990 based on the following four pillarsfamily planning antenatal care safe delivery and essential obstetric ser-vices (MoH 2011) This policy was also reflected in a strategic plan carriedout by the Ministry of Health from 2010ndash2014 to improve maternal andchild health which put specific targets on the achievement of a number ofgoals such as deliveries being assisted by a a qualified birth attendant (atarget of 90) completing the first ANC visit (90) and delivering anormal weight infant (85) (Kemenkes 2010) Indonesiarsquos MDGs includethe target that 95 of pregnant women will make their first ANC visitduring pregnancy and that 90 will make at least four ANC visits(Pritasari 2012) However the latest national data showed that only 20of 33 provinces had achieved the first target (ge95) and only 12 provincesachieved the second (MoH 2014)

Many studies have documented that getting pregnant at a young age decreasesthe quality of health outcomes for women (Rai Singh and Singh 2012 Singhet al 2012) Despite a number of global strategies that have focused on repro-ductive health adolescent pregnancy remains a widespread problem which is asignificant contributor in maternal and child mortality especially in low- andmiddle-income countries (World Health Organization 2014) with around 16million adolescent females aged 15ndash19 years old giving birth every year (WordHealth Organization 2012) The importance of delaying marriage and pregnancyin adolescent women is thus receiving increased attention For Indonesia acountry with 4075 million adolescents this issue is of particular importance(Badan Pusat Statistik 2010) Data published by the Badan Kependudukan danKeluarga Berencana Nasional (BKKBN) or National Family PlanningCoordinating Board in 2013 showed that adolescent pregnancies accounted for48 of every 1000 pregnancies a 10 increase from the previous year (Jalal 2014)The reduction of adolescent marriage and pregnancy has therefore become anational goal to aid in Indonesiarsquos development (BKKBN 2012)

However in spite of the urgent need to provide effective ANC services inIndonesia little attention has been given to analyzing the use of ANC andparticularly the differences in such use between adolescent girls (15ndash19 yearsold) and young women (20ndash24 years old) A nationwide quinquennial surveyconducted 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

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death among adolescent mothers (15ndash19 years of age) was higher than thatseen with other age groups (Balitbangkes 2010)

To the best of our knowledge few studies have been conducted on the useof ANC in Indonesia In particular limited attention has been paid toexamining adolescent girls and young women who become mothers as aseparate population group thus indicating a greater need to understand thevarious factors related to the use of ANC among these individuals Inaddition this study may also shed light on why despite government effortsto reduce the rate of adolescent pregnancies this number actually increasedin recent years (Jalal 2014)

Therefore this study was used to attempt to assess the determinants of thedifferences in ANC use seen among adolescent girls and young women whobecame mothers in Indonesia It is anticipated that the results of this work wouldnot only help policy makers develop strategies to achieve the related nationaltargets and MDGs but also provide insights into what the government can do inthe 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 IndonesiaIndonesia is the fourth most populous country in the world with an esti-mated population of 252 million (BPS 2014) The country has 34 provincesand more than 17504 islands stretching from its east to west regions(Kemendagri 2015) The poverty rate was 1166 in 2012 with 2859 millionpeople living below the poverty line (MoH 2013) Nationally the percentageof illiteracy rate was about 719 with the highest rate in Papua province(359) and the lowest rate in Sulawesi province (11) (MoH 2013) Thisreflects the disparities between regions which also exist in health outcomessuch as the number of completed first and fourth ANC visits (MoH 2010Pritasari 2012) For example the rates at which pregnant women make theirfirst and fourth ANC visits in DKI Jakarta province were 979 and 843respectively while in Papua Barat province the figures were only 713 and347 (MoH 2010) In 2012 the Indonesian Demographic Health Survey(IDHS) was thus conducted to gain a broader view of this issue This surveywas carried out by Statistics Indonesia in collaboration with the Ministry ofHealth and the National Population and Family Planning Board with theInner City Fund (ICF) International and MEASURE (Monitoring andEvaluation to Assess and Use Results) Demographic and Health Surveysproviding technical assistance in data analysis and report writing The surveyprocess was initiated in 2011 followed by fieldwork in 2012 which wascompleted a year later (Statistics Indonesia et al 2013)

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Data

A two-stage stratified sampling procedure was used in the 2012 IDHS Instage one census blocks (CBs) which represented urban and rural areas ofeach province in Indonesia were determined In stage two households fromthe CBs list were randomly selected All women aged 15ndash49 years old wereeligible for an interview in the IDHS and a total of 47533 participated (aresponse rate of 96) Details of the sampling method of the IDHS 2012 havebeen reported elsewhere (Statistics Indonesia et al 2013)

Using the UNrsquos and WHOrsquos definition for adolescent age two maternalage categories women aged between 15 and 19 years and women between 20and 24 years were compared To be included in the analysis the womenneeded to (1) be married at the time of survey (2) be aged 15ndash24 years oldand (3) have had their most recent births within the 5 years preceding thesurvey A total of 3459 women met these criteria and were included in theanalyses Questionnaires were employed to gather data from the respondentsand 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 employmentstatus partnerrsquos background HIVAIDS and other health issues (StatisticsIndonesia et al 2013)

