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College of Nursing and Health Sciences, Flinders University, AustraliaSchool of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Australia
High infant mortality remains a global health problem, particularly in less developed countries. Indonesia has one of the highest infant mortality rates in Southeast Asia. Known factors relate to documented medical conditions and do not necessarily explain their origin.
Aim
To identify and explore factors that contribute to infant mortality in Papua, Indonesia, through the lens of health workers’ perceptions.
Methods
A qualitative descriptive approach using semi-structured interviews was used. Twelve Indonesian health workers participated. Interviews were audio-recorded and transcribed, and then analysed thematically.
Findings
Five main themes were generated: beliefs and practices related to pregnancy, birth, and infants; infant health factors; maternal health factors; barriers to seeking, receiving and providing infant health care; and enablers and strategies for improving infant health.
Discussion
Cultural factors were perceived as contributing to poor health outcomes by shaping decisions, help seeking behaviour and health care access. Poverty, health literacy, road access and transport, shortage of health staffing, and health equipment and medicines exacerbate poor health outcomes.
Conclusion
Cultural knowledge and sensitivity are central to the provision and acceptance of health care by local families in Papua, Indonesia. Recommendations include: improving cultural sensitivity and cultural safety of service; implementing community health promotion to enhance maternal and infant health; improving community participation in health care planning and delivery; and enhancing collaboration between national, provincial, regency and local governments.
Indonesia has a high infant mortality rate, and the province of Papua has one of the highest in the country. The reasons for the high infant mortality rates are poorly understood.
What is already known
Factors contributing to infant mortality are varied and unique. In Indonesia, prematurity and low birth weight, birth asphyxia, birth trauma, and congenital anomalies are the main direct causes known of infant mortality. However, contributing factors to these causes of death are poorly understood.
What this paper adds
This study shows it is essential to promote health worker cultural sensitivity and respect for, and partnership with local people, shamans, and tribal leaders to achieve health service objectives, and to reduce infant morbidity and mortality.
1. Introduction
Significant progress has been made in reducing infant mortality globally with a 54% decrease in the global infant mortality rate (IMR) from 61 per 1000 live births in 1994 to 28 in 2019 [
]. Most neonatal deaths occurring in the first 28 days of life (79%) are caused by complications related to preterm birth, intrapartum events such as birth asphyxia, or infections such as sepsis or pneumonia [
]. Factors that lead to infant death in less developed countries are rarely seen in high-income countries, and when those factors arise in developed countries, they do not usually end in death. Used as an indicator of a population’s health status, a high infant mortality rate may also reflect the effectiveness of the health system [
]. In 2019, the Indonesian IMR was 21 per 1000 live births, already achieving the Sustainable Development Goal (SDG) 3 of less than 25 infants per 1000 live births [
]. However, high rates of infant mortality remain an issue in the most disadvantaged regions. One such example is Papua Province, which had a high estimated IMR of 27 per 1000 live births in 2019 [
] found that in Ethiopia a lack of skilled health workers resulted in insufficient antenatal and postnatal care that contributed to neonatal mortality. A study in India concluded that socioeconomic and geographical factors play a pivotal role in infant mortality [
]. Similarly, a study conducted in Vietnam found that socio-economic status and access to skilled health care are factors contributing to inequality in infant mortality in some regions [
] also found that cost of treatment and location of patients contributed to the mortality of newborns with sepsis in Ghana. In Indonesia, Sethi et al. [
] found that a lack of maternal and newborn care guidelines for midwives and nurses may have contributed to the slower IMR reduction. Similarly, Muhidin et al. [
] found a lack of access to medical facilities, especially in rural communities, can be attributed for the high rates of infant mortality in Indonesia.
