Pregnancy Knowledge, Attitudes, and Practices in

PREGNANCY KNOWLEDGE, ATTITUDES, AND PRACTICES IN
INDONESIA: DOES HUSBANDS SOCIAL SUPPORT MAKE A DIFFERENCE?
by
Corinne L. Shefher-Rogers
A dissertation submitted to The Johns Hopkins University in conformity with the

requirements for the degree of Doctor of Philosophy
Baltimore, Maryland
February 17, 2004
Corinne L. Shefiier-Rogers 2004

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ABSTRACT
In Indonesia, women are dying from pregnancy-related complications and

childbirth at a relatively high rate, up to 470 per 100,000 live births. The majority of
women give birth in their homes, under less-than-sterile conditions, and without the
assistance of a skilled healthcare provider. Delays in recognizing danger signs during
pregnancy and seeking care from unskilled healthcare providers often result in poor
pregnancy outcomes and premature maternal death. Prior research suggests that an
individuals social environment and interpersonal communication with others influence
her healthcare seeking behavior, her health status, and may influence maternal health
outcomes.
The purpose of this dissertation study is to determine whether husbands social
support (informational and instrumental support) contributes to a womans knowledge
about pregnancy danger signs, attitudes toward skilled healthcare providers, and use of a
skilled healthcare provider for delivery. The present investigation uses cross-sectional
population-based survey data from 2,269 women of reproductive age and lower
socioeconomic strata living in six districts of West Java, Indonesia.
The level of husbands instrumental support was a predictor of (1) the level of a
womans knowledge about pregnancy danger signs, and (2) use of a skilled attendant for
delivery. A womans place of residence was a stronger predictor of use of a skilled
attendant than was husbands informational or instrumental support. The odds of using a
skilled healthcare provider for delivery were greater for women with higher levels of
knowledge about pregnancy danger signs and more positive attitudes toward skilled
healthcare providers.
The findings from this study show that husbands play a role in their wifes
pregnancy knowledge and attitudes, and in the selection of a skilled attendant for
delivery. This study represent a first step toward understanding the social interaction
between husbands and wives in Indonesia, and a stepping stone for the exploration of the
decision-making processes among couples about pregnancy and delivery.
Patricia OCampo
ill
ACKNOWLEDGEMENTS
Writing a dissertation is not the lone process that many imagine. Yes, there are
the hours spent at a computer composing, analyzing, re-writing. This process, however,
is orchestrated by an advisor, and, in my case, made possible by an abundance of positive
social support. Dr. Patricia OCampo, my advisor at the Johns Hopkins Universitys
Bloomberg School of Public Health, has been my behind-the-scenes champion. Without
Pat, I could not have navigated the dissertation process. She has been honest, clear,
encouraging, and compassionate. I am grateful for her trust in my ability to accomplish
this task.
My dissertation committee, composed of four women role models, made this
process friendly. Dr. Cynthia Stanton has been a role model for academic generosity. I
thank Cindy for sharing her depth of knowledge about maternal mortality reduction, and
encouraging me to think in new directions about this topic. Dr. Andrea Gielen helped me
to think about the theoretical foundations of this study. Her kind demeanor was very
much appreciated. Dr. Linda Pughs interest in this topic and intellectual probing
inspired me to think about study design issues.
I am especially indebted to Linda Adams, Academic Coordinator for the
Department of Population and Family Health Sciences, who has been an invaluable
administrative champion. I thank Linda for handling all of administrative paperwork, for
k e e p in g m e in th e J H U lo o p , and fo r b e in g so caring. S p ecia l th a n k s to D r. Sharon K rag
for her flexibility and infectious positive attitude.

I also thank Sherry Weber at the Johns Hopkins University/Center for
Communication Programs (JHU/CCP) for following the paper trail for the necessary
IV
CJIR/IRB approval, and USAID and the Government of Indonesia for funding the MNH
study and data collection. The women respondents in this study deserve thanks for their
time in responding to the survey questionnaire.
A fortuitous and relevant event led to my involvement with the Maternal and
Neonatal Health (MNH) Project in Indonesia, and to the present dissertation topic: Dr.
Suruchi Sood's pregnancy with Sidharth. In January, 2001, Suruchi, a friend and
colleague, and a Senior Evaluation Officer in the Research and Evaluation Division at the
Johns Hopkins University Center for Communication Programs, asked me to work on the
evaluation component of the MNH Project's Behavior Change Intervention Program
while she took maternity leave. Her faith in my abilities opened the door to one of the
most enriching experiences of my academic career. Suruchi has been, perhaps
unwittingly, a mentor and role model to me. She has given so generously of her time and
knowledge about research and evaluation, STATA, and SPSS, and I have learned so
much from my association with Suruchi.
Several photos sat on my desk in Baltimore, Maryland during the year that I
completed my coursework, and on my home-oflfice desk in the shadow of the Sandia
Mountains in Albuquerque, New Mexico, where I wrote the present dissertation. The
people in these photos silently motivated and encouraged me to do my best as a scholar
and as a person. The photo of my mother, Julianna Shefner, kept me grounded and was a
reminder of the unconditional love and support I have always received, especially with
regard to my academic endeavors. Her questions about my dissertation topic led to
interesting discussions and gave me food for thought. The photo of my father, Mordecai
Shefner, who died many years ago, inspired me to build my dissertation in the same way
that he designed and built houses, with vision, patience, and pleasure. The photo of my
brother, Yves Shefner, was a constant reminder of all that I have learned from him over
the years. Yves has always been a teacher to me, patiently answering my endless stream
of questions, and making me laugh when I needed it most. His support of my endeavors
has never wavered.
Last, but definitely not least, was the photo of my husband, Everett M. Rogers,
who left me to my own devices, but never let me forget that I had the capability to
achieve my academic goal. His love and support have been my guiding light. I thank
him for taking his sabbatical year when it suited my schedule, coming to Baltimore for
the year that I took my doctoral courses, and for all the tea and biscotti breaks he made
me take while I studied on the top floor of our Otterbein row-house.
My world has been shaped by each of these individuals, for which I am
profoundly thankful.
I am deeply gratefiil to Anne Palmer, not only for our friendship, but also for
encouraging me to work on the MNH Project in Indonesia for which Anne was the Senior
Program Officer in charge. To Anne Palmer, her husband Bill Vondrasek, and their sons
Max and Roy, I give special thanks for their hospitality and generosity. Their house was
my home whenever I traveled to Baltimore from Albuquerque to meet with my advisor
and committee members.
Many thanks to Hal Nelson in the Department of Mathematics and Statistics at the
University of New Mexico for his help with factor analyzing dichotomous variables.
This dissertation journey involved closest friends Wendy and Kate, who always
asked with interest about that little paper I was writing. I am lucky to have such
VI
supportive friends. To all my family, friends, and colleagues, this little paper is done.
Onward!
Vll
TABLE OF CONTENTS
Page Number
ABSTRACT....................................................................................................................... ii
ACKNOWLEDGEMENTS........................................................................................... iv
TABLE OF CONTENTS............................................................................................. viii
LIST OF TABLES............................................................................................................xi
LIST OF FIGURES....................................................................................................... xiii
CHAPTER!. INTRODUCTION..................................................................................1
Causes of Maternal Mortality in Indonesia....................................................... 2
Demand for Maternal Healthcare in Indonesia................................................. 4
Social Status and Maternal Health in Indonesia................................................5
Social Custom and Maternal Health in Indonesia.............................................6
Maternal Mortality Prevention Strategies......................................................... 8
The Mother Friendly Movement in Indonesia..................................................14
A Social Ecological Approach to Maternal Health Behavior Change...............18
Purpose of the Present Study............................................................................. 19
CHAPTER 2. LITERATURE REVIEW..................................................................... 23
What Is Social Support?.................................................................................... 24
Social Support and Health................................................................................. 29
Social Support and Maternal Health..................................................................33
Measuring Social Support................................................................................. 38
Pregnancy-Related Social Support Interventions..............................................40
Summary........................................................................................................... 44
CHAPTER 3. CONCEPTUAL FRAMEWORK AND HYPOTHESES............... 46
Conceptual Framework..................................................................................... 46
Theoretical Assumptions................................................................................... 50
Study Research Questions and Hypotheses...................................................... 53
Summary........................................................................................................... 58
CHAPTER 4. METHODOLOGY................................................................................ 59
Study Area......................................................................................................... 59
Study Sample.....................................................................................................60
Source of Data...................................................................................................62
Study Variables..................................................................................................64
Data-Analysis....................................................................................................75
Summary........................................................................................................... 82
V lll
CHAPTERS. RESULTS................................................................................................. 83
Profile of Respondents....................................................................................... 83
Differences Between Category 3 and Category 4 Women................................86
Research Question 1; Are social support measures that were developed
and tested in developed world contexts reliable in the Indonesian
context?...................................................................................................86
Hypothesis #la: High levels of husbands informational support during
pregnancy is positively associated with high levels of womens
knowledge about pregnancy danger signs among Indonesian women of
reproductive age from lower socioeconomic strata.................................... 88
Hypothesis #lb: High levels of husbands informational support during
pregnancy is positively associated with womens positive attitudes
toward trained healthcare providers among Indonesian women of
reproductive age fiom lower socioeconomic strata.................................... 98
Hypothesis #2: High levels of husbands instrumental support during
pregnancy is positively associated with using a trained healthcare provider
for delivery among Indonesian women of reproductive age from lower
socioeconomic strata................................................................................... 98
Hypothesis #3: High levels of knowledge about pregnancy danger signs is
positively associated with positive attitudes toward trained healthcare
providers among Indonesian women of reproductive age from lower
socioeconomic strata................................................................................... 106
Hypothesis #4: High levels of knowledge about pregnancy danger signs is
positively associated with using a trained healthcare provider for delivery
among Indonesian women of reproductive age from lower socioeconomic
strata............................................................................................................ 106
Hypothesis #5: Positive attitudes toward trained healthcare providers is
positively associated with using a trained healthcare provider for delivery
among Indonesian women of reproductive age from lower socioeconomic
strata............................................................................................................. 111
Summary........................................................................................................... 119
CHAPTER 6. DISCUSSION..........................................................................................123
Overview .......................................................................................................... 123
Are Western Measures of Social Support Appropriate in Indonesia? ..............126
Does Husbands Social Support Make a Difference?...................................... 127
Theoretical Implications................................................................................... 132
Research Implications ...................................................................................... 133
Implications for Safe Motherhood Programs....................................................135
Limitations of the Study.................................................................................... 136
Conclusions.......................................................................................................137
APPENDICES...................................................................................................................139
Appendix A: Istri Baseline Questionnaire........................................................139
IX
REFERENCES................................................................................................................... 171
VITA
LIST OF TABLES
Page Number
Table 1.1 Maternal Health Indicators for Indonesia..................................................... 5

Table 2.1 Types of Social Support Studied by Researchers Investigating
the Relationship Between Social Support and Maternal Well-Being During
Pregnancy.......................................................................................................................35
Table 4.1 Principal Components Factor Analysis Rotated Factor Loadings and
Item-to-Total-Score Correlations for Knowledge of Danger Signs During
Pregnancy........................................................................................................................66
Table 4.2 Principal Components Factor Analysis Component Matrix for Attitude
Toward a Skilled Provider..............................................................................................68
Table 4.3 Item-to-Total Score Correlations for Husbands Informational Support..... 71
Table 4.4 Item-to-Total Score Correlations for Husbands Instrumental Support...... 72
Table 4.5 Percent Distribution of the Study Variables.................................................76
Table 4.6 Study Hypotheses and the Methods Used for Statistical Analyses..............80
Table 5.1 Selected Demographic Characteristics of Category 3 and Category
4 Women Respondents in West Java, Indonesia............................................................ 84
Table 5.2 Difference Between Category 3 and Category 4 Women Regarding
the Study Variables........................................................................................................ 87
Table 5.3 Principal Components Factor Analysis Rotated Factor Loadings for
Husbands Informational Support.................................................................................. 89
Table 5.4. Principal Components Factor Analysis Rotated Factor Loadings for
Husbands Instrumental Support................................
91
Table 5.5. Percentage Distribution of Women Respondents Knowledge about

Pregnancy Danger Signs, by Level of Husbands Informational Support in West
Java, I n d o n e s ia .................................................................................................................................................... 9 4
Table 5.6. Model Summary for Standard Multiple Regression of Womens

Knowledge about Pregnancy Danger Signs by Husbands Informational
Support in West Java, Indonesia.................................................................................... 95
Table 5.6a. Model Summary for Standard Multiple Regression of Womens
XI
Knowledge about Pregnancy Danger Signs by Husbands Instrumental

Support in West Java, Indonesia....................................................................................97
Table 5.7. Percentage Distribution of Category 3 Women Respondents Use of a
Skilled Healthcare Provider for Delivery by Level of Husbands Instrumental
Table 5.8. Model Summary for Logistic Regression Analyses of Use of a Skilled
Healthcare Provider for Delivery by Instrumental Support, Age, Education,
and Residence, for Category 3 Women in West Java, Indonesia..................................101
Healthcare Provider for Delivery by Instrumental Support, Age, Education,
and Residence, for Category 4 Women in West Java, Indonesia...................................105
Table 5.11. Percentage Distribution of Category 3 and 4 Women Respondents Use
of a Skilled Healthcare Provider for Delivery by Level of Knowledge About
Pregnancy Danger Signs in West Java, Indonesia.........................................................108
Healthcare Provider for Delivery by Knowledge, Age, Education, Parity, Monthly
Household Expenditure, and Residence, for Category 3 and 4 Women in West Java,
Indonesia........................................................................................................................ 109
Table 5 .13. Percentage Distribution of Category 3 Women Respondents Use
of a Skilled Healthcare Provider for Delivery by Level of Attitude Toward Skilled
Healthcare Providers in West Java, Indonesia................................................................112
Healthcare Provider for Delivery by Attitudes Toward Skilled Healthcare Providers,
Age, Education, Parity, Monthly Household Expenditure, and Residence, for
Category 3 Women in West Java, Indonesia..................................................................113
Table 5.15. Percentage Distribution of Category 4 Women Respondents Use
of a Skilled Healthcare Provider for Delivery by Level of Attitude Toward Skilled
H ea lth c a r e P r o v id e r s in W e s t Java, I n d o n e s ia ..................................................................................... 116
Healthcare Provider for Delivery by Attitudes Toward Skilled Healthcare Providers,
Age, Education, Monthly Household Expenditure, and Residence, for Category 4
Women in West Java, Indonesia.....................................................................................117
X ll
LIST OF FIGURES
Page Number
Figure 3.1. The Three Delays M odel.............................................................................47

Figure 3.2. MNH Conceptual Framework for Indonesia.............................................. 48
Figure 3.3. The Conceptual Model of the Influence of Husbands Social Support on
Womens Pregnancy Knowledge, Attitudes, and Practices for Women of
Reproductive Age From Lower Socioeconomic Strata in West Java, Indonesia.......... 49
Figure 4.1. Map of Study Districts in West Java, Indonesia........................................ 61
Figure 5.1. Summary of Conceptual Model of the Influence of Husbands Social Support
on Womens Pregnancy Knowledge, Attitudes, and Practices for Women of
Reproductive Age From Lower Socioeconomic Strata in West Java, Indonesia...........120
Xlll
Chapter 1
INTRODUCTION
Giving birth is an important public health concern in Indonesia. The majority of

Indonesian women give birth in their homes, under less-than-sterile conditions, and
without the assistance of a skilled healthcare provider. * Some 5 million women give
birth in Indonesia each year. Approximately 22,000 Indonesian women die annually as a
result of pregnancy and childbirth. The maternal mortality ratio for Indonesia is 470 per
100,000 live births, the fourth highest estimated number of maternal deaths in the world
(World Health Organization, 2001b).^ The present maternal mortality ratio is almost half
of what it was between 1980 and 1982 (858 maternal deaths per 100,000 live births)
(MotherCare/Indonesia, 1996). Since the launch of the Indonesian Safe Motherhood
Initiative in 1987, however, the present maternal mortality ratio has remained relatively
constant.^
' A skilled provider (or attendant) is a person with midwifery skills (a medical doctor with appropriate
training and experience, mnse with additional midwifery education, or midwife) who is proficient in the
skills necessary to manage normal labor, delivery, and the postpartum period, recognize the onset of
complications, perform essential interventions, begin treatment, and refer mothers to higher levels o f care
when necessary (World Health Organization, 1999b). In 1996, the World Health Organization replaced tlie
term trained providers or attendants with skilled attendants, recognizing that trained implies but does
not guarantee knowledge gain and proficiency, whereas skilled implies the competent use o f knowledge.
Skilled attendance at delivery is as a proxy indicator for monitoring progress in maternal mortahty.
^ It is important to note that maternal deaths are, on average, underreported by a factor at least 50 percent
The range o f uncertainty for the maternal mortality ratio for Indonesia includes a lower estimate o f 370
maternal deaths per 100,000 live births, and an upper limit of 580 maternal deaths per 100,000 live births.
These large margins o f uncertainty preclude using maternal mortahty ratios to look at trends in maternal
deaths (World Health Organization, 2001b). When the number of maternal deaths is estimated as the
product o f the total number o f births and obstetric risk per birth, the region with the highest numbers of
maternal deaths (on a risk per births basis) is Africa (World Health Organization, 2001b).
^ The maternal mortality ratio estimates for Indonesia were lowered following a 1995 revision in the
method for calculating maternal mortality ratios by the World Health Organization in collaboration with
Causes of Maternal Mortality in Indonesia
Maternal mortality is the death of a woman while pregnant or within 42 days of

termination of pregnancy, from any cause related to, or aggravated by, the pregnancy or
its management, but not from accidental or incidental causes (ICD-10, 1992). Globally,
at least 515,000 women die each year from pregnancy and childbirth complications
(World Health Organization, 2001b). About 99 percent of maternal deaths occur in
developing countries. At least 90 percent of maternal deaths occur in Sub-Saharan Africa
or in Asia. The World Health Organization (2001b) reports that 15 percent of women
who become pregnant each year experience complications that require treatment by a
skilled provider. This estimate of complications, however, is not supported by empirical
evidence, and the assumption that the incidence of obstetric complications is constant
across populations may be false (Ronsmans, Campbell, McDermott, & Koblinsky, 2002).
Disparities in maternal mortality ratios reflect (1) racial or socioeconomic
differences in access to healthcare within nations, and (2) the socioeconomic disparities
between developed and developing countries. In the United States for example, the
maternal mortality ratio for Black women is four times higher than for white women
(Maine & Chavkin, 2002). In Indonesia, over a womans reproductive lifespan, she
faces a 1 in 41 lifetime risk"* of dying from pregnancy and childbirth complications,
compared to women in developed countries, whose lifetime risk of death from pregnancy
is 1 in 1,800 (Nguyen, 1998).
UNICEF and UNFPA (World Health Organization, 2001b). The maternal mortality ratio prior to 1995 was
approximately 650 maternal deaths per 100,000 live births (UNICEF, 1996).
Lifetime risk is the risk o f an individual woman dying from pregnancy or childbirth during her lifetime.
Lifetime risk is calculated as 1/(1.2*1 FR*MMR), where 1.2 is an adjustment factor for pregnancy loss,
TFR is the total fertihty rate, and MMR is the maternal mortality ratio (World Health Organization, 2001b).
A lifetime risk o f 1 in 41 represents a high risk o f dying from pregnancy or childbirth.
At least 75 percent of maternal deaths result from direct obstetric factors. The
three most common, direct medical causes of maternal death in Indonesia are hemorrhage
(40-60 percent), infection (sepsis) (20-30 percent), and pre-eclampsia/eclampsia (20-30
percent) (MotherCare/Indonesia, 1996; Cholil, 1997). Abortion complications, prolonged
labor, anemia, and other pre-existing conditions (for example, diabetes, malaria,
HIV/AIDS) are also important causes of maternal death in Indonesia (Achmad, 1999;
IDHS, 1998). A majority of these deaths are preventable with timely and appropriate
medical attention (Thaddeus & Maine, 1994).
Non-medical and indirect causes of death are most often attributed to (1) delays in
recognizing pregnancy-related complications and seeking care, (2) delays in reaching a
healthcare facility, and (3) delays in receiving adequate healthcare (Thaddeus & Maine,
1994). Any one of these three delays can result in maternal death. In a study of perinatal
mortality in South Kalimantan, Indonesia (Supratikto, Wirth, Achadi, Cohen, &
Ronsmans, 2002), delays in decision-making about when to seek appropriate obstetric
care contributed to 77 percent of maternal deaths, and poor quality of care in health
facilities contributed to 60 percent of maternal deaths. Factors that contribute to these
delays include (1) a low value placed on a womans life, (2) traditional belief systems,
and (3) inability in recognizing specific danger signs during pregnancy.
Barriers that make it difficult for women to access emergency obstetric care
include (1) a lack of awareness about the need to seek emergency care, (2) an inequitable
distribution of power in social relationships that prevents pregnant women from
demanding and receiving emergency obstetric care, (3) a lack of transportation, and (4) a
lack of funds to pay for such care (Beegle et al., 2001; Geefhuysen, 2000). Supratikto
and others (2002) estimated that economic constraints contributed to 37 percent of

maternal deaths, and that distance to a healthcare facility and transport to a facility did
not contribute significantly to maternal deaths in South Kalimantan, Indonesia. Some 68
percent of Indonesian women deliver their child(ren) in their own home (IDHS, 1998).
Demand for Maternal Healthcare in Indonesia
Table 1.1 shows selected indicators of maternal health in Indonesia. These

indicators suggest a strong need to reduce maternal mortality and increase maternal
health. Women in Indonesia marry young, and start childbearing at an early age. The
majority of Indonesian women (1) cannot maintain a nutritious diet, and (2) cannot afford
basic healthcare, transportation to healthcare facilities, and medicines (Tandon, 2001).
Traditional birth attendants {dukunf with minimal training in managing pregnancy or
delivery complications are the primary maternal care providers in Indonesia.
On the supply side, by 1998, some 54,000 skilled midwives^ were trained and
placed in villages by the government of Indonesia (Frankenberg & Thomas, 2000),^ yet
very few health centers in Indonesia have adequately skilled healthcare providers,
necessary equipment, and medicines to manage obstetric emergencies. Prior to January,
2001, healthcare services were organized at the Indonesian governments Health Ministry
level; budgeting and policy decisions were made by Ministry officials. The size of sub
district health centers was determined by the size of the population and the number of
^ In the Indonesian language, the word dukun is singular and plural (i.e., no s is used to mark these
words as plural).
A midwife is an individual who possesses the cognitive and practical skills that enable her to provide
basic healthcare services during normal pregnancy, labor, and the postpartum period, including preventive
measures, detection o f abnormal conditions in the mother or her child, and obtaining medical assistance in
the event o f obstetric emergency. A midwife must complete a prescribed course o f studies in midwifery
that is recognized by the government that licenses the midwife to practice (WHO/FIGO/ICM, 1992).
^ Geefhuysen (2000) estimated that 56,000 midwives were placed in villages between 1991 and 1997.
villages that the center served. Newly graduated doctors were placed in these health
centers on contract, and were charged with managing the center. Usually, a new doctor
left his post in the remote village area within a year. In January, 2001, the government of
Indonesia decentralized the healthcare system, shifting all planning and budgetary
activities to local governments. The impact of this decentralization for maternal health is
yet to be determined (Geefhuysen, 2000; USAID, 2002).
Table 1.1 Maternal Health Indicators for Indonesia.

Indicator
Total population4
Maternal mortality ratio'
Lifetime risk of maternal death'
Total fertility rate^
Prevalence of anemia among pregnant womens
Perinatal mortality rate^
Neonatal mortality rate^
Women receiving at least one antenatal care visit^*
Assisted delivery by a medically trained health professionaP
Deliveries at health facilities^
Contraceptive prevalence rate, modem methods, married
women^
HIV prevalence, adult4
Abortion policy^
Level
228,437,872
470 per 100,000
1 in 41
2.8
51%
40 per 1,000
25 per 1,000
93 %
49%
21 %
55%
0.05%
Illegal or permitted only to
save a womans life
' World Health Organization (2001b).

IDHS (1998).
World Health Organization (2001a).
4 PHNIP (2002).
5World Health Organization (200 Ic).
* Antenatal care is the care that a woman receives throughout her pregnancy (MNH/JHPEIGO, 2001).
Social Status and Maternal Health in Indonesia
Women represent a majority of the poor in Indonesia. The generally low social
status of Indonesian females contributes to a womans limited ability to access the
economic resources needed for maternal healthcare. Most women wait for their husbands
to decide whether they should seek help for pregnancy complications. During labor, this
waiting period can be deadly (Cholil, 1997). Traditional values dictate that women
behave in a submissive and obedient manner; women are expected to obey their husband.
The younger generation of women believe that men and women should be equal, but, in
general, society has not allowed the expression of these beliefs, and women still care for
other family members before they care for themselves (Cholil et al., 1998). The lack of
social and economic security among Indonesian women leaves them (1) vulnerable to
health problems and childbirth complications, and (2) dependent on their husband for
economic resources.
An Indonesian womans pregnancy, prenatal care, and birth experiences are
influenced (1) by her level of education and knowledge about pregnancy, (2) by her
ability to afford healthcare services, and (3) by the information and aid that she receives
from family and friends. Recourse to modem services is taken only in an emergency
situation. The definition of an emergency is ambiguous at the lay level. When a
pregnancy-related emergency occurs, the woman and her family are responsible for
seeking appropriate care (Beegle et al., 2001; Geefhuysen, 2000).
Social Custom and Maternal Health in Indonesia
Maternal death has implications for the entire family, and for the community. In
Indonesia, childbirth is considered a routine activity of life, not deserving of special care
for a prolonged period of time (Tandon, 2001). The discomfort or pain experienced
during pregnancy is a matter of individual perception, molded by social custom and
religion. Silent self-sacrifice and tolerance for pain among Indonesian women are
socially determined. This tolerance often leads to delays in seeking timely and
appropriate care to manage pregnancy complications (Tandon, 2001).
Despite the general perception among Indonesians of childbirth as routine,
Indonesian religious beliefs recognize pregnancy as an important time for both mother
and child. A sequence of ritual ceremonies are associated with childbirth, especially the
birth of the first child, to protect mother and child from malevolent forces. For example,
(1) pengerujakan is performed in the sixth month of pregnancy to strengthen the baby
while in the mothers womb in order to avoid miscarriage, (2) mujah bulanan is
performed in the seventh month during which the family prays for the well-being of the
mother and child, and (3) lolosan, conducted in the eighth month of pregnancy, is
believed to assure a smooth delivery (Tandon, 2001). These social customs suggest an
acknowledgement of the potential dangers of pregnancy and childbirth. Many Javanese
believe that if a woman suffers complications during childbirth, then these difficulties
must be deserved, that is, they are the result of previous transgressions in her behavior, or
in the behavior of her ancestors (Achmad, 1999).
A woman should adhere to a number of food-related taboos during pregnancy.
For example, a woman should not eat dried fish because it will weaken her body, and
drinking Sprite during the first six months of pregnancy could cause a miscarriage
because Sprite is believed to contain alcohol. But drinking Sprite after the sixth
month will promote the babys hair-growth inside the womb (Tandon, 2001). Tandon
(2001) reported (1) that malnutrition during pregnancy was identified as a causal factor of
complications during delivery, (2) that respondents were unclear about what constituted a
balanced, healthy diet, and (3) that most women try to save the money they would
normally spend on food to pay for pregnancy-related religious ceremonies and

emergencies, consequently changing the type and amount of food that they consume
during pregnancy.
The Indonesian Ministry of Health recommends that pregnant women obtain
prenatal care four times during their pregnancy: (1) Once during the first trimester; (2)
once during the second trimester, and (3) twice during the third trimester. An important
part of this prenatal care is receiving at least two tetanus toxoid immunizations and iron
tablets. On average, 93 percent of pregnant women in Indonesian received some
antenatal care (i.e., at least one antenatal visit)^; 74 percent of women from the poorest
households received some antenatal care, and 99 percent of women from the richest
households received some antenatal care (World Bank, 2000; PHNIP, 2002). Women
who were 35 years and older were less likely to receive antenatal care, compared to 20-34
year olds (Jirojwong et al., 1999). In 1997, the mothers of 53 percent of live births
received two or more tetanus immunizations during pregnancy; the mothers of another 18
percent of live births received one immunization (Beegle et al., 2001; IDHS, 1998).
Maternal Mortality Prevention Strategies
Maternal mortality prevention programs in developing nations are largely based

on strategies that contributed to reducing maternal deaths in developed countries. The
availability of such technological innovations for addressing pregnancy and delivery
complications as antibiotics, caesarean procedures, blood transfusions, and control of pre
eclampsia, made declines in maternal mortality possible first in developed countries, and
then in developing nations. Early declines in maternal mortality in such countries as
* Some 89 percent of Indonesian women received two or more antenatal visits, and about 71 percent of
women received the govermnent-recommended number o f four antenatal visits or more (PHNIP, 2002).
England, Sweden, the Netherlands and Denmark resulted from (1) early recognition of
the magnitude of maternal mortality, (2) identification of the factors affecting the
distribution of maternal deaths, and (3) establishing priorities for addressing the problem,
for example, professionalizing midwifery care (De Brouwere et al., 1998; Van Lerberghe
& De Brouwere, 2001; Loudon, 1992).
Maternal mortality reduction strategies have developed in stages over the last five
decades. In the early 1950s, maternal mortality prevention interventions consisted of
establishing antenatal clinics and educating mothers about pregnancy and childbirth. In
the late 1960s, family planning promotion was added as a measure for maternal welfare.
A decade later, traditional birth attendants (TBAs)^ were trained in methods for clean
delivery (i.e., professionalized) and promoted as a strategy to arrest maternal death rates.
TBAs provided risk assessment at delivery and could deliver low-risk births.' By the
1980s, however, the training of traditional birth attendants, while still promoted as a key
element in the strategy to prevent maternal deaths by the World Health Organization, was
called into question by researchers. A new approach was proposed: Make it possible for
women to reach a well-equipped hospital (De Brouwere et al., 1998; Maine et al, 1991;
Koblinsky et al., 1994). Proponents for training traditional birth attendants continue to
argue that such training is effective when trained traditional birth attendants (1) have
A traditional birth attendant (TBA) is an individual whose role is to support women during labor. In
general, TBAs are not defined as skilled attendants and are not trained to manage obstetric complications.
Most trained TBAs receive one month or less o f trauiing in vaginal delivery (World Health Organization,
1998a).
TBAs were trained to conduct risk assessment at delivery and refer women with obstetric complications
to liigher levels o f healthcare, but were never expected to save lives directly. Risk assessment, however,
proved insufficient to determine which women would or would not develop obstetric complications
(Maine, 2000), and, consequently, TBAs were considered failures in managing complicated pregnancies
(Stanton, 2003). Evidence that the risk approach to maternal mortahty reduction is inadequate for
identifying which women will develop obstetric complications justifies an increasing emphasis on being
prepared for normal births, as well as being ready for birth comphcations (Rohde, 1995; Yuster, 1995).
adequate supervision and support, and (2) encourage women with complications to seek a
higher level of care (Sai & Measham,1992; Bergstrom & Goodbum, 2001)
In 1987, the jointly sponsored'^ Nairobi Conference on Safe Motherhood focused
maternal mortality prevention activities on improving access to quality emergency
obstetric services, training qualified healthcare providers, and ensuring the adequate
distribution of skilled healthcare providers throughout the country (De Brouwere et al.,
1998). This initiative recognized the need to use a multi-sectoral approach, yet failed to
consider the various social and cultural contexts that may prevent women from gaining
access to skilled healthcare providers. Risk assessment and training traditional birth
attendants to prevent complications were emphasized at the Nairobi Conference (Tinker,
2000). At the International Conference on Population and Development (ICPD) in Cairo
in 1994, the emphases were on (1) detecting and managing high-risk pregnancies and
births, and (2) deliveries assisted by trained persons, preferably nurses and midwives,
but at least by trained birth attendants (ICPD, 1994). The Cairo Conference marked the
initial push toward focusing on some minimum level of skilled attendance*^ at delivery.
In 1997, a meeting of technical experts in Colombo, Sri Lanka produced the Safe
Motherhood Action Agenda, which, in 1999, was released as a Joint Statement on
Maternal Mortality Reduction by the WHO, UNICEF, UNFPA, and the World Bank.
This new agenda for maternal mortality reduction recommended interventions at three
Knowing alx)ut pregnancy-related danger signs and using a skilled healthcare provider for delivery are
means by which women can prepare for normal and complicated births.
" The Nairobi Safe Motherhood Conference was jointly sponsored Ity the World Health Organization,
UNICEF, U N FPA and the World Bank, all members o f the Safe Motherhood Inter-Agency Group (lAG).
Skilled attendance is defined as the process by which a woman is provided with adequate care during
labor, delivery, and the early postpartum period... .(T)he process requires a skilled attendant AND an
enabling environment which includes adequate su^Jlies, equipment and infrastructure as well as efficient
and effective systems o f commimication and referral (Graham et al., 2001, p. 100). Skilled attendance
does not preclude delivery in a womans own home (Curtis et al., 2003).
10
levels: (1) national and local governments, (2) health systems, and (3) communities.
Specifically, attention was shifted toward interventions that considered the social context
and status of women. The action messages included empowering women, ensuring
skilled attendance at everv birth (by a healthcare provider with midwifery skills, i.e., not
a TBA), recognizing that every pregnancy faces risk, improving access to quality
maternal health services, and preventing unwanted pregnancies and addressing unsafe
abortion (Safe Motherhood, 2002).^^
Improved healthcare services alone will likely increase the demand and use of
services, primarily among early adopters or spontaneous acceptors, usually local opinion
leaders who are more educated, more literate, have higher social status, and are more
favorable toward science than later acceptors (Rogers, 2003). However, for the majority
of the intended population, social and cultural dynamics factor into the decision to accept
or adopt a behavior such as using a healthcare facility. In Pakistan, for example, many
women who died from childbirth complications lived close to an improved healthcare
facility, but their husbands were not home to give them permission to seek care at the
facility (Jafaraey & Korejo, 1995). The communication process between husband and
wife is an under-appreciated factor in the maternal mortality prevention behavior change
process.
The most effective individual-level and population-level interventions are family
planning, attendance at delivery by a skilled healthcare provider, and timely diagnosis
and treatment of complications (Winikoff & Sullivan, 1987; Fortney & Smith, 1997;
These messages were developed using coimtry-level data, as opposed to the messages which were
formulated at the initial Nairobi Conference in 1987 that were grounded in community-based assessments
(Safe Motherhood, 2000; Stanton, 2003).
11
World Bank, 1999; Graham, Bell, & Bullough, 2001). In Matlab Thana, Bangladesh,
where abortion is a leading cause of maternal deaths, and is prevalent among young,
unmarried women, a study of the impact of family planning on maternal mortality
showed that the greatest impact was for women less that 20 years old (Trussell & Pebley,
1984), Trussell and Pebley (1984) reported that if women in Matlab had no births below
the age of 20 years, nor above 39 years, and had no more than five children, the maternal
mortality ratio would drop from 5.7 maternal deaths per 1,000 live births to 4.5 deaths per
1,000 live births, a decline of 21 percent.*"^ In Ethiopia, abortion contributed to more than
half of all maternal deaths to women under the age of 20 years (FHI, 2002; Fauveau et
al., 1988). Thus, delaying pregnancy or preventing abortions by increasing family
planning use among married and unmarried women under the age of 20 years may save
many lives.
In 1991, an evaluation of the Maternity Care Program in Matlab, Bangladesh
showed that the decline in maternal deaths was partially due to treatment received from
trained midwives and referral by midwives to the government district hospital in
Chandpur (Maine et al., 1996; Ronsmans, Vanneste, Chakraborty, & van Ginneken,
1997b). In Kebbi State, Nigeria, a community education intervention used weekly
meetings with community opinion leaders, video shows, posters, and pamphlets to
encourage use of emergency obstetric services of upgraded obstetric healthcare facilities.
Survey results following this educational intervention showed that there was a 59 percent
increase among women, and a 55 percent increase among men regarding knowledge
about the need for timely attention for women with obstetric complications. Utilization
A maternal mortality ratio o f 5 .7 deaths per 1,000 live births in Matlab, Bangladesh was reported by
C henetal. (1974).
12
of emergency obstetric services, however, did not increase during the project time period
(Gummi et al., 1997).
Evaluations of safe motherhood programs in low income nations suggest (1) that
maternal mortality does not decrease by itself (Loudon, 1992), (2) that maternal mortality
decline requires multiple and synergistic interventions, and (3) that reductions in maternal
mortality ratios can be achieved without necessarily reaching a high level of economic
development. In Sri Lanka, the maternal mortality ratio dropped as a result of an
initiative that included universal access to prenatal, delivery, and postnatal healthcare,
access to quality emergency obstetric care, access to family planning services, and skilled
attendance at delivery, despite that nations low annual income per capita (Donnay, 2000;
Pathmanathan et al., 2003). In Honduras, the maternal decline was halved between 1990
and 1997 following the Honduran governments commitment to womens health.*^
Traditional birth attendants were trained and integrated into the health system, which led
to an increase (1) in deliveries using a skilled healthcare provider, and (2) in obstetric
emergency referrals to hospitals. The Honduran government improved the healthcare
infrastructure by increasing the number of emergency obstetric care facilities, health
centers, maternity houses, and district hospitals in relatively inaccessible areas, and
improved emergency transportation roads and communication (Danel, 1999; LTNEPA,
1999; Danel & Rivera, 2003).
In the late 1980s, the Honduran National Ministry o f Health began promoting improved access to
healthcare services. It is imelear from Danels (1999) report (1) what effect such promotion had on
maternal mortality decline, and (2) what other changes in the healthcare system between 1980 and 1990
contributed to the dramatic decline in maternal mortality in the 1990s.
13
The Mother Friendly Movement in Indonesia
High maternal mortality levels reflect a poor healthcare system, inappropriate