Outcome variables

The present study measured one health outcome variable namely having hadat least four ANC visits (yesno) The ANC policy in Indonesia follows theWorld Health Organizationrsquos guidelines and those prepared by theIndonesian Ministry of Health (MoH) Under these guidelines it is requiredthat every mother has at least four ANC visits (MoH 2013 World HealthOrganization 1994)

Explanatory variables

Important demographic characteristics that were considered included mater-nal age (15ndash19 and 20ndash24 years) place of residence (rural and urban)motherrsquos education (no education primary secondary and higher) hus-bandrsquos education (no education primary secondary and higher) economicstatus (low-income middle-income and high-income with categoriesdefined as provided below) motherrsquos employment status (not working andworking) mass media (ie television) exposure (no exposure and someexposure) and birth order of the infant (first second and third or more)Exposure to mass media was assessed by asking how often the respondentwatched television (not at all versus ever) Economic status quintiles were

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calculated based on ownership of a standard set of assets as outlined in theDemographic Health Survey guidelines (Statistics Indonesia et al 2013)These assets included a television car flooring material source of drinkingwater toilet facilities and other items related to health (Statistics Indonesiaet 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 datadistribution

Analytical approach

To determine ANC use among young mothers both bivariate and multi-variate analyses were performed Bivariate analyses were used to examine theassociations between the use of ANC services and various socio-economicand demographic characteristics Factors significantly associated (p lt 05)with ANC use were included in the multiple logistic regression modelAdjusted odds ratios (OR) with 95 confidence intervals (CI) were com-puted The analyses were conducted using SPSS version 170 (SPSS IncChicago IL USA) We tested our model with the Omnibus test of modelcoefficients with the results indicating that the model fit (p lt 001) Furtherthe results of Hosmer and Lemeshowrsquos goodness-of-fit test were p gt 05which indicated model fit

Ethics statement

The 2012 IDHS was conducted under the collaborative supervision of theBoard of Research and Health Development (Balitbangkes) part of the MoHof Indonesia The Balitbangkes conducted an independent ethics review ofthe 2012 IDHS protocol All respondent identifiers were removed from thedata and the participants provided their written informed consent to beincluded in the current study with the signed consent forms being keptunder management of the MoH Interviews for 2012 IDHS were then con-ducted after obtaining the signed consent of each participant Permission forthe use of the data in the current study was obtained from ICF Internationalpart of the DHS program (DHS 2013)

Results

The mean age at marriage was 159 years among adolescent girls while it was184 among young women (Table 1) The mean age at first birth was169 years among adolescent girls while for young women it was196 years Adolescent girls were more likely to come from families in thelow-income category compared to young women The rate of present

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contraceptive use among both groups was around two-thirds and more than10 of all the respondents experienced heavy vaginal bleeding during andafter delivery

Sample characteristics

The majority of the respondents resided in rural areas (Table 2) and morethan half had completed secondary high school as had their husbands Themajority of both groups had low socio-economic status and most wereunemployed A majority of the women often watched television and inboth groups most of the women surveyed had recently given birth to theirfirst birth child

Differences in antenatal care utilization

Out of the 3459 eligible women who gave birth between the ages of 15ndash19and 20ndash24 70 and 80 respectively had had at least four ANC visits forthe period 2007ndash2012 (Table 3) Both early marriage (married before the ageof 18 years) and adolescent pregnancy had associations with ANC use amongIndonesian young women All of the demographic variables examined in thiswork except for employment status showed significant associations with theuse 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 adjustedanalyses place of residence womenrsquos education economic status massmedia exposure and birth order all had significant associations with theuse of a minimum of four ANC visits among young women Participantsliving in urban areas were more likely to use ANC at least four times Youngwomen who had less than a formal education were less likely to reach thefour visit minimum The odds of completing four ANC visits was three timeshigher among young women from the high-income category than among

Table 1 Comparison of selected characteristics of married women by ageAge in years

Selected characteristics 15ndash19 20ndash24Mean age at marriage 159 184Mean age at first birth 169 196Percent belonging to the low-income wealth quintile 433 345Percent currently not using contraceptive 324 309Percent experienced massive vaginal bleeding after birth 123 182N 543 2916

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those from the low-income category The odds of ANC use also increasedwith increased mass media exposure Birth order was negatively associatedwith ANC use with young women whose most recent birth was their firstbeing more likely to have at least four ANC visits than those whose mostrecent birth was their third or greater birth Among the adolescents thosefrom the high-income category were 19 times as likely to have four ANCvisits compared to those from the low-income category Overall for both agegroups only economic status was significantly related to ANC use with thoseindividuals in the high and middle-income categories being more likely tocomplete four ANC visits than those from the low-income category