There is a lack of understanding about the determinants of health that contribute to infant mortality specific to Papua Province. In addition to those identified above, there may be other determinant factors specific to Papua, which may explain the high IMR. For example, Papua province has very high rates of malaria, with 86% of all of the national cases (250,644 cases) detected in Papua Province [
]. Papuan health workers are well positioned to provide insights from their lived professional experiences of the factors contributing to infant mortality in these communities. Keerom Regency is one of the most remote areas in Papua Province and covers an area of 8,390 km2, with a population of 59,723 and a population density of just 6 persons/km2 [
]. A map showing the location of Keerom Regency is shown in Fig. 1. The Keerom Health Department provides 1 hospital and 10 public health centres, with 21 doctors, 196 nurses and 80 midwives [
]. The health provider density of 3.80 doctors, nurses and midwives per 1000 population is well below the minimum of 4.45 per 1000 population recommended by the World Health Organization (WHO) [
A qualitative descriptive approach was used to identify and explore health workers’ perceptions of factors that contribute to infant mortality in Papua. Qualitative description relies on the participants’ perspectives or perceptions rather than on theory. Purposive sampling was adopted with the intention of selecting participants prepared to share experiences of caring for infants in community health centres in Papua. Ethics approval was obtained from the University Human Research Ethics Committee (number 7897). Participant recruitment was undertaken through flyers displayed on notice boards in all community health centres in Keerom Regency, Papua Province, Indonesia. Health workers who were interested in participating in this study contacted the researcher directly. This region was selected because it is a region of high IMR (30/1000) [
]. A letter of permission to recruit from these locations was gained from the Keerom Health Department. None of the potential participants were known to the research team. There were no exclusion criteria based on gender, and all potential participants who self-nominated and were available were interviewed. We aimed to recruit 10–15 participants through this method [
Semi-structured interviews were used to collect data. The primary researcher, a female nurse academic and normally a Papuan resident, was living in Australia, when conducting the research. The interviews were conducted by telephone from Australia to Indonesia, and audio-recorded with participant consent. The semi-structured format of the interviews enabled the researcher to include clarifying questions as needed, providing participants the opportunity to explain their responses. Data saturation was reached after 10 interviews; however, the researcher interviewed two further participants for confirmation of data saturation. Participant details are presented in Table 2. The interviews were conducted in the Indonesian language and the recordings were transcribed verbatim by the primary researcher in Bahasa Indonesia. Pseudonyms were used in the transcripts to maintain participants’ anonymity. Research data were stored in a secure password protected computer.
The data were managed with NVivo 12 and subjected to thematic analysis process outlined by Braun and Clark. The first and second transcribed interviews were translated into English by the bilingual primary researcher, and subsequently analysed independently by each member of the research team. Following this initial team coding, the remaining transcripts were analysed in Bahasa Indonesian by the primary researcher, translating relevant quotes into English for discussion with the team. The research team consisted of a registered nurse undertaking a Masters degree and three supervisors experienced in conducting research.
1.2 Findings
Following the analytic process, five main themes were identified and agreed upon by the research team. Participants perceived that the factors that contribute to infant mortality in Papua Indonesia include: cultural beliefs and practices related to pregnancy, birth, and infants; infant health factors; maternal health factors; barriers to seeking, receiving, and providing health care; enablers and strategies for improving infant health.
1
Cultural beliefs and practices related to pregnancy, birth, and infants
Participants spoke about the impact of cultural, and family traditions and beliefs around pregnancy, birth, and infant care practices on infant mortality rates. In some remote villages, health workers found it difficult to provide care to families that still hold some traditional customs and practices. These included where birth takes place, who helps the birthing mother, and the treatment of newborn infants, particularly ill infants. For example, a baby under one month old is not taken outside, as explained:There is a family belief of local people that it is taboo for a newborn baby under one month to go out of the home because it is prone to evil spirits. Therefore, they do not bring their baby to the health centre when their baby is sick or to have immunization. (P7)
Some families’ beliefs were so strong that they refrained from seeking health care despite knowing that their baby may die. For example, there is a strong cultural belief by some families that congenital problems are caused by “evil spirits” (P6). Many believed that their baby’s sickness was caused by “black magic” (P8), was a “curse” (P7), or “a talisman” (P2) from their enemy, and that their baby is therefore beyond medical help.When I found a sick baby in my workplace, the family were reluctant to bring it to the community health centre because they said, “It is useless to bring the sick baby to health centre. They cannot help the baby because this disease is caused by magic power; no one in the health centre can help magic power diseases”. (P5)
A significant cultural practice identified by participants was the place and practices of birth. Participants described how the local people prefer to birth their infants in their community with only the support of their family. The birth takes place outside of the home because it is believed that blood products in the home can cause other members of the family to become ill.