policies, and inadequate programs to address the basic needs of women. In 1988,
Indonesias then President Soeharto instituted the Safe Motherhood Initiative to reduce
maternal mortality by 50 percent by the year 2000.^* In 1991, the Indonesia National
Family Planning Coordinating Board (BKKBN) launched the Healthy and Prosperous
Mother Movement, a community-based initiative to promote nutrition, the use of prenatal
care services, tetanus toxoid immunization, and the use of skilled*^ healthcare providers
during delivery. A village-based midwife (bidan desdf^ was to be placed in each of the
countrys 65,000 villages. Bidan desa provide a variety of reproductive health services to
community members, including family planning, antenatal exams, deliveries, and
postpartum visits (JHPIEGO, 1998). Before the Safe Motherhood Initiative, there were
no trained midwives in the villages (Geefhuysen, 2000).
Midwives were recruited from nursing academies and attended a one-year
midwifery training course. The original training course for bidan desa focused on
midwifery, without attention to communication skills and practical training in delivery
situations, and without experience in managing birth complications (Geefhuysen, 2000).
Communication skills are essential in order for the bidan to penetrate the community and
to gain the trust and confidence of women and their families. For example, when a
The Safe Motherhood Initiative in Indonesia follows the World Health Organizations Safe Motherhood
Initiative recommendations to provide skilled attendance at birth as the most likely way to reduce
pregnancy-related mortality (Geefhuysen, 2000).
In Indonesia, a skilled healthcare provider refers to one o f the following persons; Doctor,
Specialist/OBGYN, Health Center Midwife (bidan puskesmas/polindes). Village Midwife (bidan desa), or
Private Practice Midwife (bidan swasta). A traditional midwife (dukun) is an imskilled practitioner.
In the Indonesian language, the word bidan is singular and pliual (i.e., no s is used to mark these
words as plural).
14
woman experiences a complication that requires her to be transferred to a better-equipped

facility, the bidan must be able to persuade her to pay for more expensive treatment.
Once they completed their training, these midwives were contracted by the government
for a three-year period and each placed in a village. Evaluations of these bidan desa in
the field showed that their communication and problem-solving skills were insufficient.
The training curriculum was revised in 1997 to include communication skills, and the
first graduates of the new training course were placed in villages in 2000 and 2001
(Geefhuysen, 2000).^^
The strategy of placing a midwife in every village resulted in a marked increase in
the number of births attended by a skilled healthcare provider (Ronsmans, 2001; Curtis,
2003).^ The norm for home births remained strong (IDHS, 1998). Despite the large
number of skilled midwives placed in villages, the rate of decrease in maternal mortality
in Indonesia changed very little.^^ One reason for this lack of change in deaths from
childbirth may have been because of the bidan desas incapacity to manage obstetric
emergencies in practice, which may, in turn, have been the result of a lack of experience
(due to a low number of deliveries), and the yet lower number of complications during
delivery (Ronsmans, 2001; Sloan et al., 2001; Starrs, 1998).
At the end of their three-year contract, it was expected that each midwife would
become a private practitioner in the village that she served. The majority of midwives.
Geefhuysen (2000) noted that revisions to the training curriculiun are based on confidential evaluations
o f the training program, thus information from these assessments are not provided in this article (Note #9).
An evaluation of three districts in South Kalimantan, Indonesia showed an increase in skilled attendance
at delivery from 37 percent to 59 percent, with tlie greatest increase in home deliveries with a bidan desa
(village midwife) (Ronsmans, 2001).
Other public health indicators in Indonesia showed marked changes, for example, fertility decreased,
contraceptive prevalence increased, and infant mortaUty decreased dramatically (Johnson, 1996).
Relatively small changes in the proportion o f deliveries attended by a skilled provider, however, may not
be a sensitive marker for changes in maternal mortality (Ronsmans, 2001).
15
however, could not sustain their services due to the poverty of their village.
Many
midwives do not want to stay in a village that was not their birthplace because they felt
lonely without familial connections (Geefhuysen, 2000); 19 percent of midwives placed
in villages left within three years of their employment (Ronsmans, 2001).
Results from a longitudinal study to evaluate whether the Indonesian
governments village midwife program was effective in increasing the body mass index
(BMI) of reproductive-aged women, showed that BMI increased significantly among the
target group of women in communities that had a skilled village midwife, compared to
the control group of men and older women in those communities who experienced
smaller BMI gains (Frankenberg & Thomas, 2000).
To accelerate the decrease in maternal mortality. President Soeharto launched the
Mother Friendly Movement (Gerakan Sayanglbu or MFM) in Indonesia in 1996. The
goal of the MFM was to decrease the maternal mortality ratio by 50 percent (to 225
deaths per 100,000 live births) by the year 2000. The focus of the Mother Friendly
Movement was to empower women, her family and the community so that they can
participate fully in the acceleration of maternal mortality reduction (Cholil et al., 1998,
p. 37). The MFM stressed the importance of involving husbands in pregnancy-related
issues, for example, in making joint decisions about where the couple will have the
delivery, who will assist with the delivery, and what the couple will do to obtain
transportation and funds in the event of an obstetric emergency.
A social safety net program began in Indonesia in 1998 in response to the Asian economic crisis in
1997. This program, fiinded by the World Bank, was intended to preserve access o f the poor to healthcare,
education, affordable food, and social services. A study o f this social safety net program showed that a
large number o f the poor were not reached by the program, and substantial program benefits went to the
non-poor (Stunarto, Siuyahadi, & Widyanti, 2001). The relatively high cost o f healthcare by a skilled
provider (especially for emergency obstetric interventions) compared to healthcare from a dukun (TEA)
may have precluded women fi-om using skilled healtheare providers for delivery (Ronsmans, 2001).
16
In 1996, a pilot project was launched in eight of Indonesias 27 provinces,

including West Java. These eight provinces represented about 70 percent of all maternal
deaths in Indonesia. Few women and their family members in these areas were aware of
the risk factors associated with maternal mortality (Cholil et al., 1998). The pilot project
consisted of an information campaign using radio, newspapers, and small group meetings
to disseminate maternal health information (including information about nutrition and
pregnancy danger signs), and using local religious leaders to educate individuals about
safe motherhood. Despite this, and other, government efforts, including making skilled
midwives {bidan) available in a majority of villages, most births are still attended by
traditional birth attendants {dukun) or by family members, and not by a skilled healthcare
provider. Indonesia did not achieve its goal of reducing maternal mortality by 50 percent
(225 deaths per 100,000 live births^^) by the year 2000.
The Government of Indonesia has made substantial improvements to the
healthcare system. However, this progress has been undermined by (1) the 1997 Asian
Economic Crisis, and (2) several years of political turmoil. At least 40 percent of the
Indonesian population currently live below the poverty line and cannot afford basic
healthcare (Friend, 2003).
In 1998, the Indonesian Ministry of Health, together with the State Ministry of
Womens Empowerment, developed a 5-year Maternal and Neonatal Health (MNH)
Program. The goal of the MNH Program is to promote maternal and neonatal survival by
preventing and minimizing the effects of common complications such as postpartum
hemorrhage and neonatal hypothermia. A key component of the MNH Program is the
This target maternal mortality ratio was based on the 1999 estimated ratio o f 450 deaths per 100,000 live
births (Genderstats, 1999).
17
Behavior Change Intervention (BCI), The BCI component is part of an integrated

strategy to increase demand for quality services, that includes communication,
community and social mobilization interventions. BCI interventions are designed to
encourage men and women (1) to prepare for birth and emergency delivery, and (2) to
use a skilled healthcare provider for delivery.
The MNH Program is managed by JHPIEGrO^'^, the Johns Hopkins
University/Center for Communication Programs (JHU/CCP), PATH, and CEDPA, with
funding from the United States Agency for International Development (USAID), This
program is being implemented by Indonesian agencies, including BKKBN (the national
family planning agency), the Indonesian Society of OB/GYNs, the Indonesian Midwifery
Association, the National Clinical Training Network, and local NGOs and communitybased organizations. The present study utilizes data from the baseline survey for the
MNH Program in West Java,
A Social-Ecological Approach to Maternal Health Behavior Change
To date, the focus of maternal mortality prevention interventions in developing

countries has been on (1) training midwives and traditional birth-attendants, (2)
establishing community-based maternal healthcare systems, (3) improving health
facilities, and (4) on establishing systems of referral to a higher level of care. It is widely
recognized that developing the healthcare infrastructure in a nation is key to improving
the health of that nation. Yet without mechanisms for overcoming infrastructure
development problems, the rate of adoption of safe motherhood practices, for example,
delivering at a healthcare facility with a skilled attendant, will be slow. At the individual
JHPIEGO is a nonprofit international health organization whose mission is to improve the health of
women and famihes, JHPIEGO is an affiliate o f Johns Hopkins University,
18
level, a woman will be slow to adopt the use of a skilled provider at delivery as a first
choice if she does not have access to the resources required for skilled attendance at birth.
Social factors influence health directly through biological mechanisms, and
indirectly through specific behaviors. Most behavioral research is concentrated on
individual strategies to achieve behavior change. Behavioral research using socialecological models considers the relationships between people and their environment. The
social-ecological approach to health promotion places behavior in an interactive context,
influenced by intrapersonal and interpersonal interaction, physical environment, and
social and cultural variables.
The social-ecological model is based on four assumptions: (1) Personal attributes
influence health decisions, (2) social and physical environments are complex behavior
setting factors, (3) levels of aggregation (for example, individuals, families, communities,
and populations) impact health behavior, and (4) feedback about health behavior occurs
at multiple levels of environments and aggregates (Stokols, 1992). Thus there are
multiple influences on health behavior, many of which are external to the decision
making individual.
Purpose of the Present Study
There is no clear conceptual framework that illustrates how interventions to

reduce maternal mortality work, especially in paternalistic cultures such as Indonesia.
Traditionally, epidemiology and medical sociology did not recognize the influences of
social relations on the health and well-being of childbearing mothers (Oakley, 1985).
Current models do not provide guidance with respect to which health sectors or social
structures to strengthen in order to reduce maternal deaths (Ravindran & Berer, 2000).
19
Few interventions have addressed the role that social support plays in a womans
pregnancy, delivery, and postpartum care.
The purpose of the present study is to explore the role of husbands social support
in increased knowledge of pregnancy danger signs, positive attitudes toward skilled
providers, and the use of a skilled provider for delivery, among women of childbearing
age and low socioeconomic status in Indonesia. This study examines the extent to which
husbands social support explains variations in pregnancy knowledge, attitudes, and
practice among Indonesian women of reproductive age and low socioeconomic status.
Efforts to improve maternal mortality outcomes by changing womens behavior
during pregnancy, for example, by encouraging women to use a skilled healthcare
provider for prenatal care and delivery, may be futile if the social mechanisms that
contribute to their pregnancy-related knowledge, attitudes, and actions are not
understood. It is important to contextualize individual-level behavior in order to
understand why women have differing levels of knowledge, attitudes, and actual
behaviors during pregnancy (Link & Phelan, 1995). Without an understanding of the
context that leads to potential negative maternal outcomes, the responsibility for reducing
this potential is left solely to the individual, and little is done to change the more
fundamental factors that put people at risk (Link & Phelan, 1995). Husbands may be key
to lowering the relatively high rate of maternal mortality in Indonesia,
The present study tested the following research question and hypotheses:
Research Question #1: Are social support measures that were developed and
tested in developed world contexts reliable in the Indonesian context?
20
Hypothesis # la : High levels of husbands informational support^^ during

pregnancy are positively associated with high levels of womens knowledge about
pregnancy danger signs among Indonesian women of reproductive age from lower
socioeconomic strata.
Hypothesis #lb: High levels of husbands informational support during
pregnancy are positively associated with womens positive attitudes toward skilled
healthcare providers among Indonesian women of reproductive age from lower
Hypothesis #2: High levels of husbands instrumental support^^ during pregnancy
are positively associated with using a skilled healthcare provider for delivery among
Indonesian women of reproductive age from lower socioeconomic strata.
Hvpothesis #3: High levels of knowledge of pregnancy danger signs are
positively associated with positive attitudes toward skilled healthcare providers among
Hvpothesis #4: High levels of knowledge of pregnancy danger signs are
positively associated with using a skilled healthcare provider for delivery among
Hvpothesis #5: Positive attitudes toward skilled healthcare providers are
Data from a Maternal Mortality and Neonatal Health Household Survey of 2,824
women of reproductive age from lower socioeconomic strata, conducted in six districts of
The concept o f informational support is explained in Chapter 2.

The concept o f instrumental support is explained in Chapter 2.
21
West Java, Indonesia were analyzed. Findings from this study are presented in the
chapters that follow.
The present dissertation is comprised of five chapters in addition to this
introduction chapter (Chapter 1). Chapter 2 presents a review of literature (1) on social
support and health in general, (2) on social support and maternal health specifically, (3)
on measuring social support, and (4) on social support interventions related to pregnancy.
We discuss the difficulties of measuring social support, and in defining maternal
mortality. Chapter 3 describes the conceptual framework and hypotheses used in the
present study. Chapter 4 details the study methodology. In Chapter 5, results from the
present study are given. The research question and each of the studys hypotheses will be
addressed in this findings chapter. Chapter 6 provides a discussion of the study findings.
This final chapter will include (1) implications for Safe Motherhood Programs based on
the research results, (2) a discussion of the shortcomings of the proposed study, and (3)
suggestions for future research.
22
Chapter 2
LITERATURE REVIEW
Health and health behavior are influenced by factors at multiple levels, including
biological, psychological, and social. The extent to which individuals are integrated into
their social environment influences their health status. Past health research focused on
identifying proximate, individual-level causes of disease, or risk factors associated with
specific diseases, and with maternal mortality. There is an expanding body of literature
on the social and cultural context of health, illness and medicine that recognizes the
influence of individuals, family, community, social institutions, and social norms on
health behavior, including childbearing behavior (Cassel, 1976; Hoveil, Wahlgren, &
Gehrman, 2002; Institute of Medicine, 2001; Jafarey & Korejo, 1995; Kennedy &
Crosby, 2002; Krieger, & Gruskin, 2001; Loustaunau & Sobo, 1997; Minkler &
Wallerstein, 1997; Misra, OCampo, & Strobino, 2001; Syme, 1996; Yen & Syme,
1999).
Social support has been used to explain a multitude of health outcomes and health
behaviors of specific populations. The social support literature is highly varied in focus.
The present chapter summarizes the various definitions of social support, and presents a
review of literature (1) on social support and health in general, (2) on social support and
maternal health, (3) on measuring social support, and (4) on pregnancy-related social
support interventions. These four areas of research are most relevant to the purposes of
the present dissertation study, which is to examine the relationship between husbands
social support and women knowledge of pregnancy danger signs, positive attitudes
23
toward skilled providers, and the use of a skilled provider for delivery, among women of
childbearing age from lower socioeconomic strata in West Java, Indonesia.
A review of the related research on social capital^^ and social networks^^ is
beyond the scope of the proposed research since the purpose is to determine the
dimensions of social support and the relationship between social support and pregnancy
knowledge, attitudes, and behaviors, rather than to explore the structure of womens
social action or the nature of womens social organization. Despite the increasing
popularity of computer-mediated social support, we do not include a review of on-line
social support since such means of social support are not currently available to lowincome women in Indonesia.
A review of the literature on maternal health/maternal mortality in Indonesia
revealed no studies that focused on the effects of social support on the knowledge or
attitudes of pregnant woman to ensure the safe pregnancy and delivery of their child, in
either developed or developing nations. One reason for this lack of scholarly literature
may be that the study of maternal mortality has been dominated by a paradigm that
promotes investigation of proximate rather than distal causes of disease and death.
Another possible reason may be the difficulty of measuring social support.
What Is Social Support?
For the purposes of the present study, social support is any exchange (e.g.,
emotional, informational, tangible) between individuals that assists a focal person in
Social capital is those features o f a social organization (e.g., personal relationships, networks of
associations) that serve as resources for individuals and that facihtate collective action (Lochner et al..
1999). Most social capital studies focused on explaining the performance o f civic institutions and the
economic development o f societies (Kawachi et al., 1997, p. 1492).
A social network is the pattern o f friendship, advice, commimication, or support that exists among
members o f a social system (Valente, 1995).
24
managing her well-being or attaining her goals. The elements of social support include
having family, friends, and others who demonstrate caring and concern, and who provide
information and tangible assistance to an individual.
Social support has been broadly defined as the quantity, structure, and functional
content of social relationships (House & Kahn, 1985). Bryce and others (1988) defined
social support as the comfort, assistance, and information that one receives through
formal and informal contacts with individuals or groups. Kahn (1979) defined social
support as interpersonal transactions that include one or more of the following. The
expression of positive affect by one person toward another; the affirmation or
endorsement of another persons behaviors, perceptions, or expressed views; the giving
of symbolic or material aid to another (p. 85). Social support is not necessarily a
function of similarity between the focal person and the individual providing support.
An array of conceptual typologies of social support functions is provided in the
scholarly literature. Craven and Wellman (1973) suggested that support may be (1)
tangible, for example, money or transportation provided to a pregnant woman so that she
may receive emergency obstetric care, or (2) intangible, in the form of emotional support.
Virtually all studies of social support include (1) an emotional or affiliative function, and
(2) an instrumental or material function (Brown et al., 1975; Cobb, 1976; Dean & Lin,
1977; Schaefer et al., 1981). Emotional support is feelings that make an individual
believe that she is part of a group, loved, and cared about, including empathy,
understanding, intimacy, attachment, reassurance, and being able to trust and rely on
another person. Instrumental support (also called tangible support) is direct aid or
services, for example, cash loans, food, and/or childcare services. The extended family is
25
often an important part of the emotional and instrumental support system (Billings &
Moos, 1982).
A third general category of social support is informational support. Informational
support is providing knowledge, news, and advice that could help solve a problem, and
providing feedback (Schaefer et al., 1981). Informational support may affect health
outcomes by providing alternative solutions to address a specific issue. For example, a
woman who receives information about the benefits of adopting a contraceptive method
to prevent an unwanted pregnancy, may decide to adopt a method thus delaying or
preventing pregnancy. The term social support implies the propping up of someone
who is in danger of falling down (which often implies someone in crisis) (Caplan,
1976, p.7).
Dean and Lin (1977) identified two functions of support: (1) expressive
(satisfying individual needs and maintaining group solidarity), and (2) instrumental (taskoriented behavior). Dean and Lin (1977) suggested that the expressive function was
more important in protecting against illness, given the limitations of the welfare system to
address issues related to instrumental support, including income and unemployment.
Other scholars have made similar suggestions (Brown et al., 1975; Cobb, 1976).
In a review of ten key articles that described the content of social support, Barrera
and Ainlay (1983) identified six main categories of social support:
1. Material aid: Providing tangible goods and services, including money and
other physical objects.
2. Behavioral assistance: Task-sharing, including providing labor.
26
3. Intimate Interaction: Providing non-directive counseling such as listening,

caring, and understanding.
4. Guidance: Providing advice, information, coaching, or instruction.
5. Feedback: Providing evaluative or corrective information about an
individuals behavior, thoughts, or feelings.
6. Positive social interaction: Providing an outlet for fim and relaxation by
engaging in social activities.
The above typology reflects the most commonly-described content areas of social
support.
Barrera (1986) suggested three categories of support based on evidence that these
functions of support are relatively independent, each function with its own pattern of
association with stress or adverse health outcomes: (I) Social embeddedness (that is, the
connections between individuals in their social environment); (2) perceived social
support; and (3) enacted support (for example, providing assistance). Perceived social
support received substantial research attention. The relationship between perceived
support and adverse health outcomes is consistently negative, that is, fewer negative
health effects occur when support is perceived to be high (Turner, Grindstaff, & Phillips,
1990).
A considerable amount of research on social support focused on (1) identifying
types of support, and (2) relating these types of support to the management of different
types of stressful situations. Some scholars believe it is important to distinguish among
different types or functions of social support because specific types of support (1) may
have independent effects on mental and physical health (Schaefer et al., 1981), and (2)
27
may be more effective in reducing negative health outcomes at different stages of a health
concern (Jacobson, 1986). For example, several studies found that in the early stages of
cancer (i.e., immediately following diagnosis), patients most needed and appreciated
emotional support. Material assistance (i.e., instrumental support) was more appropriate
in later stages of the illness (Dunkel-Schetter, 1984; Dunkel-Schetter & Wortman, 1982;
Wortman, 1984) .
Findings from a study by Gjerdingen and others (1991) showed that the
importance of various types of support change with the changing needs of the receiver,
Gjerdingen and others (1991) stated that during pregnancy, emotional and tangible
support provided by the spouse and others was related to the expectant mothers well
being, while informational support in the form of prenatal classes was related to
decreased physical complications during labor and delivery, and to improved postpartum
health. Thus, the timing and type of support is important to the effectiveness of social
support in managing health.
Some scholars suggest that social support is perceived as a unidimensional
construct by the recipients of the support, that is, receivers of support view support in a
global sense, they either feel supported or do not feel supported, and do not distinguish
between the various types of support (Brown, 1986; John & Winston, 1989; Norwood,
1996; Norbeck & Tilden, 1983). Early studies that treated social support as a unitary
factor were criticized for simplifying a complex phenomenon and ignoring its constituent
elements (Jacobson, 1986). While many scholars examined social support as a
multidimensional construct (for example, Barrera, 1986; Billings & Moos, 1981; Giblin
et al., 1990; Mercer et al., 1983; Norbeck & Anderson, 1989; Schaefer et al., 1981), some
28
studied only one type of support (for example, LaRocco et al., 1980), and many assessed
support for the multiple functions, but in their analyses the subscales of support were
collapsed to provide a single score measuring support (for example, Cohen & Wills,
1985).
The concept of social support has been adopted and empirically tested by
epidemiologists, sociologists, and other scholars, without much theoretical clarification or
standardized operationalizations (Barrera & Ainlay, 1983; Brown, 1986; Cassel, 1974a,
1974b; Kaplan, 1975; Kaplan et al., 1977). Findings from studies of the effects of social
support on health outcomes conducted in the past two decades have been inconsistent or
contradictory. Comparative analyses of such studies are difficult to conduct because the
operationalized constructs vary from study to study. A more systematic and exact
conceptualization and measurement is needed for the construct of social support.
Social Support and Health
The hypothesis that social support contributes to reducing the risk of illness has
received considerable notice in a number of studies. One of the earliest studies of social
influence on human behavior was conducted by the sociologist Emile Durkheim.
Durkheim (1951) observed that suicide rates varied from place to place, and suggested
that differences in social environments (including the shared beliefs, customs, norms, and
the groups that one belonged to) played an important role in differences in suicide rates.
Prior to the 1970s, however, the concept of social support was not a popular topic for
scholarly investigation. The term social support appeared in only two citations in
1970, and in 50 citations in 1982, in the Social Sciences Citation Index (House & Kahn,
29
1985). A recent review of PubMed showed that the words social support appeared in
more than 19,000 articles (PubMed, 2003).
Social support gradually emerged as an important psychosocial variable in healthrelated research. Since the early 1970s, scholars have noted that social support
contributes to physical and psychological health (Broadhead et al., 1983; Cassel, 1976;
Cobb, 1976; Dean & Lin, 1977; House et al., 1982; House et al., 1988; Kaplan et al.,
1977; Syme, 1981). This literature suggests that social support is beneficial to both
mental and physical health, either directly, or indirectly as a buffer to the negative effects
of stress and other perceived health hazards (Broadhead et al., 1983; Cassel, 1976; Cobb,
1976; House, 1981; Kahn, 1981).
The epidemiology literature strongly suggests that the social environment is a risk
factor for a multitude of health outcomes. In an influential article published in the
American Journal o f Epidemiology, Cassel (1976) summarized findings on disease risk
associated with (1) rapid social change, (2) social and family disorganization, and (3) the
absence of social support. He concluded (1) that social relationships are protective of
health, (2) that epidemiologists needed to recognize the contributions of social support to
health, and (3) that prevention programs needed to attempt to reinforce social support, as
opposed to more commonly-accepted interventions that attempt to reduce exposure to
stressors. Burke and Weir (1977) found that partner support in the form of marital
helping contributed to health.
Cassel (1976) and Cobb (1976) reviewed some 30 human and animal studies that
supported the hypothesis that social relationships are protective of health. The studies
included a variety of study designs and health outcomes (including pregnancy
30
complications, low birth weight, and depression) among populations that varied in age.
Despite this range in studies, the evidence pointed toward a robust, causal association
between social relationships and health. Both Cassel and Cobb emphasized the buffering
or moderating role of social relationships in preventing negative health outcomes. They
theorized that social support was a resource that sustained the organism (human or
animal) by promoting adaptive behavior to stressful situations or potential health hazards
(House et al., 1988).
Following Cassels (1976) article, a body of literature emerged that (1) supported
the idea that stressful life events can trigger physiologically-based illness, and (2) argued
that social support can protect individuals from a variety of pathological states (Cobb,
1976; Berkman & Syme, 1979; Blazer, 1982; House, Robbins, & Metzner, 1982; Leavy,
1983; Welin, Tibblin, Svardsudd, Tibblin, Ander-Peciva, Larsson, & Wilhelmsen, 1985;
Schoenback, Kaplan, Freedman, & Kleinbaum, 1986; Kaplan, Salonen, Cohen, Brand,
Syme, & Puska, 1988).
Social support theorists state that in order for social support to promote health (1)
it must provide a sense of belonging and intimacy, and (2) it must help individuals to
become more self-efficacious (Bandura, 1986, 1997; McLeroy et al., 1984; Wortman &
Lehman, 1985). Some studies suggest that social support that encourages dependence
may not be health promoting (Helgeson, 1993; McLeroy et al., 1984; Revenson et al.,
1983; Wortman & Lehman, 1985).
Many journal articles have shown that the absence of social support is associated
with an increase in coronary heart disease, complications during pregnancy and delivery,
suicide, and negative outcomes for other diseases (House et al., 1988). These studies.
31
and others, confirmed that reduced social connections are related to morbidity and
mortality for a variety of disease and spawned a new area of research, called
psychoneuroimmunology, dedicated to understanding the link between a range of
psychosocial factors and immunological fimction (Syme, 1996).
By the 1980s, publications appeared that summarized findings from crosssectional, retrospective case-control, and prospective cohort studies conducted to
determine the direct association between a variety of social support measures and various
health/disease states and mortality (Berkman & Syme, 1979; Blazer, 1982; Broadhead,
Kaplan, James, Wagner, Schoenbach, Grimson, Heyden, Tibblin, & Gehlback, 1983;
Ortho-Gomer & Johnson, 1987; Schoenbach, Kaplan, Fredman, & Kleinbaum, 1986;
House, Robbins, & Metzner, 1982; Schoenback, Kaplan, Fredman, & Kleinbaum, 1986;
Welin, Tibblin, Svardsudd, Tibblin, Ander-Peciva, Larsson, & Wilhelmsen, 1985). The
overall picture emerged of a relationship between social support and physical health
outcomes. The magnitude of the mortality risk varied substantially from study to study.
The question of how social support affects health outcomes is not well
understood. Berkman (1984) suggested four pathways that link social support and health:
(1) Providing pro-medical care values, knowledge of how to access healthcare services,
and access to services, which result in individuals receiving better medical care than
others; (2) providing tangible aid (e.g., economic assistance, services) to a member of a
social network directly influences ones health status; and (3) promoting, or not
promoting, health within a social group influences a group member to adopt positive or
negative health habits as a result of peer pressure; and (4) an absence of social ties or
32
social support results in stress, and that stress produces a direct physiologic or
psychological response (e.g., high blood pressure or depression).
Cassel (1976) suggested a pathway through which social factors could increase
susceptibility to disease in general. Coyne and DeLongis (1986) found that high stress,
high social support, and their interactions predicted substance use, and substance use was
a significant predictor of pregnancy outcomes. In most perinatal research studies, social
support is conceptualized as a moderating variable that contributes to specific pregnancy
outcomes, for example, birthweight (Nuckolls et al., 1972; Norbeck & Tilden, 1983;
Oakley, 1985).
The effects of social support on health have been explained using two widely
accepted models; (1) The main effects model, which posits that social support has a
direct, beneficial effect on health, regardless of an individuals level of stress, and (2) the
stress-buffering model, which proposes that social support protects (i.e.,buffers)
individuals from stressful events that may cause negative health outcomes, and
potentially, death. Cohen and Wills (1985) suggested that the way we measure social
support produces different effects of social support on health outcomes.
Many of the social support studies suffer from selection issues associated with
cross-sectional study designs. Longitudinal studies could help to sort out the direction of
the effect being studied (Yen & Syme, 1999).
Social Support and Maternal Health
The most direct and influential evidence for the significance of social support as a
buffer for birth complications was reported by Nuckolls, Cassel, and Kaplan (1972). In
this study of 170 U.S. Army wives who gave birth at a military hospital, the women were
interviewed using a questionnaire that included items measuring the psychosocial

assets, and the presence of stressful life events before and during pregnancy. Findings
from this study showed a clear relationship between levels of life stress prior to, and
during, pregnancy, and high or low social support. Pregnant women with high social
stress and positive psychosocial assets (i.e., social support) had one-third the
complication rate of women with high social stress, but without positive psychosocial
assets.
Since the publication of the Nuckolls and others (1972) article, several scholars
have investigated the relationship between various types of support during pregnancy
(Table 2.1). Several of these studies have shown that the provision of social support in
the form of emotional, informational, and tangible support, has been positively related (1)
to mothers mental and physical health during pregnancy, delivery, and the postpartum
period (Gjerdingen et al, 1991; Turner et al., 1990), and (2) to higher birth weight and
fetal growth (Feldman et al, 2000). Norbeck and Anderson (1989) found that male
partner support during pregnancy was the most significant predictor of gestational age
and gestation complications among black women, whereas for white women, social
support reinforced negative health outcomes. Norbeck and others (1996) showed that the
partners emotional support during pregnancy influenced healthy birth outcomes, namely
a reduction in low birth weight. Berkowitz and Kasl (1983) found that husband or
partner support did not influence the occurrence of pre-term births. Mercer, Hackley and
Bostrom (1983) suggested that emotional support from a partner was an important
influence on the mothers perception of the birth experience.
34
Table 2.1 Types of Social Support Studied by Researchers luvestigating the