Discussion

A number of efforts have been made by the Indonesian government toimprove the use of ANC in recent years including the UniversalHealthcare Delivery system Integrated Health Posts in each village and theExpanding Maternal and Neonatal Survival program (MoH 2014) However

Table 2 Distribution of the percentage of women who had at least one live birth at a young ageby age group

Background characteristics15ndash19 years old

n ()20ndash24 years old

n () X2

Place of residenceRural 369 (68) 1801 (618) 7510Urban 174 (32) 1115 (382)

Womenrsquos educationNo education 14 (26) 79 (27) 30480Primary 173 (319) 856 (294)Secondary 350 (645) 1765 (605)Higher 6 (11) 216 (74)

Husbandrsquos educationNo education 20 (37) 49 (17) 23783Primary 191 (352) 925 (37)Secondary 313 (576) 1708 (586)Higher 19 (35) 234 (80)

Wealth levelLow income 369 (68) 1694 (581) 18646Middle income 81 (149) 548 (188)High income 93 (171) 674 (231)

Working statusNot working 401 (738) 1790 (614) 30624Working 142 (262) 1126 (386)

Mass media exposure (TV)No exposure 38 (7) 179 (61) 0575Some exposure 505 (93) 2737 (939)

Birth orderBirth order 1 504 (928) 2192 (752) 83168Birth order 2 35 (64) 614 (211)Birth order 3+ 4 (07) 110 (38)

Total 543 2916

p lt 05 p lt 01 p lt 001

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as reported in the Indonesia Health Profile in 2012 the country still needs toincrease its efforts to achieve the national and MDGs targets (MoH 2013)Mounting evidence from developed and developing countries shows thatadolescent mothers are at high risk of suffering adverse health outcomesfor both their babies and themselves (Fatusi and Hindin 2010 Gortzak-Uzanet al 2001 Malamitsi-Puchner and Boutsikou 2006 UNICEF 2005)

Among both age groups examined in the current study ANC use waslower than the recommended national standards Approximately 70 and80 of the adolescent and young women mothers in this survey received atleast four ANC visits respectively Our analysis found a number of factorsthat had a significant relation to the use of ANC for the different age groupsFor adolescent girls only socio-economic status had a positive associationwith four ANC visits For the young women living in an urban area mothers

Table 3 Background characteristics and ANC use of mother in IndonesiaFrequency of ANC n ()

Background characteristic Less than four times (n = 691) Four times and above (n = 2768) X2

Marital agelt18 years 363 (26) 1045 (74) 50044ge18 years 328 (16) 1723 (84)

Maternal age years15ndash19 147 (30) 396 (70) 2028220ndash24 544 (20) 2372 (80)





Womenrsquos work statusNot working 430 (20) 1761 (80) 0461Working 261 (20) 1007 (80)

Mass media exposure(TV)No exposure 110 (50) 107 (50) 136627Some exposure 581 (20) 2661 (80)


p lt 05 p lt 01 p lt 001

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who had a higher level of educational attainment higher income status andgreater mass media exposure were more likely to have adequate ANC usewhile higher parity of young women was negatively associated with the use offour ANC visits Adolescent girls with middle-income status were two timesas likely to have the recommended number of ANC visits than those withlow-income status Meanwhile young women in the high-income groupwere three times as likely to have four ANC visits compared to those inthe low-income group Similarly Singh et al (2012) found that women inrural India aged 15ndash19 years old with higher socio-economic status weremore likely to use full ANC services than those in the poorest category

The government of Indonesia is now seriously addressing the issue ofhealth inequality between provinces The results of the current study clearlyillustrate the importance of geographical factors in determining adequate use

Table 4 Multiple logistic regression model based on the frequency of ANC received of bothgroups

Background characteristics

At least four ANC received

15ndash19 years old AOR (95 CI) 20ndash24 years old AOR (95 CI) Total sample

Marital agelt18 years 1 1 1408ge18 years 1182 (0634ndash2201) 1017 (0807ndash1282) 2051

Place of residenceRural (ref) 1 1 2170Urban 1256 (0787ndash2006) 1290 (1 015ndash1640) 1289

Womenrsquos educationNo education 0238 (0021ndash2682) 0246 (0118ndash0512) 93Primary 2060 (0333ndash12726) 0899 (0538ndash1503) 1029Secondary 1991 (0335ndash11838) 1099 (0680ndash1776) 2115Higher (ref) 1 1 222

Husbandrsquos educationNo education 0439 (0082ndash2365) 0545 (0237ndash1256) 69Primary 0719 (0194ndash2665) 1034 (0630ndash1695) 1116Secondary 0682 (0190ndash2449) 1133 (0711ndash1807) 2021Higher (ref) 1 1 253

Wealth levelLow income (ref) 1 1 2063Middle income 2085 (1077ndash4039) 1587 (1189ndash2119) 629