During labour and birth only female family members are allowed to support the birthing mother. Skilled birth attendants are generally not called, as men, including a woman’s husband or strangers such as health workers, must not be in attendance. These beliefs and practices “put babies at high risk” (P1). However, three health workers said that such cultural birthing practices are becoming rarer (P1, P3, P11). As explained:The first time I worked here, some local people believed that their baby must be delivered far from home, for example in the garden or in the back yard. They believed that the blood must not spread at home because that would bring harm to the family. But that was in the past; nowadays such cases are getting rarer. (P1)
Participants suggested that due to these cultural beliefs, families tend to pay traditional healers with strong connections to community for their initial care, rather than access the free community health services. Most families are perceived to be more confident with a “shaman” or “jungle doctor” (P3) than the care offered at the health centre. Local sick people are treated with leaves and herbs, sometimes combined with traditional dance, particularly for severe illness. Participant 9 stated:Sometimes the healers either do not recognise how sick the baby is or they might discourage the family from taking the baby to the clinic to seek medical care. (P9)
Several participants confirmed that families’ preference for traditional healers cause delays in seeking care at public health centres, which can result in serious health implications. For example, Participant 3 explained: In one of villages in hinterland Keerom, all of the sick people or pregnant women about to give birth are not allowed to go to the health centre to have health care before first going to the jungle doctor… The local people call the jungle doctor, a traditional healer in that area. All the people respect and obey what the jungle doctor says. So we as health workers cannot do home visits or give care before we get permission from the jungle doctor. This is what causes danger for the mother giving birth and puts the baby at risk of death due to delays in medical help. (P3)
Another delay in seeking care was found to be due to the traditions of a predominantly “patriarchal society” (P9), where women have to wait for their male partner to come home from the fields to get permission to seek health care for themselves or their infant. Sometimes, if the infant is sick in the morning, and the husband does not return until late at night, mothers wait the whole day, which can lead to the infants’ condition deteriorating.
Historic cultural practices therefore appear to impede pregnant women and new mothers from trusting and accessing publicly funded health care services in Papua Province. Health professionals reported that this tension leads to poor outcomes for both pregnant women and their newborn infants.
2
Infant health factors
The second theme is related to the health factors of neonates and infants such as prematurity and low birth weight, birth asphyxia, hypothermia, infectious diseases, and infant malnutrition. Prematurity and low birth weight were perceived by the participants as significant factors contributing to infant death. Women’s heavy work burden and pregnancy issues, such as poor nutrition or malaria, were perceived to contribute to pregnant women birthing their babies prematurely or birthing full-term babies of low birth weight. One Participant explained: Last year I found a new couple had delivered their baby at home with low birth weight, and I told them to bring the baby to the community health centre to have neonatal care but they refused. I was so disappointed, and I felt like I really wanted to help them, but they rejected us. They said a baby under one month cannot go outside because it may harm the baby. Eventually, I heard the baby had died. I was so upset. (P3)
Most participants identified that the lack of appropriate care for a baby of low birth weight contributes to infant death. Participants also perceived that prematurity and low birth weight were major factors contributing to birth asphyxia. The use of traditional birth attendants, such as family members or unskilled attendants was thought to exacerbate these complications. As stated by Participant 7The birthing process helped by family or an unskilled birth attendant often was a long process that caused breathing difficulty for the baby or birth asphyxia. (P7)
Furthermore, the poverty of the local people was thought to be a major cause of hypothermia in infants especially those who are premature and of low birth weight. As Participant 7 stated:Beside the family not having clothes and blankets for the baby and mother, hypothermia also occurred because the family tends to bathe their babies immediately after birth so that they are clean from blood; this causes the baby to get hypothermic. (P7)