Relationship between Social Support and Maternal Well-Being during Pregnancy.
Types of Support Investigated
Tangible
Informational
Emotional
Author(s)
Aaronson et al., 1989
X*
X
Barkauskas, 1983
X*
Bergstrom-Walen, 1963
Braverman & Roux, 1978
X*
X*
X*
Brown, 1986
X*
X*
Charles et al, 1978
X*
X*
X
X*
Cronenwett, 1985
X*
X*
Cutrona, 1984
X*
Cutrona & Troutman, 1986
X*
X*
Doering & Entwisle, 1975
X
Entwisle, 1981
Giblin et al, 1990
X*
X*
Gordon & Gordon, 1960
X*
Gordon et al, 1965
X
Grossman et al, 1980
X*
X*
Hughey et al, 1978
Huttel et al, 1972
X*
X*
Laird & Hogan, 1956
X*
X*
Norbeck & Anderson, 1989
X*
X*
X*
Norbeck & Tilden, 1983
X*
X
Nuckolls et al, 1972
X*
X
X*
OHara, 1986
Patton et al, 1985
X*
X*
X*
Poland et al, 1992
X*
St. John & Winston, 1989
X
X
X
Scott & Rose, 1976
X*
Villar et al, 1992
X
X
X
Winston & Oths, 2000
X*
Zax et al, 1975
X*
* Connotes a significant relationship between the t5^ e of support and maternal well
being.
Source: Adapted from Gjerdingen et al.(1991), p. 371.
35
Norbeck and Tilden (1983) investigated the effects of life stress and social
support on pregnancy complications for a group of women of differing marital status, and
from various racial and socioeconomic backgrounds. The authors found that the
interaction of tangible support and life change during pregnancy was significant for
gestation complications, that is, women with many life changes and low support had the
highest rate of complications. Pagel and others (1990) suggested that increasing family
social support during pregnancy were associated with higher 1 minute pediatric Apgar
scores.
Past research on the effects of psychosocial assets on pregnancy, and specifically
on pregnancy complications, produced contradictory results (Norbeck & Tilden, 1983).
Many of these research studies failed to control for preexisting medical risk factors,
parity, socioeconomic status, marital status, and age (Istvan, 1986; Norbeck & Anderson,
1989; Norbeck & Tilden, 1983). Other methodological limitations of such studies
include the use (1) of small convenience samples, and (2) of self-reported survey data.
Sample selection bias in some studies, and the use of cross-sectional samples in others,
have not allowed for investigation of causal relationships. The use of unstandardized
tools to measure social support hinders comparative analyses of studies on the effects of
social support on specific health outcomes (Gjerdingen, 1991). The literature on social
support and maternal health suggests that there is a positive relationship between social
support during pregnancy and maternal and neonatal health outcomes. Much of this
research, however, has been conducted in First World settings, and many have been
challenged by such methodological problems as selection bias and sample bias.
A few studies reported the impact of social support on antenatal clinic attendance
in developing countries. In Zimbabwe, a community-based study showed that in
situations associated with diminished or no social support, the degree of social support
was related to an increased risk for maternal mortality, especially in rural areas (Mbizvo
et al., 1993). A study in Thailand by Jirojwong and others (1999) found (1) no
significant relationship between indices of social support and the use of antenatal clinic
attendance, (2) that the sources of support index (which measured emotional,
instrumental, information, and appraisal support) were inappropriate in the Thai context,
and (3) that information provided by supporters about their experiences attending
antenatal clinics could have both a positive and a negative effect on the level of antenatal
clinic attendance. Jorojwong and others (1999) suggested that their finding concerning
the lack of a relationship between social support and antenatal clinic attendance may be
due to recall bias, the presence of others during the personal interviews, and the openended questionnaire format.
A study conducted by Beegle and others (2001) to determine whether Indonesian
womens power relative to that of her husband influenced the use of prenatal and delivery
care, showed that women who are better educated than their husbands, and who are from
families of higher social status, are more likely to obtain prenatal care (relative to other
women), especially in the first trimester of pregnancy, and to deliver at a midwifes office
or health center, rather than in the home. Thus, education and social standing impact the
use of prenatal care and the use of skilled attendants for childbirth.
37
Measuring Social Support
There is a great diversity of operational definitions of social support (Gottlieb,

1983; Turner et al, 1983). Given the complex nature of this concept, scholars used (1)
various approaches to measure distinctions in social support, and (2) various instruments
to detect distinctions in social support. Dolbier (2000) reviewed three categorical
distinctions of, and measurement approaches to, social support; (1) quantity versus
quality of social support, (2) specificity versus globality of the support measure, and (3)
perceived versus received support. A quantitative approach uses measures that assess the
number of an individuals social ties and the diversity of her social network (for example,
Name five people in this village with whom you talked about pregnancy issues in the
last three months), as opposed to a qualitative approach, which studies the nature of the
relationship, the reciprocity of social support, and the specific functions of support (for
example, Have you ever lent money to (name)?). Specificitv is the degree to which
social support instruments measure a specific structure (i.e., relationship) or function (i.e.,
emotional, informational, tangible) of support (for example, What kind of support did
(name) provide to you during your last pregnancy?). In contrast, globality is the extent
to which social support measures represent a combination of social support structures and
functions in an undifferentiated, global index (for example, I feel well supported by my
friends and/or family). Global measures determine the general level of an individuals
embeddedness in a social network (Cohen & Wills, 1985). Perceived support is an
individuals perception of available support resources^^ (for example, I have close
fi-iends with whom I feel comfortable sharing personal feelings or I belong to a club).
Schaefer et al. (1981) defined perceived support as an appraisal o f the degree to which a relationship is
helpful.
38
whereas received support is the actual receipt of support resources (for example, My
partner helps me with household chores) Global, perceived support mirrors a general
perspective of ones social life, while specific, received support reflects ones anthology
of experience with specific others (Dolbier, 2000). Cohen and Wills (1985) showed that
global, quantitative measures of social support demonstrated a main effect, while
specific, qualitative measures demonstrated a stress-buffering effect.
Several scholars developed scales to measure specific dimensions of social
support. For example, the Norbeck Social Support Questionnaire (NSSQ) measures three
dimensions of social support; (1) total functional support (affirmation and aid), (2) total
network support (number, relationship duration, fi-equency of contact), and (3) total loss
(person categories lost, and amount of support lost) (Norbeck, Lindsey, & Carrieri, 1981,
1983; Norbeck & Anderson, 1989). Brown (1986) created the Support Behaviors
Inventory (SBI) to measure emotional, appraisal, informational, and instrumental support
for 313 expectant couples. Findings using the SBI showed (I) that social support was
positively related to a pregnant womans health, and (2) that multidimensionality of
social support was not confirmed, that is, that the broader concept of social support was a
dominant factor in explaining variance in partner, or others, social support.
Barrera and others (1983) developed a scale, the Inventory of Socially Supportive
Behaviors (IS SB), in order to generate a taxonomy of support types. Results from a
factor analysis showed that there was no distinction between providing material aid and
physical assistance (Barrera et al., 1983). In many of the social support studies, the
questions used to measure social support show high reliability and documented construct
validity, but yielded poor discriminant validity of the subscales (i.e., a subset of
39
questions to measure a specific support function, for example, tangible support) (Brown,
1986; Norbeck et al, 1981). Most of the instruments developed to evaluate social
support were tested on populations in the United States.
Webster and others (2000) used the Maternity Social Support Scale (MSSS) with
women attending a hospital antenatal clinic in Brisbane, Australia (1) to determine the
level of a womans social support at the time of antenatal care clinic attendance, and (2)
to examine the relationship between level of social support during pregnancy and health
and service use outcomes. Findings from the Webster and others (2000) study suggested
(1) that social support during pregnancy can be measured in a meaningful and simple
way using a brief and easy-to-administer questionnaire (p.97), and (2) that women with
low social support in pregnancy were more likely than well-supported women to report
poor health outcomes during pregnancy and to begin prenatal care at a later stage than
women who reported having been well-supported during their pregnancy.
Many scholars developed social support scales and reported measures of social
support. Empirical testing of these measures, however, yielded conflicting results with
regard to whether social support is a multidimensional or a unidimensional construct.
Very few of these social support scales or inventories have been used to study the
relationship between social support and maternal health outcomes in developing nations.
Fewer studies yet have been designed specifically for developing country populations.
Pregnancy-Related Social Support Interventions
There is accumulating evidence in developed countries that social support

improves a womans likelihood of receiving prenatal care (Poland et al, 1992; Heins et
al, 1987). Prenatal care is associated with numerous benefits for maternal and
40
neonatal/child health. The healthcare treatment choices of pregnant women are not well
understood. Decisions to seek prenatal care may or may not be made as a result of
talking to others (Winston & Oths, 2000).
Various social support interventions used paraprofessional healthcare workers to
encourage pregnant women to attend prenatal care clinics. Poland et al. (1992) reported a
case comparison study in which women who were similar to the target audience of
pregnant Black women in Detroit, Michigan were trained to counsel and assist pregnant
women with such basic necessities as health and social services. The purpose of the
study was to assess the impact of paraprofessional support services on the amount of
prenatal care received, and on the birth weight of babies bom to a sample of low-income
women. Findings from this study showed that women who received paraprofessional
support services (1) attended more prenatal appointments, and (2) had infants with higher
birth weights, than women who did not receive support services. The intensity of the
contact between the paraprofessionals and the pregnant women contributed significantly
to prenatal care seeking behavior.
In a study investigating the role of social support in the initiation of prenatal care
in Tuscaloosa, Alabama, Winston and Oths (2000) found that social support played a
significant role in encouraging first-time mothers to seek prenatal care. St. John and
Winston (1989) showed that social support had a positive impact on obtaining adequate
prenatal care among women in Oklahoma. Villar and others (1993) conducted a
prospective trial to evaluate a program of home-visits designed to provide psychosocial
support during pregnancy to Latin American women at high risk for delivering low birth
weight infants. The authors found no protective effect of the psychosocial support
41
program, even among the most high-risk mothers. A case study of the impact of social
support by specially-trained social workers or nurses on reducing adverse maternal and
infant health outcomes among high-risk pregnant women in Argentina, Brazil, Cuba, and
Mexico showed no effect of social support on perinatal, maternal, or child health
outcomes (Heaney & Israel, 1997).
Although evidence suggests that social support may impact pregnancy-related
behaviors (e.g., seeking prenatal care), the translation of social support into effective
interventions remains inconsistent (Heaney & Israel, 1997). Variability of the results
from these (and other) studies may be due to selection biases (study sample selection, or
selection of the paraprofessionals), or to such factors as the quality of the intervention, or
the intensity of the social support.
A growing body of literature exists about the role of interpersonal communication
in the adoption of family planning in general, and in the adoption of specific
contraceptive methods (Bawah, 2002; Boulay & Valente,1999; Kohler, Behrman, &
Watkins, 1999; Sharan & Valente, 2002). Communication scholars report that the
adoption of family planning methods is influenced by social interaction with others
(Kincaid, 2000; Rogers, Vaughan, Swalehe, Rao, Svenkerud, & Sood, 1999; Valente,
Poppe, & Merritt, 1996). Shefner-Rogers and Sood (in press) reported findings from an
evaluation of a multi-media intervention in East Java, South Sulawesi, and North
Sumatra, Indonesia, to encourage husbands to become involved in their wifes pregnancy.
These findings showed that men who were exposed to the intervention via mass media
and interpersonal communication channels were more likely to report that they gained
new knowledge of birth preparedness and were more likely to take action toward
42
becoming an alert husband (i.e., a husband who helps his wife during pregnancy,
delivery, and the postpartum period), than men who were exposed only to the mass media
components of the intervention.
Research-based evidence on the effects of programs to reduce maternal mortality
lags far behind that for family planning programs. In the 1980s, low contraceptive
adoption rates begged the question Why are family planning programs not working?
Research studies (1) identified the lack of spousal communication as an important
contributor to the low contraceptive prevalence among women, and (2) have
demonstrated a positive relationship between spousal communication and contraceptive
use (Bawah, 2002).
Do women leam about (1) pregnancy danger signs, for example, antepartum
bleeding, convulsions, swelling of the face and hands, fever, and vaginal discharge, and
(2) the importance of using skilled healthcare providers for prenatal care and delivery
through social support (e.g., informational support) in a similar way to women who learn
about, and adopt, family planning? Previous research suggests that womens perceptions
of health problems (as opposed to medically-defined conditions), for example,
experiencing spotting during pregnancy, can (1) highlight womens awareness of illness,
and (2) reveal womens health-related decision-making processes or health-seeking
behavior (Ronsmans et al., 1997a; Bhatia & Cleland, 1996), for example, a womans
decision to use a skilled provider for delivery. A central question of the proposed study
is whether husbands social support influences a womans knowledge of danger signs,
and consequently, from whom the couple will seek aid for delivery.
43
A paucity of information exists about the role of social support on mothers

knowledge, attitudes, and practices during pregnancy. The present study examined how
information and material support received by women of lower socioeconomic status in
West Java, Indonesia during pregnancy impacts their pregnancy knowledge, attitudes,
and behaviors.
Summary
The present chapter summarized definitions of social support. In general, social

support is any exchange (e.g., emotional, informational, tangible) between individuals
that assists a focal person in managing her well-being or attaining her goals. Researchers
identified a multitude of social support functions or categories, including material aid,
behavioral assistance, guidance, and feedback. Some scholars showed support for the
idea that specific functions of support are most effective at different stages of a health
event, or with the changing needs of the receiver.
This chapter presented evidence from the literature (1) that social support
contributes to reducing the risk of illness, (2) that the absence of social support is
associated with increases in negative outcomes for a disease, and (3) that social support
that encourages dependence may not be health promoting. This literature confirms that a
positive relationship exists between social support and health. The pathways that link
social support and health, however, are not well understood. Two models for the
relationship between social support and health have become widely known and tested the main effect model and the stress-buffering model. The way in which social support is
measured, however, may produce different effects of social support on health outcomes.
44
We reviewed the literature on social support as it relates to maternal health.

Much of the research focused on the association between maternal psychosocial factors
(e.g., stress) and obstetric outcomes, and the role of social support in determining these
outcomes. Many studies supported the hypothesis that social support during pregnancy is
related to a mothers mental and physical health, and to specific birth outcomes (e.g.,
birth weight). Many of these studies were methodologically challenged, for example,
they used small, convenience samples and cross-sectional designs. Most of the research
was carried out in developed-world settings. No attention has been given to studying the
role of social support on increasing pregnancy-related knowledge, attitudes, and
behaviors among pregnant women in Indonesia.
Much has been written about measuring social support and its components.
Social support has been analyzed through multi-item scales of the construct, for example,
the Norbeck Social Support Questionnaire and Browns Support Behaviors Inventory.
Yet a debate continues as to whether social support is indeed a multidimensional
construct or a unidimensional concept. Further study of the dimensions of social support
within specific contexts is necessary in order to determine how social support contributes
to positive health outcomes, and specifically, to positive maternal health outcomes.
Finally, we discussed the literature on pregnancy-related social support
interventions. A small body of literature showed that social support interventions had
some impact on encouraging antenatal clinic attendance among pregnant women. The
translation of social support into effective pregnancy-related interventions remains
inconsistent.
45
Chapter 3
CONCEPTUAL FRAMEWORK AND HYPOTHESES
Most behaviors are not randomly distributed in the population, but are
socially patterned and often occur together (Institute of Medicine, 2001, p.ES-5).
The purpose of the present study is to explore husbands social support during the
pregnancy period in order to understand how such support influences womens
knowledge of pregnancy danger signs, attitudes toward skilled healthcare providers, and
actual use of skilled healthcare providers for delivery in West Java, Indonesia. The
present chapter describes the conceptual framework, theoretical assumptions, and
hypotheses used in the present study.
Conceptual Framework
The Three Delays Model (Thaddeus & Maine, 1994) (Figure 3.1) has been used
as a conceptual framework for the Maternal and Neonatal Health (MNH) Program in
Indonesia. This model suggests pathways through which interventions can address
delays in receiving adequate and appropriate maternal healthcare at the individual level.
Figure 3 .2 illustrates the conceptual framework for the Maternal and Neonatal Health
(MNH) Program in Indonesia. The MNH framework suggests a two-step process for
increasing maternal and neonatal survival, (1) where promoting the use of a skilled
attendant for delivery leads to the intermediate outcome of using a skilled healthcare
provider for delivery, and (2) where managing hirth complications and postpartum care
fo r m o th er and c h ild le a d s to an in c r e a se
in m atern al
and n eo n a ta l su rvival.
The proposed model (Figure 3.3) suggests that spousal support effects a womans
pregnancy-related knowledge and attitudes, and, ultimately, the couples adoption of the
use of a skilled provider for delivery. This model represents a shift from a paradigm that
46
CDD
O
Q.
C
o
CD
Q.
CDD
PHASE I:
DECIDING TO SEEK
CARE
PHASE OF DELAY
C/)
(/)
O
O
D
cq'
FACTORS AFFECTING
UTILIZATION AND
OUTCOME
1.
3CDD
O
Q.
C
a
o
-1^
2.
o
o
CD
Q.
CDD
C/)
C/)
3.
Socioeconomic and cultural

factors
Recognition of
complications
Perceived severity
Perceived etiology
Access to money
Restricted mobility
Economic status
Education status
Perceived accessibility
Distance
Transportation (animal
vs. motorized; rainy vs.
dry season)
Cost o f transportation,
medical fees,
medications, supplies.
opportimity costs)
Perceived aualitv of care
Previous experience or
reputation
Satisfaction with
outcome (effectiveness
of treatment/remedy)
Satisfaction with service
(staff, procedures.
waiting time, visitation
Umiting social support.
Figure 3.1. The Three Delays Model.

Source: Adapted from Thaddeus and Maine (1994).
___ ^
PHASE II:
IDENTIFYING AND
REACHING MEDICAL
FACILITY
PHASE HI:
RECEIVING
ADEQUATE AND
APPROPRIATE
TREATMENT
___ ^
Actual AccessibUitv of Facilities
Actual Oualitv of Care
1.
Distribution and location

of health facilities
1.
2.
Distance
travel time
outcomes occur in
transit
Poorly staffed facilities

staff numbers
competence of
personnel
2.
Poorly equipped facilities

unavailability o f blood
unavailability o f drugs
unavailability o f other
equipment
hard currency
problems
3.
Inadequate management
incorrect diagnosis and
action
3.
Transportation
Publically available
4.
Costs
Costs exceed
expectations or ability to
pay
CDD
O
Q.
C
o
CD
Q.
CDD
INTERVENTION
C/)
(/)
PROCESS 1
INTERMEDIATE
OUTCOME
PROCESS 2
IMPACT
o
o
T3
c5'
Communication
and Social
Mobilization
33"
?
Increase
Informed
Demand for
Skilled
Attendance
at Birth
Policy/
Advocacy
CD
T3
O
Q.
C
ao
3
T3
O
00
Performance
Improvement
CD
Q.
Increase
Availability
and
Competence
of Skilled
Birth
Attendants
T3
CD
(/)
(/)
Figure 3.2. MNH Conceptual Framework for Indonesia.
Source; Putjuk, 2002.
Manage Normal
Birth
Presence of
Skilled
Attendant at
Birth
Maternal
Survival
Manage
Complications
Manage Normal
Newborns
Manage Sick
Newborns
Postpartum Care
Neonatal
Survival
7CD3
T3
O
Q.
C
o
CD
Q.
T3
CD
(/)
(/)
SOCIAL SUPPORT
VARIABLES
BEHAVIOR CHANGE
VARIABLES
O
O
T3
c5'
Husbands
Informational
Support
33"
?
Hla
Hlb
Womans
Knowledge
About Pregnancy
Danger Signs
H4
Use of a Skilled
Healthcare
Provider for
Delivery
H3
CD
T3
O
Q.
C
ao
3
O
T3
CD
Q.
'~0
Husbands
Instrumental
Support
H2
Womans
Attitudes Toward
Skilled
Healthcare
Providers
H5
T3
CD
C/)
C/)
Figure 3.3. The Conceptual Model of the Influence of Husbands Social Support on Womens Pregnancy Knowledge,
Attitudes, and Practices for Women of Reproductive Age From Lower Socioeconomic Strata in West Java, Indonesia.
focused on the individual as the primary agent of change to a paradigm that sees the
individual as part of a social system that influences her health behavior. In the latter
paradigm, the individual is still the primary agent of change, influenced by other agents
of change within a womans social network.
Theoretical Assumptions
The proposed model is grounded in two theoretical assumptions: (1) individuals

adopt new ideas, attitudes, and behaviors through talking with one another, and (2)
individuals make decisions about health behaviors that are limited by their cognitive
behavior and by environmental constraints. The first assumption is based on Diffusion of
Innovations theory (Rogers, 2003). The second assumption is based on Herbert Simons
(1956) model of bounded rationality .
Diffusion o f Innovations
Diffusion is the process by which an innovation is communicated through certain
channels over time among the members of a social system (Rogers, 2003, p.5). An
innovation is an idea, practice, or product that is perceived as new by an individual.
Channels are the means by which information about innovations is transferred from one
individual (or other unit) to another. Messages can be transmitted via interpersonal
communication (i.e., face-to-face communication) or via broadcast, print, or electronic
media. A social system is a set of individuals (or other units) that are engaged in jointproblem solving to achieve a common goal (Rogers, 2003). Every social system has a set
of norms, that is, a set of generally accepted behavior patterns with a range of acceptable
and unacceptable behaviors. Early adopters of a new idea or behavior spread the
innovation to others in their personal social networks and persuade them to become
50
adopters. Most individuals adopt an innovation based on the perceived merits of the
innovation and on the evaluation of the innovation by peers and other adopters (Rogers,
2003).
Diffusion theory focuses on how information sources and knowledge vary during
adoption of a behavior. Given the time-bound nature of pregnancy, childbirth, and
especially obstetric emergencies, the diffusion and adoption rate for using a skilled
provider for delivery would have to be rapid. The adoption of the use of a skilled
provider for delivery is limited to the number of children a woman delivers.
Bounded Rationality
Simons (1956) theory of bounded rationality suggests that individuals make
decisions about health behaviors that are bounded by such real-world limitations as time,
knowledge, emotions, and other resources. This model dispense(s) with the fiction of
optimization (Gigerenzer & Selten, 2001, p. 4), that is, with the unrealistic assumption
that individuals have access to unlimited resources available to them to use in their
decision-making processes. The constraints that limit an individuals decision-making
capability does not, however, imply that the final decision will be irrational. Rather, the
decision is considered to be an act of satisficing, that is, neither optimization nor
irrationality (Girgerenzer & Selten, 2001; Gigerenzer, 2001; Sadrieh et al., 2001).
Girgerenzer and Selten (2001) described Simons theory of decision-making as
consisting of the two blades of a scissors: One blade represents cognitive behavior or
limitations, and the second blade represents environmental constraints. The two blades
together make up the decision-making process. One cannot understand this process
without considering both blades of the scissors.
51
A central construct in the model of bounded rationality is limited search.

Individuals search for two types of information in the decision-making process; (1)
alternatives (choice), and (2) cues to action. Two types of searches may be conducted:
(1) internal, or search of ones cognitive repository (memory), for example, a woman
revisiting in her mind a previous experience with childbirth, and (2) external, that is, via
computer, library, and other individuals, for example, discussing the pros and cons of
using a skilled attendant for delivery with ones husband. There are costs associated with
each type of search. For example, an internal search is associated with the cost of time,
and external search is associated with monetary costs (Gigerenzer & Selten, 2001).
Another important concept in this bounded rationality model is the stopping
rule. This rule states that an individual will stop searching for alternatives or cues when
her decision meets her level of desire or exceeds her costs for searching. The stopping
rule does not involve optimization calculations (Klein, 2001), and can be about as
accurate as complex statistical models.. while demanding less information and
computational power (Gigerenzer & Selton, 2001, p. 9).
Emotions influence rationality and can limit the number of decisions made by an
individual. For example, love of a spouse may provide an effective stopping rule in the
search for a healthcare provider for delivery. If a husband learned that a skilled
attendant at delivery will increase the chances that his wife will live through childbirth,
he may look no further than the village bidan. In this example, a husbands emotional
involvement would lead to a sensible decision. Thus, decision-making may be based on
factors other than cognitive factors.
52
Cultural factors (i.e, factors associated with values, beliefs, and norms) can also
trigger the stopping rule and lead to sensible decisions. Culture can contribute to
decision-making by reducing the number of available options from which to choose. For
example, the established norm for delivery in Indonesian villages is home-birth with a
traditional birth attendant {dukuri). If a village does not have a resident bidan, then a
couples choice for attendant at delivery would be limited to the dukun, a family member,
a friend, or no one. If the family of the woman giving birth has the financial resources to
travel to a clinic or hospital, then the option of a higher level of maternal healthcare
service is added to the decision-making process. Cultural factors do not have to be
correct in order to influence the decision-making process (Gigerenzer & Selten, 2001).
These behavioral theories provide a framework for identifying the factors
underlying health behaviors, for example, using a skilled attendant for delivery, and help
in the selection of appropriate channels and messages for interventions intended to
change an audience individuals health-related behavior.
Study Research Question and Hypotheses
The use of skilled healthcare providers in Indonesian villages has increased

significantly in the last decade (Curtis et al., 2003). Social factors, for example, positive
attitudes toward bidan, may have contributed to this increase in healthcare-seeking
behavior. In order to understand this change in behavior, it is important to determine the
social support mechanisms that are associated with use of a skilled attendant for delivery.
The specific aim of the proposed study is to examine the associations between husbands
social support during pregnancy and (1) knowledge of pregnancy danger signs, (2)
attitudes toward skilled healthcare providers, and (3) actual use of skilled provider for
53
delivery, among Indonesian women of reproductive age. The ICPD (International

Conference on Population and Development) proposed targets for use of a skilled
attendant at delivery in developing nations are 40 percent by 2005, and 60 percent by
2015 (Graham et al., 2001).
The following research question and hypotheses address the gaps in the maternal
health literature regarding a pregnant womans social support during pregnancy (see
Figure 3.3);
A literature review of social support measures showed that the majority of scales
used to assess the various types of social support were developed and tested in developed
nations (see Chapter 2). Thus, it is important to determine whether the instruments used
to measure informational and instrumental social support in Indonesia in the present
study are reliable.
Hvpothesis la : High levels of husbands informational support during
pregnancy are associated with high levels of womens knowledge of pregnancy
danger signs among Indonesian women of reproductive age from lower
Hvpothesis lb: High levels of husbands informational support are
associated with womens positive attitudes toward skilled healthcare providers
among Indonesian women of reproductive age from lower socioeconomic strata.
Hypothesis la suggests that the more informational support a woman receives

during pregnancy, the more likely she is to know about danger signs during pregnancy.
54
Information provided by a husband can have a positive or negative impact on a pregnant

womans knowledge, attitudes, and ultimately, on the couples decision to use a skilled
healthcare provider for prenatal services, delivery, and emergency obstetric care.
Although knowledge of danger signs is difficult to validate and may be interpreted
differently at the lay level (perceived reality) versus the biomedical level (clinical
reality), use of this indicator provides general information about womens health
knowledge. Overall, improving knowledge (mens and womens) about pregnancy
danger signs is valuable as a means for reducing delays in seeking healthcare for
pregnancy, childbirth, and especially for emergency obstetric care (Iskandar, 1998).
The source of information about pregnancy can impact whether a pregnant
woman perceives certain information as credible, relevant, and important. Information
from sources that are perceived as trustworthy and knowledgeable about a given topic are
generally more effective in motivating behavior change than less trustworthy sources.
Findings from family planning studies show that spousal communication about family
planning is associated with the adoption of a contraceptive method, and with continued
use of a family planning method.
Attitude is the degree to which one likes or dislikes an idea, an individual, or a
health behavior (Rogers, 2003). An individuals attitude predisposes her actions (Rogers,
2003). The concept of attitude is usually measured with questions that assess whether an
individual is favorable or unfavorable toward a given idea, individual, or health behavior.
In general, (1) the more favorable an individual is toward a skilled healthcare provider or
health behavior, the more likely she will be to adhere to the advice of that provider, and
to adopt the behavior, and (2) if a person believes that seeking care from a skilled
55
healthcare provider or a proposed health behavior is not beneficial, she is less likely to
have a positive attitude toward that provider or behavior. Hypothesis lb suggests that the
more informational support a woman receives from her husband about using a skilled
provider for delivery, the more likely she is to have a positive attitude toward skilled
The proposed study will determine the relationship between
informational support and positive attitudes toward skilled healthcare providers among
women of childbearing age in West Java, Indonesia.
Hvpothesis 2; High levels of husbands instrumental support during
pregnancy are associated with using a skilled healthcare provider for delivery
The primary purpose of the Maternal and Neonatal Health Program in Indonesia
is to increase the number of women who use a skilled healthcare provider during
delivery. Delays in individual and household-level decision-making to treat pregnancyrelated complications, and in reaching care due to a lack of transportation and funds to
pay for care in Indonesia frequently result in death. Prior research suggests that the
selection (1) of birth location, and (2) of birth attendant varies with the amount of
autonomy women have in a country of study (Moore, 2000). Indonesian women
generally lack the capacity to make independent decisions to seek care when they are in
the throes of an obstetric emergency (Moore, 2000). Thus the role of the husband with
regard to making timely decisions about care-seeking and birth attendant becomes
especially important in emergency situations. Indonesian husbands control the resources
that often determine whether their wife will receive appropriate and timely care at
Indonesian women may have somewhat negative attitudes toward bidan (i.e., skilled providers) because
bidan are, in general, young, unmarried, and without children o f their own.
56
delivery (Iskandar, 1996). Hypothesis 2 suggests that a woman whose husband has
access to material resources and makes those resources available to pay for delivery with
a skilled healthcare provider will be more likely to use a skilled provider for delivery.
Hvpothesis 3; High levels of knowledge of pregnancy danger signs are
positively associated with positive attitudes toward skilled healthcare providers
among Indonesian women of reproductive age from lower socioeconomic strata .
Hvpothesis 4; High levels of knowledge of pregnancy danger signs are
Hvpothesis 5: Positive attitudes toward skilled healthcare providers are
positively associated with womens use of a skilled healthcare provider for delivery
Scholars who study behavior change generally accept that change occurs in
stages, and that these stages can be delineated and operationalized (McGuire, 1989;
Prochaska, 1992). Behavior change theorists also acknowledge that a change in attitude
can be an important step toward change in behavior (Valente, 2002, p.42). Hierarchy
models of behavior change such as the Innovation-Decision Process identified by Rogers
(2003) in Diffusion theory, and Steps to Behavior Change (Piotrow et al., 1997), provide
researchers with a way (1) to classify people together, and (2) to determine factors that
affect behavior within and among groups. Hypotheses 3, 4, and 5 test the relationships
between three stages of behavior change, knowledge, attitudes, and practice for maternal
mortality decline.
57
Summary
In this chapter we presented the conceptual framework, proposed model, and

hypotheses for the present study. The proposed model suggests that a husbands
informational and instrumental support influences his wifes knowledge of pregnancy
danger signs, her attitudes toward skilled healthcare providers (namely bidan), and the
couples adoption of the use of a skilled provider for delivery. The proposed model is a
socioecological model that recognizes psychosocial factors related to childbearing and
places women in the context of their social relationship with their husband, a particularly
relevant context given Indonesias patriarchal social system.
The proposed model is grounded in Diffusion of Innovations theory and the
theory of Bounded Rationality. These theories identify the factors underlying health
behaviors (for example, seeking a skilled attendant for delivery), and the process for
adopting new behaviors.
This model is limited by the data that were collected for the MNH study. Thus,
although it would be interesting to try to determine the influence of, for example, the
wifes knowledge about pregnancy danger signs on her husbands decision (or input to
the decision) of which provider to use for delivery, those data are not available. The
following chapters will report findings from analyses conducted to test the hypotheses
outlined in the present chapter.
58
Chapter 4
METHODOLOGY
This chapter describes the methodology employed in the present study. The first
section describes the geographical context in which the data were gathered. The second
section specifies the study sample. The third section presents the sources of data used to
answer the studys hypotheses. The fourth section describes the study variables used to
test the studys hypotheses. The data analysis plan is presented in a final section.
Study Area
The present investigation is a cross-sectional study of women of reproductive age

and lower socioeconomic strata living in West Java, Indonesia who have given birth to
one or more live-born children. Java is one of 6,000 inhabited islands that make up the
archipelago of Indonesia. Java is a long island divided into the main provinces of West,
Central, and East Java. This island includes the special territories of Jakarta (the capital
of Indonesia) and Yogyakarta (the center of Javanese eulture). Java is the political,
economic, and geographic center of Indonesia. The majority of the national population,
and espeeially of educated Indonesians, inhabit the island of Java. West Java is home to
the Sundanese people. Some 90 percent of the female population of West Java is Muslim
(Blackburn, 2000).
The province of West Java was seleeted by the Government of Indonesias
Ministry of Health and the State Ministry of Women's Empowerment as the site for the
five-year Maternal and Neonatal Health (MNH) Program intervention due (1) to its large
population size (approximately 42 million people), and (2) to the relatively low use of
59
skilled midwives during pregnancy and d e liv ery .T h e study districts included (1)
Kabupaten Cirebon, (2) Kota Cirebon,^^ (3) Kabupaten Kuningan, (4) Kabupaten
Bandung, (5) Kabupaten Sukabumi, and (6) Kabupaten Purwakarta (Figure 4.1) .
Study Sample
The total study sample consists of 2,269 women of reproductive age in West Java,
Indonesia. The sampling frame included (1) women who were not pregnant at the time of
the survey and had delivered a child in the past year (Category 3, N=l,105)^^, and (2)
women who were not pregnant at the time of the survey and had delivered more than one
child in the past, but not in the past year (Category 4, N=l,164). For the purposes of
the present study, we analyzed data from Category 3 and Category 4 women, that is,
women who were not pregnant at the time of the survey and who delivered a child in the
past, so that we could determine actual use of a skilled healthcare provider for a past
delivery. Category 1 and 2 women were pregnant at the time of the survey, thus use of a
skilled healthcare provider for a past delivery could not be measured.
In order to participate in the present survey, women had to be (I) from the lower
socioeconomic strata of Indonesian society with a monthly household earning of less than
About 71 percent of rural births are assisted by traditional birth attendants {dukun) in the Java-BaU region
(IDHS, 1998). The IDHS (1998) data show that in the Outer Java regions (including Aceh; North, West
and South Sumatra; Lampung; East and W est Nusa; Tenggara; East, West, Central, and South Kalimantan;
North, South, Southeast, and Central Sulawesi; Riau; Jambi; Bengkulu; East Timor; Maluku; and Irian
Jaya), an average o f 59 percent o f rural births are attended by a dukun. The IDHS data report the least
qualified attendant if more than one attendant was mentioned by a respondent.
Kabuijaten is the Indonesian word for district administrative unit and is usually the official residence
o f the head o f the district. Kota and kodva are Indonesian words used for city or large village.
Women in Category 3 are primiparas, that is, their reported birth is their first birth.
Based on the May 18, 2001 exchange rate.
60
CDD
O
Q.
C
o
ln<ioniia
CD
Q.
CDD
C/)
W
o'
o
o
3CD
O
O
D
c q
AUSTRAIIA
'
o
1
Q
o
"n
c
O
o
CD
D
O
Q .
C
a
o
Q
o
o
Study Districts
Kabupaten Cirebon
Kota Cirebon
Kabupaten Kuningan
CDD
Kabupaten Bandung
(/)
Kabupaten Sukabumi
Kabupaten Purwakarta
CD
Q .
(/)
Figure 4.1. Map of Study Districts in West Java, Indonesia.
Rp,700,000, or US$62.OO^'^, and (2) between the ages of 15 and 45 years. A simple
random sample of women were selected for the Baseline Survey. The women were
screened by the inclusion criteria of marital and childbearing status. Confidence in the
generalizability of the study findings may depend on the comparability of the present
sample to larger populations of women in Indonesia, for example, to the sample drawn
for the Indonesia Demographic and Health Survey (1998).
Source of Data
A quantitative population-based survey (the Maternal and Neonatal Health

Baseline Survey) was conducted in May, 2001, in six districts of West Java in order to
establish a baseline for the BCI component of the MNH Program (discussed in Chapter 1;
see also Figure 4.1). This Baseline Survey represented the first of three rounds of data
collection.
The proposed study will use the data from this Baseline Survey.
A core baseline questionnaire was developed by JHU/CCP in collaboration with

