Do Indonesian midwifery-led birth units provide safe, accessible care? A secondary analysis of demographic health survey cross-sectional data

Objective: In high-income countries, attended birth at home and in midwifery-led birth units is safe for low-risk women who have access to hospital transfer. These circumstances are untested in Indonesia and other low- and middle-income countries, where mortality remains unacceptably high, and studies analysing birth settings do not account for pregnancy risk. This study aimed to quantify first day neonatal mortality in Indonesia across different birth settings, adjusting for pregnancy risk and other confounding factors, and summarise barriers to accessing health care. Methods: Using self-reported data from women aged 15–49 years participating in the 2007, 2012 and 2017 Indonesian Demographic Health Surveys (n = 45,953), adjusted odds ratios (aOR) of first-day neonatal mortality were estimated using logistic regression. Barriers reported by women in accessing health care are summarised. Results: First-day neonatal death occurred in 3.45 per 1000 live births. Rates were higher for: births with pregnancy risk (7.35/1000 vs 2.31/1000 no risk; aOR = 3.17, 95 %CI 2.29–4.38); home births with and without health professionals present (5.03/1000, aOR = 2.26, 95 %CI 1.19–4.29 and 5.11/1000, aOR = 2.50, 95 %CI 1.26–4.96 respectively) vs midwife-led birth unit. Women who birthed in hospital and midwifery-led birth units reported fewer barriers to accessing healthcare; those who gave birth at home without a health professional reported the most. Conclusion: Pregnancy risk and barriers to health care access are key elements associated with neonatal mortality. Interventions should target women who face barriers to accessing healthcare, particularly those with risk factors. Midwifery-led birth units are an accessible option, with low odds of first-day neonatal mortality in Indonesia.