Accuracy of Antenatal Visits in West Java Province: Comparison between Rural and Urban Areas Data Analysis of the Indonesian Demographic and Health Survey 2017

Accuracy of antenatal visits plays a crucial role in reducing the risk of maternal death during pregnancy. West Java is a province in Indonesia that has the highest maternal mortality cases. An analysis of the accuracy of antenatal visits using a spatial approach, involving the distribution of villages and cities, was conducted to understand the interaction between humans and the environment, both physically and socially. This study aims to determine the differences in the accuracy of antenatal visits based on residential status in West Java Province in 2017. The research conducted is quantitative research using secondary data from the Indonesian Demographic and Health Survey (IDHS) 2017. The data used includes the number of pregnant women who received antenatal visits in urban and rural areas. The analysis was done by comparing rural and urban areas using the Chi-Square test. The results of the study indicate that there are differences in the accuracy of antenatal visits between rural and urban areas, with a p-value of 0.000 (less than 0.005, which means there is a difference).


Introduction
The maternal mortality ratio (MMR), commonly known as the maternal mortality ratio, which represents the number of maternal deaths per 100,000 live births, is the indicator used for maternal mortality [1].The World Health Organization (WHO) reported that the global MMR in 2017 was 211/100,000 live births.The MMR in low-income countries was 40 times higher compared to high-income countries, with a rate of 462/100,000 live births, while the MMR in high-income countries was only 11/100,000 live births [2].
The disparity between the rich and the poor is highlighted by certain regions of the world having high maternal mortality rates, which are a reflection of unequal access to high-quality healthcare.The World Health Organization (WHO) estimates that per day in 2017 there were about 810 deaths of women associated to pregnancy and delivery.This circumstance has compelled numerous nations to work together to address maternal health challenges, including listing maternal health as one of the Sustainable Development Goals (SDGs) priorities.With the first goal being to lower the maternal death ratio to fewer than 70/100,000 live births, Goal 3 of the SDGs for 2030 seeks to ensure healthy lives and promote wellbeing for everyone.
Development of the Maternal Mortality Ratio (MMR) in Indonesia throughout the years has experienced both increases and decreases.According to the health profile data released by the Ministry of Health of the Republic of Indonesia in 2020, there was a downward trend from 390 in 1991 to 228 in 2007.However, an upward trend occurred from 2008 to 2012, reaching  The Maternal Mortality Ratio (MMR) in Indonesia is also relatively high compared to other ASEAN countries.The average MMR in several ASEAN countries ranges from 40 to 60 per 100,000 live births.According to World Bank data from 2017, the MMR in Indonesia reached 177 per 100,000 live births.This data is significantly different when compared to Singapore, which has achieved an MMR of 8 per 100,000 live births, and Malaysia with an MMR of 29 per 100,000 live births in the same year [2].World Bank, an international institution providing the largest source of funding and knowledge to developing countries, aims to reduce poverty, improve shared prosperity, and promote sustainable development.They have collected data on Maternal Mortality Ratio (MMR) in Southeast Asian countries (Figure 2).The data shows that Indonesia ranks third among countries with the highest MMR, following Myanmar and Laos.
In Indonesia itself, according to the Routine Report on Maternal Health Programs in 2013 received from the Provincial Health Office, West Java had the highest number of MMR cases [3].The report states that around 765 maternal deaths occurred in West Java out of a total of 5,019 cases in Indonesia.Data from the Ministry of Health of the Republic of Indonesia also indicates a similar pattern, with West Java being among the top five provinces contributing to nearly 50 percent of the total maternal deaths in Indonesia in 2020 (Figure 3).There are both direct and indirect causes of maternal mortality.Complications during pregnancy, labor, and the postpartum period are direct causes, while hereditary conditions or illnesses that raise the risk of maternal death are indirect causes.According to the publication "Health Profile 2017" issued by the West Java Provincial Health Office (2018), maternal deaths during childbirth accounted for 60.87%, postpartum deaths for 30.43%, and deaths during pregnancy for 8.70% [4].Maternal deaths caused by complications in West Java amounted to 283 cases, accounting for approximately 18.4% of the total maternal deaths.This finding is consistent with the study conducted by Fatbinan, which identified maternal age, parity, residential area, and pregnancy complications as risk factors for maternal mortality [5].The government works to reduce and minimize complications during pregnancy, labor, and the postpartum period, notably through Antenatal Care (ANC), as the majority of high maternal mortality cases are caused by complications.
Pregnant women may receive antenatal care (ANC), which is a type of examination that includes checks on the mother's and the fetus's health in accordance with established service standards and performed by qualified healthcare workers, including general practitioners, obstetricians, midwives, and nurses.[6].ANC emphasizes the value of efficient communication when it comes to topics including physiology, biomedicine, society, culture, and social, emotional, and psychological support.[7].Complete adherence to prenatal care can lower the risk of maternal death, according to research done by Nurdin et al.Because pregnant women can identify difficulties early, adequate prenatal checks can reduce the chance of maternal death [8].
Antenatal care seeks to increase physical well-being, ensure the health of the mother and the baby during the pregnancy, prepare for a safe birth, and get the mother ready for the postpartum period.The quality of antenatal care can be assessed through the coverage of the first visit (K1) and the coverage of at least four antenatal visits (K4).The standards for antenatal visits in Indonesia have undergone changes.According to Ministerial Regulation No. 4 of 2019, antenatal visits should be conducted at least four times: once in the first trimester, once in the second trimester, and twice in the third trimester.However, in 2021, this was changed again through Ministerial Regulation No. 21 of 2021 to a minimum of six visits.In contrast, the World Health Organization (WHO) has its own recommendation regarding the minimum number of antenatal visits, with a recommended minimum of eight visits to minimize the risk of maternal mortality.An insufficient number of prenatal visits can result in ignorance of the pregnancy's status, increasing the risk of obstetric difficulties that could jeopardize both the mother and the fetus and result in high death rates [9].
According to WHO data from 2017 (Figure 4), the coverage of the first antenatal care visit (K1) in Indonesia in 2017 had reached 98%, but the coverage of at least four antenatal visits (K4) was only 77%.These results still lag compared to other Southeast Asian countries such as the Philippines (87%), Malaysia (97%), Thailand (90%), and Vietnam (88%).In 2012, the percentage of K4 coverage in Indonesia had reached 88%, which was the highest during the period from 2003 to 2017.However, this value was still lower compared to Thailand, which had already reached 91% for K4 coverage in 2012.Despite significant progress in increasing access to prenatal care, Southeast Asia's thirdhighest maternal death rate still exists in Indonesia.This variation may be due to a number of other variables, most notably the uneven distribution of accurate prenatal care visits across rural and urban areas.Concerns are raised regarding a possible gap in the accuracy of antenatal care visits between rural and urban areas in West Java because the same problem also exists there.In Indonesia, West Java Province has the highest rate of maternal mortality.