Several participants perceived that infectious diseases such as malaria, bronchopneumonia, and tuberculosis are factors that contribute to infant mortality. Participants identified that infants are often born with malaria, contracted in utero from the mother via vertical transmission. They also reported that most pregnant women in remote areas do not receive any antenatal care or screening for malaria, nor do they go to a health centre when they feel unwell. They therefore may not realise that they have been infected with malaria, which if left untreated, may impact their health during pregnancy, and impact the development of the fetus and the health of the infant. One of the main factors is malaria during pregnancy; we have often found stillbirth and sick infants because of malaria. (P11)
Participants also stated that the other main disease presenting in infants is bronchopneumonia, with household smoke exposure perceived as the major contributing factor. They explained that local people usually use a traditional wood stove in their house, which is often poorly ventilated. Two participants explained:The family here, either men or women, smoke at home and of course the baby is exposed to the smoke; that’s what I think contributes a lot to infant death with bronchopneumonia. (P1)… so the family is just exposed to the smoke from the traditional stove including the infants. This circumstance, I guess, is one of the causes of bronchopneumonia in infants. (P7)
Participants identified that families who live in very isolated areas in the jungle rely entirely on the jungle to find their food, and severe cases of malnutrition in both mother and baby occur in such communities. Participants added that due to lack of knowledge and awareness of infant health, the family introduces solid food too early to the infant, which often leads to sickness. As stated:We as health workers always educate people to give proper food according to the age of baby. We tell the family not to give them adult food because it will harm the baby, but they do not listen to us. And we often found cases of baby problems due to not eating properly. (P4)
Lack of knowledge about infectious diseases and contagions, and delays in seeking health care for both mother and infant, are factors leading to newborns and infants contracting infections such as malaria, tuberculosis, and bronchopneumonia. Traditional lifestyles, exacerbated by poverty, are major causes for concern in this area. Many of the infant health factors can be traced back to traditional cultural practices, e.g. heavy burden of work required by women in a patriarchal society, and refusal to accept ‘proper’ care because of cultural beliefs, use of traditional and unskilled birth attendants, poor nutritional practices, and hypothermia due to cultural practices.
3
Maternal health factors
Theme three shows that maternal health factors contribute to infant mortality. Participants perceived that the two most significant maternal health complications for pregnancy and birth were malaria and maternal malnutrition. Papua has a high incidence of malaria, and many pregnant women are unaware they are infected, as they do not seek antenatal care where they could receive early testing and treatment. Participants said that pregnant women present to the health centre only when they are very sick, and the impact of the disease has a significant toll on mother and baby. One thing that causes many infant deaths in Papua is the premature baby. The mother had malaria during pregnancy and with lack of nutrition they often deliver the baby before maturity. Sad to say, the family could not afford proper care for their premature baby and often times the baby ends with death. (P6)
Some participants perceived that poor nutrition of pregnant women, arising primarily from the poverty of the family, contributed to infant morbidity and mortality. Sad to say, I found many families had a meal only once a day… So, for many pregnant women with a lack of nutrition, the development of the baby is inevitably also worse. (P7)
Both poor nutrition and malaria may result in anaemia in pregnant women, which was perceived as a factor contributing to infant mortality. Participants reported that local families are usually large, they share whatever food they have with all family members, and it is customary for the women to eat last.Even though community health centres deliver supplementary and additional food for pregnant women, in fact the whole family eats the food that is supposed to be given to the pregnant women. (P1)
Maternal malaria, poor nutrition and resulting anaemia, arising from the poverty of the family, are perceived as significant contributors related to problems in both pregnancy and birth.