High income 1925 (1006ndash3685) 3123 (2164ndash4507) 767Mass media exposure (TV)No exposure (ref) 1 1 217Any exposure 1172 (0541ndash2536) 2532 (1781ndash3599) 3242

Womenrsquos working statusNot working (ref) 1 1 2191Working 0810 (0508ndash1290) 1094 (0886ndash1350) 1268

Birth orderBirth order 1 6143 (0607ndash62167) 3291 (2106ndash5144) 2696Birth order 2 3132 (0285ndash34481) 1834 (1167ndash2881) 649Birth order 3+ (ref) 1 1 114Total 691 2768 3459Nagelkerke R square 0117 0173

Note AOR Adjusted Odds Ratio 95 CI 95 Confidence Intervalp lt 05 p lt 01 p lt 001

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of ANC with women in urban areas much more likely to achieve this thanthose in rural areas This may be linked with the accessibility of ANC servicesin different areas with women in urban areas finding these easier to accessthan those in rural areas For example data from the Ministry of VillagesDisadvantaged Regions and Transmigration noted that the average distanceto a midwife practice within rural areas was 34 km while nationally it wasonly 16 km (Kemendesa-PDT 2015) Moreover Indonesia has about 74405rural villages with 5297 categorized as underdeveloped and the majoritylocated in the eastern part of Indonesia (Kemendesa-PDT 2015) In 1989 theIndonesian government launched a village-based midwife program inresponse to high mother and infant death rates Within 7 years every villagein Indonesia thus had a skilled birth attendant or midwife (MoH 2013) Inaddition community initiatives undertaken with the establishment ofIntegrated Health Post (Posyandu) program further enhanced accessibilityto such care (MoH 2013) However despite these efforts inequalities betweenvarious regions still remain and thus policy makers should focus on devel-oping innovative or non-standard approaches to address this issue based onthe actual situations in various areas with the current study providingfindings to inform these approaches

The findings of this study indicated a significant association betweenmaternal education and adequate use of ANC which is supported by pre-vious research (Ciceklioglu Soyer and Oumlcek 2005 Navaneetham andDharmalingam 2002 Titaley Dibley and Roberts 2010) This may bebecause women who have higher educational attainment may have acquiredmore knowledge about maternal and child health and the potential benefitsof ANC thus resulting in a higher level of ANC use (Titaley Dibley andRoberts 2010) In this context it should be noted that Indonesia is on track toincrease access to education among women across the nation As reported ina recent study the school participation rate increased from 55 in 2009 to61 in 2012 among girls aged 16ndash18 (Badan Pusat Statistik 2014) Howevereven though Indonesia has a 9-year compulsory education system 26 and27 of adolescent girls and young women in this study respectivelyremained uneducated It is thus suggested that by further working to improvethe education level of its citizens and meeting the specific needs of targetpopulations the government can get closer to achieving its goals with regardto reducing adolescent pregnancy as well as maternal and infant death rates

Mass media exposure was found to be significantly associated with the useof ANC among young women consistent with previous studies(Navaneetham and Dharmalingam 2002 Pallikadavath Foss and Stones2004) as the communication channel used to convey health-related messagesplays an important role in the decision to use health-care services (Grilli et al2000) Television is an especially good medium because it persuades theaudience in a visual and auditory manner and is likely to influence

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significantly more people than other forms of media Moreover healthmessages need to be tailored to the target populations particularly whenthese are illiterate women in Indonesia

The current study found that young women who had their first birthbetween ages 20ndash24 years were more likely to have four ANC visits thanwomen who had more births by this age Earlier research showed thatwomen were significantly more likely to use antenatal health-care servicesfor their first deliveries (Chakraborty et al 2003 Rai Singh and Singh 2012)as these are seen by the mothers as riskier than subsequent deliveries Thetime and resource constraints faced by women with higher parity have alsobeen reported to have an association with the low use of ANC in largerfamilies (Elo 1992 Wong et al 1987) and thus messages about the impor-tance of ANC during pregnancy should be targeted at this group

The results of the present study showed that the income status of motherswas significantly associated with the use of ANC for both age groups Similarlyother studies have found that high-income status is positively related to greateruse of maternal health-care services (Maringlqvist et al 2013 Matijasevich et al2010) Low economic status is generally a barrier to accessing health-careservices (Celik and Hotchkiss 2000 Overbosch et al 2004) This issue isespecially important in Indonesia which has around 28 million people livingin poverty or 1147 of the total population (BPS 2013) To address this issuethe government launched a Universal Delivery Care (Jampersal) plan whichallows pregnant women to deliver their children in a health-care facility forfree (MoH 2013) This plan also covers ANC services for up to four visits withmore visits available to those women who have complications during preg-nancy However as noted in an earlier study not all women who are able touse this plan due to the motherrsquos preferences additional costs that can beincurred during labor distance to the health facility and administrative pro-blems (Trisnantoro 2011) One of the solutions that has been suggested toaddress this issue is to rely on the initiative of the local communities One ofthe unique aspects of Indonesiarsquos health system is the concept of communityempowerment (MoH 2009) and the main goal of health development isindependence To achieve this however each community needs sufficientknowledge and the health workers who are on the frontline of such effortsfor 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 andpregnancy and the negative outcomes of these life events on every level ofthe community In Indonesia the minimum age of marriage for girls is16 years and for boys it is 19 years (Government of Indonesia 1974) Thisstudy showed that the mean age at marriage was 159 years for the adolescentgirls and this young age is an issue that requires special attention from areproductive health perspective In addition some studies showed that early