Methods
This study is quantitative in nature.The secondary data utilized were taken from the 2017 Indonesia Demographic and Health Survey (IDHS), which may be accessed from the DHS's official website at https://dhsprogram.com/.The National Population and Family Planning Board (BKKBN), the Central Bureau of Statistics (BPS), and the Ministry of Health worked together to conduct the survey.The United States Agency for International Development (USAID), which spearheaded the global Demographic and Health Survey (DHS) initiative, includes the IDHS as a component and offers financial and technical support for its execution [11].
Most nations strive to gather and publish statistics down to smaller administrative regions at the national level.Therefore, each location needs a minimum sample size.The survey sample is presented at the national and provincial levels, as well as urban and rural areas, in the 2017 Indonesian Demographic and Health Survey (IDHS) [12].The proportion of female respondents in each province must match the total sample size in order to get numbers that are both national and provincially representative.Consequently, there is a chance that the sample of women may not be big enough for study if a province has a tiny population.Oversampling is one approach to solving this problem in areas with limited populations.
The SPSS statistical analysis program (IBM SPSS Statistics 25) was used to process the data.Sorting the data according to the research site was the first stage.The "Individual Recode" dataset from the 2017 IDHS was the source of the raw data that was utilised.With 327 pregnant women in rural areas and 1,196 pregnant women in urban areas, the data sorting process produced a sample of 1,523 pregnant women in the West Java Province.However, after applying weighted data, a total sample size of 2,975 samples-including 979 samples from rural areas and 1,996 samples from urban areas-was achieved.
Data from respondents who were expecting mothers in the province of West Java were used in this study.The sample was created to be representative of women in the country between the ages of 15 and 49.This study also took rural versus urban residency status into account.
Inferential statistical tests are used for comparative analysis and quantitative descriptive analysis of the data in this study.Cross-tabulation is used in the descriptive analysis whereas the Chi-Square test is used in the comparison analysis.With variables structured as columns and rows in a table format, the cross-tabulation results are displayed.According to the place of residency, this cross-tabulation includes the absolute values (frequencies) and relative values (percentages) of adherence to antenatal care appointments.
The independent samples Chi-Square test is the comparative analysis technique used in this study.There is no correlation between the samples' rural and urban composition, hence they are regarded as independent.Because the data are of nominal scale and the sample size is big, the Chi-Square test for independence was chosen as the analytical tool [13].The Chi-Square test for independence is a hypothesis test.In hypothesis testing, there are two types of hypotheses used: the null hypothesis (H0) and the alternative hypothesis (H1) [14].

