The Influence of Maternal Factors and Residential Building

Characteristics on Infant Mortality in Papua Province Based on

Secondary Data Analysis of the 2017 IDHS

ABSTRACT
Introduction: Infant mortality remains a significant global health issue, with 2.4 million
infants died before one month of age in 2020. In Indonesia, the infant mortality rate was
16.85 per 1,000 live births in 2022, with Papua Province reported the highest rate. This study
aims to identify factors contributing to infant mortality in Indonesia, focusing on maternal
age, antenatal care, immunization, delivery conditions, parity, education, maternal
employment, income, and housing characteristics.
Materials and Methods: This study employed a quantitative cross-sectional design using
secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). The
sample included 658 women aged 15-49 who gave birth to infants aged 0-11 months between
2012 and 2017 in Papua Province. The analysis comprised three stages: univariate analysis
for frequency distribution, bivariate analysis using logistic regression (p<0.05) to test
relationships, and multivariate analysis with multiple logistic regression for simultaneous
evaluation. Variables with p values < 0.25 were included, while those > 0.05 were
progressively removed, focusing on changes in Odds Ratio (OR).
Results: The analysis found that maternal education level is a dominant factor influencing
infant mortality, with an Adjusted Odds Ratio (AOR) of 43.579 (p-value = 0.000, 95% CI =
5.549-342.235). Mothers with a basic education are 43.57 times more likely to experience
infant mortality compared to those with higher education.
Conclusions: Maternal socioeconomic factors significantly impact infant mortality in Papua
Province, and the findings can inform strategies to reduce mortality rates in the region.
Keywords: Infant Mortality, Maternal and Socioeconomic Factors, Papua Province, SDKI
2017

Highlight
1. This study focuses on Papua, which has the highest infant mortality rate, using a
multivariate approach to analyze various factors. Data from the 2017 IDHS and robust
statistical analysis are expected to aid in formulating effective health policies.
2. The uniqueness of this research lies in its broader scope of variables, including education
and employment, while considering the social and cultural context of Papua, providing
new insights into infant health issues.
INTRODUCTION
Infant mortality remains a serious public health issue worldwide. According to WHO (2022),
in 2020, 2.4 million babies died before reaching one month of age. Every day, approximately
6,700 infants die, contributing to 47% of all deaths among children under five years old. This
reflects the welfare and health quality of a country or region. Infant mortality has significant
emotional impacts on families and societies and affects economic growth and social
development(1).
The infant mortality rate (IMR) in Papua has decreased from 129 in 1971 to 38 in 2021.
However, Papua still has the highest IMR in Indonesia. This requires attention from the
government, health institutions, international organizations, and civil society. According to
the 2020 Population Census, Papua's IMR is 38.17, meaning there are 38-39 infant deaths per
1,000 live births, more than twice the national average of 16.85.
IMR is a crucial indicator of public health quality. A low rate indicates good health quality (2).
The Sustainable Development Goals (SDGs) target to reduce IMR to 12 per 1,000 live births
by 2030. Various efforts have been made, including ensuring deliveries by healthcare
professionals in health facilities and providing standard healthcare services for newborns.
Over the past 50 years, Indonesia's IMR has decreased by nearly 90%, from 26 per 1,000 live
births in the 2010 Census to 16.85 per 1,000 live births in the 2020 Census. Increased
complete immunization and duration of breastfeeding have contributed to this decline.
According to the Central Statistics Agency (BPS), Indonesia recorded an IMR of 16.85 per
1,000 live births in 2022, with Papua having the highest IMR at 38.17 per 1,000 live births(3).
Factors influencing infant mortality include maternal age, antenatal care visits, Tetanus
Toxoid immunization, place of delivery, birth attendant, birth spacing, number of children,
maternal education level, maternal occupation, maternal income, place of residence, and
characteristics of residential buildings. Efforts to reduce IMR include ensuring deliveries by
healthcare professionals and providing standard healthcare services for newborns. This study
aims to identify the causes of infant mortality in Indonesia.