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sexual activity and childbearing can harm the health of both the mother andinfant 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 populationmake-up the nation is expected to have a demographic dividend in the nearfuture (Kemenkokesra 2012) As stated by Tirtosudarmo (2013) ldquoA demo-graphic dividend is when the proportion of people in the productive age group(15ndash64 years) reaches a maximum and the dependency ratio is at its lowestlevelrdquo Preparation for this golden period should thus be made in advance Inthis regard it is time to invest in young womenrsquos health particularly adolescentsand young mothers who play a great role in determining the well-being of thenext generation Taking into account the results of this study future policiesand programs must address adolescents and young mothers to meet their needsbetter for accessible reliable and affordable ANC

The present study makes several noteworthy contributions to the issue ofANC use among adolescent girls and young women in Indonesia The ANCuse rates for both age groups were found to be below the national standardand this issue needs to be urgently addressed Current government policiesand programs should thus target low-income households with an emphasison 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 mayhave resulted in certain uncontrolled factors confounding the resultsMoreover the data were all self-reported which might have resulted in recallandor social acceptability bias In addition all variables were assumed to befixed over a period of 5 years prior to the survey (ceteris paribus)

A further limitation was that the use of secondary data may have resultedin misclassification of information andor a lack of comparability with regardto the results from earlier works that used standard instruments In additionthis study used a cross-sectional design which prohibited the assessment ofthe temporal and thus potentially cauasal relations among the variables

Conclusion

The results of this study suggest that any strategy created to improveantenatal care services should take into account the socio-economic contextof adolescent and young mothers to achieve the maximum impact Inparticular vulnerable individuals who have low socio-economic status loweducation levels and higher parity should be the focus of efforts to increaseaccess to the Universal Health Coverage plan In addition raising awareness

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of the problems associated with early marriage and adolescent pregnancyshould be initiated at the national level Moreover in the long term a petitionto change the marriage law to increase the minimum age of marriage may beuseful to protect the sexual and reproductive health of adolescents and youngwomen

References

Ali A A A and I Adam 2011 Lack of antenatal care education and high maternalmortality in Kassala hospital eastern Sudan during 2005ndash2009 Journal of Maternal-Fetaland Neonatal Medicine 24 (8)1077ndash78 doi103109147670582010545908

Badan Pusat Statistik 2010 Hasil sensus penduduk 2010 [Results of population census 2010]Jakarta Indonesia BPS

Badan Pusat Statistik 2014 Angka Partisipasi Sekolah (APS) [School Participation Rate]Badan Pusat Statistik httpwwwbpsgoidtab_subviewphptabel=1ampdaftar=1ampid_subyek=40ampnotab=13 (accessed May 22 2015)

Balitbangkes 2010 Laporan Nasional Riskesdas 2010 [Report of basic national health research2010] 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 IndonesiaBappenas

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 KedalamanKemiskinan (P1) dan Indeks Keparahan Kemiskinan (P2) Menurut Provinsi September2013 [Number and Percentage of Poor Population Poverty Line Poverty Gap Index (P1)and Poverty Severity Index (P2) by Province September 2013] BPS httpwwwbpsgoidtab_subviewphptabel=1ampid_subyek=23ampnotab=1 (accessed January 10 2015)

BPS 2014 Tabel Dinamis Kependudukan [Table Dynamic of Population] BPS httpwwwbpsgoidsitepilihdata (accessed December 20 2014)

Celik Y and D R Hotchkiss 2000 The socio-economic determinants of maternal healthcare utilization in Turkey Social Science amp Medicine 50 (12)1797ndash806 doi101016S0277-9536(99)00418-9

Chakraborty N M A Islam R I Chowdhury W Bari and H H Akhter 2003Determinants of the use of maternal health services in rural Bangladesh HealthPromotion International 18 (4)327ndash37 doi101093heaprodag414

Ciceklioglu M M T Soyer and Z A Oumlcek 2005 Factors associated with the utilization andcontent of prenatal care in a western urban district of Turkey International Journal forQuality in Health Care 17 (6)533ndash39 doi101093intqhcmzi076

DHS 2013 Demographic and health surveys ICF International measuredhscom (accessedOctober 4 2015)

Elo I T 1992 Utilization of maternal health-care services in Peru The role of womenrsquoseducation Health Transition Review 2 (1)49ndash69

Fatusi A O and M J Hindin 2010 Adolescents and youth in developing countries Healthand development issues in context Journal of Adolescence 33 (4)499ndash508 doi101016jadolescence201005019