4
Barriers to seeking, receiving, and providing infant health care
Participants recognised that many barriers impede families in both seeking and receiving care, and health care workers in providing care. Geographic and financial barriers cause delays in seeking care, and healthcare provision barriers further aggravate the health conditions of mother and infants and contribute to infant mortality.
The principal geographical factor impacting people’s attendance at the health clinic was identified as remoteness, as explained by one Participant:Another big factor is the geographical condition in Papua, which is a big issue. I found a village in Keerom, where people have to walk 8 to 9 hours to reach the health clinic. This is one of the reasons why people there do not come to the health clinic. (P1)
Whilst health care is free in Papua, the cost of transport to access services poses a financial barrier. It is a customary for all family members to accompany a birthing woman or a new mother bringing her infant for immunization. Some participants reported that the prohibitive cost of transport and meals for the whole family often resulted in a decision not to seek health care. As mentioned by Participant 8:I think one of the things that keeps families from coming to health services is because the habit here is when going to health services, the whole family comes along and they think about the cost of transport and the cost of eating for a large family which they could not afford. (P8)
Lack of health facilities, equipment, and medicines in existing health facilities, the shortage of health workers, poor health worker skills, and inadequate and unsafe working conditions, were all recognised as barriers to the provision of health care. According to the participants, there are still villages that do not have a local health centre and so community members need to travel to very distant health centres to access health care. In some remote areas there are still many villages that have no health centre and only in areas that are close to the city. (P2)
Other problems reported by participants were the shortages of medicine and health equipment, as well as the unavailability of clean water and electricity in some community health centre branches. In villages that have a health centre there is insufficient health equipment, medicine, no electricity, and clean water to support health care services. (P5)
Participants believed that insufficient health workers in certain community health centres may contribute to poor infant health and impact on infant mortality, as expressed by Participant 7:In my workplace and I know also in some villages in the hinterland, we are still having problems with the lack of health workers, particularly doctors and midwives. (P7)
Additionally, participants reported that the lack of skills of the health worker influences care provision. Issues of inexperience and a lack of confidence of newly graduated health workers in village settings were identified by participants as barriers to the provision of appropriate health care:I have found when the new midwife is confronted with the case of a mother giving birth, they are confused and stuttering, and the senior midwife does not assist them. (P1)
An additional factor that participants highlighted was unsafe working environments. Although health care centres were accessible in some remote villages, at times health workers refused to work there due to security concerns and leave health centres unattended or restrict the availability of maternity services. Most participants reported that the village midwives decline to stay in remote health care centres due to problems with drunken men and experiences of sexual harassment.No one can guarantee the security of the midwives to stay in the village where they work, and therefore the village midwife does not live in the remote village where they should be staying. (P8)
The mobility of the population in Papua was also identified as a challenge in the provision of health care to families, and one of the factors contributing to infant mortality. For this population, mobility causes difficulties for health workers to maintain valid population data to ensure early identification of pregnant women and infants requiring care. We do not have complete data records of the people in remote areas as they are never settled down at one place. (P3)
Lack of health facilities, medicines and equipment and skilled health workers was perceived as major barriers to providing health care for pregnant mothers and infants. The nomadic lifestyle of the population and unsafe working conditions, as well as the unavailability of clean water and electricity, aggravate the situation.
5
Enablers and strategies for improving infant health
This section describes government initiatives and strategies for improving infant health outcomes, which participants indicated, were already in place. Participants also made recommendations for further initiatives that they saw as essential to combat the high infant mortality.
Participants reported that the provision of health education about pregnancy and birth, with the use of the ‘pink books’, enabled the growth and development of the infants to be assessed and recorded. Participants also mentioned that provision of regular home visits, to vaccinate infants and provide free health care reduced morbidity. The recent government efforts to upgrade equipment in the health centres were also appreciated, as was the recent policy to employ health worker staff as permanent workers (rather than casual employees), to encourage health workers to take more responsibility in helping the community, and to encourage new health workers to transfer to Papua.