METHODS
Observational analysis with a cross-sectional research design was conducted to identify the
causes of infant mortality in Papua Province. The study was carried out from January to
March 2024, using specified inclusion and exclusion criteria for sample selection. The sample
consisted of 658 female respondents aged 15 to 49 years who gave birth between 2012 and
2017. Independent variables included maternal age, antenatal care visits, Tetanus Toxoid
immunization, place of delivery, and characteristics of residential buildings from the 2017
Indonesian Demographic and Health Survey (IDHS). Ethical approval was obtained from
Universitas Airlangga Surabaya under letter number 60/EC/KEPK/FKUA/2024 dated
February 29, 2024.
Univariate analysis was performed to determine the frequency distribution of the dependent
variable (infant mortality) and independent variables, such as maternal age, antenatal care,
Tetanus Toxoid immunization, place of delivery, birth attendant, birth spacing, parity,
maternal education, maternal employment, family income, residence, and residential building
characteristics. Bivariate analysis tested the relationships between independent and dependent
variables using a 95% confidence level and a significance level of 5% (p<0.05), employing
simple logistic regression. Multivariate analysis examined the relationships between multiple
independent variables and one dependent variable using multiple logistic regression.
Variables with p-values < 0.25 were considered, while those > 0.05 were removed
sequentially. Important variables with p-values < 0.05 were retained, and changes in Odds
Ratio (OR) were monitored to ensure significant variables remained in the model, continuing
until all variables had p-values ≤ 0.05.

RESULTS AND DISCUSSION

Based on the findings of this study, here are the characteristics of the respondents as
presented in Table 1:

Table 1. Characteristics of Respondents

Characteristics Frequency ( n ) Percent ( % )
Maternal Age
< 20 years 142 21.6
20-35 years 321 48.8
>35 years 195 29.6
Pregnancy Check-ups
First ANC 492 74.8
Complete ANC 166 25.2
Tetanus Toxoid Immunization
No 522 79.3
Yes 136 20.7
Maternity Center
Non Health Facilities 157 23.9
Health Facilities 501 76.1
Residential Building
Not Liveable 117 17.8
Liveable 541 82.2
Total 658 100.0
Table 2. Relationship of Mother's Age, Pregnancy Check-up, Tetanus Toxoid Immunization,
Place of Delivery, and Building Residence to Infant Mortality
Infant Mortality
Total ρ value
Characteristics Die Live
n
n % n % n %
Maternal Age
< 20 years 36 5.5 106 16.1 142 21.6
0.295
20-35 years 72 10.9 249 37.8 321 48.8
0.609
>35 years 40 6.1 155 23.6 195 29.6
Total 148 22.5 510 77.5 658 100.0
Pregnancy Check-ups
First ANC 103 15.7 381 59.1 492 74.8
0.100
Complete ANC 45 6.8 121 18.4 166 25.2
Total 148 22.5 510 77.5 658 100.0
TT Immunization
No 123 18.7 399 60.6 522 79.3
0.199
Yes 25 3.8 111 16.9 136 20.7
Total 148 22.5 510 77.5 658 100.0
Maternity Center
Non Health Facilities 49 7.4 108 16.4 157 23.9
0.003
Health Facilities 99 15.0 402 61.1 501 76.1
Total 148 22.5 510 77.5 658 100.0
Residential Building
Not Liveable 6 0.9 111 16.9 117 17.8
<0.001
Liveable 142 21.9 399 60.6 541 82.2
Total 148 22.5 510 77.5 658 100.0
Candidates for multiple logistic regressions were chosen from Table 2 when the p< 0.25 (4).
They were maternal age, ANC, Tetanus Toxoid immunization, place of delivery and building
residence variables.