WOMEN amp HEALTH 13

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ded

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iona

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ng K

ung

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vers

ity]

at 1

943

26

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201

6

Gortzak-Uzan L M Hallak F Press M Katz and I Shoham-Vardi 2001 Teenagepregnancy Risk factors for adverse perinatal outcome Journal of Maternal-Fetal andNeonatal Medicine 10 (6)393ndash97 doi101080jmf106393397

Government of Indonesia 1974 Undang-undang Republik Indonesia Nomor 1 Tahun 1974Tentang Perkawinan [Law of the Republic of Indonesia Number 1 Year 1974 on Marriage]Jakarta Indonesia 1ndash12

Grilli R N Freemantle S Minozzi G Domenighetti and D Finer 2000 Mass mediainterventions Effects on health services utilisation Cochrane Database of SystematicReviews (2)CD000389 doi10100214651858cd000389

Hampton T 2010 Child marriage threatens girlsrsquo health JAMA 304 (5)509ndash10 doi101001jama20101009

Hogan M C K J Foreman M Naghavi S Y Ahn M Wang S M Makela A D Lopez RLozano and C J L Murray 2010 Maternal mortality for 181 countries 1980ndash2008 Asystematic analysis of progress towards millennium development goal 5 The Lancet 375(9726)1609ndash23 doi101016S0140-6736(10)60518-1

Jalal F 2014 Paparan Kepala BKKBN Pada Konferensi Pers Rakernas ProgramKependudukan dan Keluarga Berencana Tahun 2014 [Statement head of BKKBN at aPress-conference of National Meeting on Population and Family Planning Program 2014]Jakarta Indonesia BKKBN

Kemendagri 2015 Kode dan Data Wilayah Administrasi Pemerintahan (Permendagri No56-2015) Kementerian Dalam Negeri httpwwwkemendagrigoidpagesdata-wilayah(accessed January 11 2015)

Kemendesa-PDT 2015 Program Pengembangan Desa dan Daerah Tertinggal Tahun2015ndash2019 [Program development of Village and Disadvantaged Region in 2015ndash2019]Jakarta Indonesia Kemendesa PDT

Kemenkes 2010 Rencana Strategis Kementerian Kesehatan Tahun 2010ndash2014 [Strategic Planof Ministry of Health year 2010ndash2014] Jakarta Indonesia Kemenkes

Kemenkokesra 2012 2017ndash2019 Puncak Bonus Demografi Kemenkokesra httpmenkokesragoidcontent2017-2019-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)170ndash71

Maringlqvist M O Lincetto N H Du C Burgess and D T P Hoa 2013 Maternal health careutilization in Viet Nam Increasing ethnic inequity Bulletin of the World HealthOrganization 91 (4)254ndash61 doi102471BLT12112425

Matijasevich A C G Victora D A Lawlor J Golding A M B Menezes C L Arauacutejo A JD 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 cohortstudies from Brazil and the UK Journal of Epidemiology and Community Health2010108605

MoH 2009 Sistem Kesehatan Nasional [National health system] Jakarta IndonesiaKemenkes

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 partnershipbetween midwife and traditional birth attendant] Jakarta Indonesia Kemenkes

MoH 2013 Profil Kesehatan Indonesia 2012 [Indonesia Health Profile Year 2012] JakartaIndonesia Kemenkes


14 F EFENDI ET AL

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ity]

at 1

943

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6

Navaneetham K and A Dharmalingam 2002 Utilization of maternal health care services inSouthern India Social Science amp Medicine 55 (10)1849ndash69 doi101016S0277-9536(01)00313-6

Overbosch G B N N N Nsowah-Nuamah G J M Van Den Boom and L Damnyag2004 Determinants of antenatal care use in Ghana Journal of African Economies 13(2)277ndash301 doi101093jaeejh008

Pallikadavath S M Foss and R William Stones 2004 Antenatal care Provision andinequality in rural north India Social Science amp Medicine 59 (6)1147ndash58 doi101016jsocscimed200311045

Pritasari K 2012 Kebijakan dan Strategi Percepatan Sasaran 5 MDGs Dan PelayananKesehatan Yang Mendukung Revitalisasi KB Kementerian Kesehatan [Policy and accel-eration strategy of goal 5 of the MDGs and health services that support revitalization offamily planning] httpwwwbkkbngoidmateriDocumentsMateri20Rakernas202012KEMENKES20DIRJEN20GIZI20[Compatibility20Mode]pdf (accessedMay 28 2014)

Rai R K P K Singh and L Singh 2012 Utilization of maternal health care services amongmarried adolescent women Insights from the Nigeria demographic and health survey2008 Womenrsquos Health Issues 22 (4)e407ndash14 doi101016jwhi201205001

Raj A N Saggurti M Winter A Labonte M R Decker D Balaiah and J G Silverman2010 The effect of maternal child marriage on morbidity and mortality of children under 5in India Cross sectional study of a nationally representative sample The British MedicalJournal 340 doi101136bmjb4258