Strategies that participants recommended included building networks within the community and involving all stakeholders in health literacy and education about maternal and infant health care. Participants acknowledged the importance of developing closer relationships with communities, for instance through regular family visits, and providing health education. However, whilst there are beneficial initiatives in place, there remains much room for improvement.
Strategies that participants believed have been done well include embracing community culture, such as holding regular meetings with the local leaders to involve stakeholders from the health and education sectors. The importance of cross-sectoral work between various community members, women’s organisations, and local leaders was emphasized by participants. We approach the religious leader, tribe leaders, and family leaders to try to open their minds about the importance of health care. (P7)The ongoing training of shamans and involving community sectors in health programs need to be continued. (P4)
The importance of a family-based approach to health education in nutrition and the prevention, early detection, and treatment of malaria were also highlighted. Participants believed that programs, such as the sustainable distribution of medicine and supplementary food stock in each community health centre should continue, with better planning to meet the needs of each community.
The participants believed that involving health workers from community health centres in remote villages in the annual health program meeting at the provincial health office is essential. Health workers who work in remote villages understand the specific needs of the village community, and so they could contribute significantly to health planning and budgeting according to the community’s primary needs in relation to mother and infant health, as explained by Participant 8:The health officer at the provincial level should involve our representative to hear our voice concerning the facts in the villages, so that what has been planned from the centre meets our community need. (P8)
Several recommendations regarding geographical barriers were made by participants. They explained that the local government have tried to build health care centres in each small village and better road access in remote areas, but these projects have not yet been fully achieved. For example, they felt that the government needs to provide a health service in every village, so even small villages will have their own health centre with an ambulance available for quick referral in emergency cases. They also emphasized that approaching local leaders and tribe leaders regarding legalised land and provision of building sites for new health centres is paramount.
Participants identified strategies to deal with unsafe working environments, stating that strengthening multisector cooperation is essential to building communication with the local people so that health workers are welcomed and safe. They identified that the government needs to increase security measures for health workers living and working in rural areas, so that health workers, particularly the female village midwives can work safely. The Government needs to provide safe working places in remote areas by involving multi stakeholders such as the local leader, tribe leader, religious leader, and policeman. (P4)
Further, participants recommended that the government could reconsider the health programs in remote areas to find solutions to meet the lack of health workers, health facilities, equipment, and consumables. For instance, they recommended improving health facilities, upgrading health equipment, and providing sufficient health workers in each health centre. They also recommended regular reviews of perinatal mortality cases in each village to evaluate and address the factors leading to infant death, and to facilitate a quick referral system for premature and low birth babies who require advanced hospital care. We expect the Health Department to undertake perinatal maternal review activities so that every midwife who works in the villages must review what happened in the midwifery and neonatal cases that occur in each community health centre, and these reviews must be adopted and presented at the community health centre meeting. (P7)
Current strategies included government programs such as government funding of health centres, free health care, food supplement and medicine, which participants hoped would be continued and further developed. Efforts by health workers to develop and maintain good communication with all stakeholders, including traditional village leaders and healers, as well as focusing on family visits was recognised. Health literacy in relation to maternal and infant health was a priority for these health workers, and participants emphasised that working with the whole community to raise awareness about pregnancy and birth is essential in the fight against infant mortality and its devastating effect on the survival of the whole community.
2. Discussion
This study identified five themes including: cultural beliefs and practices related to pregnancy, birth, and infants; infant health factors; maternal health factors; barriers to seeking, receiving, and providing infant health care; enablers and strategies for improving infant health. The findings of this study will be discussed under the subsections of culture, tradition, and patriarchy; poverty; road access and transportation; health literacy; and staff and material shortages. These factors contributing to infant morbidity and mortality will be further discussed in relation to access to and provision of appropriate health care.