Table 3. Results of Multiple Logistic Regression Analysis

Adjusted Odds Ratio
Variables Β p-value 95% CI
(AOR)
Pregnancy Check-up 0.135 0.548 1.144 0.738-1.775
Tetanus Toxoid Immunization 0.273 0.337 1.314 0.752-2.294
Maternity Center -0.660 0.003 0.517 0.333-0.803
Residential Building 1.861 0.000 6.427 2.732-15.120
Constant 0.836 0.001 2.306
Four hypotheses were tested regarding factors influencing infant mortality. The analysis
results show variation in the significance of these factors in relation to infant mortality rates.
Firstly, no significant relationship was found between pregnancy check-ups and infant
mortality (p = 0.548). Similarly, Tetanus Toxoid immunization did not show a significant
relationship with infant mortality (p = 0.337). However, significance was found in the
relationship between place of delivery and infant mortality (p = 0.003), with mothers
delivering at health facilities having 0.517 times higher odds of preserving their baby's life
compared to those delivering at non-health facilities. Lastly, the condition of the building
residence significantly affects infant mortality (p = 0.000), where babies living in
uninhabitable conditions have a 6.427 times higher risk of death compared to those living in
habitable residences. These results underscore the importance of access to and quality of
health services during delivery and the living environment in reducing infant mortality rates.

This study evaluated the relationship between maternal age and infant mortality. The majority
of respondents were aged 20-35 years, and no significant relationship was found between
maternal age and infant mortality(5).However, early marriage (under 19 years) increases
serious health risks(6), including infant mortality due to immature reproductive systems.
Maternal health also influences infant mortality risk, but regular pregnancy care and
competent health assistance can mitigate this risk(7).

This study indicates that the majority of pregnant women in Papua do not receive optimal
antenatal care (ANC). While some research shows a relationship between ANC visits and
infant mortality(5), the low number of ANC visits meeting standard guidelines can increase
the risk of neonatal death(8). Factors such as low maternal nutritional status, including Chronic
Energy Deficiency (CED), and inadequate iron intake pose significant challenges to maternal
health in Papua(9). Research suggests that strenuous work habits during pregnancy can affect
timely ANC visits, often influenced by socio-economic and cultural factors in Papua (9).
Overall, while ANC is crucial for maternal and infant health, challenges in its implementation
and suboptimal quality, along with socio-economic issues like CED and low iron intake
among pregnant women, are major barriers in reducing infant mortality rates in Papua and
Indonesia as a whole. More effective interventions are needed to enhance awareness, access,
and quality of healthcare services for pregnant women.

This study also shows that the majority of respondents have received Tetanus Toxoid
immunization, and research findings indicate that TT immunization significantly prevents
infant deaths caused by neonatal tetanus infections (10). Tetanus infection in infants can result
from non-sterile deliveries or maternal wounds before childbirth. Tetanus Toxoid
immunization is a key strategy in the Maternal and Neonatal Tetanus Elimination (MNTE)
program, aimed at ensuring safe and sterile deliveries (11). Data from the 2023 Provincial
Health Profile of Papua indicate that complete basic immunization programs play a crucial
role in preventing various infectious diseases, including those that can cause infant deaths (3).
Despite improvements in immunization coverage in Papua, challenges remain in achieving
complete immunization for all children, which is a focus for enhancing awareness and access
to healthcare services. Overall, Tetanus Toxoid immunization is not only important for
protecting individuals from tetanus but also as part of a broader strategy to improve maternal
and infant health. By increasing awareness of the importance of immunization and expanding
access to healthcare services, it is expected to reduce infant deaths caused by preventable
diseases like tetanus(12).

The majority of mothers give birth in healthcare facilities, and research shows a significant
relationship between the place of delivery and neonatal mortality rates (13). This research
confirms that childbirth assistance in healthcare facilities equipped with trained healthcare
personnel and adequate facilities can reduce the risk of infant mortality compared to
deliveries elsewhere that are not sterile or lack proper care. Another study by Mogi &
Anggraeni (2021) presents contrasting findings, suggesting that the place of delivery does not
significantly correlate with infant mortality. However, the study emphasizes that deliveries in
healthcare facilities meeting appropriate standards can minimize complications leading to
infant death(14). Data from the Health Profile of Papua Province 2023 indicates an increase in
the percentage of women giving birth in healthcare facilities in recent years, yet challenges
remain in improving access and quality of healthcare services in urban and rural areas (15).
Factors such as education, economic status, and age also influence mothers' decisions in
choosing the place of delivery (decision-making)(16).