Ram F and A Singh 2006 Is antenatal care effective in improving maternal health in ruralUttar Pradesh Evidence from a district level household survey Journal of Biosocial Science38 (04)433ndash48 doi101017S0021932005026453

Singh P K R K Rai M Alagarajan and L Singh 2012 Determinants of maternity careservices utilization among married adolescents in rural India Plos One 7 (2)e31666doi101371journalpone0031666

Statistics Indonesia National Population and Family Planning Board KementerianKesehatan and ICF International 2013 Indonesia demographic and health survey 2012Jakarta Indonesia BPS BKKBN Kemenkes and ICF International

Tirtosudarmo R 2013 The politics of a lsquodemographic bonusrsquo The Jakarta Post wwwthejakartapostcomnews20130924the-politics-a-demographic-bonushtml (accessedJanuary 12 2014)

Titaley C M Dibley and C Roberts 2010 Factors associated with underutilization ofantenatal care services in Indonesia Results of Indonesia demographic and health survey20022003 and 2007 BMC Public Health 10 (1)485 doi1011861471-2458-10-485

Trisnantoro L 2011 Pemantauan Pelaksanaan Kebijakan Jampersal dan BOK UntukPelayanan Kesehatan Ibu dan Bayi Di Papua Barat Yogyakarta dan NTT [MonitoringImplementation of Jampersal and BOK Policy for Maternal and Infant Health Services inWest Papua Yogyakarta and NTT] Kemenkes httpwwwkesehatanibudepkesgoidwp-contentuploadsdownloads201208Hasil-Studi-Jampersal-2011_Laksono-Trisnantoropdf (accessed January 10 2014)

UNDP 2012 MDG acceleration framework Saving the lives of mothers in central JavaIndonesia UNDP httpwwwundporgcontentdamundplibraryMDGMDG20Acceleration20FrameworkMAF20ReportsMDG20Indonesia20sep-24pdf(accessed January 2 2014)

UNICEF 2005 Early marriage a harmful traditional practice a statistical exploration 2005New York NY UNICEF

WOMEN amp HEALTH 15

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at 1

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Wong E L B M Popkin D K Guilkey and J S Akin 1987 Accessibility quality of careand prenatal care use in the Philippines Social Science amp Medicine 24 (11)927ndash44doi1010160277-9536(87)90286-3

Word Health Organization 1994 Mother-baby package Implementing safe motherhood incountries Geneva Switzerland Author

World Health Organization 2012 Adolescent pregnancy httpwwwwhointmediacentrefactsheetsfs364en (accessed January 12 2015)


16 F EFENDI ET AL

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Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References

Determinants of utilization of antenatal care servicesamong adolescent girls and young women in IndonesiaFerry Efendi SKepNs MScab Ching-Min Chen RN DNSac Anna Kurniati SKM MAadand Sarni Maniar Berliana SST MSie

aInstitute of Allied Health Sciences College of Medicine National Cheng Kung University TainanTaiwan China bFaculty of Nursing Airlangga University Surabaya Indonesia cDepartment of Nursingand Institute of Gerontology National Cheng Kung University Tainan Taiwan China dCenter forPlanning and Management of Human Resources for Health The Board for Development andEmpowerment of Human Resources for Health (BPPSDMK) Ministry of Health Jakarta IndonesiaeInstitute of Statistics (STIS) Statistics Indonesia (BPS) Jakarta Indonesia

ABSTRACTDue to the high number of maternal deaths provision ofantenatal care services (ANC) in Indonesia is one of the keyaims of the post-Millennium Development Goals agenda Thisstudy aimed to assess the key factors determining use of ANCby adolescent girls and young women in Indonesia Data fromthe Indonesia Demographic and Health Survey 2012 wereused with a focus on married adolescent girls (aged15ndash19 years n = 543) and young women (20ndash24 yearsn = 2916) who were mothers Bivariate and multiple logisticregression analyses were performed to determine the factorsassociated with ANC use The findings indicated that adoles-cents were less likely to make ANC visits than young womenRicher women were more likely to make four ANC visits in bothgroups compared to the poorer women Living in urban areashigher educational attainment and lower birth order were alsoall associated with higher levels of receiving ANC amongyoung women The results showed that socio-economic factorswere related to the use of ANC among adolescent girls andyoung women Ongoing health-care interventions should thusput a priority on adolescent mothers coming from poor socio-economic backgrounds

ARTICLE HISTORYReceived 9 July 2015Revised 20 March 2016Accepted 21 March 2016

KEYWORDSAdolescent girls antenatalcare use young women

Introduction

In 2015 Indonesia set a target to achieve a critical goal of reducing theMaternal Mortality Rate (MMR) to 102 per 100000 live births (Bappenas2012 UNDP 2012) However this target appears difficult to obtain as thelatest data showed that the MMR was 359 per 100000 live births (StatisticsIndonesia et al 2013) A recent publication also showed that Indonesia failedto reduce MMR to the level needed to reach the target included in the