JHPEIGiO and Taylor Nelson Sofres (TNS), a research organization in Jakarta, Indonesia.
This core questionnaire was adapted for each category of women in the sample
(Appendix A). TNS was contracted by JHU/CCP (I) to develop the baseline survey, (2)
to pilot test the survey, (3) to administer the survey questionnaires in the six study
districts, (4) to input the data in SPSS computer format, (5) to conduct preliminary
analysis of the data, and (6) to present the preliminary survey findings to Government of
Indonesia, USAID/Jakarta, and other officials in Indonesia.
Data will be collected at two subsequent points in time following a planned intervention to promote the
use o f skilled midwives for prenatal care and childbirth in West Java. The data from the second and third
waves o f data collection will not be used in the present stucfy.
62
An experienced research team from TNS (1) attended a training session facilitated
by the TNS team supervisor to familiarize themselves with the data collection
instruments, and (2) traveled to the study sites and administered the survey questionnaire
to eligible women in personal interviews. Each respondent received a contact card
upon completion of the interview to reiterate the anonymity of the respondent, and to
provide the respondent with contact information for Taylor Nelson Sofres if they had
questions about the survey. A series of random checks were conducted in the field and in
Jakarta by TNS to assure the accuracy of the data. Supervisors examined the completed
questionnaires in the field for coding errors and incomplete responses. Following data
entry, computer records were compared with the original questionnaires to verify the
accuracy of the data entry process.
The present author worked as a consultant to JHU/CCP beginning in January,
2001, to develop and finalize the Baseline Survey questionnaires. In July, 2001, the
present author traveled to Jakarta, Indonesia to assist with preparing a presentation of
preliminary findings from the baseline study to USAID officials and other involved
parties.
Human subjects approval for the protocol entitled Baseline and Follow-up
Impact Evaluation for the JHU/CCP Maternal & Neonatal (MNH) Project in Indonesia
was received by JHU/CCP in January 2001 (CHR# H.52.01.02.27.C). An amendment to
this human subjects approval that added the present author as a student investigator to the
MNH Project was submitted by JHU/CCP to the Johns Hopkins University Committee
for Human Research (CHR) on June 19^, 2003 and approved on August 4, 2003.
63
Study Variables
The dependent and independent variables for the present study were operationalized
as follows:
Dependent Variables
1. Knowledge: Current awareness knowledge of danger signs during pregnancy was
assessed using a multiple response question consisting of 15 scale items in the
survey questionnaire. During the personal interviews, women were prompted as
to whether they were familiar with each of the 15 danger signs specified in the
survey instrument. A yes response to the prompted danger sign was scored as
one, and a no response was scored as zero (that is, each danger sign was coded
as a dichotomous variable). Spontaneous awareness was not measured. A
womans knowledge could range from knowledge of no danger signs to knowing
all 15 danger signs. The danger signs were assumed to be approximately
equivalent triggers to action.
Exploratory Principal Components Factor Analysis (PCA) for
dichotomous variables, with varimax rotation, was used to determine what, if any,
underlying structure exists for knowledge of danger s ig n s .T h e analysis
revealed five factors with eigenvalues greater than 1.0 (Kaiser, 1960). Table 4.2
shows the factor loadings for the five latent variables in the rotated component
matrix. The five factors with eigenvalues greater than 1.0 explained 13 percent of
the variance for knowledge of danger signs. Chronbachs alpha for each of the
five factors was less than .70. Thus the 15-item scale for knowledge of danger
The factor analyses, using tetrachoric correlation coefficients (Benedetti, 1977), were conducted using
SAS for Windows, Version 8e (1999-2000).
64
signs does not meet the conventional standards for scale reliability (Nunally,
1978) and does not consistently measure knowledge of danger signs during
pregnancy among women of reproductive age and lower socioeconomic status in
West Java, Indonesia,
Knowledge items were summed for each woman respondent.Item -tototal Pearsons correlations were calculated using SPSS. All fifteen items had
significant (p<.05) item-to-total score correlations (Table 4.2).^* Based on the
distribution of scores, the following categories were created; 0=no knowledge of
danger signs during pregnancy (N=l,187 or 52%); l=a low level of knowledge of
dangers signs during pregnancy, measured as knowing one danger sign (N==321 or
14%); 2=a medium level of knowledge of danger signs during pregnancy,
measured as knowing two danger signs (N=417 or 18%); and 3=a high level of
knowledge of danger signs, measured as knowing three or more danger signs
(N=344 or 15%). The number of danger signs known was considered to be an
interval-level variable. The maximum number of danger signs identified using
the present survey instrument was five danger signs. The mean number of danger
signs identified by respondents was 1.00 (s.d. = 1.15).
2. Attitude: Attitudes toward skilled healthcare providers were measured using four
scale items from the survey questionnaire. The four items included:
1. Bidan are respectful about the pregnant mothers needs.
2. Bidan know their j ob.
Hair et al. (1992) stated that if scales are untested and exploratory, with little evidence o f reliability,
summated scores should be constructed. These summated scores preserve the variation in the data and can
thus be used in further analyses.
65
Table 4.1. Principal Components Factor Analysis Rotated Factor Loadings and Item-to-Total-Score
Correlations for Knowledge of Danger Signs During Pregnancy (N=2,269).
Rotated Factor Loadings^
Factor 5
0.862
Item-toTotal-Score
Correlations
.722**
1.
Item (Danger Sign)

Bleeding
Factor 1
0.075
Factor 2
0.503
Factor 3
-0.053
Factor 4
-0.012
2.
H igh blood pressure
0.284
0.503
-0.009
0.015
0.340
.435**
3.
Swollen feet
0.351
0.687
-0.029
-0.257
0.225
.511**
4.
Swollen hands
1.106
0.242
0.001
0.219
0.107
.296**
5.
Swollen faee
0.754
0.327
-0.702
0.115
0.154
.285**
6.
Infection
-0.124
0.300
0.986
0.049
0.243
7.
Vomiting
-0.225
0.688
-0.007
0.187
0.184
.510**
8.
Blurred vision
-0.018
0.607
0.091
-0.062
0.135
.307**
9.
Body weight doubles
0.003
0.836
-0.048
0.384
-0.250
.312**
10. Rupture of amniotic

fluid
-0.114
0.052
0.057
0.122
0.804
.437**
11. Spotting
-0.850
0.200
0.176
0.281
0.182
.222**
12. Breeeh position
-0.585
0.176
-0.207
-0.364
0.409
.315**
13. Spasms
-0.061
0.019
-0.094
0.889
0.354
.212**
14. High fever
-0.078
0.109
-0.826
0.443
0.217
.228**
15. Baby twisted in

umbilical cord
-0.381
-0.206
0.432
-0.926
0.445
.181**
4.48
3.51
2.39
Eigenvalue
1.76
1.22
~
~
0.30
0.39
Chronbachs alpha***
3.3%
Variance explained
2.9%
2.4%
2.4%
2.3%
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
*** Chronbachs alpha was assessed using items with a factor loading greater than 0.6 or less than -0 .6 for
each factor. Factors with only one or two factor loadings greater than 0.6 or less than -0 .6 did not yield a
Chronbachs alpha that met the conventional standard for reliability o f a = .70.
These item-to-total-score correlations are all somewhat inflated because each item score is included in
the total score.
^ Factor analysis assumes correlation across all o f the items, while polychoric correlations are pairwise.
Thus it is possible to obtain factor loadings beyond the interval {-1, 1}. A key point to note for this data set
is that for two variables with a correlation o f -.999, they should be nearly identical in their respective
correlations with any and all other variables. The farther from identical correlations between these two
variables, the greater the error that will appear in the factor analysis (considering error in the factor analysis
to have factor loadings outside the interval {-1, 1}).
66
3. The delivery process should be handled by a bidan instead of a dukun.

4. The bidan is a trustworthy provider for prenatal care/delivery/post
partum care.
Respondents were asked to rate their attitudes on a four-point Likert scale, with
possible responses including: Strongly agree, agree, disagree, and strongly
disagree (scored 4, 3, 2, 1, respectively).^^
Exploratory Principal Components Factor Analysis (PCA) with varimax
rotation, was used to determine what, if any, underlying structure exists for
attitude toward a skilled provider. The analysis revealed one factor with an
eigenvalue of 1.9, that explained 48 percent of the variance. Table 4.2 shows the
factor loadings for the latent variable in the component matrix. Chronbachs
alpha was .61. A summed index was created using the four attitude questions.
Higher total responses indicated more favorable attitudes toward skilled
Based on the distribution of scores, the following categories were created:
O=not very positive (N=358 or 16%); l=somewhat positive (N=797 or 35%);
2=positive (N=435 or 19%); 3=very positive (N=349 or 15%); and 4=extremely
positive (N=330 or 15%). Attitude was considered to be an interval-level
variable. Total scores ranged from 0 to 4 (x = 1.8, s.d. = 1.3).
3. Use: Respondents were asked to identify who was present during the delivery of
their last child. If a doctor, specialist/OBGYN, health center midwife {bidan
The studys intention was to measure womens attitudes (i.e., the mental state involving beliefs, feelings,
values, and a disposition to act in certain ways). The translation o f the wording of the items into English
suggests that some attitude items may be construed as beliefs (i.e., any cognitive content held as true)
(Curbow, 2003).
67
Table 4.2. Principal Components Factor Analysis Component Matrix for
Component
Matrix
Attitude Item
1. Bidan is respectful about pregnant mothers needs
.704
2. Bidan knows her job
.132
3. The delivery process should be handled by bidan instead

of dukun
.579
4. Bidan is a trustworthy provider
.738
Eigenvalue
1.91
Chronbachs alpha
0.61
Variance explained
M.1%
68
puskesmas), village midwife {bidan desa), or private practice midwife {bidan

swasta), or some combination of the above, were present at delivery, the woman
was considered as having used a skilled provider for delivery. If a traditional
birth attendant {dukun), family member, or no one besides the pregnant woman
herself was present at delivery, the respondent was categorized as not using a
skilled healthcare provider for delivery. Use was considered a categorical
variable. The index was skewed and revealed approximately a 64 percent/36
percent split between respondents who used a skilled healthcare provider for
delivery (64 percent, scored as 1) and those who did not use a
skilled healthcare provider for delivery (36 percent, scored as 0). Total scores
ranged from 0 to 1, with a mean of 0.64 and a standard deviation of 0.48.
Independent Variables
1. Husbands informational support: To assess the level of husbands informational
support (i.e., a husband providing knowledge, news, and advice about pregnancyrelated issues, and providing feedback), women were asked to acknowledge, from
a list of 17 scale items, what type of informational support they received from their
husband during their previous pregnancy period. Each of the 17 items were read
to the respondent by the interviewer. For each item, a dichotomous measure was
created that assessed whether the respondent indicated that she received (scored as
1) or did not receive (scored as 0) informational support from her husband.
A scale was created by summing the 17 dichotomous husbands
informational support scale items. Item-to-total score Pearsons correlations were
calculated using SPSS. All seventeen scale items had significant (p<.05) item-to-
69
total-score correlations (Table 4.4).'^ Based on the distribution of scores, the

following categories were created; 0=no husbands informational support (N=501
or 22%); l=a low level of husbands informational support, indicated by one item
of support (N=361 or 16%); 2=a low-medium level of husbands informational
support, indicated by two items of support (N=644 or 28%); 3=a high-medium
level of husbands informational support, indicated by three items of support
(N=457 or 20%); and 4=a high level of husbands informational support,
indicated by four or more items of support (N=306 or 14%). Higher scores
indicated a higher level of husbands informational support. Total scores ranged
from 0 to 17 (x = 1.9, s.d. = 1.3).
2. Husbands instrumental support: Level of husbands instrumental support (i.e.,
direct aid or services with regard to his wifes pregnancy) was measured using 19
scale items from the survey questionnaire. For each item, a dichotomous measure
was created that assessed whether the respondent indicated that she received
(scored as 1) or did not receive (scored as 0) instrumental support from her
husband.
A scale was created by summing these 19 dichotomous instrumental
support items. Item-to-total score Pearsons correlations were calculated using
SPSS. All nineteen items had significant (p<.05) item-to-total correlations (Table
4 .5). Based on the distribution of total scores, the following categories were
created: 0=no husbands instrumental support (N=485 or 21%); l=a low level of
husbands instrumental support, indicated by one or two items of husbands
Although these correlations are overestimates because each scale item is included in the total score.
70
Table 4.3. Item-to-Total-Score Correlations for Husbands Informational Support
Item
1. Get medical treatment from trained provider
Item-to-Total Score
Correlations
.448**
2. Get advice from traditional provider
.086**
3. Get rest/no hard work
.564**
4. Advice on nutritious food
.584**
5. Ask midwife/doctor about my pregnancy
.450**
6. Notify people about my pregnancy
.205**
7. Advice about bleeding
111**
8. Advice about swollen feet

9. Advice about breathing techniques for delivery
.148**
10. Advice to prepare transportation
.331**
11. Advice to prepare blood donor
.176**
12. Advice to make financial arrangements for

emergency
.438**
13. Information on necessary immunization
.320**
14. Information not to consume food containing a lot of

salt
J47**
15. Information about taboos
.294**
16. Information about safe delivery ceremony
.349**
149**
17. Advising me to consume egg yolk
* Correlation is significant at the 0.05 level (2-tailed)

71
Table 4.4. Item-to-Total-Score Correlations for Husbands Instrumental Support

(N=2,269).
Item-to-Total Score
Correlations
Item
.189**
1. Routine medical check-up
2. Check babys position
.082**
3. Check babys weight
.068**
4. Check blood pressure
.054**
5. Check urine sample
.047**
6. Assess age of pregnancy
.129**
7. Provide vitamins
3 [4**
8. Provide traditional medicines
.193**
9. Massage stomach
.122**
10. Teaching breathing techniques for delivery
.054*
11. Manages any danger signs
.263**
12. Monitoring the babys growth
.376**
13. Accompanying me to routine check-ups
.573**
14. Preparing nutritious food for me
.606**
15. Organizing religious ceremonies for safe delivery

16. Preparing transportation if needed during delivery
.524**
17. Preparing blood donors if needed during delivery
,233**
18. Preparing funds for delivery
.603**
19. Preparing extra funds for emergency during delivery
.524**

72
instrumental support (N=282 or 12%); 2==a low-medium level of husbands

instrumental support, indicated by three or four items of support (N=503 or 22%);
3=a high-medium level of husbands instrumental support, indicated by five or
more items of support (N=455 or 20%), and 4=a high level of husbands
instrumental support (N=544 or 24%). Higher scores were considered to indicate
a higher level of instrumental support (x = 2.1, s.d. = 1.5).
Possible Confounders
The following sociodemographic variables were investigated as possible
confounders in the present study. Some 99 percent of the study sample identified their
religion as Islam, thus religion was not included as a potential confounding variable.
1. Age; Women were asked to report their age in years. All women provided a
numeric response (the number of years). Age was treated as an interval-level
variable (x = 26.4, s.d. = 6.1).
2. Education: Level of education was measured by asking women to identify the
highest level of education that they received, ranging from no formal education to
a university degree. Education was considered an interval-level variable [0=at
least some primary school (N=273 or 12%)"**; l=completed primary school
(N=945 or 42%); 2=at least some junior high school (N= 529 or 23%)^^^; 3=at
least some senior high school (N=522 or 23%)]. The mean level of education for
respondents was 1.6 (s.d. = 1.0).
3. Parity: Parity was assessed using a multi-part question. Respondents were asked
This first category also includes 17 women (0.7%) who reported having no formal education.
Category 2 includes 127 women (5.6%) who did not complete junior high school, and 402 (17.7%) who
completed junior h i ^ school.
73
whether or not they had given birth in the past. Women who reported ever giving
birth were asked to identify the sex of each of their children and whether each
child was still living. The number of living sons and daughters was added to
obtain a measure of parity. Parity was treated as an interval-level variable ( x =
2.0, s.d. = 1.4),
4. Socioeconomic Status: Respondents socioeconomic status was derived from
their reported monthly household expenditure. Women were asked how much
money their household spent in total per month for such items as food, clothes,
transportation, electricity, rent if paid monthly (rent was excluded from this
calculation if paid yearly), and other regular expenses. Reported monthly
household expenditure was measured as a five-level ordinal variable [0= Rp
150,000 or less (N=74 or 3%); l=Rp 150,001-250,000 (N=432 or 19%); 2=Rp
250,001-350,000 (N=837 or 37%); 3=Rp 350,001-500,000 (N=616 or 27%);
4=Rp500,001-700,000 (N=310 or 14%)]. The mean level of monthly household
expenditure for respondents was 2.29 (s.d. = 1.0).
5. Ethnicity: Respondents were asked to identify the ethnic group to which they
belonged. Interviewers used a pre-set coding system for 13 relatively common
ethnic groups. Additional responses were coded at the completion of the survey
interview. Ethnicity was coded as a nominal or categorical variable [0=Jawa
(N=580 or 26%)]; l=Sunda (N=l,661 or 73%); 2=Other than Sunda or Jawa
(N=28 or 1%).
6. Residence: Residence was measured as a categorical variable. The sample of
74
women respondents was drawn from each of the six districts of study in West
Java, Indonesia [l=Kabupaten Kuningan (N=389 or 17%); 2=Kabupaten Cirebon
(N=361 or 16%); 3=Kota Cirebon (N=381 or 17%); 4=Kabupaten Bandung
(N=383 or 17%); 5=Kabupaten Sukabumi (N=374 or 17%); 6=Kabupaten
Purwakarta (N=381 or 17%)].
Data Analysis
Analysis of the survey data was conducted in two phases. The first phase
consisted of univariate examination of the study variables. The second phase consisted of
bivariate and multivariate analyses to examine the associations between the dependent
variables (womens knowledge of dangers signs during pregnancy, attitudes toward
skilled healthcare providers, and use of a skilled healthcare provider for delivery) and
independent variables (husbands informational support and husbands instrumental
support) using correlation and regression statistical methods. There were no missing
data. Erroneous data were identified and addressed. All analyses were performed using
the SPSS statistical software package. Version 11.0 (SPSS Inc., 2000).
Univariate Analysis
The frequencies, distributions, and measures of central tendency for each
categorical variable were examined to ensure that each category contained a sufficient
number of respondents for a meaningful analysis. The levels of skewness and kurtosis
for each interval-level variable were investigated to assess the extent to which its
distribution deviated from a normal distribution. The univariate analyses are presented in
Table 4.5.
75
Table 4.5. Percent Distribution of the Study Variables

Percent of
Respondents
(N=2,269)
Study Variables
DEPENDENT VARIABLES
Knowledge of Pregnancy Danger Signs
Average number of current danger signs known
S.D.
Skewness
Kurtosis
Range
1.00
1.15
0.67
-1.10
0-3
Attitudes Toward Skilled Provider

Average
S.D.
Skewness
Kurtosis
Range
1.78
1.29
0.38
-0.99
0-4
Use of a Skilled Provider for Delivery

No use
Use
36.0
64.0
INDEPENDENT VARIABLES
Husbands Informational Support
Average level of informational support
S.D.
Skewness
Kurtosis
Range
1.87
1.33
0.19
-1.11
0-4
Husbands Instrumental Support

Average level of instrumental support
S.D.
Skewness
Kurtosis
Range
2.13
1.46
-0.17
-1.30
0-4
DEMOGRAPHIC CHARACTERISTICS
Age
Average
S.D.
Skewness
Kurtosis
Range
26.39
6.11
0.64
-0.35
15-45
76
Education Level
Average
S.D.
Skewness
Kurtosis
Range
1.57
0.97
0.15
-1.05
0-3
Parity
Average number of living children
S.D.
Skewness
Kurtosis
Range
1.99
1.42
2.18
7.59
0-14
Monthly Household Expenditure (Rupiah)

Average
S.D.
Skewness
Kurtosis
Range
2.29
1.03
-0.02
-0.61
0-4
Ethnicity
Sunda
Jawa
Other
73.0
26.0
1.0
Residence
Kabupaten Kuningan
Kabupaten Cirebon
Kota Cirebon
Kabupaten Bandung
Kabupaten Sukabumi
17.0
16.0
17.0
17.0
17.0
17.0
77
The Kolmogorov-Smirnov test was used to determine whether the distribution of

each of study variable was significantly different from a normal distribution (Mertler &
Vannatta, 2002). Variables that were significantly moderately positively skewed
(knowledge, attitude, informational support, and age), were transformed using the
square root (NewX= SQRT of X). The variable of parity was significantly and
severely positively skewed, and was transformed using the inverse (NewX= 1/parity).
The variable instrumental support was significantly moderately negatively skewed, and
was transformed using the following formula:
NEW VARIABLE INSTRUMENTAL SUPPORT - SQRT (K-X)
where:
SQRT = the square root
K = a constant from which each score is subtracted so that the smallest score
equals one (here K=5)
X = the original variable of instrumental support (Mertler & Vannatta, 2002).
An inspection of the transformed variables showed no improvement in the

distribution for each variable toward normality. Moderate violations of the normality
assumption may be ignored with a large sample size, without any adverse affect on the
ensuing analysis (Mertler & Vannatta, 2002). Thus, the non-transformed variables were
used for subsequent analyses.
Bivariate and Multivariate Analyses
Bivariate analyses, including t tests and the Chi-square test of independence were
used to determine if there were significant differences in the dependent variables
(knowledge of danger signs during pregnancy, attitudes toward skilled healthcare
78
providers, use of a skilled healthcare provider for delivery), the independent variables
(reported husbands informational support, and reported husbands instrumental support),
and the potential confounding variables (age, education, parity, monthly household
expenditure, ethnicity, and residence) between Category 3 women (i.e., those who were
not pregnant at the time of the survey and had delivered a child in the past year) and
Category 4 women (i.e., those who were not pregnant at the time of the survey and had
delivered more than one child in the past). Pearsons correlation coefficients were
calculated to measure the strength of the association between ordinal measures. Each of
the above statistical tests provided the basis for inclusion in subsequent multiple
regression equations. A probability of .05 or less was used as the criterion for statistical
significance.
Table 4.6 presents the principal analysis method for each of the study hypotheses.
Regression analyses were used to examine the main effects of the independent variables
(husbands informational support and husbands instrumental support) on the dependent
variables (knowledge of danger signs during pregnancy, attitudes toward skilled
healthcare providers, and use of a skilled healthcare provider for delivery), while
adjusting for potential confounding variables. The regression model used for these
analyses (of a dependent variable like knowledge of danger signs during pregnancy) was
of the following form:
Y= Po + PiXi + P2X2 + ... PkXk + e
w here:
Y = is the predicted value for the dependent variable.

P = coefficients measuring the association between each
explanatory variable and the predicted value of Y (i.e.,
the expected change in Y for each unit change in X).
79
7J
D
CD
O
Q.
C
o
CD
Q.
CD
D
2(/)2
o'
o
Table 4.6. Study Hypotheses and the Methods Used for Statistical Analysis
Dependent
Hypothesis
Method
Variable
la. Informational Support and

Womans Knowledge
Independent
Variable
Potential
Confounders
Level of Significance
oD
lb. Informational Support and

Womens Attitudes
Toward Skilled Providers
2.
Instrumental Support and

Use of a Skilled Attendant at
Birth
Regression
Regression
Logistic
Regression
Informational
Support
(interval)
A ge, Education,
Parity, SES
Informational
Support
(interval)
A ge, Education,
Parity, SES,
Residence
p<.05
Instrumental
Support
(interval)
A ge, Education,
Parity, SES,
Ethnicity Residence
p<.05
Attitude
(interval)
Knowledge
(interval)
A ge, Education,
Parity, Residence
p<05
Use
(nominal)
Knowledge
(interval)
A ge, Education,
Parity, SES,
Ethnicity, Residence
p<.05
A ge, Education,
Parity, SES,
Ethnicity, Residence
p<05
Knowledge
(interval)
Attitude
(interval)
Use
(nominal)
p<.05
CD
D
O
Q.
C
a
o
o
O
o
3. Womens Knowledge and

Womens Attitudes
Regression
4. Womens Knowledge and

Use of a Skilled Attendant at
Birth
Logistic
Regression
5. Womens Attitudes and Use

of a Skilled Attendant at
Birth
Logistic
Regression
00
CD
Q.
CD
C/)
(/)
Use
(nominal)
Attitude
(interval)
X = the raw score value of each independent variable,

E = the error term (or residuals).
The assumptions in multiple regression (linearity, homoscedasticity, and

normality) were tested using residuals scatterplots (i.e., plots of the values on the
combination of predictive values of the dependent variable and the standardized residuals
or prediction errors). When the assumptions for linearity, homoscedasticity, and
normality are met, the data points will cluster along the horizontal line in a somewhat
rectangular pattern. Any systematic differential patterns will be indicative of possible
model violations. Where a priori evidence of expected interactions existed, those
interaction terms were included in the standard regression analyses.
The following logistic regression model was used for response variables that
followed a binomial distribution (that is, use of a skilled provider for delivery):
,log
MY,---= 1) = x,B + e
Pr(f^=0)
'
where:
Yi = the value of the binary dependent variable for person i.
Xi = a matrix of explanatory variables measured on person i.
^ = coefficients measuring the association between each
explanatory variable and the log-odds that Y = 1.
8 = the error term
Associations were presented in the exponentiated form of P, the odds ratio. For
categorical covariates, the odds ratio compares, for example, the odds of using a skilled
healthcare provider for delivery for each category of the covariate to the odds for the
81
reference category, which is assigned an odds ratio of 1.0. To assess the fit of the model,
the Hosmer-Lemeshow Goodness of Fit statistic was calculated.
Summary
The present chapter described the methodology employed in the present study.
The first section described the study area. West Java, Indonesia, a largely Sundanese,
Muslim section of the island of Java. The second section specified the size of the study
sample (N=2,269) and the criteria for participating in the study (i.e., females aged 15-45,
from the lower socioeconomic strata of Indonesian society). Women in the study were
stratified by marital and childbearing status. Category 3 (women who were not pregnant
at the time of the study and who had delivered one child in the past year) and Category 4
(women who were not pregnant at the time of the study and who had delivered more than
one child in the past) respondents were retained for the present study. The third section
presented the source of data used to answer the studys hypotheses, namely a quantitative
population-based survey conducted in six districts of West Java in 2001.
The fourth section described the study variables and their measurement used to
test the studys hypotheses. The two phases of the data analysis were presented in the
fifth section. The data analysis plan described the univariate, bivariate, and multivariate
statistical analyses. The univariate analyses were presented in Table 4.6. Regression
models used for the analyses were also detailed.
82
Chapter 5
RESULTS
This chapter presents the results of the data analyses. First, we present a profile
of the two categories of women respondents (Category 3 and Category 4) to the survey
questionnaire. Next we present a comparison of the distributions of the study variables
for the two categories of women respondents. Then we present the analyses for the
studys research question and for each of the study hypotheses.
Profile of Respondents
The total number of Category 3 and Category 4 women who responded to the
survey questionnaire was 2,269. There were 1,105 Category 3 women (i.e., women who
were not pregnant at the time of the survey and who had delivered a child in the past
year), and 1,164 Category 4 women (i.e., women who were not pregnant at the time of
the survey and who had delivered more than one child in the past, but not in the past
year).
Table 5.1 shows the demographic characteristics for each of the two categories of
women in the present study. The majority of women in Category 3 (59 percent) were
between the ages of 20 and 24 years, while the majority of women in Category 4 (61
percent) were slightly older, between the ages of 25 and 34 years. All of the respondents
were married. More Category 4 women had completed their primary education (45
percent) than Category 3 women (38 percent). Fewer Category 4 women had gone to
junior high school (18 percent) or had achieved some higher education (19 percent) than
Category 3 women (29 percent and 27 percent, respectively). Some 69 percent of women
83
Table 5.1. Demographic Characteristics of Category 3 and Category 4 Women

Demographic
Characteristics
Percent of Category 3
Women Respondents (N)
Percent of Category 4
Women Respondents (N)
Age
15-19 years
20-24 years
25-29 years
30-34 years
35-39 years
40-45 years
Totals
18.6 (205)
59.3 (655)
16.3 (180)
4.6(51)
1.0(11)
0.3 (3)
100 (1,105)
0.3 (4)
14.5 (169)
30.8 (358)
30.2 (352)
17.2(200)
7.0(81)
100 (1,164)
Marital Status
Not married
Married
Totals
0(0)
100(1,105)
100 (1,105)
0(0)
100(1.164)
100 (1,164)
6.6 (73)
17.2(200)
37.8(418)
28.6(316)
45.3 (527)
18.3 (213)
27.0 (298)
100 (1,105)
19.2 (224)
100 (1,164)
Parity
1 live birth
2 live births
3 or more live births
Totals
99.9(1,104)
0.1(1)
0.0 (0)
100 (1,105)
2.5 (29)
47.6 (554)
49.8 (581)
100 (1,164)
Monthly Household
Expenditure
Less than Rp. 150,000
Rp. 150,000-250,000
Rp. 250,001-350,000
Rp. 350,001-500,000
Rp. 500,001-700,000
Totals
4.5 (50)
24.5 (271)
39.8 (440)
21.5 (238)
9.6 (106)
100 (1,105)
2.1 (24)
13.8(161)
34.1 (397)
32.5 (378)
17.5 (204)
100 (1,164)
Education Level
At least some primary
education'^^
Completed primary school
At least some junior high
school
Some senior high or higher
Totals
Includes 17 women with no formal education.
84
Ethnicity
Jawa
Sunda
Other
Totals
26.1 (288)
72.8 (804)
1.2(13)
100 (1,105)
25,1 (292)
73.6 (857)
1.3(15)
100 (1,164)
Residence
Kab. Kuningan
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Purwakarta
Totals
17.4(192)
16.7(185)
16.1 (178)
17.0 (188)
16.1 (178)
16.7 (184)
100 (1,105)
17.0(198)
15.1 (176)
17.4(203)
16.7 (194)
16.8(196)
16.9(197)
100 (1,164)
85
in Category 3 lived in a household with a monthly household expenditure of Rp.350,000

or less, compared to 50 percent of Category 4 women with the same monthly household
expenditure. In each of the two categories of women, there was an approximately equal
distribution among the Sunda and Jawa ethnic groups. The distribution of women from
each of the six study sites was approximately equal in each of the two categories.
Differences Between Category 3 and 4 Women
Analyses of the differences between Category 3 (N=l,105) and Category 4

(N=l,164) women showed that these two groups of women differed significantly with
regard to the dependent variable of attitudes toward skilled providers, the independent
variable of husbands instrumental s u p p o r t , a n d four control variables, namely age,
education, parity, and monthly household expenditure (Table 5.2). Differences in these
control variables were expected, given that the two categories were based on parity, thus
women with more children were likely to be older and more likely to have husbands with
occupations that allowed for higher monthly household expenditures.
Based on the results of this comparison, hypotheses that involve the variable of
attitude or instrumental support (Hypothesis lb. Hypothesis 2, Hypothesis 3, and
Hypothesis 5) were analyzed separately for Category 3 and Category 4 women.
Analysis Results for the Study Research Question and Hypotheses
Following are the results from the analyses for the study research question and
hypotheses.
A liigher level o f husbands instrumental support reflected a higher number o f perceived tangible aid
actions by a womans husband, and was considered more desirable.
86
Table 5.2. Differences Between Category 3 and Category 4 Women Regarding the
Study Variables
Category 4
Women
(N=l,164)
Category 3
Women
(N=l,105)
Test Statistic
Significance
Knowledge
1.00
.93
t=1.32
p=.188
Attitude
1.90
1.66
t=4.45
p=.000*
Use
375 (49.9%)
431 (53.5%)
X''=2.36
p=.124
Informational Support
1.90
1.85
t=0.92
p=356
Instrumental Support
2.20
2.06
t=2.33
p=.020*
Age
22.35
30.21
t=-40.11
p=.000*
Education
1.76
1.40
t=9.05
p=.000*
Parity
0.99
2.95
t=-45.75
p=.000*
MHE
Rp. 150,000 or less
Rp. 150,001-250,000
Rp.250,000-350,000
Rp.350,001-500,000
Rp. 500,001-700,000
50 (67.6%)
271 (62.7%)
440 (52.5%)
238 (38.7%)
106 (34.2%)
24 (32.4%)
161 (37.3%)
398 (47.5%)
377 (61.3%)
204 (65.8%)
x 2=100.18
p=.000*
Ethnicity
Jawa
Sunda
Other
288 (49.7%)
804 (48.4%)
13 (46.4%)
292 (50.3%)
857(51.6%)
15 (53.6%)
X^===0.33
p=.849
192 (49.2%)
185 (51.2%)
178 (46.7%)
188 (49.2%)
178 (47.6%)
184 (48.3%)
198 (50.8%)
176 (48.8%)
203 (53.3%)
194 (50.8%)
196 (52.4%)
197 (51.7%)
X"=1.83
p=.872
Residence
Kab. Kuningan
Kab. Cirebon
Kota Cirebon
Kab. Bandung
K ab. S u k a b u m i
Kab. Purwakarta
fBetween-category comparisons were made using t-test for interval-level variables, and
for categorical variables.
* Test statistic is significant at the 0.05 level.
87
Exploratory Principal Components Factor Analysis (PCA), with varimax rotation,

was used to reduce the 17 informational support items to a smaller number of items
(Table 5.3). The analysis retained seven components with eigenvalues greater than 1.0.
These seven factors explained 17.1 percent of the variance for informational support.
Chronbachs alpha for each of the seven factors was less than .70 (Table 5.3), thus
indicating that this scale measure did not meet the conventional standard of reliability,
and did not consistently measure husbands informational support among women of
reproductive age and lower socioeconomic status in West Java, Indonesia.
Exploratory Principal Components Factor Analysis (PCA), with varimax rotation,
was used to determine underlying structures for the measure of husbands instrumental
support (Table 5.4). The analysis revealed six factors with eigenvalues greater than 1.0,
that together explained 19.6 percent of the variance in husbands instrumental support.
Chronbachs alpha for each of the six factors was less than .70 (Table 5.4). Thus, this
scale measure was not reliable by a conventional measure of reliability and does not
consistently measure husbands instrumental support among women of reproductive age
and lower socioeconomic status in West Java, Indonesia.
Hypothesis # la : High levels of husbands informational support during
Bivariate analyses showed that womens level of knowledge increased as the level
of husbands informational support increased (Table 5.5). Some 60 percent of women
88
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Rotated Factor Loadings
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Item
1. Get medical treatment from
trained provider
Factor 1
-0.073
Factor 2
0.041
Factor 3
-0.023
Factor 4
0.764
Factor 5
-0.016
Factor 6
0.279
Factor 7
-0.187
2. Get advice from traditional

provider
0.756
-0.255
0.588
0.296
0.165
0.026
-0.431
oo
3. Get rest/no hard work
-0.020
0.042
0.117
0.018
-0.041
0.860
-0.054
c"n
o
4. Advice on nutritious food
-0.005
0.008
-0.018
0.192
-0.010
0.859
0.037
CaD
5. Ask midwife/doctor about

my pregnancy
0.069
0.519
0.093
0.492
-0.219
-0.016
0.102
c
a
oo
O
6. Notify people about my

pregnancy
1.047
0.372
-0.132
-0.025
0.066
0.136
-0.185
7. Advice about bleeding
0.384
0.406
0.119
0.230
0.210
0.455
0.353
8. Advice about swollen feet
0.177
0.015
0.320
0.204
1.005
0.236
0.172
0.531
0.044
0.206
0.839
0.163
0.103
0.440
CD
D
9. Advice about breathing

techniques for delivery
(/)
(/)
10. Advice to prepare
0.050
0.791
-0.191
0.331
0.112
-0.063
-0.055
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^Factor analysis assumes correlation across all of the items, while polychoric correlations are pairwise. Thus it is possible to obtain factor loadings beyond the
interval {-I, 1}. A key point to note for this data set is that two variables with a correlation o f -.999, should be nearly identical in their respective correlations
with any and all other variables. The farther from identical correlations between these two variables, the greater the error that will appear in the factor analysis
(considering error in the factor analysis to have factor loadings outside the interval {-1, 1}).
7D3
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Table 5.3 (continued)
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transportation
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13
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3
\0
11. Advice to prepare blood

donor
0.131
0.650
-0.945
-0.121
-0.440
0.059
-0.319
12. Advice to make financial

arrangements for
emergency
0.017
0.822
-0.010
-0.190
-0.170
0.147
-0.057
13. Information on necessary

immunization
0.128
0.192
0.148
0.213
-0.894
0.257
0.112
14. Information not to consume

food containing a lot of salt
-0.848
-0.048
0.363
-0.306
0.241
0.227
0.132
15. Information about taboos
-0.098
0.050
0.923
0.003
-0.050
0.124
0.068
16. Information about safe

delivery ceremony
-0.742
0.533
-0.074
0.462
-0.075
-0.003
0.116
17. Advising me to consume egg

yolk
-0.415
-0.111
0.157
-0.027
0.017
-0.019
0.979
Eigenvalue
4.38
4.03
3.17
1.72
1.57
1.12
1.11
Chronbachs alpha***
0.03
0.35
Variance explained
3.63
2.70
2.51
2.26
2.26
2.01
1.73
T3
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(A
(A

*** Chronbachs alpha was assessed using items with a factor loading greater than 0.6 or less than -0.6 for each factor. Factors with only one or
two factor loadings greater than 0.6 or less than -0.6 did not yield a Chronbachs alpha measure for reliability.
7J
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W
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Table 5.4. Principal Components Factor Analysis
............ .................. .....