2.1 Culture, tradition, and patriarchy
The health workers in this study perceived that culture and traditional beliefs of the family influenced their decision to seek health care. The study findings demonstrated that cultural norms influenced families’ decision to seek medical attention for complications presenting in the pregnant woman or infant. Seeking initial treatment from traditional healers, or their permission to access modern medical care was thought to cause a significant delay in infants receiving timely health care. Preference for traditional healers, birth attendants and medicine has been shown in studies from Nepal, Sudan, and Aceh Province of Indonesia to impede families in seeking appropriate health care [
Adhering to cultural practices, such as home confinement of a mother and infant for 30 days after birth regardless of the presence of illness, relate to findings by Onta et al. This study identified that a Nepalese tradition of isolating women during and for the first few days after childbirth, decreased women’s use of health facility birthing services and skilled birth attendants, thereby increasing the risk of adverse health outcomes for both mother and infant.
Participants in this study explained that women were prevented from seeking care for both themselves and their baby when they are sick because of the requirement to gain their husband’s permission. This description by participants is reflective of a patriarchal social structure, which, as Mattebo et al. explain, creates and maintains male domination over women. This social structure was also found by participants to influence the way mothers make decisions to seek care.
Participants reported that families prevent mothers from bringing their babies to health care facilities to receive postnatal care or immunizations for cultural reasons. Rather, the health worker had to visit the family’s home to ensure that Department of Health scheduled, and WHO recommended health services were provided. Despite these efforts, more needs to be done to share knowledge and belief systems between local peoples and health professionals. More efforts need to be made to involve the whole community, particularly its leaders, in the resolve to protect the health and survival of new mothers and their newborn babies. More understanding of the cultural values and nuances may lead to the development of more effective strategies.
2.2 Poverty
Participants identified that financial constraints were part of the family considerations that often delayed their decision to seek care. The family’s consideration of the cost of transport and food for the whole family delays their seeking care. These findings are consistent with previous studies that found that the low socio-economic condition of families as one of the determinant factors of neonatal mortality [
]. The average monthly income in Papua is below the poverty line at Rp.440.021 ($41.91)/family. Findings of this study highlight that poverty is a major obstacle for Papuan communities, resulting in delays in seeking and accessing care.
This study identified that financial constraints meant that families often could not afford quality nutritional food for the mother or clothes for the infant, increasing the risk of low birth weight neonates and neonatal hypothermia.
2.3 Road access and transportation
Participants stated that another factor contributing to neonatal mortality related to logistical issues in reaching care, such as challenging geographical terrain, poor road conditions, and lack of available transport. Participants reported that, as many villages do not have community health centres, families seeking care need to travel to centres geographically closer to the city. Participants pointed out that to reach a community health centre, many people need to walk through hilly areas with poor road conditions for up to eight hours or hire motorcycles which are very expensive and often unaffordable. These findings are consistent with the previous studies conducted by Ezeh et al. and Martinez et al., who identified that geographical conditions in remote areas, poor road infrastructure, and long travelling distances were barriers to accessing care, which increased the risk of infant mortality in Nigeria and South East Asian countries.
2.4 Health literacy
Participants perceived that poor health literacy was a barrier to accessing care. Health literacy is an individual’s ability to understand and make decisions about their health and healthcare [
]. Women and men over 15 years of age in rural Indonesia have low levels of schooling, with 25.62% and 19.0% respectively having no certificate of any schooling [
]. This low education level would impact their health literacy. These findings support Berkman et al. who found that people with low levels of health literacy have lower rates of health service use, and worse health outcomes, compared to people with higher health literacy, as those who with low level of health literacy are less able to identify their health needs and their health risks. These findings also concur with those from a study about health literacy to understand why newborns die in eastern Uganda [
]. This study found that mothers may not be able to recognise serious illness in their neonates resulting in a delay to seek care.
While health workers perceived the health literacy of families to be a problem, an additional problem appears to be a need for health workers to accept and work with the cultural practices of families for whom they care. Without this mutual acceptance little may change. Mutual respect is a premise upon which capacity can be built to enable empowerment. Where health workers did identify a need to work more closely with the community, they described keeping their advice within cultural parameters. They only taught the community and mothers the basics of health care, such as the importance of antenatal care, nutrition, how to keep baby warm, and maintaining hygiene. The health workers’ advice did not appear to incorporate principles of empowerment embedded in critical health literacy. Shifting the goal of health literacy from functional day-today task based information to critical health literacy would enable health workers and community to address the broader determinants of health [
] that impact on family’s capacity to birth and raise healthy infants.