Results
Chi-square test was conducted between the variables of adherence to antenatal care visits and the place of residence.The results of the chi-square test analysis in this study can be seen in the data table 1 below.Table 1 shows the data of pregnant women who had accurate and inaccurate antenatal visits in rural and urban areas of West Java.In this study, the categories of accurate and inaccurate visits are based on the recommendations by WHO, where pregnant women who had a minimum of 8 antenatal visits are considered to have accurate visits, while those with fewer than 8 visits are considered inaccurate.
Most pregnant women in West Java, both in rural and urban areas, had accurate antenatal visits.This means that most pregnant women had at least eight antenatal visits.Based on Table 1, the percentage of pregnant women with accurate antenatal visits was 79.81% in urban areas and 64.25% in rural areas.
The percentage of pregnant women with accurate antenatal visits was higher in urban areas compared to rural areas.Based on the Chi-Square test results, a p-value of 0.000 (p≤0.05) was obtained.This indicates that there is a significant difference in the accuracy of antenatal visits between rural and urban areas of West Java in 2017.Therefore, the hypothesis of this study is accepted as the test results show a significant value.

Discussion
Knowing about each pregnant woman's antenatal visits is crucial to reducing hazards to the mother during pregnancy and ensuring the health of both the mother and the fetus [15].In West Java, there may be a difference in the accuracy of prenatal visits between rural and urban areas based on where people live.Contrary to pregnant women in rural regions, the majority of pregnant women in metropolitan areas attend antenatal appointments more frequently [16].In addition, compared to women in rural regions, a higher percentage of urban-dwelling women finish their antenatal consultations [17].However, the risk of maternal death can be decreased if expectant mothers adhere to complete prenatal care at a high rate [8].
Urban and rural places differ from one another in numerous ways, both qualitatively and statistically, including the features of pregnant women and their homes as well as the overall backdrop of both.The usage of Antenatal care (ANC) can vary depending on all of these individual and regional variables [18].
Rural pregnant women are more likely to skip ANC consultations and less likely to receive at least four ANC appointments [19].The underuse of ANC services is caused by the difference in places of living.Contrary to pregnant women in rural areas, pregnant women in metropolitan areas typically have better access to healthcare facilities and medical resources.This may cause the two groups to have antenatal visits that are not as thorough as one another.Different regional differences in socio-demographic factors like employment, education, and access to healthcare facilities may be responsible for variations in the underutilization of ANC services [20].
Pregnant women in metropolitan regions typically view prenatal care more favorably than those in rural ones [21].Pregnant women in rural regions may delay ANC consultations because they are unaware of the value of early ANC utilization [18].Pregnant women who are educated have a higher degree of awareness and are better able to make responsible decisions about their health, which can lead to a higher use of healthcare services like ANC [22].Pregnant women who are educated also have better access to information about contemporary health issues and a better grasp of particular disorders associated with pregnancy.
Regarding employment, working pregnant women tend to have regular ANC visits [23].Pregnant women who work have greater knowledge than pregnant women who do not because they have more opportunity to engage with others and learn about their medical conditions [24].Having a work also increases financial resources, which makes it easier to acquire healthcare, especially antenatal care [25].
Generally speaking, healthcare facilities and services are less accessible in rural areas.Other variables that lead to the underutilization of maternal services, such as antenatal care, in rural areas include traditional beliefs, inadequate healthcare facilities, and low socioeconomic conditions.According to several studies, pregnant women who live in cities have easier access to healthcare facilities than those who do not.[26], [27].The imbalance of development between rural and urban areas can be used to explain the discrepancy between pregnant women in urban and rural locations in terms of the accuracy of antenatal visits.Compared to urban regions, rural areas generally experience slower development, particularly in Indonesia.This tendency extends to the healthcare sector.This can be because urban areas have a denser population than rural areas due to the size difference between the two.Accessibility for the populace may be problematic due to the absence of healthcare facility development in rural areas.A key element that permits and promotes healthcare services is easy accessibility [28].With good accessibility, pregnant women can maximize the utilization of ANC services.