Rotated Factor Loadings
Factor 1
-0.033
Factor 2
0.058
Factor 3
-0.241
Factor 4
-0.033
2. Check babys position
0.679
-0.191
-0.510
-0.615
0.090
0.241
3. Check babys weight
0.557
-0.116
-0.089
-0.346
-0.858
-0.048
4. Check blood pressure
0.677
-0.777
0.325
-0.142
-0.510
0.332
5. Check urine sample
-1.231
0.261
-0.046
-0.302
-0.267
0.248
6. Assess age of pregnancy
0.641
-0.166
-0.689
-0.026
-0.017
0.166
7. Provide vitamins
0.673
0.162
-0.083
-0.004
-0.171
0.061
8. Provide traditional medicines
0.641
0.109
0.111
-0.080
-0.021
-0.031
9. Massage stomach
0.754
0.050
-0.053
-0.557
-0.078
-0.540
10. Teaching breathing techniques

for delivery
0.320
0.023
1.100
-0.201
-0.117
-0.444
11. Manages any danger signs
0.390
0.279
-0.024
0.021
1.032
-0.013
12. Monitoring the babys growth
0.045
0.478
-0.827
0.110
-0.107
-0.110
Item
1. Routine medical check-up
Factor 5
-0.014
Factor 6
1.066
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^Factor analysis assumes correlation across all of the items, while polychoric correlations are pairwise. Thus it is possible to obtain factor loadings beyond the
interval {-1 ,1 }. A key point to note for this data set is that two variables with a correlation o f -.999, should be nearly identical in their respective correlations
with any and all other variables. The farther from identical correlations between these two variables, the greater the error tliat will appear in the factor analysis
(considering error in the factor analysis to have factor loadings outside the interval {-1, 1}).
7J
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5
a
3
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(/)
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13. Accompanying me to routine

check-ups
0.189
0.452
-0.006
0.512
-0.138
0.165
14. Preparing nutritious food for me
0.230
0.632
0.011
0.322
-0.123
0.227
[O
15. Organizing religious ceremonies

for safe delivery
0.523
0.439
0.164
0.044
0.171
0.164
16. Preparing transportation if

needed during delivery
0.671
0.271
-0.175
0.495
0.158
-0.078
17. Preparing blood donors if

needed during delivery
-0.058
0.054
-0.351
1.126
0.472
-0.087
18. Preparing funds for delivery
-0.009
0.883
-0.054
0.003
0.094
-0.001
19. Preparing extra funds for

emergency during delivery
0.048
0.815
-0.093
0.028
0.284
-0.091
Eigenvalue
5.85
5.05
3.15
2.29
1.79
1.46
Chronbachs alpha***
0.24
0.50
0.03
Variance explained
5.7%
3.4%
3.0%
2.9%
2.6%
2.0%
Table 5.4 (continued)
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*
Correlation is significant at the 0,05 level (2 -tailed).
** Correlation is significant at the 0.01 level (2 -tailed).
*** Chronbachs alpha was assessed using item s w ith a factor loading greater than 0 .6 or less than - 0 .6 for each factor.
tw o factor loadings greater than 0.6 or less than - 0 .6 did not yield a Chronbachs alpha measure for reliability.
Factors with on ly one or
who reported receiving no informational support from their husbands had no knowledge
of pregnancy danger signs, compared to 46 percent of women with high informational
support and no knowledge of danger signs. Twenty-six percent of women with a high
level of informational support reported a high level of knowledge about pregnancy
danger signs, compared to 12 percent of women who had a high level of knowledge and
reported no informational support from their husbands (Table 5.5).
The correlation coefficient between husbands informational support and the
dependent variable of knowledge is . 108, which is significantly different from zero
(p<01).
Standard multiple regression was carried out to determine whether husbands
informational support was a predictor of womens knowledge about pregnancy dangers
signs. Data screening revealed no missing data and no outliers. An evaluation of
linearity and homoscedasticity showed that these assumptions were met. Table 5.6
presents a summary of the regression models. Model 1 presents the main effect of
husbands informational support in predicting knowledge about pregnancy danger signs.
This model explained only one percent of the variance in knowledge about pregnancy
danger signs (R2=.01). Model 2 shows the effect of husbands informational support in
predicting knowledge about pregnancy danger signs in the presence of control variables
(age, education, parity, monthly household expenditure, ethnicity, and residence). Model
3 presents the regression results when husbands instrumental support was included in the
regression analysis. Regression results presented in Model 3 indicated an overall model
of four predictors (husbands instrumental support, age, education, and ethnicity) that
93
Table 5.5. Percentage Distribution of Women Respondents Knowledge about

Pregnancy Dangers Signs, by Level of Husbands Informational Support in West
Java, Indonesia (N=2,269).*
Knowledge of Pregnancy Danger Signs
Medium
Knowledge
%(N)
High
Knowledge
%(N)
15.0 (75)
13.2(66)
12.2(61)
100(500)
50.4(183)
14.6 (53)
21.2(77)
13.8 (50)
100(363)
Low-medium
support
53.3 (343)
13.7 (88)
20.1 (129)
12.9 (83)
100(643)
High-medium
support
48.7 (222)
15.4 (70)
20.6 (94)
15.4 (70)
100 (456)
High Support
45.9(141)
11.1 (34)
16.6(51)
26.4(81)
100 (307)
Totals
52(1,187)
14.1 (320)
18.4 (417)
15.2 (345)
100 (2,269)
No
Knowledge
%(N)
Low
Knowledge
%(N)
No support
59.6 (298)
Low support
Level of
Husbands
Informational
Support
Chi-square for the relationships shown in this table is 54.49 (p<.001).
94
Totals
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Table 5.6. Model Summary of Standard Multiple Regression of Womens Knowledge about Pregnancy Danger Signs by
Husbands Informational Support in West Java, Indonesia (N=2,269)._______ _____ ______________ _
O
O
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^
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Model 1
B
SE"^
Husbands Informational Support
Controls
Age
Education
Parity
Monthly Household Expenditure
Ethnicity
Residence
.108***
.02
Model 2
SE
B
Model 3
SE
B
079***
.02
.015
.089**
.03
.02
.069*
235***
- 047***
-.002
.080***
-.037
.01
.03
.03
.02
.05
.01
.066*
232***
-.042
-.003
.083***
-.036
.01
.03
.03
.02
.05
.01
R
.108
.282
R-square
.012
.077
* p<0.05 **p<0.01 ***p<0.001; =Not applicable; 13=Standardized Beta coefficient;
SE=standard error.
.288
.083
significantly predict womens knowledge of pregnancy danger signs, R^= .083,

F(8,2,261)=25.56, p<.001. This model accounted for only eight percent of the variance
in womens knowledge about pregnancy danger signs. An evaluation of the model fit
showed that the residuals were not normally distributed. This violation of normality
weakens the regression, but does not invalidate the findings (Mertler & Vannatta, 2002).
Analyses of the differences between Category 3 and Category 4 women showed
that these two groups differed significantly with regard to husbands instrumental
support. Thus, the analyses for Hypothesis #la, investigating husbands instrumental
support as a predictor of womens knowledge about pregnancy danger signs, were
conducted separately for each of the two groups of women. The results are reported in
Table 5.6a. Model 1 presents the main effect of husbands instrumental support in
predicting womens knowledge about pregnancy danger signs. Model 2 shows the effect
of husbands instrumental support in predicting knowledge about pregnancy danger signs
in the presence of control variables.
Husbands instrumental support was not a significant predictor of instrumental
support for Category 3 women when controlling for age, education, parity, monthly
household expenditure, ethnicity, and residence. Regression results for Category 4
women indicated an overall model of two predictors (husbands instrumental support and
womens education) that significantly predicted womens knowledge about pregnancy
danger signs, R^=.091, F(7, 1,156)=17.58, p<.001.
The hypothesis that husbands informational support is a predictor of womens
knowledge about pregnancy danger signs was supported. However, husbands
96
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Table 5.6a. Mode! Summary of Standard Multiple Regression of Womens Knowledge about Pregnancy Danger Signs by
Husbands Instrumental Support in West Java, Indonesia.
_____ __________ _______ __________________ _
Category 4 Women (N=l,164)
Category 3 Women (N=l,105)
O
O
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Model 1
6
SE
'
Independent Variable
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-4
Controls
Age
Education
Parity
Monthly Household Expenditure
Ethnicity
Residence
.074*
.02
Model 2
0
SE
.051
.02
.05
.01
.04
1.13
.04
.08
.02
.03
-.00
08**
-.03
Model 1
SE
184***
.184
.281
.074
R
.033
.005
.073
R-square
* p<0.05 **p<0.01 ***p<0.001; =Not applicable; 13=Standardized Beta coefficient;
SE=standard error.
02
Model 2
B
SE
248***
.02
.05
229***
-.06
-.01
.07
-.04
.01
.03
.03
.03
.07
.02
.310
.091
instrumental support explained slightly more variance in womens knowledge about

pregnancy danger signs.
Hypothesis # lb : High levels of husbands informational snpport dnring
Bivariate analysis showed no significant relationship between husbands

informational support and womens attitude toward skilled healthcare providers for
Category 3 and Category 4 women (r=.017, p>.05). Thus, this hypothesis was not
supported.
Hypothesis # 2 : High levels of husbands instrumental support during
pregnancy are positively associated with using a skilled healthcare provider for
delivery among Indonesian women of reproductive age from lower socioeconomic
strata.
Analyses of the differences between Category 3 and Category 4 women showed

that these two groups differed significantly with regard to attitudes toward a skilled
healthcare provider, and husbands instrumental support (see Chapter 5, p. 86).
Consequently, the analyses for Hypothesis #2 were conducted separately for each of the
two groups of women. The results are reported by category of women below.
Results for Category 3 Women
Bivariate analyses for Category 3 women revealed a significant, positive
relationship between use of a skilled attendant for delivery and husbands instrumental
support (r=. 185, p<.01). A higher percentage (75 percent) of Category 3 women with
98
high levels of instrumental support used a skilled attendant for delivery than Category 3
women who reported no instrumental support (50 percent) (Table 5.7). Among those
Category 3 women who reported that they did not use a skilled provider for delivery, 25
percent reported that they had a high level of instrumental support, compared with 50
percent who received no instrumental support (Table 5.7).
Logistic regression was conducted to determine whether husbands instrumental
support is a predictor of use of a skilled healthcare provider for delivery. Data screening
revealed no missing data, and several outliers. Regression analyses were run with and
without outliers,
Regression coefficients are presented in Table 5.8. Model 1 show the main
relationship of husbands instrumental support and use of a skilled provider for delivery.
Model 2 represents the effect of husbands instrumental support on use of a skilled
attendant for delivery, controlling for age, education, and residence.'*^ Model 3 shows the
results of the analysis that included the variable of husbands informational support.^^
Logistic regression results indicated that Model 2 was the best fitting model for
predicting use of a skilled provider for delivery. The overall model fit of four predictors
(husbands instrumental support, age, education, and residence) was questionable (-2 Log
Likelihood=l,117.257, Goodness of Fit= 1,109.906), but was statistically reliable in
distinguishing between use of a skilled provider for delivery (x^=298.501, p<.0001). The
The logistic regression analyses conducled witliout tire oulUers yielded similar results to tlie analyses
conducted with the outliers included. The model fit without the outliers was questionable (-2 Log
Likelihood= 1,110.828, Goodness of Fit= 1,128.422), yet significantly predicted group membership for
women who used a skilled provider for delivery (x^(l 1)=304.930, p.<.0001).
Forward and backward logistic regression analyses were conducted using the same variables. The results
o f the forward and backward logistic regression analyses confirmed the results o f the standard logistic
regression.
Collinearity diagnostics using tolerance and variance inflation factors (VIFs) revealed no collinearity
among the independent variables. All VIFs were less than 2.1.
99

Use of a Skilled Healthcare Provider for Delivery
Level of Husbands
Instrumental
Support
No Use
%(N)
No support
49.8 (106)
50.2 (107)
100 (213)
Low support
40.3 (54)
59.7 (80)
100(134)
Low-medium
support
32.4 (81)
67.6 (169)
100 (250)
High-medium
support
28.0 (65)
72.0 (167)
100 (232)
High Support
25.0 (69)
75.0 (207)
100(276)
Totals
33.9(375)
66.1 (730)
100(1,105)
Use
%(N)
Totals
%(N)
* Chi-square for the relationships shown in this table is 39.94 (p<.001).
100
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Table 5.8. M odel Sum m ary for L ogistic R egression A nalyses o f U se o f a Skilled H ealthcare P rovider for D elivery by Instrum ental Support, A ge,
E ducation, and R esidence, for C ategory 3 W om en in W est Java, Indonesia (N = l,1 0 5 ).t
M od el 1
O
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Independent V ariables
C ontrols
A ge
Education
Residence
Kab. Kuningan (r)
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Purwakarta
M odel 2
M od el 3
SE
OR
95% C l
SE
OR
95% C l
SE
OR
95% C l
.2746***
.05
1.32
1.20, 1.44
.1259*
.05
1.13
1.02, 1.25
.0492
.1283
.07
.08
1.05
1.13
0 .9 1 ,1 .2 1
0.97, 1.34
0974***
.6268***
.02
.09
1.10
1.87
1.05, 1.16
1 .57,2.23
.0943***
.6046***
.02
.09
1.10
1.83
1.05, 1.15
1 .5 3 ,2 .2 0
1.00
5.36
8.05
4.99
1.18
.83
3.24, 8.85
4 .7 9 ,1 3 .5 4
2 .7 7 ,9 .0 0
0.77, 1.83
0.53, 1.29
1.7169***
1.6343***
1.1473***
.1417
-.1 2 9 2
.26
.33
.36
.22
.23
1.00
5.57
5.13
3.15
1.15
.88
3 .3 2 ,9 .3 2
2.70, 9.74
1 .5 6 ,6 .3 5
0.74, 1.79
0.56, 1.38
1.6784***
2.0859***
1.6078***
.1716
-.1 8 4 7
.26
.26
.30
.22
.23
t Monthly household expenditure and ethnicity were included as control variables in the logistic regression analysis, but were not significant in either
Model 2 or M odel 3.
* p<0.05 **p<0.01 '*'**p<0.001, (r)=Reference category; =Not applicable; B=beta coefficient or log odds (interpreted as the
difference in the log odds holding other Xs constant); SE= standard error; OR=odds ratios; 95% CI=95 percent confidence interval.
model correctly classified 74 percent of the cases. Wald statistics indicated that
husbands instrumental support, age, education, and residence, significantly predicted use
of a skilled provider for delivery. However, the odds ratio for husbands instrumental
support suggests that women who receive instrumental support are only somewhat more
likely to use a skilled provider for delivery than women who do not receive any
instrumental support (0R=1.13; CI=1.02,125). The district in which a woman resides
was a stronger predictor of her use of a skilled provider for delivery. Women who live
in Kota Cirebon are eight times more likely to use a skilled provider for delivery
(OR=8.05; 1=4.79,13.54) than women in Kabupaten Kuningan, and women in
Kabupaten Purwakarta (OR=.83; 1=0.53,1.29) are less likely to use a skilled provider
for delivery than women in Kabupaten Kuningan.
The hypothesis that husbands instrumental support is a predictor of use of a
skilled healthcare provider was supported for Category 3 women. The four predictors of
use of a skilled provider for delivery were husbands instrumental support, age,
education, and residence.
Results for Category 4 Women
Bivariate analysis of the relationship between husbands instrumental support and
use of a skilled attendant for delivery showed that more women (77 percent) who
reported a high level of instrumental support used a skilled provider for delivery,
compared to women who reported that they received no instrumental support and used a
skilled attendant for delivery (47 percent) (Table 5.9). Fewer women with a high level of
husbands instrumental support did not use a skilled attendant for delivery (23 percent)
than women with no support who did not use a skilled provider for delivery (53 percent).
102

Level of Husbands
Instrumental
Support
No Use
%(N)
No support
53.5 (145)
46.5 (126)
100 (271)
Low snpport
43.9 (65)
56.1 (83)
100(148)
Low-medium
support
37.2 (94)
62.8(159)
100 (253)
High-medium
support
29.5 (66)
70.5 (158)
100 (224)
High Support
22.8 (61)
77.2 (207)
100 (268)
Totals
37.0(431)
63.0(733)
100(1,164)
Use
%(N)
Totals
%(N)
* Chi-square for the relationships shown in this table is 63.46 (p<.001).
103
The correlation coefFicient between husbands instrumental support and the

dependent variable of use of a skilled healthcare provider for delivery is .233 (p=.000),
which is statistically significantly different from zero.
Logistic regression was conducted to determine whether husbands instrumental
support is a predictor of use of a skilled provider for delivery among Category 4 women.
Data screening revealed no missing data and no outliers. Table 5.10 presents a summary
of the regression models. Model 1 shows the main effect of husbands instrumental
support on use of a skilled provider for delivery. Model 2 represents the effect of
husbands instrumental support in the presence of control variables (age, education,
monthly household expenditure, and residence). A third model was run including the
variable of husbands informational support.^^
Logistic regression results in Model 2 (Table 5.10) indicated that the overall
model fit of five predictors (husbands instrumental support, age, education, monthly
household expenditure, and residence) was questionable (-2 Log Likelihood=l,098.315,
Goodness of Fit=l,200.207), but was statistically reliable in distinguishing between use
of a skilled provider for delivery (x^=436.074, p<.0001). The model correctly classified
78 percent of the cases. Wald statistics indicated that the variables in the Model 2, with
the exception of residence in Kabupaten Sukabumi, and in Kabupaten Purwakarta,
significantly predict use of a skilled provider for delivery.
The odds ratios in Model 2 (Table 5.10) suggest that women with higher levels of
education are twice more likely (OR=2.22; CI=1.84, 2.66) to use a skilled provider for
delivery compared to women with only some primary school. Women who live in
among the independent variables. All VIFs were less than 2.3.
104
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Table 5.10. Model Summary for Logistic Regression Analyses of Use of a Skilled Healthcare Provider for Delivery by
(/)
(/)
Model 1
O
O
D
Model 2
Model 3
SE
OR
95% Cl
SE
OR
95% Cl
SE
OR
95% Cl
.3369***
.04
1.40
1.28, 1.52
.1840***
.05
1.20
1.08, 1.33
.1528*
.0461
.08
.08
1.17
1.05
1.00, 1.36
0.89, 1.23
.0343*
.7960***
.1997*
.01
.09
.08
1.03
2.22
1.22
1.01, 1.06
1.84, 2.66
1.04, 1.44
.0344*
.01
.09
.08
1.03
2.21
1.22
1.01, 1.06
1.84,2.66
1.04, 1.44
1.00
6.75
11.21
17.89
1.28
1.00
4.08, 11.1
6.61, 19.0
8.87,36.1
0.82, 2.00
0.64, 1.57
Controls
3CDD
O
Q.
C
a
o
o
o
A ge
Education
Monthly Household Exp.
Residence
Kab. Kuningan (r)
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Purwakarta
1.9186***
2.4285***
2.8888***
.2456
-.0028
.26
.27
.36
.23
.23
1.00
6.81
11.34
17.96
1.28
1.00
7 9 4 j***
.2004*
4.12, 11.25
6.69, 19.21
8.90, 36.23
0.82, 1.99
0.64, 1.56
1.9095***
2.4168***
2.8846***
.2481
.0000
.26
.27
.36
.22
.23
CD
Q.
CDD
C/)
C/)
t Ethnicity was included as a control variable in the logistic regression analysis, but was not significant in Models 2 or 3.
* p<0.05 **p<0,01 ***p<0.001, (r)=Reference category; =Not applicable; B=beta coefficient or log odds (interpreted as the
Kabupaten Cirebon (OR=6.81; 1=4.12, 11.25), Kota Cirebon (0R=11.34; 1=6.69,

19.21), and Kabupaten Bandung (OR=17.96; 1=8.90, 36.22) are much more likely to
use a skilled provider for delivery than women who live in Kabupaten Kuningan.
Hypothesis #2 for Category 4 women was supported. Husbands instrumental
support is a predictor of use of a skilled healthcare provider for delivery. The five
predictors of use of a skilled attendant for delivery were husbands instrumental support,
age, education, monthly household expenditure, and residence.
Hypothesis #3: High levels of knowledge about pregnancy danger signs are
positively associated with positive attitudes toward skilled healthcare providers
Findings from the analyses of the differences between Category 3 and Category 4
women showed that these two groups of women differed significantly with regard to their
attitudes toward skilled healthcare providers (see Chapter 5, p. 86). For this reason, the
analyses for Hypothesis #3 were conducted separately for Category 3 and Category 4
women.
Bivariate analyses for womens attitudes toward skilled healthcare providers and
womens knowledge of pregnancy danger signs showed no significant relationship
between these two variables for Category 3 women (r=.036, p>.05), or for Category 4
women (r=-.022, p.>05). Thus, Hypothesis #3 was not supported.
106
The relationship between knowledge about pregnancy danger signs and use of a
skilled healthcare provider for delivery is significant and positive (r=. 138, p< 01). As a
womans level of knowledge increases so does the percentage of use of a skilled provider
for delivery (Table 5.11). A higher percentage of women with a high level of knowledge
about danger signs used a skilled attendant for delivery (74 percent), compared with
women who reported a no knowledge of danger signs (58 percent). Among women who
did not use a skilled attendant for delivery, 41 percent reported no knowledge of danger
signs, compared with 26 percent who reported a high level of knowledge (Table 5.11).
Logistic regression was used to determine whether knowledge about danger signs is a
predictor of use of a skilled attendant for delivery. Data screening led to the
identification and removal of several outliers with regard to use of a skilled provider and
parity. Data analyses were conducted without these outliers (N=2,262). There were no
missing data.
Regression coefficients are reported in Table 5.12. Model 1 presents the main
effects of womens knowledge about pregnancy dangers signs on use of a skilled
healthcare provider for delivery. Model 2 shows the relationship between the dependent
variable (use) and the independent variable (knowledge) in the presence of the control
variables of age, education, parity, monthly household expenditure, and residence. The
interaction between knowledge and attitudes was tested, based on a priori evidence
of the relationship between knowledge and attitudes in predicting use of family planning
methods (Valente et al., 1998)."*^ Model 3 presents the results of the analysis that
among the variables. All VIFs were less than 2.4.
107
Table 5.11. Percentage Distribution of Category 3 and 4 Women Respondents Use

of a Skilled Healthcare Provider for Delivery by Level of Knowledge About
Level of Knowledge
About Pregnancy
Danger Signs
No Use
%(N)
Use
%(N)
No Knowledge
41.5 (493)
58.5 (694)
100(1,187)
Low Knowledge
34.7(111)
65.3 (209)
100 (320)
Medium Knowledge
26.6(111)
73.4 (306)
100 (417)
High Knowledge
26.4 (91)
73.6 (254)
100 (345)
Totals
35.5 (806)
64.5 (1,463)
100 (2,269)
Totals
%(N)
Chi-square for the relationships shown in this table is 45.85 (p<.001).
108
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Table 5.12. Model Summary for Logistic Regression Analyses of Use of a Skilled Healthcare Provider for Delivery by Knowledge, Age,
C/)
(/)
M odel 2
M odel 1
Independent V ariables
O
O
D
c q
Knowledge
A ttitu d e
'
M od el 3
SE
OR
95% C l
SE
OR
95% C l
.2620***
.04
1.30
1.20, 1.41
.1626***
.05
1.18
1.07, 1.29
Interaction
Knowledge X Attitude
O
Q
CD
D
O
Q .
C
a
o
o
o
CD
Q .
o
'O
Controls
A ge
Education
Parity
Monthly Household Exp.
Residence
Kab. Kuningan (r)
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Piuwakarta
.0624***
.6504***
- 2 1 2 1 ***
.1596**
1.8786***
2.3837***
2.5170***
.3048
-.1014
.01
.07
.06
.06
.18
.19
.23
.16
.16
1.06
1.92
0.81
1.17
1.04,
1 .6 8 ,
0.71,
1.05,
1.09
2.18
0.91
1.31
1.00
6.54
10.84
12.39
1.36
0.90
SE
.0049
.0642
.0600
.0617***
.6300***
1944**
.1592*
OR
95% C l
.11
1.00
.08
1.07
0.81, 1.25
0.91, 1.25
.04
.01
1.06
.07
.06
.06
1.88
.82
1.17
.18
.19
.23
.16
.16
6.06
9.91
12.82
1.47
.84
1.00
4 .5 9 ,9 .3 4
7.47, 15.73
7.90, 19.42
1.00, 1.84
0.66, 1.24
1.8025***
2.2936***
2.5507***
.3865*
-.1 7 7 4
CD
(/)
(/)
1.04, 1.09
1 .6 5 ,2 .1 4
0.73, 0.93
1.05, 1.3f
t Ethnicity was included as a control variable in the logistic regression analysis, but was not retained in either M odel 2 or Model 3.
* p<0.05 **p<0.01 ***p<0.001, (r)Reference category; =Not applicable; B=beta coefficient or log odds (interpreted as the
4.23, 8.68
6.80, 14.4
8.17, 20.1
1 .08,2.01
0.61, 1.14
included the interaction term of knowledge * attitude.^^

Model 2 represented the best fitting model for predicting use of a skilled provider
for delivery. Regression results indicated the overall model fit of six predictors
(knowledge about pregnancy danger signs, age, education, parity, monthly household
expenditure, and residence) was poor (-2 Log Likelihood=2,202,980, Goodness of
Fit=2,328.457), but was statistically reliable in distinguishing between use of a skilled
attendant for delivery (x^==738,615, p<.0001). The model correctly classified 77 percent
of the cases. Wald statistics indicated that residence in Kabupaten Sukabumi and
Kabupaten Purwakarta did not significantly predict use of a skilled provider for delivery.
Odds ratios for these variables indicated women with higher levels of education
were almost two times more likely (0R=1.92; CI=1.68, 2.19) to use a skilled attendant
for delivery compared with women with only some primary school. Women with higher
parity were less likely to use a skilled provider for delivery than women with lower parity
(0R=.81; CI=0.71, 0.91). The strongest predictors of use of a skilled provider for
delivery was a womans place of residence. Women who lived in Kabupaten Cirebon
(OR=6.59; 1=4.62, 9.41), Kota Cirebon (OR=8.58; 1=5.43, 13.56), and Kabupaten
Bandung (OR=9.64; 1=5 .68, 16.34) were, on average, eight times more likely to use a
skilled provider for delivery than women living in Kabupaten Kuningan. Women who
resided in Kabupaten Sukabumi were somewhat more likely to use a skilled provider for
delivery than women who lived in Kabupaten Kuningan (OR=1.36; 1=1.00, 1.85).
Female residents of Kabupaten Purwakarta were slightly less likely to use a skilled
attendant at delivery than women in Kabupaten Kuningan (0R=.91; 1=0.66, 1.25).
Other interaction terms were assessed, namely knowledge * husbands informational support and
knowledge * husbands instrumental support. These interactions were not significant, that is the p-value
110
Hypothesis #4 stated that higher levels of knowledge about pregnancy danger

signs are positively associated with using a skilled healthcare provider for delivery. This
hypothesis was supported. However, the odds ratio for knowledge (0R=1.18; CI=1.07,
1.29) was fairly small, thus women with higher levels of knowledge are only slightly
more likely to use a skilled provider for delivery than women with no knowledge of
pregnancy danger signs.
Hypothesis #5: Positive attitudes toward skilled healthcare providers are
Category 3 women and Category 4 women differed significantly with regard to

the variable attitudes toward a skilled healthcare provider (see Chapter 5, p.86). Thus,
the analyses for Hypothesis #5 were conducted separately for each of the two categories
of women. The results are presented separately for each category of women.
Category 3 Women
Results of the bivariate analyses of the relationship between womens attitudes
toward skilled healthcare providers and use of a skilled healthcare provider for delivery
showed that fewer women with a not very positive attitude toward skilled providers
used a skilled provider for delivery (45 percent), compared to women in the same attitude
category who did not use a skilled attendant (55 percent) (Table 5.13). This relationship
is significant, positive, and linear (r=. 173, p=.000). As the level of attitude increases, the
percentage of women who use a skilled attendant for delivery increases. Some 80
percent of women with an extremely positive attitude used a skilled attendant for
delivery (Table 5.13).
was greater than .05 (results not reported).
Ill

Skilled Healthcare Provider for Delivery by Level of Attitude Toward Skilled
Attitude Toward
Skilled Healthcare
Providers
No Use
%(N)
Not very positive
54.7 (82)
45.3 (107)
100(150)
Somewhat positive
33.7(122)
66.3 (240)
100 (362)
Positive
33.9 (76)
66.1 (148)
100(224)
Very Positive
31.9 (59)
68.1 (126)
100(185)
Extremely Positive
19.6 (36)
80.4 (148)
100(184)
Totals
33.9(375)
66.1 (730)
100(1,105)
Use
%(N)
Totals
%(N)
Chi-square for the relationships shown in this table is 46.06 (p=.000).
112
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(/)
Table 5*14. Model Summary for Logistic Regression Analyses of Use of a Skilled Healthcare Provider for Delivery by Attitudes Toward Skilled
Healthcare Providers, Age, Education, Parity, M onthly Household Expenditure, and Residence, for Category 3 W om en in W est Java, Indonesia
(N = l,105).t
CD
O
O
D
Model 1
Attitudes Toward
Skilled Healthcare
Providers
Kjiowledge
Model 2
M odel 3
SE
OR
95% C l
.1070
.12
1.11
0.89, 1.40
.0049
.15
1.00
0.96, 1.18
.0635
.05
SE
OR
95% C l
SE
OR
95% C l
.2924***
.05
1.34
1.21, 1.48
.2340***
.06
1.26
1.12, 1.42
Interactions
Attitude X Knowledge
CD
D
O
Q.
C
a
o
D
O
CD
Q.
Controls
Age
Education
Residence
Kab. Kuningan (r)
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Purwakarta
.0969***
.5946***
.02
1.10
.09
1.81
1.00
1.6438***
2.0485***
1 7544 ***
.26
.26
.30
.3003
- .2980
.22
.23
5.17
7.76
5.78
1.35
.74
1.05, 1.15
1.52, 2.16
0957***
.5415***
.02
1.10
.09
1.72
.26
.27
.30
.23
.23
5.07
8.39
6.26
1.41
.74
1.00
3.13,
4.60,
3.22,
0.87,
0.47,
8.56
13.07
10.38
2.09
1.16
1.6233***
2.1268***
1.8339***
.3421
- .2988
1.05, 1.15
1.44, 2.06
3.05,
4.95,
3.47,
0.90,
0.47,
8.42
14.20
11.29
2.19
1.17
CDD
C/)
00
t Monthly household expenditure and ethnicity were included as control variables in the logistic regression analysis, but was not retained in either Model 2 or
Model 3 /
* p<0.05 **p<0.01 ***p<0.001, (r)==Reference category; =Not applicable; B-beta coefficient or log odds (interpreted as the difference in the log odds
holding other Xs constant); SE= standard error; OR=odds ratios; 95% CI=95 percent confidence intervâl.
Logistic regression was used to determine whether attitudes twoard skilled

healthcare providers is a predictor of use of a skilled attendant for delivery. Data
screening showed no missing data and no outliers.
Regression results are presented in
Table 5.14. Model 1 shows the main relationship between attitudes toward skilled
healthcare providers and use of a skilled healthcare provider for delivery. Model 2
presents the effect of attitude on use in the presence of control variables. A priori
evidence of the link between knowledge, attitudes, and use of a family planning method
(Valente et al., 1998) was used as a basis for including the interaction term of attitude X
knowledge for Category 3 women. Model 3 presents the results of the analyses
including this interaction term.^^
Regression results indicated that Model 2 best predicts use of a skilled provider
for delivery. The overall model fit of four predictors (attitudes toward healthcare
providers, age, education, and residence) was questionable (-2 Log Likelihood=
1,107.869, Goodness of Fit=l,105.561), but was statistically reliable in predicting use of
a skilled attendant for delivery (x^=307.889, p<.0001). The model correctly classified 75
percent of the cases. Wald statistics indicated that residence in Kabupaten Sukabumi and
Kabupaten Purwakarta did not significantly predict use of a skilled provider for delivery.
Odds ratios for the variable of attitude indicated only a slight change in the
likelihood of using a skilled attendant for delivery (0R=1.26; CI=1.12, 1.42). Women
who resided in Kabupaten Cirebon (OR=5.17; CI=3.13, 8.56), Kota Cirebon (OR=7.76;
Other interaction terms were assessed, namely attitude X husbands informational support and attitude
X husbands instrumental support. These interaction terms were not significant, that is, the p-value was
greater than .05 (results not reported).
114
CI=4.60, 13.07), and Kabupaten Bandung (OR=5.78; CI=3.22, 10.38) were five to seven
times more likely to use a skilled provider for delivery than women who lived in
Kabupaten Kuningan. Women in Kabupaten Sukabumi were somewhat more likely to
use a skilled attendant for delivery than women in Kabupaten Kuningan (OR=1.35;
CI=0.87, 2.09). Women who lived in Kabupaten Purwakarta were less likely to use a
skilled provider for delivery (OR=.74; CI=0.47, 1.6).
Hypothesis #5 was supported for Category 3 women. Positive attitudes toward
skilled healthcare providers are positively associated with using a skilled healthcare
provider for delivery among women who had delivered a child in the past year in West
Java, Indonesia.
Category 4 Women
Analyses of the bivariate relationship between use of a skilled provider for
delivery and attitudes toward skilled healthcare providers for Category 4 women showed
a significant, positive relationship between these two variables (r=. 137, p=.000). This
relationship is generally linear (i.e., as the level of attitude increased so did the
percentage of women who used a skilled provider for delivery), with a slight deviation
for women in the positive attitude category (Table 5.15).
Logistic regression was used to determine whether attitude toward skilled
healthcare providers is a predictor of use of a skilled attendant for delivery. Data
screening detected no missing data and no outliers.^^ Regression results are presented in
Table 5.16. Model 1 presents the main effect of attitude on use. Model 2 shows the
effect of attitude on use in the presence of control variables (age, education, monthly
Collinearity diagnostics using tolerance and variance inflation factors (VIFs) showed no collinearity
115

