Background: Indonesia has implemented several maternal health programs aiming to improve access to maternal healthcare:1) the Village Midwives, 2) the Alert Campaign, and 3) the Social Health Insurance (SHI) Program. However, differences in maternal healthcare utilization by family wealth and region persist. This dissertation’s aims address: 1) the progress in skilled delivery in relation to the initiation of maternal health programs; 2) the progress in antenatal care (ANC) in relation to the initiation of the SHI; and 3) the contribution of select socio-demographic factors in the gaps of skilled delivery utilization in Indonesia.Methods: Data from the Indonesian Demographic and Health Survey (IDHS), obtained from repeated cross-sectional surveys with multistage sampling, were analyzed. For the first aim, six rounds of IDHS data were used (n=105,176 live births from 84,022 women who gave birth in 1986-2012). For the second aim three rounds of IDHS data were used (n=36,598 live births and women who gave birth in 2001-2012). For the third aim the IDHS 2012 was used (n=16,083 live births from 14,013 women). We considered several socio-demographic factors that might influence maternal healthcare utilization in our analyses. Segmented logistic regression analyses using STATA survey (svy) were conducted to assess progress in skilled delivery and ANC. The regression-based decomposition method using STATA mvdcmp was used to identify the contribution of each factor in the gap of skilled facility delivery (SFD) utilization by family wealth. Results: Following the Village Midwife Program, there was a significant yearly increase in skilled birth attendance (SBA), aOR per year= 1.12, (95%CI 1.08-1.15), but not in SFD. There also were significant yearly increases in SBA and SFD after SHI initiation. The increasing trends of SFD following SHI were more evident among women of low socioeconomic status (SES) and women living in Java Bali. We also observed increasing yearly trends of ANC 4 visits utilization after SHI implementation, aOR per year =1.11 (95%CI 1.01, 1.21), but not in ANC 8 visits. However, the trends were not significantly different from the trends that predated SHI initiation. After 2008, there were decreasing trends of ANC 4 visits across family wealth and regions, which might be caused by data artifact or real events. In the decomposition analyses, approximately 69.7% of the SFD gaps by family wealth in Java Bali, 61.6% in the more populated other islands, and 54.6% in the less populated other islands could be attributed to the differences in characteristics. The decomposition methods classify the contribution of differences in characteristics (i.e. different distribution of characteristics) and differential effect/responses by groups. Across all regions, the predominant contributors to the gap in SFD utilization were differences in the distribution of education level, area of residence, and parity between the lower and higher family wealth quintiles. Meanwhile, the most predominant factor in differential effect across the three regions is unmeasured factors. Conclusions: There were positive changes in the progress of skilled delivery and antenatal care after the initiation of maternal health programs in Indonesia. Differences in maternal characteristics between the lower and higher family wealth groups in Indonesia were the main contributors to the persisting differences by family wealth in skilled facility delivery. These findings can be the basis for designing specific and targeted programs to improve maternal healthcare utilization across different family wealth groups and regions in Indonesia.
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