CONTACT Ching-Min Chen RN DNS chingminmailnckuedutw Institute of Allied Health SciencesCollege of Medicine National Cheng Kung University No 1 Daxue Rd East Dist Tainan City 70101 Taiwan China

WOMEN amp HEALTHhttpdxdoiorg1010800363024220161181136

copy 2016 Taylor amp Francis

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2 F EFENDI ET AL

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Setting


WOMEN amp HEALTH 3

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Data



Outcome variables




4 F EFENDI ET AL

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at 1

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Analytical approach


Ethics statement


Results


WOMEN amp HEALTH 5

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at 1

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6










6 F EFENDI ET AL

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at 1

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6


Discussion





n () X2








Total 543 2916

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WOMEN amp HEALTH 7

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8 F EFENDI ET AL

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10 F EFENDI ET AL

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at 1

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26

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201

6





WOMEN amp HEALTH 11

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Limitations



Conclusion


12 F EFENDI ET AL

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References















WOMEN amp HEALTH 13

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14 F EFENDI ET AL

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at 1

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6















WOMEN amp HEALTH 15

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16 F EFENDI ET AL

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May

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6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References





2 F EFENDI ET AL

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at 1

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6





Setting


WOMEN amp HEALTH 3

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by [

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ung

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vers

ity]

at 1

943

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May

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6

Data



Outcome variables




4 F EFENDI ET AL

Dow

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ded

by [

Nat

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l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

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6


Analytical approach


Ethics statement


Results


WOMEN amp HEALTH 5

Dow

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by [

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ity]

at 1

943

26

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201

6










6 F EFENDI ET AL

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ded

by [

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vers

ity]

at 1

943

26

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201

6


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

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6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

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6
















WOMEN amp HEALTH 9

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6




10 F EFENDI ET AL

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at 1

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6





WOMEN amp HEALTH 11

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6




Limitations



Conclusion


12 F EFENDI ET AL

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References















WOMEN amp HEALTH 13

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6



















14 F EFENDI ET AL

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6















WOMEN amp HEALTH 15

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at 1

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6





16 F EFENDI ET AL

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at 1

943

26

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201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References





Setting


WOMEN amp HEALTH 3

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vers

ity]

at 1

943

26

May

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6

Data



Outcome variables




4 F EFENDI ET AL

Dow

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ded

by [

Nat

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l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


Analytical approach


Ethics statement


Results


WOMEN amp HEALTH 5

Dow

nloa

ded

by [

Nat

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l Che

ng K

ung

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ity]

at 1

943

26

May

201

6










6 F EFENDI ET AL

Dow

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ded

by [

Nat

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vers

ity]

at 1

943

26

May

201

6


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

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at 1

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26

May

201

6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

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ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

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by [

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at 1

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26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

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l Che

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ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

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ded

by [

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vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

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ded

by [

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ung

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vers

ity]

at 1

943

26

May

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6


References















WOMEN amp HEALTH 13

Dow

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by [

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ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

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ded

by [

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ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

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by [

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l Che

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ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

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l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References

Data



Outcome variables




4 F EFENDI ET AL

Dow

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ded

by [

Nat

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l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


Analytical approach


Ethics statement


Results


WOMEN amp HEALTH 5

Dow

nloa

ded

by [

Nat

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l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6










6 F EFENDI ET AL

Dow

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ded

by [

Nat

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ung

Uni

vers

ity]

at 1

943

26

May

201

6


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

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by [

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at 1

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26

May

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6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

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ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

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at 1

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26

May

201

6




10 F EFENDI ET AL

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ity]

at 1

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26

May

201

6





WOMEN amp HEALTH 11

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by [

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at 1

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26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

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at 1

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References















WOMEN amp HEALTH 13

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14 F EFENDI ET AL

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6















WOMEN amp HEALTH 15

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16 F EFENDI ET AL

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26

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6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References


Analytical approach


Ethics statement


Results


WOMEN amp HEALTH 5

Dow

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by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6










6 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References










6 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References


Discussion





n () X2








Total 543 2916

p lt 05 p lt 01 p lt 001

WOMEN amp HEALTH 7

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References














p lt 05 p lt 01 p lt 001

8 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6
















WOMEN amp HEALTH 9

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References
















WOMEN amp HEALTH 9

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References




10 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References





WOMEN amp HEALTH 11

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References




Limitations



Conclusion


12 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References


References















WOMEN amp HEALTH 13

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References



















14 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References















WOMEN amp HEALTH 15

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References





16 F EFENDI ET AL

Dow

nloa

ded

by [

Nat

iona

l Che

ng K

ung

Uni

vers

ity]

at 1

943

26

May

201

6

Abstract

Introduction


Setting

Data

Outcome variables


Analytical approach

Ethics statement

Results




Discussion

Limitations

Conclusion

References