Conclusion
The location of residency and the accuracy of prenatal visits are significantly correlated.This indicates that antenatal visits in rural and urban areas varied significantly in terms of accuracy.A p-value of 0.000 (p≤0.05)demonstrating a substantial correlation between the accuracy of antenatal visits and residence supports this finding.In comparison to rural areas, the proportion of pregnant women who obtain accurate antenatal care is higher in metropolitan areas.Pregnant women in urban regions typically have better access to medical resources, educational opportunities, and healthcare facilities than pregnant women in rural areas.This may be a factor in the two groups' prenatal visits being less thorough than one another.

Suggestion
The government of West Java Province needs to enhance awareness and education about the importance of complete antenatal visits in accordance with the recommendations of the government and the World Health Organization (WHO).This is especially crucial in rural areas where the percentage of accurate antenatal visits is still low.
Additionally, improving access to healthcare services, providing training and enhancing the competency of healthcare workers, strengthening monitoring and supervision systems, and collaborating with relevant community or non-governmental organizations related to the accuracy of antenatal visits should be maximized.Moreover, the government should invest in adequate healthcare infrastructure development in rural areas, including the establishment of health centers, clinics, or village health units equipped with essential equipment and facilities to provide antenatal care.It is important to increase the availability of healthcare professionals in villages by ensuring the presence of doctors, midwives, and other trained medical personnel in remote areas.Launching focused health education campaigns on antenatal care in villages is also necessary, providing accurate information to rural communities about the importance of IOP Publishing doi:10.1088/1755-1315/1313/1/0120388 antenatal visits, signs of danger during pregnancy, and measures to maintain the health of mothers and infants.
Improving transportation accessibility to healthcare facilities in villages, such as improving road networks, providing transportation subsidies, or supplying mobile health units to assist pregnant women in hard-to-reach areas, is essential.Regular monitoring and evaluation of antenatal healthcare services in both rural and urban areas should also be conducted.
By taking these steps, the government can help reduce disparities between antenatal visits in rural and urban areas, ensuring that pregnant women in rural areas receive comprehensive and quality care.For further research, it is recommended for other researchers to conduct studies using primary data and analyze other factors influencing the accuracy of antenatal visits conducted by pregnant women.

Ackhnowledgement
The author would like to express gratitude to several parties who have assisted in the completion of this research.Appreciation is extended to the National Population and Family Planning Agency, the Indonesian Central Bureau of Statistics, the West Java Provincial Central Bureau of Statistics, the Government of West Java Province, and the Ministry of Health of the Republic of Indonesia for providing the data used in this study.

Figure 1 .
Figure 1.The development of MMR (Maternal Mortality Ratio) (per 100,000 live births) in Indonesia.

Figure 2 .
Figure 2. Distribution of Maternal Mortality Ratio in Southeast Asian Countries in 2017.

Figure 3 .
Figure 3.The Five Provinces with the Highest Number of Maternal Deaths in Indonesia in 2020.

Figure 4 .
Figure 4. Percentage of Coverage of Antenatal Care K4 Visits in Southeast Asia According to the Indonesian Health Profile of 2018 (Figure 5), the coverage of Antenatal Care K4 in Indonesia over a period of 10 years (2008-2017) experienced both increases and decreases each year, with the highest percentage recorded in 2012 at 90.18% and the lowest in 2009 at 84.54%.For the year 2017, the coverage stood at 87.3%.The adequacy of antenatal care visits can be deemed satisfactory when it reaches the target set by the Ministry of Health.Based on the Strategic Plan (Renstra) for the years 2015-2019 issued by the Ministry of Health, the target for the coverage of K4 antenatal care visits in 2017 was set at 76%.Therefore, it can be concluded that the achievement of K4 antenatal care visits in Indonesia in 2017 has met the target.

Figure 5 .
Figure 5.The Coverage Percentage of K4 Visits in Indonesia from 2008 to 2017

Table 1 .
Accuracy of Antenatal Visits by Residential Status in West Java Province in 2017.