Skilled Healthcare Provider for Delivery by Level of Attitude Toward Skilled
Healthcare Providers in West Java, Indonesia (N=l,164).* __________________
Attitude Toward
Skilled Healthcare
Providers
No Use
%(N)
Use
%(N)
Not very positive
60.6 (126)
39.4 (82)
100 (208)
Somewhat positive
31.3 (136)
68.7 (299)
100 (435)
Positive
33.6 (71)
66.4 (140)
100 (211)
Very Positive
31.7 (52)
68.3 (112)
100 (164)
Extremely Positive
31.5 (46)
68.5 (100)
100 (146)
Totals
37.0(431)
63.0 (733)
100(1,164)
Totals
%(N)
Chi-square for the relationships shown in this table is 60.60 (p=.000).
116
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(/)
Table 5.16. Model Summary for Logistic Regression Analyses of Use of a Skilled Healthcare Provider for Delivery by Attitudes Toward Skilled
Healthcare Providers, Age, Education, M onthly Household Expenditure, and Residence^ for Category 4 W omen in W est Java, Indonesia (N = l,164).t
O
O
o
CD
Model 2
M odel 1
CD
Attitudes Toward
Skilled Healthcare
Providers
Knowledge
SE
OR
95% C l
SE
OR
.2306***
.05
1.26
1.14, 1.39
.1243*
.06
1.13
M odel 3
95% C l
1.00,
1.28
Interactions
Attitude X Knowledge
SE
OR
.0320
.11
1.03
0.82, 1.31
.0101
.16
1.01
0.74, 1.38
.0540
.06
95% C l
CD
o
O
Q.
C
a
o
"D
O
CD
Q.
CD
D
(/)
(/)
Controls
Age
Education
Monthly Household
Expenditure
Residence
Kab. Kuningan (r)
Kab. Cirebon
Kota Cirebon
Kab. Bandung
Kab. Sukabumi
Kab. Purwakarta
.0327*
7945***
.1894*
1.03
2.21
1.06
1.84, 2.66
.0338*
.7587***
.09
1.03
2.14
1.00, 1.06
1.77, 2.57
.08
1.21
1.03, 1.42
.1935*
.08
1.21
1.03, 1.43
.25
.27
.35
.23
.23
7.10
10.65
21.78
1.46
.91
1.9025***
2.4451***
3.1045***
.4137
-.0916
.26
.28
.36
.23
.23
6.70
11.53
22.30
1.51
.91
1.00
1.9609***
2.3657***
3.0812***
.3781
- .0991
1.00,
.01
.01
.09
1.00
4.31, 11.71
6.24, 18.17
10.84, 43.75
0.94, 2.27
0.58, 1.42
4.06, 11.07
6.71, 19.81
11.09, 44.84
0.97, 2.37
0.58, 1.43
t Parity and ethnicity were included as a control variable in the logistic regression analysis, but was not significant in either Model 2 or Model 3.
* p<0.05 **p<0.01 ***p<0.001, (r)=Reference category; =Not applicable; B=beta coefficient or log odds (interpreted as the difference in the log odds
holding other Xs constant); SE= standard error; OR=odds ratios; 95% CI=95 percent confidence interval.
household expenditure, and residence).
Prior research has demonstrated the effects of
knowledge and attitudes on the use of family planning methods (Valente et al, 1998).
Based on this evidence, a regression model was built that included the interaction term of
attitude X knowledge for Category 4 women. Model 3 is a summary of the regression
analysis including this interaction term.
Model 2 was the best fitting model for predicting use of a skilled provider for
delivery for Category 4 women. Regression results indicated the overall model fit of five
predictors (attitudes toward skilled healthcare providers, age, education, monthly
household expenditure, and residence) was questionable (-2 Log Likelihood= 1,106.718,
Goodness of Fit=l,148.656), but was statistically reliable in distinguishing between use
of a skilled attendant for delivery (x^=427.671, p<.0001). The model correctly classified
78 percent of the cases. Wald statistics indicated that residence in Kabupaten Sukabumi
and Kabupaten Purwakarta did not significantly predict use of a skilled provider for
delivery.
Odds ratios for the variable of attitude indicated little change in the likelihood
of using a skilled attendant for delivery among women with more positive attitudes
(0R=1.13, CI=1.00, 1.28), compared with women who had not very positive attitudes
toward skilled healthcare providers. Women who had higher levels of education
were more than two times more likely to use a skilled provider for delivery (OR=2.21;
CI=1.84, 2.66) than women with some primary school. Women in the district of
Bandung were 22 times more likely to deliver with a skilled attendant (OR=21.78;
CI=10.84, 43.75) than women in the district of Kuningan. Similarly, women in
Parity and ethnicity were included as control variables in the regression equation, but they were not
signifant in either Model 2 or Model 3.
118
Kabupaten Cirebon (0R=7.10; CI=4.31, 11.71) and Kota Cirebon (OR=10.65; CI=6.24,
18.17) were much more likely to use a skilled attendant for delivery than women in
Kabupaten Kuningan.
Hypothesis #5 was supported for Category 4 women, however, the odds ratio for
the variable attitudes toward skilled healthcare providers indicated little change in the
likelihood of using a skilled attendant for delivery.
Summary
In this chapter, the results of the data analyses were presented. The two
categories of women (Category 3 and Category 4) were profiled and compared. Based on
this comparison, data analyses that involved the independent variables of attitudes
toward skilled healthcare providers, and husbands instrumental support, the two
variables in which these groups of women differed significantly, were conducted
separately for each category of women (i.e.. Hypothesis #lb. Hypothesis #2, Hypothesis
#3, and Hypothesis #5). Data analyses for Hypothesis # la and Hypothesis #4 were
conducted using both categories of women together. The findings are presented in Figure
5.1.
Research Question #1 asked whether husbands social support and husbands
instrumental support were reliable measures in the Indonesian context. Factor analyses
suggested that these measures were not reliable by a conventional measure of reliability,
namely Chronbachs alpha greater than .70.
Hypotheses #la suggested that high levels of husbands informational support
were positively associated with high levels of womens knowledge about pregnancy
dangers signs. Regression analyses showed that this hypothesis was supported.
119
CDD
O
Q.
C
o
CD
Q.
CDD
SOCIAL SUPPORT
VARIABLES
C/)
(/)
BEHAVIOR CHANGE
VARIABLES
o
o
T3
Hla
c5'
Husbands
Informational
Support
33"
?
Hlb
F.Ol
Womans
Knowledge
About Pregnancy
Danger Signs
Hla
H4
i=.138*
0 R = 1 .1 8
Use of a Skilled
Healthcare
Provider for
Delivery
H3
r=,036
-.0 2 2
CD
T3
O
Q.
C
a
o
3
T3
O
CD
Q.
T3
CD
H2
O
, 1 -.233***
O R=1.20
Husbands
Instrumental
Support
Womans
Attitudes Toward
Skilled
Healthcare
Providers
O R=1.26
r=.137***
0 R = 1 ,1 3
H5
^ = Category 3 Women
^ = Category 4 Women
^ = Category 3&4 Women
(/)
(/)
Figure 5.1. Summary of the Conceptual Model of the Influence of Husbands Social Support on Womens Pregnancy
Knowledge, Attitndes, and Practices for Women of Reproductive Age From Lower Socioeconomic Strata in West Java,
Indonesia.
NB: r=correlation; B=standardized beta coefficient; * p< 05, **p<.01, ***p<.001; OR=odds ratio,
However, the amount of variance explained by the regression model was low (8 percent).
Similarly, Hypothesis #lb purported that high levels of husbands informational support
was positively associated with womens positive attitudes toward skilled healthcare
providers. This hypothesis was not supported among Category 3 or Category 4 women.
There was no significant relationship between the independent variable (husbands
informational support) and the dependent variable (attitude).
The hypothesis that high levels of husbands instrumental support during
pregnancy were positively associated with use of a skilled attendant for delivery
(Hypothesis #2) was supported for both Category 3 and Category 4 women. However,
the model fit for each Category of women was questionable. The variable of residence
appeared to be an important predictor of use of a skilled healthcare provider for delivery
in at least three districts (Kabupaten Cirebon, Kota Cirebon, and Kabupaten Bandung) for
both Category 3 and Category 4 women.
Hypothesis #3 was not supported for either Category 3 or Category 4 women.
There was no significant relationship between womens knowledge about pregnancy
dangers signs and their attitudes toward skilled healthcare providers. There was,
however, a significant, positive relationship between womens knowledge about
pregnancy danger signs and use of a skilled healthcare provider for delivery (Hypothesis
#4). However, women with higher levels of knowledge were only slightly more likely to
use a skilled provider (0R=1.18; CI=1.07, 1.29) than women with no knowledge about
pregnancy dangers signs.
Hypothesis #5 proposed that positive attitudes toward skilled healthcare providers
was positively associated with using a skilled healthcare provider for delivery. This
121
hypothesis was support for Category 3 and Category 4 women. The odds of using a
skilled provider for delivery among women with more positive attitudes toward skilled
healthcare providers was low for both categories of women. A womans place of
residence was a stronger predictor of use of a skilled healthcare provider among Category
3 and Category 4 women.
122
Chapter 6
DISCUSSION
The present chapter provides an overview of the present dissertation study and
discusses the relevance of the findings presented in Chapter 5 (Results). The implications
of the study findings for maternal health theory, research, and for Safe Motherhood
Programs in Indonesia are considered. Limitations of the present study are discussed.
Overview
The maternal mortality ratio for Indonesia is one of the highest in the world.
At
least half of all women give birth in their homes, without a skilled attendant present at
delivery. In 1987, an international conference held in Nairobi, Kenya brought global
attention to the large number of women dying from childbirth-related causes and put the
issue of maternal mortality on the national agenda in Indonesia. Following this
conference, the Government of Indonesia implemented a Safe Motherhood Initiative to
address that nations high maternal death rate. Trained midwives were dispatched to
nearly every village in Indonesia, addressing one important aspect of the supply-side of
maternal care.
Use of a skilled healthcare provider for delivery is the current standard for
measuring gains in maternal mortality reduction, and a proxy for the measure of maternal
mortality. The presence of a skilled provider at delivery is positively related to maternal
mortality reduction^^, and is measurable. However, correlation does not imply causation,
and the presence of a provider does not necessarily mean that the provider is capable of
Tlie current maternal mortality ratio in Indonesia is roughly equivalent to the maternal mortality ratio in
the United States in the mid-1930s.
Although this relationship explains only about eight percent o f the variance in maternal mortality (World
Health Organization, 2001b).
123
effectively managing the delivery. The midwives who were dispatched to villages by the
Government of Indonesia had inadequate skills to support safe deliveries. Their training
was not competency-based, thus they were trained but not skilled.
The Indonesian governments progress toward reducing the number of maternal
deaths was undermined (1) by the 1997Asian Eeonomic Crisis, (2) by several years of
political turmoil, and (3) by the social and cultural factors that lead pregnant women to
seek maternal care from traditional birth attendants (older, married women who have
completed their own families, who have lived all of their lives in the village that they
serve, and who have years of hands-on experience in delivering babies) rather than from
the newly-trained village midwives (young, unmarried, childless women who are
considered outsiders to the village that they serve, and with little, if any, practical
experience in delivery). Demand for the use of skilled attendance at delivery was not
sufficiently generated. However, use of these skilled attendants by mothers was one
important action that could decrease the number of maternal deaths.
The purpose of the present study was to explore the role of husbands social
support in increased knowledge about pregnancy danger signs, positive attitudes toward
skilled healthcare providers, and the use of a skilled provider for delivery, among women
of childbearing age and low socioeconomic status in Indonesia. The definition of social
support used in the present study was any exchange (emotional, informational, tangible)
between individuals that assists the focal person (in this case, a pregnant woman) in
managing her well-being or attaining her goals. The data used for this dissertation study
contained measures of informational support (i.e., providing knowledge and advice) and
instrumental (i.e., tangible) support.
124
The present research answered one research question, Are social support
measures that were developed and tested in developed world contexts reliable in the
Indonesian context? and tested six hypotheses:
Hvpothesis # la : High levels of husbands informational support during
Hvpothesis #Ib: High levels of husbands informational support during
Hvpothesis #2: High levels of husbands instrumental support during pregnancy
are positively associated with using a skilled healthcare provider for delivery among
positively associated with positive attitudes toward skilled healthcare providers among
Hvpothesis #4: High levels of knowledge about pregnancy danger signs are
Hypothesis #5: Positive attitudes toward skilled healthcare providers are
125
Data from two categories of women (N=2,269) from a Maternal Mortality and
Neonatal Health Household Survey of women of reproductive age from lower
socioeconomic strata, conducted in six districts of West Java, Indonesia were analyzed.
Category 3 women were women who were not pregnant at the time of the survey, and
who had delivered a child in the past year (N=l,105). Category 4 women were women
who were not pregnant at the time of the survey, and who had delivered more than one
child in the past, but not in the past year. Regression analyses were used to determine (1)
whether the independent variables of husbands informational support and husbands
instrumental support predicted womens knowledge about pregnancy danger signs,
attitudes toward skilled healthcare providers, and use of a skilled attendant for delivery,
(2) whether knowledge about pregnancy danger signs was a predictor of positive attitudes
toward skilled healthcare providers, and of use of a skilled provider for delivery, and (3)
whether positive attitudes toward skilled healthcare providers predicted use of a skilled
provider for delivery. A discussion of the findings are presented below. A model of the
findings are presented in Figure 5.1.
Are Western Measures of Social Support Appropriate iu Indonesia?
The scale reliability of the measures of husbands informational support and of

husbands instrumental support were not reliable by a conventional standard of reliability
(Chronbachs alpha) (Research Question #1). These social support measures did not
seem to tease out specific elements of informational or instrumental support. The nature
and specificity of the definitions of informational and instrumental support were designed
specifically for the MNH Baseline Survey. This was the first time that such a measure
was used for a study of maternal health in Indonesia. Perhaps the scale items included in
126
these measures did not adequately reflect the types of support or marital help that
husbands in Indonesia actually provide during a womans pregnancy. Open-ended
questions on the survey questionnaire may have yielded more specific information about
the types of social support women perceived that their husbands provided.
The Maternal Mortality and Neonatal Health Household Survey used for the
present study did not include measures of emotional support (i.e., feelings that make a
woman believe she is loved and cared for). Perhaps women who feel loved and who
perceive that their partner is empathetic and understanding of their pregnancy experience
would be more likely to give their pregnancy greater priority, learn more about pregnancy
danger signs, and use a skilled healthcare provider for delivery. Including culturally
appropriate measures of emotional support may contribute to our understanding of social
support between husbands and their pregnant wives in Indonesia.
Does Husbands Social Support Make a Difference?
Findings from the present study indicated that husbands social support does
make a difference with regard to womens knowledge about pregnancy danger signs, and
to use of a skilled healthcare provider for delivery (Hypothesis # la and Hypothesis #2).
The evidence is statistically significant but relatively weak.
Does Husbands Informational Support Make a Difference?
The hypothesized relationship between husbands informational support and
womens knowledge about pregnancy danger signs (Hypothesis #la) was significant.
Husbands instrumental support, however, was a slightly stronger predictor of womens
knowledge about pregnancy dangers signs. Perhaps mens knowledge about womens
needs during pregnancy and delivery is low or incorrect, thus they are unable to
127
contribute more to their wives knowledge about pregnancy danger signs. In rural
Maharashtra, India a majority of husbands interviewed about their involvement in
maternal care said that they were aware of the problems that could arise during pregnancy
and delivery, but did not know details (ICRW, 2003).
The effect of husbands instrumental support suggests that tangible support may
indirectly convey information about the importance of some information about pregnancy
dangers signs. For example, women who received high levels of instrumental support
may have perceived that their pregnancy was important (a Hawthorne effect), and thus
were prompted to pay more attention to the information provided by their husband. In
turn the women retained more information about pregnancy danger signs and reported
higher levels of knowledge about pregnancy danger signs.
Husbands informational support was not significantly related to womens
attitudes toward skilled healthcare providers (Hypothesis #lb). There is no existing
empirical research on the relationship between husbands informational support and
womens attitudes toward skilled healthcare providers. One possible reason for the lack
of correlation between these two variables may be that husbands and wives do not discuss
their attitudes toward skilled healthcare providers. Since childbirth is considered to be in
the female domain in Indonesia, healthcare providers for childbirth may be considered by
husbands to be a part of that female domain, and so they either do not form an attitude
about these providers, or do not express their attitudes to their wives. It may be that
womens attitudes are formed through discussion with their network peers (i.e., female
family members and friends), and not with their husband.
128
Does Husbands Instrumental Support Make a Difference?

Category 3 and Category 4 women who reported higher levels of husbands
instrumental support were somewhat more likely to use a skilled provider for delivery
than women who reported no instrumental support from their husbands (Hypothesis #2).
Wide differences were found in use of a skilled provider among the six districts of study:
(1) women who resided in Kota Cirebon were eight times more likely to use a skilled
provider for delivery than were women in Kabupaten Kuningan, (2) women who lived in
Kabupaten Cirebon and Kabupaten Bandung were about five times more likely to use a
skilled attendant for delivery than were women in Kabupaten Kuningan, (3) women in
Kabupaten Sukabumi were only slightly more likely to use a skilled provider than were
women in Kabupaten Kuningan, and (4) women in Kabupaten Purwakarta were less
likely to use a skilled attendant for delivery than were women in Kabupaten Kuningan.
These findings may point to (1) a difference in the healthcare infrastructure from
district to district, (2) a difference in the availability of a skilled provider for maternal
care, especially at the time of delivery, (3) a difference in womens access to skilled
attendants for delivery, or (4) a difference in the skill level and/or personality, and hence
the reputation, of the hidan or higher-level providers in each area. The word kota refers
to a city or large village. Perhaps a larger district (or slightly more urban district)
like Kota Cirebon may have a greater number of skilled providers who are geographically
more accessible to women, and who are more qualified to provide maternal healthcare.
Kabupaten Bandung is a regional center and may have better infrastructure than other
districts, which may account for the greater likelihood of using a skilled attendant for
delivery. Further study is necessary to determine whether, for example, Kota Cirebon or
129
Kabupaten Bandung have more skilled providers than the other four districts. The
authors efforts to obtain data on district to district skilled providers were unsuccessful.
Does Womens Knowledge Predict Womens Attitudes?
The hypothesis that womens knowledge about pregnancy dangers signs would
predict womens attitudes toward skilled healthcare providers (Hypothesis #3) was based
on the Diffusion of Innovations innovation-decision process (Rogers, 2003). The
persuasion stage of the innovation-decision process is the stage during which an
individual forms a positive or negative attitude toward an innovation (in this case, toward
a skilled healthcare provider). This stage (1) follows the knowledge stage, when an
individual becomes aware of an innovation and begins to understand the characteristics of
the innovation, and (2) precedes the decision stage, the period during which an
individual takes steps toward adopting the innovation. Findings from the present study
did not support this classic decision-making model of movement from knowledge to
attitudes.
Valente and others (1998) presented alternative knowledge (K), attitudes (A), and
practice (P) models to describe the behavior change process, that may explain why our
hypothesis was not supported. These authors considered six models representing six
different combinations of knowledge, attitudes, and practices. The Learning Model is
the classic K-A-P model, a cognitive progression by an individual through each stage of
the behavior change process. The other five models suggest that (1) knowledge of the
benefits of an innovation lead to practice, irregardless of attitude (K-P-A, or the Rational
Model), (2) attitudes lead to knowledge, and then to the adoption of the behavior (A-KP, or the Affinity Model), (3) attitudes lead to practice, and knowledge is a secondary
130
consideration or an ultimate outcome (A-P-K, or the Emotional Model), (4) the

experience of practice generates knowledge, and attitudes shift later (P-K-A, or the
Grudging Acceptance Model), and (5) practice leads to positive attitudes, and
knowledge follows (P-A-K, or the Dissonance Model).
Valente and others (1998) suggested that a deviation from the learning model
(K-A-P) creates uninformed publics, which in turn does not ensure sustained behavior
change (p. 380). One of these five typologies may explain the relationship between
knowledge about pregnancy danger signs and attitudes toward skilled healthcare
providers among Indonesia women of reproductive age and low socioeconomic status in
the study districts, and characterize the deviation from the classic learning model. The
implications of this deviation may be that intervention programs designed to increase use
of a skilled provider for delivery without first increasing knowledge about the advantages
of using a skilled provider for delivery, may deter individuals from using a skilled
provider and create dissatisfied users (Valente et al., 1998),
Are Womens Knowledge and Attitudes Related to Use of a Skilled Provider for
Delivery?
Womens knowledge about pregnancy danger signs (Hypothesis #4) and attitudes
toward skilled healthcare providers (Hypothesis #5) were significant, but not strong,
predictors of use of a skilled attendant for delivery. A womans place of residence was a
stronger predictor of use of a skilled healthcare provider for delivery. These findings,
similar to the findings for Hypothesis #2, suggest that the environmental context in which
a women (or a woman and her husband) operates influences her decision to adopt the use
of skilled provider at the time of her delivery.
131
The theory of bounded rationality (Girgerenzer & Selten, 2001) may offer insight
into this finding. This theory suggests that an individuals decision-making process is
influenced by two factors: (1) cognitive behavior, and (2) environmental constraints.
There are costs associated with each of these factors (as discussed in Chapter 3). It may
be that certain of the study districts fostered more enabling environments (i.e.,
environments that were politically supportive of maternal mortality reduction, that had
more adequate supplies, equipment, and infrastructure for maternal care, that
implemented a referral system to higher levels of care when necessary, and that were
socially/culturally adapted to using skilled healthcare providers) that reduced the costs
(emotional and/or monetary) of using a skilled attendant for delivery, and thus made it
relatively easier for women to use a bidan or other skilled provider for delivery. It is
important to understand the reciprocity between individual-level decisions about maternal
care and the environmental context in which these decisions are made.
Theoretical Implications
A major challenge to the field of maternal health is the development of models

that describe individual-level behavior within a social context (a social ecological
approach). There is ample evidence of the influence of social support on health, and
limited evidence of the effects of social support on maternal health (see Chapter 2,
Literature Review). There have been no previous studies of the influence of social
support on pregnancy knowledge, attitudes, and practices.
The present dissertation study provided a model of the influence of husbands
social support on womens knowledge about pregnancy danger signs, attitudes toward
skilled healthcare providers, and use of a skilled healthcare provider for delivery. The
132
evidence from this study suggests that husbands social support does influence womens
pregnancy knowledge, attitudes, and choice of skilled attendant for delivery. This model
also reminds us that women exist in a social context. In Indonesia, husbands are an
important part of that social context. The present model should be used as a stepping
stone toward understanding the complex relationship between a woman, her social
network influences (including her husband), and the environment in which she operates.
Research Implications
This dissertation study raised many questions. These questions raised from the
findings suggest avenues for future research. Listed below are some areas for further
study:
1. The present research utilized social support scale items relevant to developed-world
settings to measure husbands informational and instrumental support. These scale
measures were not reliable by conventional measures of scale reliability. There is a
need to develop, use, and interpret more culturally sensitive indicators of social
support in Indonesia, and to validate such culturally appropriate measures.
2. Residence was an important predictor of use of a skilled provider for delivery in the
present study. The data set used for this study did not contain specific information
about the healthcare infrastructure in each of the study districts. We need to answer
the question What are the community-level factors or local healthcare infrastructure
variables that make residence in some of the six study districts a significant and
strong predictor of use of a skilled healthcare provider for delivery?
3. The present research utilized quantitative data collected in a household survey in
Indonesia. The use of qualitative methods (e.g., focus group interviews, participant
133
observation, in-depth interviews) is necessary in order to understand the healthcare

decision-making process for pregnancy and delivery, and to highlight the social and
cultural factors associated with maternal mortality.
Social network analysis may help to conceptualize, describe, and model a
womans discussion partners and sphere of influence during pregnancy and delivery.
How much do each of the pregnant womans discussion partners know about
pregnancy danger signs? Is her husband a member of her discussion network? In
Indonesian culture, collective needs (i.e., the needs of the family) take precedence
over individual-level needs, and healthcare decisions are, in general, made at the
family level. Indonesias paternalistic culture dictates that the male head of the
household makes the healthcare decisions in the family, usually based on family
priorities and financial capacity. It is imperative that we understand the decision
making process so that we can identify the opinion leaders in this process. Educating
opinion leaders about pregnancy dangers signs and the importance of skilled
attendance at delivery may contribute to the adoption of using a skilled healthcare
provider for delivery.
4. Childbirth, an activity in the womens domain in Indonesia, is often misunderstood by
men (Iskandar, 1998). A survey of husbands knowledge about pregnancy, attitudes
toward skilled healthcare providers, and actions with regard to informational and
instrumental support, would be useful (1) to understand husbands capacity to convey
accurate information about pregnancy dangers, and (2) to ascertain differences in
womens perceived social support, and their received social support. The answers to
such questions as Do men feel responsible for their wives well-being during
134
pregnancy? If so, How do men operationalize their sense of responsibility? Do

men want to participate in their wives pregnancy? What are the characterstics of
men who provide social support to their wives compared with those men who do not
provide support?, would provide insight into the male role in maternal health.
Implications for Safe Motherhood Programs
The generation of government policies, a national action plan (e.g., the Making
Pregnancy Safe Strategic Plan), and programs (e.g., the Safe Motherhood Initiative) to
address the issue of maternal mortality in Indonesia was, by itself, a positive step toward
reducing the number of maternal deaths among Indonesian women of childbearing age.
A gap exists, however, between the political will to address the nations high maternal
mortality ratio, and the implementation of interventions to reduce the number of maternal
deaths. The Government of Indonesia must work to improve access to appropriate,
adequate, effective, and efficient maternal care at the village-level. The Indonesian
Department of Health (DepKes), which is responsible for all nursing and midwifery
education, must include and emphasize competency-based clinical training for bidan.
Refresher courses for managing delivery complications should be required to help bidan
maintain their level of skill, especially since pregnancy is considered a rare event, and
low caseloads may lead to a decline in competence. Subsequently, these midwives
should be promoted to couples as trustworthy and competent providers.
Indonesias paternalistic culture means that men are the ultimate decision-makers
in a household. Yet men are rarely targeted by health programs in Indonesia. The
Mother Friendly Movement was a recent effort (launched in 1996) to include men in
pregnancy-related issues. The concept of birth preparedness was promoted to men in
135
East Java, Indonesia. Specifically, husbands were encouraged to (1) prepare

transportation to a health facility in the event of a complication, (2) prepare funds to pay
for delivery by a skilled attendant, and (3) prepare a blood donor to accompany the
pregnant woman to the health facility in the event that she required a blood transfusion.
The findings from the present study that husbands play a supportive role in the
pregnancy and delivery of their child(ren) supports this effort to include men in
pregnancy-related activities, and suggests that further efforts should be made to include
husbands in the maternal health domain.
Limitations of the Study
The present study is characterized by both strengths and limitations. The

strengths include a large, random sample of women who delivered at least one child, and
high-quality data that were collected by experienced fieldworkers in Indonesia. These
data, however, are cross-sectional, and the measures used were based on self-reported
data. Recall bias may have occurred since women were asked to report on their last
delivery experience (within one year of the interview). Response bias may have occurred
due to prompted rather than spontaneous responses to various survey questions.
Another limitation is that West Java may be ethnically and culturally different
from other parts of Indonesia, even though the national population is relatively
homogeneous with regard to religion.
The findings are limited to the six districts of
study. The internal validity (i.e., the degree of certainty in the results) of the present
study may be compromised by history or contemporaneous activities in the selected areas
of study in West Java.
Bali, a small island of the coast o f East Java, is an exception with a largely Hindu population.
136
A further limitation of the data were that they did not allow the present
investigator to distinguish between use of a skilled healthcare provider for a normal
delivery versus a complicated delivery. Such a distinction would have been useful for
determining the relationship between, for example, husbands instrumental support and
type of delivery (normal versus complicated or emergency).
With these limitations in mind, the analyses presented in this study offer support
for most of the study hypotheses. Husbands do have some influence on their wives
knowledge and practices regarding pregnancy and delivery. The diffusion of
information occurs through discussion between husbands and wives. Interventions
designed to address maternal mortality issues must recognize this social interaction
between husbands and wives, and harness this partnership to motivate couples to practice
safe pregnancy and delivery.
Conclusions
The present study sought to fill a void in the scientific literature with regard to the
role of a husbands social support in ensuring a safe pregnancy and delivery for the
mother of his child. A key finding was that husbands social support is a predictor in the
decision to use a skilled healthcare provider for delivery. The findings from this study
represent a first step toward understanding the social interaction between husbands and
wives, and a stepping stone for the exploration of the decision-making processes among
couples related to pregnancy and delivery.
The causes of maternal mortality are multiple, interrelated, and preventable.
Social mechanisms contribute to the individual-level health-seeking behavior of pregnant
women. In the context of a paternalistic culture such as Indonesias, the exchange of
137
information and tangible support within the social context of marriage played a role in
determining a womans knowledge about pregnancy danger signs, and in using a skilled
healthcare provider for delivery.
138
Appendix A: MNH Baseline Questionnaire
PROJECT: P. STORK (ISTRI)
QUESTIONNAIRE No._____
JOB #; 3558/2000
Resp. Unique ID no._______

KEYPUNCHER #
INTERVIEWER #
SUPERVISOR #
CHECKER #
VERIFIER #
CODER #
LAMA INTERVIEW (MENIT)
NAMA RESPONDEN :
ALAMAT:
TEL:
HANYA INTERVIEWER
Saya dengan ini menyatakan bahwa
kwesioner ini benar2 berisi hasil interview
dan saya teiah memeriksa kembali dengan
teliti semua jawaban responden sesuai
dengan petunjuk dan briefing yang diberikan.
HANYA SUPERVISOR
Saya dengan ini menyatakan bahwa isi dan
cara pengisian kwesioner sudah benar dan
bahwa saya telah memeriksa dengan teliti
semua jawaban yang ada sesuai dengan
petunjuk dan briefing yang diberikan.
Tanda Tangan Interviewer:
Tanda Tangan Supervisor:

,./
A,
,./
A,
PERSETUJUAN MENGAJUKAN WAWANCARA SECARA LISAN

Survey Kesehatan Ibu dan anak, Indonesia 2001.
Selamat pagi/siang/sore. Nama s a y a ________________________
(Interviewer)
Saya mewakili sebuah group yang sedang melakukan penelitian mengenai kesehatan ibu
dan anak di Indonesia. Penelitian ini dilakukan untuk mengukur pengetahuan, sikap,
rencana, kebiasaan, dan dukungan kesehatan bagi ibu dan anak di lingkungan masyarakat
umum, bidan, dan tokoh-tokoh masyarakat dan juga untuk melihat persepsi dan harapan dari
bidan dan penyedia jasa ibu hamil dan melahirkan lainnya. Hasil dari penelitian ini akan
digunakan untuk merancang isi dari Komponen Campur Tangan Perubahan Perilaku dari
Proyek Kesehatan Ibu dan Anak untuk mendidik pria, wanita, keluarga-keluarga dan
masyarakat bagaimana meningkatkan status kesehatan ibu dan anak.
Anda telah dipilih untuk mengikuti interview dengan proses pemilihan yang acak atau
kebetulan, seperti mengambil jeruk dari dalam keranjang tanpa melihatnya teriebih dahulu.
Interview akan berlangsung selama 1 jam. Informasi yang kami dapatkan dari anda tidak
akan diperlihatkan kepada orang lain di luar proyek ini. Jika anda memiliki pertanyaan
tentang penelitian ini, anda dapat menghubungi kantor kami di Jakarta dengan alamat yang
terdapat pada kartu yang kami berikan pada anda.
Dapatkah saya melanjutkan pertanyaan? Ya/Tidak.
Saya telah membacakan formulir persetujuan wawancara kepada responden dan
responden secara sukarela menyetujui untuk berpartisipasi dalam penelitian ini.
Tanda tangan interviewer
Tanda tangan responden
139
Jawa Barat (West J ava) niled b y supervisor prior to beiwork

Remark
DISTRIK UTAMA
(MAIN DISTRICT)
Kabupaten
Kuningan
Kabupaten CIrebon i
Kota CIrebon
BCI
Component
All
2
3
All
All
Remark
DISTRIK TAMBAHAN
BCI Component
( p r o p o s e d ADOITIONAL
d is t r ic t )
Kabupaten Bandung
Kabupaten Sukabumi
5
6
Community
mobilization
Radio
Print
TIPE RESPONDEN /TYPE OF RESPONDENT:

Saat ini sedang hamil anak pertama /currently pregnant (first child)
Saat ini sedang hamil bukan anak pertama (dulu pernah melahirkan)
/Currently pregnant not the first child (has delivered in the past)______________________
Saat ini sedang tidak hamil tapi tahun lalu melahirkan anak pertama
/ Currently not pregnant but last year delivered the first child________________________
Saat ini sedang tidak hamil, tahun lalu melahirkan bukan anak pertama
(sebelumnya pem ahm e\ah\t\âr\'\uga)/C urrently not pregnant, last year
delivered not the first child (tias delivered in the past)__________________________________
RESPONDENTS UNIQUE ID
Nama panggilan responden/ Respondents nick name:
Tanggal lahir anak yang terakhir (utk category 2,3,4) Birthday of the last child (for category 2,3,4) . .
tgl date
bln month
thn year
Nama ibu//w of/?ers
Nama a y a h /F a f h e r s name:
Usia a g e ;
name:
Suam i/H usband's name:
Nama lengkap
Nama-nama ar\ak/childrens name:

1
2
Usia Suami Husband age:
Kelas sosial/SES
1
01
2
C2
D
El
E2
4
5
i
Suami Pmawancarai/ Husband
interviewed:
S1.
Ya / yes
1
Tidak /W o
2
SCREENING
Apakah ada wanita yang sudah menikah antara umur 1 5 - 4 5 tahun dalam keluarga
ini? Dapatkah saya bertemu dengannya?//s there any married women aged between 15 - 45
years old in this family? Can I see her?
Ya
Tidak
1
2
Lanjut ke S2/Continue to S2
STOP dan TKistop
IN I; APABILATIDAKTERDAPAT WANITA YANG SUDAH MENIKAH DAN BERUSIA

ANTARA UMUR 1 5 - 4 5 TAHUN, CARI KE RUMAH SEBELAHNYA. APABILA
ORANG YANG DITUJU TIDAK ADA DIRUMAH, DATANGI KEMBALI RUMAH
RESPONDEN//f there is no married woman aged betw een 1 5 - 4 5 years old, go to the next house.
the person is not available at that moment, come back again next time
S2.
Berapakah usia Anda sekarang? How old are you?