2.5 Staff and material shortages
Participants highlighted that insufficient health workers with appropriate skills, and lack of health equipment, medicines, and even electricity and clean water, contributed to delays in receiving care once a facility had been reached. This delay refers to phase III of the three delays stated by Thaddeus and Maine [
Participants explained that some families, who had made the initial decision to attend a health care clinic and had been able to find ways to travel to the clinic, arrived to find the clinic inadequately staffed and sometimes not staffed at all. These findings are consistent with the earlier studies, which have identified that health facility management and processes, and skilled birth attendants without adequate training and experience, negatively impact neonatal health outcomes [
Why do some women still prefer traditional birth attendants and home delivery?: A qualitative study on delivery care services in West Java Province, Indonesia.
Participants highlighted the need to upgrade health worker skills including the village midwives’ skills to ensure that even in remote areas mothers have access to appropriate and adequate care at childbirth. Birth Preparedness and Complication Readiness interventions are recommended by the WHO as essential to reducing delays in receiving care in emergency cases. The WHO [
] also recommends upgrading the skills of health workers/skilled birth attendants in order to improve maternal and newborn health services.
2.6 Limitations
This study has several limitations. Participants in this study were health workers who work in Papua. We did not seek data from health service users, such as families and communities, which would provide a different perspective and potentially rich information. Further, because the research setting of Papua Province has unique political, geographical, and social characteristics, the results may not be generalizable to other parts of Indonesia or other low and middle-income countries. Future research using clinical outcome data and involving other key stakeholders is warranted.
3. Conclusion
This is the first known qualitative study that focuses on the Papua Province in Indonesia and explores health workers’ (nurses, midwives, and doctors) perceptions about factors that contribute to infant mortality. Through the lens of these health workers perceptions, this study has identified numerous factors that may contribute to infant mortality in Papua, Indonesia, and potential strategies to reduce infant mortality.
The local people’s cultural beliefs about maternal and infant health and poverty were thought to be major factors contributing to infant mortality. Other barriers included lack of functional health literacy, isolation, geographical factors, and poor transport and road infrastructure. The nomadic nature of the local population also contributed to the delays in seeking and reaching health care. Furthermore, participants raised logistical concerns such as the lack of skilled health workers, lack of health facilities and health equipment/medicines, and unsafe working environments as barriers to the availability of, and access to appropriate health services.
This study has uniquely focussed on understanding health workers’ perceptions and found that cultural knowledge and sensitivity are central to the provision and acceptance of health care by local families, particularly for maternal and infant health. Engaging more fully with cultural factors would lay foundations for both health workers and community members to develop critical health literacy. This would attend to the social, economic, and environmental determinants of health that shape infant mortality in Papua. The principal recommendation is that health care providers approach and embrace community and stakeholders, enhance collaboration between national, provincial, regency, and local governments, and work together using more creative, culturally respectful approaches to the many issues in need of attention.
Conflict of interest
The Deputy Editor Linda Sweet is a co-author on this paper. To reduce any real or perceived conflict of interest, she had no role in the review of this paper.
Ethical statement
Ethics approval was obtained from the Flinders University Human Research Ethics Committee (the approval number 7897). Approval date March 2018.
Funding
This research was funded by Australia Awards Scholarship Program for Indonesian students.
We would like to thank the health workers who participated in the study, and the Community Health centres and the local government of Keerom Papua who supported this study.
References
United Nations Department of Economic and Social Affairs Population Division. World Mortality 2019. 2019 (Highlights (ST/ESA/SERA/432))
Why do some women still prefer traditional birth attendants and home delivery?: A qualitative study on delivery care services in West Java Province, Indonesia.
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