Tab u n /y e a r
INT; CATAT UMUR ASLI RESPONDEN DAN MASUKKAN JUGA DALAM KELOMPOK
UMUR DI TABEL BAWAH Record the actual age and hii in the age group below
140
If
Kurang dari 15 tahun/ Younger than IS y.o
^ STOP & IK
15-19
20-24
25-29
30-34
35-39
40-45
46 keatas/ 46 y.o or older
Menolak/ Refused
-^LANJUTKAN/ CONTINUE
7 __
8
9
STOP & TK
INT: CATAT JAWABAN S3a-C DI LEMBAR RESPONDEN PROFIL DI DEPAN / RECORD THE
ANSWER FROM S3a-c ON APPROPRIATE COLUM IN RESPONDENT PROFILE IN THE FRONT PAGE
S3a Apakah Anda saat ini sedang mengandung?Mre you currently pregnant?
S3b. Apakah dalam 1 tahun terakhir ini Anda pernah melahirkan? /Have you delivered a baby in
the past year?
S3c Apakah anda pernah melahirkan lebih dari setahun vana lalu? Have you ever delivered a
baby more than a year ago?
Ya yes
Tidak no
83a
Saat ini
hamil
S3b
Melahirkan tahun lalu
mulai dari Feb 2000
Currently
pregnant
Delivered In the past year

from Feb 2000
1
2
1
2
S3c
Melahirkan lebih dari satu
tahun lalu
Sebelum Februari 2000
Delivered more than a year ago before
february 2000
1
2
S3a
S3a
S3a
-> Ambil sebagai responden

kategori 1
Take as a category 1 respondent
Bila kode berikut ini terlingkar:
Ambil sebagai responden

kategori 2
Take as a category 2
-> Ambil sebagai responden
If the following codes are circled:

2
kategori 3
Ambil sebagai responden

kategori 4
CATAT KATEGORI RESPONDEN DI LEMBAR RESPONDEN PROFILE DI DEPAN RECORD

THE RESP. CATEGORY ON THE PRFILE SHEET IN THE FRONT PAGE
STOP & TK OTHER THAN THE ABOVE COMBINATION -*
STOP
SELAIN DARI KOMBINASI DI ATAS
34 HANYA UNTUK YANG MENJAWAB YA KODE 1 DI S3a/4SK
S 4 IF CODE 1 A T S 3a IS
CIRCLED
54.
Berapakah usia kehamilan anda?/whatis

Usia k a n d u n g a n /A g e o f pregnancy:________ /m in g g u /w e e fc ^
BULATKAN KE MINGGU
TERDEKAT/Round to the nearest week

TANYA SEMUA A S K ALL
55. Apakah Anda atau salah satu anggota keluarga Anda atau teman dekat Anda ada yang
bekerja di bidang-bidang berikut ini? Do you or any member in your family Including your close
friend work In the tollowing business?
141
Biro
iklan/perusahaan
hum as/ Advertising
agendes/pubUc
reiation company
Perusahaan penelitian pemasaran/ Market research agency

2
Institusi kesehatan seperti : Badan Kesehatan Dunia, 3
Departemen Kesehatan/ Puskesmas/Polindes/ Rumah
sakit bersalin dll. /Heaith institutions such as WHO. Department of
Heaith/Puskesmas/Poiindes/ Matemity hospitais etc.
Mass media/perusahaan ikian/ Mass media/advertising agency
Tidak satupun/ None of these
^STOP
&TK/
TERMINATE
4
5
LANJUTK
AN/
CONTINUE
KARTU BANTU SHOW CARD

S6. Hanya untuk tujuan pengklasifikasian, termasuk ke dalam grup manakah total
pengeluaran rumah tangga Anda dalam satu bulannya, yaitu termasuk pengeluaran
untuk makanan, pakaian, transportasi, listrik, biaya sewa rumah bulanan (tapi tidak
termasuk sewa rumah tahunan), atau kebutuhan-kebutuhan lainnya yang dikeluarkan
secara rutin setiap bulan?
Just for classification purposes, into which of these groups does the total monthly expenditure of this
household fail, that is the total expenditure per month on items including food, clothes, transportation,
electricity, rent (if paid monthly) but excluding rent (if paid yearly), and any regular expenses?
E2
E1
D
Rp 150,000 atau kurang/ Rp i50,000oriess

Rp 150,000-250,000
2
-^LANJUTKAN/
Rp 250,001 - Rp 350,000
CONTINUE
4
5
6
C2 Rp 350,001 - Rp 500,000
C1 Rp 500,001 - Rp 700,000
B Rp 700,001 - Rp 1,000,000
A Lebih dari Rp 1,000,000/
More than Rp 1,000,000,Menolak/ refused
^ STOP & TERIMA

KASIH
INT: JIKA RESPONDEN MEMENUHI SYARAT, LANJUTKAN KE PERTANYAAN UTAMA

YANG SESUAI DENGAN KATEGORI RESPONDEN (LIHAT S3A-C) IF THE p e r s o n is
QUALIFIED A S RESPONDENT, CONTINUE TO THE APPROPRIATE MAIN QUESTIONNAIRE ACCORDING
TO THE CATEGORY OF RESPONDENT (SEE S 3 A - C )
142
CD
D
O
Q.
C
o
CD
Q.
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BAGIAN 1: STATUS KEHAMILAN, MELAHIRKAN DAN MASA NIFAS
PREGNANCY, DELIVERY, AND POST-PARTUM STATUS
C/)
(/)
o
o
P1.
Berapa orangkah jumlah anak yang telah anda lahirkan baik dilahirkan hidup maupun diiahirlân meninggal? Laki-laki atau perempuan?
Dan berapa usianya (JIKA HIDUP)? Berapakah usia bay! anda saat dia meninggal dunia (JIKA DILAHIRKAN MENINGGAL)? Siapakah
nama mereka? (BAIK YANG HIDUP MAUPUN YANG MENINGGAL/C anyoutellm e about your children that you delivered in the past? Born live or
D
cq'
dead? Boy or girl? IF ALIVE: how old is h e/sh e now? IF DEAD: when (on what age) d idshe/he die? What are theirnames? (LIVE OR DIE)
Kelahiran ke
C hildbirth No
^3.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
CDD
O
Q.
C
a
o
o
o
CD
Q.
CDD
C/)
C/)
INT :
Jenis
kelamin/
Dilahirkan
hidup/mati?/Born
JIKA HIDUP:
Usia anak ?
sex
iiv e /d ie d
IF A L IV E : C hild A g e ?
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
UPlM/F
H/M/L/D
H/M/l/d
W hen (on w h a t a g e ) d id
s h e /h e d ie?
H M I ud
H/M/L/D
H/M/l/d
H M I l/ d
H/M/L/D
H/M/MD
H/M/DD
HIMIud
H/M/l/D
H/M/l/d
H M Iu d
H M I ud
H M I ud
CATAT SEBAGAIBERIKUT.........Record as follow...

Jika usia ketlka dilahirkan hingga meninggal dunia
Age from childbirth to death:
< 1 bulan Month
< 2 tahun Year
> 2 tahun Year
Jika mati if dead:

Kapan (usia berapa)
meninggalnya?
Catat dalam Records In :

Hari Day(s)
Bulan Month(s)
Tahun Year(s)
Nama anak
C h ilds n am e
7J
CDD
O
Q.
C
o
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Q.
CDD
(/)
(/)
CD
O
O
D
UNTUK KONFIRMASI FOR CONFIRMATION:

Jumlah anak yang dilahirkan meninggal iTotaiofstnibom babies
Jumlah anak \aK\-\ak\fTotai of baby boy(s)
Jumlah anak p e r e m p u a m o ta i of baby giri(s)_______________________
Jumlah }ê\]avr\\\aafTotal of pregnancy
P3c.
A a a k l Child(re n)
A nak/Child (ren)
Anak/Chiid(ren)
Anak/Chlid(ren)
Pada kehamilan anda yang terakhir. bagaimana anda pertama kali tahu bahwa anda hamil? (SA) on your last pregnancy how did you
first know that you are pregnant? (SA)

CD
P3d.
Pada kehamilan anda yang terdahulu (sebelum vano terakhir). bagaimana anda pertama kali tahu bahwa anda hamil? (SA)
On your pastpregnancy how did you first know that you were pregnant?(SA)
Cek sendiri dengan alat cek kehamilan yang tersedia di apotek/toko obat/
CD
D
O
Q.
C
a
o
o
o
Check using pregnancy test available at pharmacy/drug stores

Cekoleh bidan puskesmas checked by puskesmas bidan
Cek oleh bidan d e s a / Checked by bidan desa
Cek oleh bidan swasta (bukan bidan desa)/ Checked by a private bidan (non bidan desa)
Cek oleh dukun/paraji/ Checked by a dukun/parajl
Cek oleh dokter/ Checked by a doctor
Ketika saya tidak mens/datang bulan When l didnt get my mentruation/monthty period
Lainnya (tolong sebutkan) / others (s p e c if y )
P3c
P3d
2
3
4
6
6
7
2
3
4
5
6
7
CD
Q.
KARTU BANTU/showc//?d
P4a.
Menurut anda kapankah waktu yang tepat bagi seorang wanita untuk memulai perawatan kehamilan?(SA)//n your opnion when is the
T3
CD
(/)
(/)
Sejak awal saya tahu bahwa saya hamil (1-2 bulan kehamilan)/n^/7en / first know that i am pregnant ( i - 2 month of
my pregnancy)
Setelah 2 3 bulan kehamilan saya! After 2 - 3 months of my pregnancy

Setelah 3 - 4 bulan kehamilan saya! After 3 - 4 months of my pregnancy
Kalau sudah lebih dari 4 bulan/Wften my pregnancy has reached more than 4 months
Kalau tiba-tiba saya mengalami masalah dengan kandungan sayaAvften / suddenly have a problem with my
pregnancy
Lainnva (SEBUTKANVot/jerr'SDec/Zv)
1
2
3
4
5
7)
CDD
acO
o
CD
Q.
CDD
C/)
C/)
KARTU B A N J U /S H O W C A R D
P4c.
O
oD
c q
Dibawah 1 bulan/ Less than one month

1-2 bulan/ 1-2 months
2 - 3 bulan 2 - 3 months
3-4 bulan/ 3-4 months
Diatas 4 bulan/ over 4 months
Lainnya (SE B lilK A H )! Others/(SPECIFY)
'
3Q
CDD
O
Q .
C
a
o
3
o
o
Pada usia kehamilan berapa bulankah pertama kalinva memeriksakan kehamilan anda yang terakhir?
4L/t^
1
2
3
4
5
P5.
Berapa kalikah seharusnya seorang wanita hamil memeriksakan kehamilannya selama usia kehamilan
KEHAMI LAN)/How many times should a pregnant woman chek-up her pregnancy duirng her (READ AGE OF PREGNANCY)
Usia kehamilan /Age of pregnancy____________________________________________________________________________
1 - 7 bulan/7 - l months
=
Kali/r/mes
Tidak tahu Dont know 97
8 bulan/8/77o/?f/?
=
Kali/r/mes
9 bulan/9/T7o/?f/?s
=
Kali/r/mes
TOTAL
K b W/Times
P6a.
(BACAKAN USIA
Menurut anda, kepada siapakah seharusnva seorang wanita memeriksakan ke\]am \\am ya7{SA )/inyouropinionw hichprovidershouda
woman go to for prenatal examination?(SA)

CD
Q .
P6c.
Kepada siapakah anda memeriksakan kehamilan anda yang terakhir?/H//?/c/? provider do you ao to tor vour prenatal examination for your last
DoVXer!Doctor
CDD
C /)
C /)
Dokter kandungan/spe/cafef os
Bidan puskesmas/s/dan puskesmas
Bidan desa/b/dan d e sa
Bidan S w a s ta / P w a f e bidan
D u km ! Dukun
Tidak ada None

Lainnya (tolong sebutkan) / others (please mention)
P6a
1
2
3
4
5
6
12
P6c
1
2
3
4
5
6
12
KARTU B A N TU I s h o w c a r d
P8b.
Dimanakah anda merencanakan melahirkan bayi anda pada kehamilan anda yang { e r a ^ ^ / W h e r e did you plan to deliver your baby for your
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
fast pregnancy? (SA)
P8c.
Dimanakah akhlrnya anda melahirkan bayi anda pada kehamilan anda yang terakhir? / where did you actually deliver your baby on your last
pregnancy? (SA)
CD
O
O
T3
P u ske sm a s/ Puskesmas
<
c q
P8b
P8c
go to P9c
'
Rumah sakW/Hospitai
s
Q
3 3"
Q
CD
T3
O
Q .
Q
3
4
5
3
4
5
> Jika tidak terlingkar di P8b

lanjut ke P9d ft not circled on P8b
go to P9d
Polindes
Rumah pribadi bidan/Private midwife's house
Rumah dukun/Du/cunshouse
Rumah sendin/ My own house
Lainnva rSEBUTKANVOf/iere (SPECiFY)
n
c
Jika tidak terlingkar di P8b

lanjut ke P9c if not circled on P8b
Tidak tahu/tidak ingat/Donf know/Dontremember
c^
P9c.
Tolong sebutkan 3 alasan utama mengapa anda tidak berencana melahirkan di Puskesmas pada kehamilan anda yang terakhir?
Please tell me your 3 main reason for not planning to deliver your baby at puskesmas on your last pregnancy
P9d.
Tolong sebutkan 3 alasan utama mengapa anda tidak berencana melahirkan di rumah sakit pada kehamilan anda yang terakhir?
CD
Q.
CDD
C/)
C/)
Rumah sakit /puskesmas/polindes letaknya terialu jauh/ Hospitai/puskesmas/poHndes was too far
Bidan lebih dekat/ Bidan iocated nearby
Dukun lebih dekat/ Oukun iocated nearby
Bidan dapat dipanggil ke rumah/ Bidan can be cauedhome
Dukun dapat dipanggil ke rumah/ Dukun can be calied home
Biaya meiahirkan dengan bidan lebih murah/ oeiivery by bidan is cheaper
Biaya melahirkan dengan dukun lebih murah/ oeiivery by dukun is cheaper
Sudah terbiasa dengan memakai jasa bidan/ Already used to using bidan
Sudah terbiasa dengan memakai jasa dukun/ Already used to using dukun
Dianjurkan oleh orang tua/ mertua/ Recommended by parent/parent in law
Lainnya/of/jers (cataVsoecifv)'.
P9c
1
2
3
4
5
6
7
8
9
10
P9d
1
2
3
4
5
6
7
8
9
10
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
P12a.
Menurut anda, siapa sajakah yang seharusnva hadir menolong anda pada saat persalinan?(MA)///7 you/'opm/o/? who are the people who
should be present when a woman delivers her baby?(MA)
P12c.
O
O
D
c q
P12d.
Siapakah yang akhirnva hadir saat anda melahirkan di masa kehamilan anda yang terakhir?('MAVH^/?o actually present during delivery for
'
Dokter/Docfor
Dokter kandungan/spe/ca/zsr ob
Bidan pUSkesmas/S/dan puskesmas
Bidan 6eSB/bldan desa
Bidan syyasia!Private bidan
Dukun/Oukun
O
Q
SuawMHusband
CDD
O
Q .
C
a
Ibu/ Ibu mertua IVIother/Motherln law

7 eman/ie\.anQga/Friend/neighbour
Saudari/ ipar wanita sister/s-in-iaw

Teman ibu hamil lainnya di lingkungan saya other
o
o
CD
Q .
CDD
C /)
C /)
Siapa sajakah yang anda rencanakan untuk hadir menolong anda saat anda melahirkan yang terakhir?(MA) what were your plans on
which people would be present during delivery for your last pregnancy? (MA)
<1
pregnant women In the neighbourhood
Tidak ada/ saya pergi sendirian/ Nobody/rii go alone

Lainnya (SEBUTKANyofdere
P12a
1
2
3
4
5
6
7
8
9
10
P12c
1
2
3
4
5
6
7
8
9
10
PI 2d
1
2
3
4
5
6
7
8
9
10
11
11
11
12
12
12
(SPECIFY)
Tidak ta h u /D o n 'f know
99
CD
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C
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CD
Q.
CDD
BAGIAN 2: PENGETAHUAN MENGENAI KESEHATAN KEHAMILAN
KNOWLEDGE ABOUT HEALTH DURING PREGNANCY, DELIVERANCE AND POST PARTUM
C/)
(/)
P 19 .
O
O
D
c q
Apakah anda mengetahui tanda-tanda bahaya yang dialami seorang wanita selama masa... (BACAKAN TABEL P19A,19B, 19C)
Doyou know of any danger signs or complications that a woman might suffer from during ... (READ TABLE P19A)
P19a. hamil
During pregnancy
'
Ya/yes
Tidak/wo
7^
O
Q
o
o
CD
Q .
CDD
C /)
C /)
- * Ke P20a/ G o to
P 20a
-KeP26/Goto
P26
JANGAN DIBANTU/ DO NOT AID

P20.
Apa sajakah tanda-tanda bahaya & situasi darurat yang anda ketahui selama masa...) what are the danger signs symptoms & emergency
CDD
O
Q .
C
a
o
P20a.
K e h a m i l a n (M A )/
preartan ev.
400^
Pendarahan/ Bleeding
Tekanan darah tinggi/ High blood pressure
Pembengkakan di bagian kaki/ swollen feet
Pembengkakan di bagian tangan/ swollen hands
Pembengkakan di wajah / Swollen face
Infeksi infection
Muntah-muntah yang berlebihan/ vomiting (more than usual)
Mata berkunang-kunang Blurred vision
Berat badan bertambah 2 kali lipat dari ukuran kehamilan
normal/ Body weight doubles than normal pregnancy condition
Keluar cairan /pecah ketuban sebelum waktunya melahirkan/
Rupture of amnlotic fluid before the delivery process
Keluar bercak-bercak darah/ spotting
Letak bayi sungsang/ melintang Horizontal/breech presentation
Kejang-kejang/spasm
Panas Wnggl/HIgh Fever
Bayi terlilit oleh ari-ari/ baby gets twisted by umbilical cord
Ibu mendadak merasa hendak pingsan, lemas, dan pusing
1
2
3
4
5
6
7
8
g
10
11
12
13
14
15
-
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
O
oD
c q
'
dalam proses persalinan Mother is suddenly in shock when delivering

Lainnya others (catat/s/sec/M:
JANGAN D IB A N T U / d o n o t a /d
P21.
Dari manakah anda mengetahui/ belajar tentang tanda-tanda bahaya dan situasi darurat semasa... (TANYA SATU PERSATU
Yang memberi tahu tanda bahaya
Source of danger signs awareness
O
Q
CDD
O
Q .
C
a
o
o
o
Bidan Puskesmas/polindes /Bidan Puskesmas/Poiindes

Bidan di desa Bidan in the village
Bidan swasta Bidan Bidan private practice
Dokter di rumah sakit / klinik khusus bersalin/
Doctor at the hospital/maternity clinic
Ibu atau kakak/Mof/)erors/sfer

Teman/tetangga iPhends/nelghbors
Sau6ara/ Relatives
Dukun beranak /Paraji

TV
Radio
Lainnya others (catat specify):
P21a
Kehamilan (MA)/
Pregnancy
1
2
3
4
5
6
7
8
9
10
CD
Q .
PENGALAMAN SENDIRI/ PERSONAL e x p e r ie n c e
CDD
(/)
(/)
P22a.
Apakah anda pernah mengalami kondisi yang berbahaya selama masa kehamilan anda yang sekarang? iHave you personally
experienced any complications during your current pregnancy 7.
CD
D
O
C
o
Q.
CD
Q.
CDD
C/)
(/)
P 22a.
Ya Yes Tidak No
Masa kehamilan/pregnancy
Masa melahirkan/ bersalin/d e//v ery
Masa setelah melahirkan/nifas/ p o s t
O
O
D
c q
partum
'
INT:
P 22b.
JIKA YA Kondisi Apakah Itu? if
KODE JAWABAN UNTUK P 22b ADALAH SEPERTI YANG ADA DI P20.
yes,
what was it?
THE A N SW ER CODE F O R /s THE s a m e w /T H O N E S /N
Q20
c
P23 DITANYAKAN HANYA PADA YANG MENJAWAB YA DI P22a. JIKA TIDAK->LANGSUNG KE P26
^ S K /P T O Q je
P23.
CD
D
O
Q .
C
a
o
o
o
CD
Q .
U
i
o
Apa yang anda lakukan untuk mengatasi keadaan situasi tersebut?/n//)sf was done to
overcome that emergency? (MA)
Saya langsung dibawa ke rumah sakit/puskesmas/t was taken/mmed/ate/y to t/?e hospitai/puskesmas
Saya beristirahat i took a rest
Saya di kompres l used compressed
Saya/ keluarga saya memanggil dokter i / my family called the doctor
Saya/ keluarga saya memanggil bidan i / my family called the midwife
Saya/ keluarga saya memanggil dukun/paraji i / my family called the dukun/paraji
Saya meminum jamu/ramuan tradisional/obat aWernaW i consumedherbs/traditionai
potlon/altematlve medicine
Saya/ keluarga saya memanggil orang pintar untuk mendoakan kondisi s a y a /i/ my family called
CDD
a supranatural healer to come to pray for me

Lainnya (SEBUTKAN)/ot/7ers (s p e c i f y )
Masa hamil
Pregnancy
1
2
3
4
5
6
7
8
BAGIAN 3: KOMUNIKASI PERORRANGAN

INTERPERSONAL COMMUNICATION
(/)
(/)
INFORMATIONAL SUPPORT
P 37 TANYA UNTUK TIAP ORANG YANG DIANGGAP PENTING (KODE 3 & 4) DI P36b
(C O D E 3 & 4 )I N Q 3 6 b
A S K f o r EACH P E R SO N MENTIONED A S IMPORTANT
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
JANGAN DIBANTU. ISI SEBANYAK YANG DISEBUT. PROBE SAMPAI DENGAN 4 KALI
DO N OT PROM PT,
f /l l
/N A S MAUYMENT/ONED.
PROBE"ANYTH/NG ELSE" 4 TIMES
P37a. Informasi atau nasihat-nasihat apakah yang diberikan oleh.... (SEBUTKAN ORANGNYA) pada kehamilan anda yang terakhir mengenai
kehamilan, melahirkan, dan masa nifas (setelah persalinan)? What informational support have ... (mention the person) provided during your last pregnancy?
O
O
D
c q
'
KARTU BANTU SKALA KEPENTINGAN SH O W CARD OF IMPORTANCE SCA LE {SA fAA DENGAN DI P 36b/ t h e s a m e A S t h e o n e u s e d i n
P37b. Seberapa penting
(BACAKAN TIAP HAL YANG TERLINGKAR DI DI P37a) dilakukan oleh..... (SEBUT ORANGNYA). How
important is.... (READ EACH SUPPORT MENTIONED IN Q 37a) done by
Dokter
Doctor
O
Q
CDD
O
Q .
C
a
o
o
o
CD
Q .
CDD
C/)
C/)
Bidan
Puskemas
Bidan di
Desa
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
TAHAP KEHAMILAN
Nasihat untuk
mendapatkan
perawatan
medis selama
masa
kehamilan dari
tenaga terlatih
seperti dokter
atau bidan
Advice for getting
medicai treatment
during pregnancy
from trained
provider such as
doctor, or midwife
DURING PREG N AN CY
Bidan
swasta
Q 3 6b)
(MENTION THE PERSON)?

Dukun
beranak/
paraji
Suami
H usband
ibu/lbu
mertua
M other/
M-in-iaw
Saudara/
ipar
wanita
S/S-in-law
Tetangga
Neighbor
Teman
Friends
TOMA
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
BERI TANDA
y SEMUA YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
'
Nasihat dari
dukun
beranak/
paraji gett/ng
O
Q
advice from a
traditional
provider - dukun
beranak/ paraji
CDD
O
Q .
C
a
o
o
o
CD
Q .
CDD
(/)
(/)
Ui
Nasihat untuk
beristirahat
yang cukup
dan tidak
bekerja berat
Advice regarding
getting enough
rest and not doing
hard/hazardous
work
Nasihat
tentang
makan
makanan
bergizi
Advice on
nutritious food
Bidan
Puskemas
Bidan di
Desa
Bidan
swasta
Dukun
beranak/
paraji
Suami
H usband
ibu/lbu
mertua
h/iother/
f/l-in-law
Saudara/
ipar
wanita
S/S-ln-law
Tetangga
Neighbor
Teman
Friends
TOMA
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
'
Anjuran untuk
menanyakan
hal-hal
seputar
kehamilan
saya kepada
dokter, atau
bidan Adv/ce to
O
Q
CDD
O
Q .
C
a
o
o
o
CD
Q .
CDD
(/)
(/)
U
U)i
ask about my
pregnancy to a
doctor, or midwife.
Anjuran untuk
memberitahuk
an masyarakat
sekitar
mengenai
kehamilan
saya hingga
saya bisa
mendapatkan
pertolongan
jika diperlukan
Advice to notify
peopie about my
pregnancy so i
can get help if
needed
Bidan
Puskemas
Bidan di
Desa
Bidan
swasta
Dukun
beranak/
paraji
Suami
Musb^rtd
Ibu/lbu
mertua
M other/
M-in-iaw
Saudara/
ipar
wanita
S/S-in-law
Tetangga
Neighbor
Teman
Friends
TOMA
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
'
O
Q
CDD
O
Q .
C
a
o
o
o
CD
Q .
CDD
(/)
(/)
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
Nasihat
mengenai
tanda-tanda
bahaya
kehamilan
seperti
pendarahan
Advice regarding
specific danger
signs such as
bleeding________
Nasihat
mengenai
tanda-tanda
bahaya
kehamilan
seperti
pembengkaka
n kaki Advice
rgarding specific
danger signs such
as swolien feet
Bidan
Puskemas
Bidan di
Desa
Bidan
swasta
Dukun
beranak/
paraji
Suami
H usband
Ibu/lbu
mertua
M other/
M-in-iaw
Saudara/
ipar
wanita
S/S-in-iaw
Tetangga
Neighbor
Teman
Friends
TOMA
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
'
O
Q
CDD
O
Q .
C
a
o
o
o
CD
Q .
CDD
(/)
(/)
Bidan
Puskemas
Bidan di
Desa
Bidan
swasta
10
10
10
Dukun
beranak/
paraji
Suami
H usband
Ibu/lbu
mertua
M other/
M-in-law
Saudara/
Ipar
wanita
S/S-in-law
Tetangga
Neighbor
10
10
Teman
Friends
TOMA
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
Nasihat
mengenai
cara bernafas
ketika
melahirkan
Advice on
breathing
techniques for
deiivery_________
Nasihat
mengenai
penyediaan
transportasi
darurat untuk
berjaga-jaga
jika diperlukan
Advice to prepare
transportation
arrangements in
advance in case
needed
10
10
10
10
10
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
Nasihat
mengenai
penyediaan
donor darah
untuk berjagajaga jika
diperlukan
O
Q
CDD
O
Q .
C
a
CD
Q .
CDD
(/)
(/)
Tetangga
Neighbor
11
11
11
11
11
12
12
12
12
12
12
13
13
13
13
13
13
Bidan
swasta
11
11
11
11
11
12
12
12
12
13
13
13
13
Ibu/lbu
mertua
M other/
M-in-law
Teman
Friends
TOMA
Advice to prepare
blood donor
arrangements in
case needed
o
o
Saudara/
ipar
wanita
S/S-in-law
Suami
H u sb a n d
Bidan di
Desa
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
'
Dukun
beranak/
paraji
Bidan
Puskemas
L
O/tn
Nasihat
mengenai
penyediaan
dana untuk
berjaga-jaga
jika diperiukan
Advice to prepare
financial
arrangements for
emergency when
needed
Anjuran/inform
asi mengenai
imunisasi
yang
diperlukan
information on
necessary
immunization
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
'
O
Q
CD
D
O
Q .
C
a
o
o
o
CD
Q .
CDD
(/)
(/)
Bidan di
Desa
Bidan
swasta
Dukun
beranak/
paraji
RBkatd
14
14
14
14
14
15
15
15
15
15
Bidan
Puskemas
Suami
Saudara/
ipar
wanita
S/S-in-law
Tetangga
Neighbor
14
14
14
14
14
15
15
15
15
15
Ibu/lbu
mertua
M other/
M-in-law
Teman
Friends
TOMA
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
Nasihat/lnform
asi untuk tidak
memakan
makanan yang
banyak
mengandung
garam
Information not to
consume food
containing a lot of
salt
Nasihat/lnform
asi tentang
pamali/tabu
yang tak boleh
dilanggar
information about
beiief./ taboo
which are not
supposed to be
broken/ done
73
CD
T3
O
Q.
C
o
CD
Q.
T3
CD
(/)
(/)
Bidan
Puskemas
Bidan di
Desa
Bidan
swasta
16
16
16
16
17
17
17
17
Dokter
Doctor
O
O
'
33"
Q
CD
T3
O
Q .
Q
ao
3
O
T3
CD
Q .
T3
CD
(/)
(/)
Ibu/lbu
mertua
M other/
M-in-law
Saudara/
Ipar
wanita
S/S-in-law
Tetangga
Neighbor
16
16
16
16
16
16
16
17
17
17
17
17
17
17
Teman
Friends
TOMA
BERI TANDA
yS E M U A YG
MENDAPAT
KODE 3 ATAU
4 DI P36b
T3
c q
Suami
H usband
Dukun
beranak/
paraji
00
Nasihat/lnform
asi tentang
upacara/selam
atan yang
harus
dilakukan
supaya
kehamilan dan
proses
melahirkan
berlangsung
selamat
Information about
safe delivery
ceremony________
Menganjurkan
saya untuk
mengkonsums
i kuning
telur//^cfv/s//7g
me to consume
egg yolk_________
Lainnya others
CATAT Specify
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
BERI TANDA
yS E M U A YG
MENDAPAT
KODE 3 ATAU 4
DI P36b
'
Memeriksa
posisi bayi
Check babys
position
O
Q
Memeriksa
berat badan
bayi check babys
CD
D
O
Q .
C
a
o
CD
Q .
CDD
Bidan di
Desa
Bidan
swasta
Suami
Husbarid
Ibu/lbu
mertua
M other/
M-in-law
Saudara
/ ipar
wanita
S/S-inlaw
Tetangga
Neighbor
Teman
Friends
TOMA
weight
Bidan
Puskemas
Dukun
beranak/
paraji
U
'Oi
Memeriksa
tekanan darah
Check blood
pressure
Memeriksa air
seni Check urine
sample
Memberikan
perkiraan
mengenai usia
bayi Assessing
age of pregnancy
(/)
(/)
Menyediakan
vitamin
Providing vitamins
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
BERITANDA
SEMUA YG
MENDAPAT
KODE 3 ATAU 4
DI P36b
'
Menyediakan
obat-obatan
tradisional
O
Q
Providing
traditionai
medicines
CDD
O
Q .
C
a
Mengurut perut
ibu Massages the
CD
Q .
CDD
(/)
(/)
Bidan dl
Desa
Bidan
swasta
Suami
H usband
Ibu/lbu
mertua
M other/
M-in-law
Saudara
/ ipar
wanita
S/S-inlaw
Tetangga
Neighbor
Teman
Friends
TOMA
10
10
10
10
10
10
10
10
10
10
10
11
11
11
11
11
11
11
11
11
11
11
12
12
12
12
12
12
12
12
12
12
12
stomach
Bidan
Puskemas
Dukun
beranak/
paraji
OS
Mengajarkan
cara bernafas
ketika
melahirkan
Teaching the
breathing
techniques for
deiivery
Mengatasi
tanda-tanda
bahaya yang
muncul Manages
any danger signs
Mengawasi
perkembangan
bayi Monitoring
the babys growth
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Dokter
Doctor
O
O
D
c q
BERI TANDA
yS E M U A YG
MENDAPAT
KODE 3 ATAU 4
DI P36b
'
Menemani
saya
melakukan
pemeriksaan
rutin
O
Q
o
o
CD
Q .
CDD
(/)
(/)
Bidan di
Desa
Bidan
swasta
Sugmi
H usband
Ibu/ibu
mertua
M other/
M-in-law
Saudara
/ ipar
wanita
S/S-inlaw
Tetangga
Neighbor
Teman
Friends
TOMA
13
13
13
13
13
13
13
13
13
13
13
14
14
14
14
14
14
14
14
14
14
14
15
15
15
15
15
15
15
15
15
15
15
Accompanying me
to routine check
ups
CDD
O
Q .
C
a
o
Bidan
Puskemas
Dukun
beranak/
paraji
ON
Menyediakan
makanan yang
bergizi untuk
saya Preparing
nutritious food for
me
Menyiapkan
upacara
keagamaan
untuk
keseiamatan
keiahiran saya
Organizing
religious
ceremonies for
safe deiivery
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Menyiapkan
transportasi
sedini mungkin
diperlukan
pada saat
melahirkan
o
o
CD
Q.
CDD
C/)
C/)
Tetangga
Neighbor
Teman
Friends
Bidan di
Desa
Bidan
swasta
16
16
16
16
16
16
16
16
16
16
16
17
17
17
17
17
17
17
17
17
17
17
TOMA
BERI TANDA
/S E M U A YG
MENDAPAT
KODE 3 ATAU 4
Dl P36b
CDD
O
Q.
C
a
o
Saudara
/ ipar
wanita
S/S-inlaw
Bidan
Puskemas
Dokter
Doctor
O
O
D
cq'
Suanhi
H usband
Ibu/ibu
mertua
M other/
M-in-law
Dukun
beranak/
paraji
c^
N>
Preparing for
transportation in
advance if needed
during delivery
Menyiapkan
donor darah
sedini mungkin
diperlukan
pada saat
melahirkan
Preparing for biood
donors in advance
if needed during
delivery___________
CD
D
O
Q.
C
o
CD
Q.
CDD
C/)
(/)
Bidan
Puskemas
Dokter
Doctor
O
O
D
c q
BERI TANDA
yS E M U A YG
MENDAPAT
KODE 3 ATAU 4
Dl P36b
'
Menyiapkan
dana yang
cukup sedini
mungkin untuk
meiahirkan
O
Q
o
o
CD
Q .
CDD
(/)
(/)
Bidan
swasta
Dukun
beranak/
paraji
Suami
H usband
Ibu/lbu
mertua
M other/
M-in-law
Saudara
/ ipar
wanita
S /S-inlaw
Tetangga
Neighbor
Teman
Friends
TOMA
18
18
18
18
18
18
18
18
18
18
18
19
19
19
19
19
19
19
19
19
19
19
Preparing for
adequate funds in
advance if needed
during deiivery
CDD
O
Q .
C
a
o
Bidan di
Desa
O
UN
)
Menyiapkan
dana iebih
sedini mungkin
diperiukan
pada saat
melatiirkan
Preparing for extra
funds in advance if
needed during
deiivery
Lainnya others
C A T A T Specify
BAGIAN 4: ORANG-ORANG YANG TERLIBAT DALAM PERAWATAN MASA

KEHAMILAN, MELAHIRKAN, DAN MASA NIFAS
INDIVIDUALS INVOLVED IN PRENATAL, DELIVERY, AND POST-PARTUM CARE
A. SUAM I HUSBAND
KARTU BANTU SH O W C A R D S
P39a Menurut anda, seberapa pentingkah suami anda ikut menemani dan saat
memeiiksakan kehamilan anda? (SA) How important was it for your husband to accompany you during
Sangat penting very important
Renting important
Tidak penting Not important
Sangat tidak penting Not at an important
4
3
2
1
P39b Menurut anda, apa keuntungannya bila suami anda menemani anda saat melakukan
pemeriksaan
kehamilan anda?(MA) PROBE in your opinion, what are the advantages of having your husband
Suami dapat segera tahu jika ada hal yang tidak beres dengan kehamilan
saya Husband can quickly knows if there is something wrong with my pregnancy
Memberi saya rasa tenang/ diperhatikan /fee/ peaceful and cared for
Suami tahu apa yang harus dilakukan Jika terjadi sesuatu dengan
kehamilan saya Husband knows what to do if something happen to my pregnancy
Suami tahu apa yang harus dilakukan jika terjadi sesuatu saat saya
melahirkan Husband knows what to do if something happen during delivery
Suami tahu apa yang harus dilakukan jika terjadi sesuatu dengan saya
Setelah melahirkan Husband knows what to do if something happen to me after delivery/
1
2
3
4
5
post partum
Suami tahu apa yang harus dilakukan jika terjadi sesuatu dengan si bayi
setelah dilahirkan Husband knows what to do if something happen to the newborn baby
Suami mengerti pentingnya mempersiapkan dana untuk melahirkan Iebih
awal Husband understands the importance of preparing money for deiivery in advance
Suami mengerti pentingnya mempersiapkan dana Iebih jika terjadi kondisi
berbahaya pada saat melahirkan Husband understands the importance of preparing
6
7
8
extra money for deiivery in advance
Suami Iebih tanggap dalam mempersiapkan kelahiran bayi, misalnya

dengan menyiapkan transportasi untuk istri melahirkan Husband is more
anticipated in preparing for the deiivery, for example by arranging transportation for his wife to
go to deiivery place
Hubungan dengan dokter/bidan Iebih baik sehingga akan cepat meminta

dokter/bidan datang jika diperlukan Relationship with bidan win be better, so that it will
10
be quicker to ask bidan to come, if necessary

Lainnya others CATAT specify
P39c Menurut anda, adakah kerugiannya bila suami anda menemani anda saat melakukan
pemeriksaan
kehamilan anda? in your opinion, is there any disadvantage of having your husband accompany you forprenatai
visits?
Ya Yes
1
^ KE P 39d TO P39d
Tidak No
2
- KE P 40a TO P40a
P39d Menurut anda, apakah kerugian tersebut? P R O B E in your opinion,
what are the disadvantages?
164
PROBE
KARTU BANTU SH O W C A R D S
P40a Menurut anda, seberapa pentingkah suami anda hadir saat anda meiahirkan? (SA)
Sangat penting very important
Penting important
Tidak penting Not important
Sangat tidak penting Not at an important
3
2
1
P40b Menurut anda, apa keuntungannya bila suami anda hadir menemani anda saat anda
melahirkan?
(MA)PROBE In your opinion, what are the advantages of having your husband accompany you during
Suami dapat segera membantu jika terjadi keadaan darurat yang
membahayakan jiwa saya atau si bayi pada saat saya melahirkan
Husband can immediately help if there is an emergency situation that may threaten my or
the baby's life during deiivery
Memberi saya rasa tenang/ diperhatikan i feel peaceful and cared for
Suami dapat segera memberi doa di telinga si bayi, begitu ia dilahirkan

Husband can immediately summon a prayer to the baby right after the babys bom
Lainnya others CATAT specify
1
2
3
P40c Menurut anda, adakah kerugiannya bila suami anda hadir menemani anda saat anda
melahirkan?
Ya Yes
Tidak No
1
2
^ KE P 40d TO P40d
- KE P 41 TO P41
P40d Menurut anda, apakah kerugian tersebut? PROBE in your opinion, what are the disadvantages?
PROBE
BAGIAN 5: PERILAKU DAN PERSEPSI/ATTITUDES AND PERCEPTIONS
TANYA SEMUA/ A S K ALL

KARTU BANTU S K A L A f SH O W CARD
P55. Berikut akan saya bacakan daftar pandangan umum masyarakat tentang hal-hal yang
berkenaan dengan seorang ibu yang sedang hamil, melahirkan dan dalam masa nifas (baru
saja melahirkan). Saya ingin mengetahui, seberapa setujukah/tidak setujukah Anda dengan
pernyataan tersebut? Disini tidak ada jawaban benar atau salah, kami hanya ingin
memperoleh pendapat yang jujur dari anda. Anda dapat menjawab menggunakan skala 1
sampai 4 di mana. Now, i win read out a list of common perceptions pertaining a woman who is pregnant,
delivering and in post-partum period (just delivering the baby, i would like to know how agree or disagree are you with
these statements...? There is no right on wrong answer, we are only interested with your honest opinion. You may
choose your answer using scale 1 to 4, where'.
165
ROTASI, MULAI DARI KALIMAT YANG

DILINGKARI/ ROTATE, START FROM THE STATEMENT
CIRCLED
Setiap ibu hamil berhak mendapatkan

pelayanan kesehatan yang baik semasa
kehamilan dari tenaga terlatih seperti dokter
atau bidan Every pregnant mother has the right to
S an g at
setuju sekali Setuju/
Extremely
agree
Agree
Tidak
setuju
S an g at
tidak setuju
Disagree
Extremely
disagree
receive good pregnancy care from trained provider such

as doctor or midwife

pelayanan kesehatan yang baik ketika
melahirkan dari tenaga terlatih seperti dokter
receive good delivery care from trained provider such as
doctor or midwife

pelayanan kesehatan yang baik semasa
masa nifas dari tenaga terlatih seperti dokter
receive good post partum care from trained provider
such as doctor or midwife
Kehamilan merupakan sesuatu yang

seharusnya ditangani bersama oleh suami
dan istri Pregnancy is a joint matter between
husbands and wives
Pendarahan disaat kehamilan dapat

dicegah/diobati Bleeding during pregnancy can be
prevented/cured
Kematian ibu hamil dapat dicegah. Hal itu

bukan merupakan kesialan atau nasib
Maternal death is preventable event it is not fate
Bidan sangat mengetahui kebutuhan ibu

hamil Bidan is respectful about pregnant mothers
needs
Suami biasanya merasa segan untuk

meminta pertolongan tetangga untuk
memperhatikan keluarganya ketika dia harus
berpergian / Husbands are reluctant to ask their
neighbors to look after their family when they are away
Kehamilan dan melahirkan bayi adalah suatu

hal yang wajar bagi seorang wanita, jadi
tidak perlu terlalu dikhawatirkan / Pregnancy
and giving birth is a natural phenomena for women,
therefore nothing much to worry about
Pendarahan yang berlebihan dimasa

kehamilan dan persalinan adalah akibat dari
10 ibu hamil melanggar suatu hal yang tabu
(pamali) / Bleeding during pregnancy and delivery is
caused by pregnant mother breaking the taboos
Pendarahan adalah akibat ibu hamil bekerja

11 terlalu berat, Bleeding is caused by pregnant mother
works too hard
166
Pendarahan adalah akibat ibu hamil kurang

12 gizi
Pendarahan adalah akibat ibu hamil tidak

13 rutin memeiiksakan kehamilannya Bleeding is
14
Bleeding is caused by pregnant mother is malnourished
caused hy pregnant mother does not do routine check

up
Bidan ahli dalam pekerjaannya Bidan knows
her job
Meminta bantuan warga desa

menyumbangkan darah bagi ibu hamil yang
sedang
kritis adalah suatu hal yang
15
wajar/biasa / Asking the viiiage communitys helps to
donate the blood for pregnant mother who is in the
critical condition is a nomial thing
Meminta bantuan warga desa memberikan

dana/sumbangan biaya persalinan bagi ibu
hamil yang sedang mendapatkan kesulitan
16 keuangan adalah suatu hal yang wajar/biasa
/ Asking the village communitys helps to donate money
for pregnant mother who is in the critical condition is a

normal thing
Lebih mudah pergi ke dukun karena mereka

17 sudah seperti keluarga sendiri it is easier to go
to the dukun since she is like a part of the family
ROTASI, MULAI DARI KALIMAT YANG

DILINGKARI/ ROTATE, ST A R T FROM THE STATEMENT
S an g at
setuju sekali S etuju/
Extremely
disagree
Agree
Dukun dapat mengurut perut saya untuk

18 memperbaiki posisi bayi yang sungsang
Apabila ari-ari tidak keluar maka bidan

seharusnya mengeluarkannya dengan cara
19 memasukkan tangannya ke dalam rahim if a
Dukun can massage a mother stomach to correct the

position of the baby
20
placenta does not come out the midwife should push it

out by inserting her hands in the womb
Biaya pelayanan bidan itu mahal Bidan is
expensive
Ibu hamil harus banyak makan makanan

21 yang bergizi / Pregnant mother need to consume
S an g at
tidak setuju
Disagree
Extremely
agree
CIRCLED
Tidak
setuju
nutritious foods
Keluarga ibu hamil harus melakukan upacara

selamatan/menjalankan tradisi tertentu agar
22 ibu dan bayi selamat The family should do safe
delivery/traditional ceremony for the safety of the mother
and the baby
Suami yang menolong istri mengerjakan

pekerjaan rumah saat istrinya hamil akan
23 kehilangan wibawa/ tidak dihormati oleh
teman-temannya Husband who help wife with
housework when she is pregnant lose the respect of
their friends
Proses melahirkan seharusnya ditangani

24 oleh bidan, bukan dukun beranak/ paraji the
delivery process should be handled by bidan instead of

dukun
167
Bidan adalah seseorang yang dapat

dipercaya sehubungan dengan soal
25 kehamilan/ melahirkan/ perawatan setelah
meiahirkan Sldan is a trustworthy provider for
prenatal care/deHvery/post-partum care
Suami tidak perlu menemai istrinya

26 memeriksakan kehamilannya it is not necessary
for husbands to accompany their wives for prenatal
check ups
BAGIAN 8: DEM OGRAPHICS
KARTU BANTU / SHOW CARD

D1. Apakah tingkat pendidikan terakhir anda? SA m a t is the highest education ievei did you
receive?
Tidak ada pendidikan formal No formal education

Tidak tamat Sekolah Dasar Primary school not completed
Tamat Sekolah Dasar Primary school cnmniete
Tidak tamat Sekoiah Menengafi i 167 Junior high school not complete
Tamat Sekolah Menengah Pertai
Ugh school complete
Tidak tamat Sekolah Menengah >
>rhigh school not complete
Tamat Sekolah Menengah Atas senior mgn school complete
Tidak tamat Akademi/setingkatnya Academy/higher education - not complete
Tamat Akademi/setingkatnya Academy/higher education-complete
Tidak tamat Universitas University - not complete
Tamat Universitas University - complete
Lainnya (catat) other (specify)
Madrasah Religion school
Menolak Refused
01
02
03
04
05
06
07
08
09
id
11
12
13
14
D2.
Siapa sajakah yang tinggal di rumah tangga ini, selain suami /anak anda? MA
BACAKAN
Could you tell me people who live In this house hold exiuding your husband and your children? READ OUT
Ayah Father
1
Ibu Mother
2
Ayah mert.ua Father In law
3
Ibu Mertua Mother in law
4
Kakak (ipar) laki-laki Brother in law
5
Kakak (ipar) perempuan sister in law
6
Lainnya (catat) other (specify)
1
KARTU BANTU SHOW CARD

D3a. Apakah pekerjaan Anda? m a t is your occupation
D3b. Apakah pekerjaan suami Anda? m a t is your husband occupation
Pegawai Tinggi High Rank officer
President DirekturA/ice-President/Direktur/Assisten Direktur/Pemilik
perusahaan President Director/ VIce-Presldent/Dlrector/Asslstance
D3a
01
Director/Company owner
Pegawai Negeri Gol III A keatas Government worker GoI lll A and above
Militer: pangkat Kolonel keatas Military: Coionei and above
168
D3b
01
Pegawai Menengah Middie Rank officer

Senior Manager/Manager/Assisten Manager Senior
Manager/Manager/Assistant Manager
Pegawai Negeri Go! ilAv/lIB Government worker Got UA &ilB
Militer: pangkat Letnan keatas MiUtary: Uutenant and above
Pembantu Pimpinan A ssstant ievei
(Supervisor/Officer/yang mempunyai tanggung jawab penting tetapi

bukan Manager) (Supervisor/ofhcerAhose who have Manager)
Pegawai Biasa ordinary staff
staff Admin/Typist Admin Staff/Typist
Militer : pangkat Sersan ke bawah MiUtary: Sergent and above
Profesional (Beketja Sendiri - Dokter, Notaris, dll.) Profesionai (Seif-
02
02
03
03
04
04
05
05
06
06
07
07
08
08
09
10
11
12
13
14
15
16
88
09
10
11
12
13
14
15
16
88
empioyed-Doctor, Lawyer,etc)
Pedagang Besar (dengan pegawai lebih dari 5 orang) Big Trader (with
more than 5 empioyees)
Pedagang Kecil (dengan pegawai 5 orang atau kurang) Smaii Trader

(with 5 or less employees)
Wiraswasta (pemilik salon, penjahir, dll) Entrepreneur (Hair beautician,

tailor, etc)
Buruh terlatih (Tukang batu, Tukang kayu) Skilled worker

Buruh kasar unskilled worker
Petani Fawner
Nelayan Fisherman
Pensiunan Retiree
Tidak bekerja Not working
Ibu Rumah Tangga Housewife
Lainnya (catat)/ others (specify)
Tidak Menjawab Refused
D3c. Apakah suami anda menerima gaji yang tetap setiap bulannya? do you get regular salary
for
each month?
Ya/ Yes
Tidak/ No
D4.
1
2
Pada USia berapakah anda menikah? how old were you when you got married?
ta h Un years old
D5.
Dapatkah anda membaca surat atau koran dengan lancar,atau tidak iancar atau tidak
bisa membaca sama sekali? can you read a letter ornewspaper easily, or with difficulty, or can not
read at all?
D6
D7.
Dapat membaca dengan Iancar can read easily

Dapat membaca tapi tidak Iancar can read but with difficulty
Tidak dapat membaca sama sekali can not read at an
1
2
3
Cendaraan apa yang Anda miliki? what vehicle do you have?

Mobil/cs/Motor/ motordde
Tidak satupun None
Lainnya catat 1others fsoeciiv)
1
2
3
Berasal dari suku makah anda? which ethnic group do you beiong?
169
Jawa
Sunda
Batak
Minang
Banjar (Kalsel)
Dayak
Bugis
1
2
3
4
5
6
7
Manado
Irian
Ambon
Keturunan Cina
Keturunan India
Keturunan Arab
Lainnya catat: others specify
8
9
10
11
12
13
14
Makasar
D8.
Agama/kepercayaan apakah yang anda anut? what is your reiigion/beiief?

Islam
Katolik
Kristen
Protesta n
-
1
2
3
Hindu
Budha
Kong Hu Cu
5
6
7
Lainnya ca tat: others specify
INTERVIEWER
Interviewers name;
Interviewer N : |
|_
INTERVIEW BERAKHIR PUKUL
ISI SEMUA 6 KOTAK
PUKUL MENIT
HARI
TAHUN
Termasuk nol. Semua
dilengkapi
BULAN
Tanggal
Saya menjamin bahwa apa yang telah saya lakukan adalah interview yang lengkap dan
akurat, dilakukan sesuai dengan instruksi kepada saya dan ICC/ESOMAR International
Code.
Tanda tangan interviewer______________
170
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191
CORINNE L. SHEFNER-ROGERS
13732 Apache Plume Place, Albuquerque, NM 87111
Phone: 505-797-0492; cshefher@jhsph.edu
Corinne L. Shefiier-Rogers is an Adjunct Professor in the Masters o f Public Health Program at the
University o f New Mexico. She also works as an independent health communication consultant based in
Albuquerque, New Mexico. She specializes in designing and implementing preventive health communication
programs, including the development o f entertainment-education programs with messages about health issues
for radio and television, mass communication campaign materials, and training curricula for health care
providers and outreach workers. Shefner-Rogers is a former Program Officer for the Johns Hopkins
University Population Communication Services (JHU/PCS), where she developed and managed family
planning promotion campaigns in African nations and in Haiti. She has studied the impact o f entertainmenteducation programs on the adoption o f family platming in African nations, and the process by which
Hollywood lobbyists insert their messages about certain pro-social issues into television programs. She has
collaborated with scholars in India on a women's empowerment project for the National Dairy Development
Board, and with colleagues in Indonesia in designing and implementing a maternal and neonatal health study.
EDUCATION
Ph.D. ~ Public Health Candidate
Department o f Population and Family Health Sciences, Bloomberg School o f Public Health Johns
Hopkins University - Baltimore, MD
Graduate Certificate in Health Communication - May, 2000
Department o f Population and Family Health Sciences, School of Hygiene and Public Health - Johns
Hopkins University Baltimore, MD
M.A. Communication Management May 1991, with Distinction
Annenberg School for Communication - University o f Southern California
Honors - Phi Kappa Phi; Academic Achievement Award for International Students and Scholars
B.A. - Anthropology 1987, with Distinction
McGill University Montreal, Quebec
EXPERIENCE
INDEPENDENT COMMUNICATION CONSULTANT, Albuquerque, NM, 1994-present.
Provide health/development communication consulting services, including needs assessments, media materials
development, and technical writing, to such entities as the State o f New Mexico Department o f Health, the
Bernalillo County Environmental Health Department, Planned Parenthood o f New Mexico, Population
Environment Network, Mental Health Center o f Boulder Colorado, The World Psychiatric Association, The
Johns Hopkins University/Population Communication Services, and the National Dairy Development Board of
India.
ADJUNCT PROFESSOR AND RESEARCH ASSOCIATE
University o f New Mexico. Communication and Journalism. Albuquerque, NM, 1996 - present.
Teach a mixed undergreiduate- and graduate-level course in H ea lth C o m m u n icatio n , an d c o llab o rate w ith
faculty members on funded research projects.
University o f New Mexico. Public Health Program. School o f Medicine. Albuquerque, NM, 2001-present.
Teach graduate-level courses in International Health, Community Health Intervention Models, and Program
Evaluation.
192
ASSOCIATE FACULTY
The Intercultural Communication Institute. Portland, OR, July, 1996 and July, 1997.
Co-teach a week-long workshop entitled Healthcare Communication Across Cultures for trainers and
professionals who wish to understand how cultural sensitivity affects the effectiveness o f preventive health
communication programs.
PROGRAM OFFICER
Johns Hopkins Universitv/Population Communication Services. Africa Division. Baltimore. MD. 1991 - 1994.
Responsible for conducting needs assessments and project design; research and draft special technical reports;
draft proposals, contracts, and budgets for regional/country projects in Africa; review project progress and
financial reports and draft response letters (in French and/or English); travel to Africa and the Caribbean to
provide technical assistance for project activities (countries include Ivory Coast, The Gambia, Kenya,
Zimbabwe and Haiti); manage project activities in Burkina Faso, Madagascar, and Mali from Baltimore; brief
U.S. Government Officials on JHU/PCS activities; plan and coordinate French Health Communication
Workshop, English Materials Development Workshop and a Radio Drama Conference in Africa.
TEACHING ASSISTANT
Annenberg School for Communication. Los Angeles, CA, 19 9 1.
Planned and delivered class lectures; provided stimulating workshop materials; coordinated materials with the
professor as well as with other teaching assistants; evaluated students (did all grading); counseled students.
CONSULTANCIES
January - September, 2001. Johns Hopkins University, Center for Communication Programs. Developed
baseline quantitative survey instruments for a large-scale evaluation about birth preparedness/maternal and
neonatal health (MNH) in Indonesia. Developed quantitative survey instruments for a network analysis study
about birth preparedness in three districts in Indonesia. Solved data collection/entry issues and reviewed
research reports. Traveled to Jakarta, Indonesia to provide technical assistance to the research firm hired to
conduct these two field studies. Conducted preliminary data analysis for the MNH baseline quantitative survey
and the MNH Ethnographic/Social network study.
April - September, 1999. University o f New Mexico, Office o f Evaluation. Developed a knowledge, attitude,
and practice (KAP) survey instrument about child restraint use in New Mexico, and a protocol for
administering the instrument in New Mexico after September 30,1999.
December, 1998. Planned Parenthood o f New Mexico. Wrote a competitive grant proposal to the Border
AIDS Partnership for PPNM HIV Risk Reduction Education programs in Southern New Mexico (funding was
received by PPNM).
November, 1998. Planned Parenthood o f New Mexico. Wrote a competitive grant proposal for PPNM
sexuality education activities in New Mexico (funding was received by PPNM).
June, 1998. Planned Parenthood o f New Mexico. Wrote a statewide competitive grant proposal to the New
Mexico Department o f Health, Public Health Division to develop an Abstinence-Only Education Program in
response to Section 510 o f Title V o f the Social Security Act (funding was received by PPNM).
February - March, 1998. Lead Poison Prevention Program, State o f New Mexico Department of Health.
Collaborated with LPPP staff to write a grant proposal for a Childhood Blood Lead Surveillance Program to
the Centers for Disease Control and Prevention.
February, 1998. Planned Parenthood o f New Mexico. Wrote a statewide competitive grant proposal to the
193
New Mexico Department o f Education/Vocational-Technical and Adult Education, for Carl D. Perkins
Vocational and Applied Technology Education Grant funds to support Planned Parenthoods Male Educator
Program. The Male Educators provide youth and incarcerated males in New Mexico with the necessary skills
to plan their families, their academic future, and their career goals. ($76,710 was received June, 1998.)
September-November, 1997. Tactics! Marketing Consultants and Micro-Swiss Israel. Developed a
marketing survey questionnaire to determine the market segments for sintered blades in such countries as
Israel, Malaysia, and Singapore.
September - November, 1997. Lead Poison Prevention Program, State o f New Mexico Department o f Health.
Developed media materials, including flyers and information packets, about the Lead Hazard Act for New
Mexico State legislators.
March, 1997 - February, 1998. Environmental Protection Agency, Office o f Environmental Justice. Co
principal Investigator. Wrote grant and received funding (I) to conduct a community-based survey o f Kinney
Brick (an unincorporated district o f Bernalillo County, New Mexico) residents to determine their perceived
need for curb-side solid waste pick-up, ( 2 ) to design and implement a workshop to educate community leaders
about community empowerment, and (3) to assist the Kiimey Brick community association with producing a
monthly newsletter for residents.
March, 1997. Planned Parenthood o f New Mexico. Wrote a statewide competitive grant to the New Mexico
Department o f EducationAôcational-Technical and Adult Education, for Carl D. Perkins Vocational and
Applied Technology Education Grant fiinds to support Planned Parenthoods Male Educator Program. The
Male Educators provide youth and incarcerated males in New Mexico with the necessary skills to plan their
families, their academic future, and their career goals. ( Funding was received in July, 1997.)
January, 1997. Population Environment Network, New Mexico. Developed a proposal to address sexual
responsibility among adolescents in Albuquerque, New Mexico, utilizing radio spot advertising. Designed a
pre-/post-test questioimaire to evaluate the impact o f the radio ads, analyzed the findings, and drafted a project
impact report.
December, 1996. Mental Health Center o f Boulder Colorado. Participated in developing an international
campaign to reduce the stigma associated with schizophrenia for the World Psychiatric Association.
September, 1996. Planned Parenthood o f New Mexico. Wrote a proposal to the New Mexico Department of
Health, Public Health Division, Maternal and Child Health Bureau, to receive funding to carry out family
planning educational activities, and clinical family planning services, in Santa Fe and Taos counties. (Funding
awarded to Planned Parenthood o f New Mexico in September, 1996.)
August, 1996-December, 1997. Bernalillo County Department o f Environmental Health. Phase II o f the
Environmental Health Department Promotion Project. Develop (I) a training program for BCEHD staff to
improve mediation, stress management, and team building skills, and ( 2 ) information, education, and
communication materials for three priority audiences: Environmental Health Department staff, realtors and
contractors, and Bernalillo County constituents. These materials will help to improve the effectiveness o f the
Department in communicating pertinent information and services about environmental health to its
constituents.
September, 1995-March, 1996. Bernalillo County Department o f Environmental Health. Phase 1 o f the
Environmental Health Department Promotion Project. Conduct a needs assessment to determine what types of
communication products and staff training should be developed to improve the effectiveness o f the Bernalillo
County Environmental Health Department in reaching its priority audiences with pertinent information and
services about environmental health.
August-December, 1995. The State o f New Mexico Department o f Health. Develop a Cancer Plan for the
194
State of New Mexico, to improve coordination of, and collaboration among, cancer programs throughout the
state.
June/July, 1995. Johns Hopkins University/Population Communication Services. Collaborate with
Zimbabwean colleagues and with JHU/PCS Africa Division staff to frnalize two project proposals for the
Zimbabwe National Family Planning Council in Zimbabwe, Africa; (1) the Male Motivation Expansion and
Promotion o f Long-term and Permanent Contraceptive Methods, and (2) the Zimbabwe Adolescent Pilot
Project.
April, 1995. Johns Hopkins University/Population Communication Services. Develop two project proposals
for new JHU/PCS projects with the Zimbabwe National Family Planning Council in Zimbabwe, Africa: (1)
the Male Motivation Expansion and Promotion o f Long-term and Permanent Contraceptive Methods, and (2)
the Youth Sexual Responsibility Promotion Project.
March, 1995. The State o f New Mexico Department o f Health. Design a state-wide project for breast and
cervical cancer prevention.
February, 1995. The University o f New Mexico. Research study on Native American womens perceived
medical barriers to breast and cervical cancer screening.
December, 1992; June, 1993; June, 1994. The National Dairy Development Board, India. Develop message
materials for Cooperative Development (CD) field-workers, including a training module for teaching CD
workers in ( 1) how to use message materials and ( 2 ) how to conduct participatory education programs.
SKILLS
Teaching; training; proposal writing; project design; project management; conducting needs assessments;
materials development; formative, process, and impact evaluations (including focus group discussion, in-depth
interviewing, observation, and pretesting); data analysis; report writing.
LANGUAGES AND TECHNICAL SKILLS
Fluent in French; Basic Spanish.
Skilled in Word, STATA, SPSS, Powerpoint, UCINet, Krakplot, Amos 5.
SELECTED PUBLICATIONS/PRESENTATIONS
Shefrier-Rogers, C.L. and Suruchi Sood (in press). Involving husbands in safe motherhood: Effects of the
Suami SIAGA campaign in Indonesia. Journal o f Health Communication.
Shefner-Rogers, C.L. and Everett M. Rogers (November, 2002). Cultural factors in the patient-provider
relationship. Paper presented to the Health Communication Division, National Communication Association,
New Orleans, LA.
Shefner-Rogers, C.L (July, 2002). Involving husbands in safe-motherhood: Effects o f the Suami SIAGA
campaign in Indonesia. Top Student Paper presented to the Health Communication Division, International
C o m m u n icatio n A sso ciatio n C o n feren ce, S eoul, South K orea.
Papa, Michael, Arvind Singhal, Sweety Law, Suruchi Sood, Everett M. Rogers, and Corinne Shefner-Rogers
(1999). Entertainment-Education and Social Change: Parasocial Interaction, Social Learning, and
Paradoxical Communication. Journal o f Communication, 50(4):31-55; Top Paper Award in the
Development Communication Division, International Communication Association, Jerusalem, Israel (July,
1998).
195
Rogers, Everett M. and Corinne L. Shefner-Rogers (1998). Dififusion of Innovations and HIV/AIDS
Prevention Research, in William N. Elwood (ed.). Power in the Blood: AIDS, Politics, and Communication,
pp. 401-410. Mahwah, NJ: Lawrence Erlbaum Associates.
Shefiier-Rogers, Corinne L., Nagesh Rao, Everett M. Rogers, and Arun Wayangankar (August, 1998).
"Communication and Empowerment: Women Dairy Farmers in India." Journal o f Applied Communication
Research, 26 (3), 319-337.
Shefiier-Rogers, Corinne L., Everett M. Rogers, and Arvind Singhal (1998). "Parasocial Interaction and the
Television Soap Operas "Simplemente Maria" and "Oshin": Implications for Entertainment-Education
Television Soap Operas." Keio Communication Review, 20:3-18.
Svenkerud, Peer J., Corinne Shefiier-Rogers, Everett M. Rogers, Arvind Singhal, and Nagesh Rao (October,
1997). Communication as a Cause and a Cure o f Alcoholism, in Developing Countries." Paper presented to
the National Communication Association, Chicago, IE.
Shefiier-Rogers, Corinne L. and Everett M. Rogers (May, 1997). Evolution o f the Entertainment-Education
Strategy: The Importance o f Peer Communication and Improved Evaluation Research Methods. Paper
presented to the Second International Conference on Entertainment-Education and Social Change, Athens, OH.
Rogers, Everett M., Peter Vaughn, and Corinne L. Shefiier-Rogers (May, 1995). "Evaluating the Effects o f An
Entertainment-Education Radio Soap Opera in Tanzania: A Field Experiment with Multi-Method
Measurement." Paper presented to the International Communication Association, Albuquerque, NM.
Rogers, Everett M. and Corinne L. Shefiier-Rogers (February, 1994). "A History o f the EntertainmentEducation Strategy." Papaer presented to the Centers for Disease Control and Prevention's Conference on
Using Entertainment-Education to Reach a Generation at Risk, Atlanta, GA.
Wayangankar, Arun, Everett M. Rogers, Nagesh Rao, Corinne L. Shefiier-Rogers (1994). "Empowering
Indian Women Dairy Farmers: The Cooperative Development Programme o f the National Dairy
Development Board (NDDB)," Journal o f Rural Reconstruction, 28(l):29-40.
Kim, Young Mi, Margaret Thuo, Dan Odallo, Shanyasi Khasiani, Ian Tweedie, Cheryl Lettenmaier and
Corinne L. Shefiier (November, 1994). "Impact o f Counseling and Quality o f Care on Client Behavior in
Kenya: Experience with Pills and Injectables Users." Paper presented at the 122nd Annual Meeting o f the
American Public Health Association, Washington, DC.
Shefiier, Corinne L., Thomas W. Valente and Thierry Bardini (May, 1993). "Fakube Jara Says EntertainmentEducation Works: Using Radio Drama to Promote Family Planning in The Gambia." Paper presented to the
International Communication Association, Washington, DC, 1993.
M a rc h , 2 0 0 4
196

Pregnancy Knowledge, Attitudes, and Practices in

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PREGNANCY KNOWLEDGE, ATTITUDES, AND PRACTICES IN

INDONESIA: DOES HUSBANDS SOCIAL SUPPORT MAKE A DIFFERENCE?

A dissertation submitted to The Johns Hopkins University in conformity with the

Corinne L. Shefiier-Rogers 2004

UMI Number: 3130787

All rights reserved.

ProQuest Information and Learning Company

In Indonesia, women are dying from pregnancy-related complications and

for her flexibility and infectious positive attitude.

Table 1.1 Maternal Health Indicators for Indonesia..................................................... 5

Table 5.5. Percentage Distribution of Women Respondents Knowledge about

Table 5.6. Model Summary for Standard Multiple Regression of Womens

Knowledge about Pregnancy Danger Signs by Husbands Instrumental

Figure 3.1. The Three Delays M odel.............................................................................47

Giving birth is an important public health concern in Indonesia. The majority of

Causes of Maternal Mortality in Indonesia

Maternal mortality is the death of a woman while pregnant or within 42 days of

and others (2002) estimated that economic constraints contributed to 37 percent of

Table 1.1 shows selected indicators of maternal health in Indonesia. These

Table 1.1 Maternal Health Indicators for Indonesia.

' World Health Organization (2001b).

Social Status and Maternal Health in Indonesia

normally spend on food to pay for pregnancy-related religious ceremonies and

Maternal mortality prevention programs in developing nations are largely based

The Mother Friendly Movement in Indonesia

High maternal mortality levels reflect a poor healthcare system, inappropriate

woman experiences a complication that requires her to be transferred to a better-equipped

In 1996, a pilot project was launched in eight of Indonesias 27 provinces,

Behavior Change Intervention (BCI), The BCI component is part of an integrated

To date, the focus of maternal mortality prevention interventions in developing

There is no clear conceptual framework that illustrates how interventions to

Hypothesis # la : High levels of husbands informational support^^ during

The concept o f informational support is explained in Chapter 2.

3. Intimate Interaction: Providing non-directive counseling such as listening,

interviewed using a questionnaire that included items measuring the psychosocial

Table 2.1 Types of Social Support Studied by Researchers luvestigating the

Measuring Social Support

There is a great diversity of operational definitions of social support (Gottlieb,

There is accumulating evidence in developed countries that social support

A paucity of information exists about the role of social support on mothers

The present chapter summarized definitions of social support. In general, social

We reviewed the literature on social support as it relates to maternal health.

Socioeconomic and cultural

Figure 3.1. The Three Delays Model.

Actual AccessibUitv of Facilities

Actual Oualitv of Care

Distribution and location

Poorly staffed facilities

Poorly equipped facilities

The proposed model is grounded in two theoretical assumptions: (1) individuals

A central construct in the model of bounded rationality is limited search.

The use of skilled healthcare providers in Indonesian villages has increased

delivery, among Indonesian women of reproductive age. The ICPD (International

Hypothesis la suggests that the more informational support a woman receives

Information provided by a husband can have a positive or negative impact on a pregnant

The proposed study will determine the relationship between

In this chapter we presented the conceptual framework, proposed model, and

The present investigation is a cross-sectional study of women of reproductive age

Figure 4.1. Map of Study Districts in West Java, Indonesia.

A quantitative population-based survey (the Maternal and Neonatal Health

A core baseline questionnaire was developed by JHU/CCP in collaboration with

Item (Danger Sign)

H igh blood pressure