Overall, despite healthcare facilities offering a safer environment for childbirth, challenges
remain in improving service quality and accessibility to reduce infant mortality rates in Papua
Province. Continuous interventions to enhance public awareness of the importance of
delivering in healthcare facilities and to improve health infrastructure are crucial to achieving
better maternal and child health outcomes.

The majority of survey respondents live in habitable buildings, and there is a correlation with
significant influence on infant mortality rates related to the attributes of residential buildings.
The health status of infants is influenced by the physical condition and cleanliness of their
living environment. Diseases such as flu, diarrhea, and typhoid can arise from unclean
environments, hindering infant growth and increasing the likelihood of newborn mortality (17),
(18).
Gozali et al. (2023) found a strong correlation between the prevalence of diarrhea in
children and the presence of healthy toilets and closed waste disposal systems (19). UNICEF
Indonesia also found that 88% of child deaths due to diarrhea worldwide are caused by
inadequate sanitation and contaminated drinking water, limiting children's potential and
reducing human resource quality. Infant health is influenced by the quality of residential
structures, including construction, building materials, and community conditions. These
factors also reflect household financial health. Protecting infants from the outdoors and
diseases partly depends on the condition of walls, floors, and roofs of homes. Eighty-three
percent of homes in Papua experiencing infant deaths are in high-quality buildings, while
only 17% have low-quality homes. Low-quality homes is generally identified by features like
inadequate heating, ventilation, structural issues, overcrowding, and the presence of health
hazards such as mold, all of which significantly increase the risk of health problems for
residents (WHO, 2018; Healthy People 2030, 2023).

According to the study's findings, there are noteworthy correlations between infant mortality
and prenatal checkups, Tetanus Toxoid vaccinations, birth sites, and the standard of
residential buildings. Based on the research findings, the type of housing structure is the most
significant factor contributing to infant mortality among all other factors. The study indicates
a significant correlation between infant mortality and several aspects, including prenatal care,
Tetanus Toxoid vaccination, place of birth, and housing standards. For instance, Okech et al.
(2021) emphasize that poor housing conditions, such as inadequate construction and lack of
basic facilities, can elevate the risk of infant mortality. Additionally, Rahman et al. (2022)
highlight that access to quality prenatal health services and a safe living environment can
significantly reduce infant mortality rates. However, maternal age does not significantly
correlate with infant mortality in Papua Province according to 2017 SDKI data. Regular
prenatal check-ups and Tetanus Toxoid immunizations can reduce the risk of infant mortality.
Delivering in non-healthcare facilities increases the risk of infant mortality, consistent with
previous research findings(20). The increasing rate of deliveries in healthcare facilities,
particularly in urban areas among economically better-off mothers, underscores the
importance of healthcare access and quality services. Cleanliness and the physical condition
of living spaces also affect infant health. Unhealthy environments and poor sanitation can
cause diseases that hinder infant growth and increase mortality risk. This study emphasizes
the importance of good sanitation practices and cleanliness to enhance community quality of
life and reduce infant mortality rates. Sustained efforts are needed to improve healthcare
accessibility, service quality, and living conditions to mitigate infant mortality risk, especially
in Papua Province(5).
The research on infant mortality in Papua Province presents several advantages and
disadvantages. One key advantage is its high relevance, focusing on an area with the highest
infant mortality rates in Indonesia, which is crucial for improving public health. The use of
secondary data from the Indonesia Demographic and Health Survey (SDKI) ensures that the
data is reliable and standardized. Additionally, the study's comprehensive analysis involves
various independent factors affecting infant mortality, providing a thorough understanding of
the issue. The findings can inform better health policies in regions with high infant mortality
rates and raise community awareness about risk factors. However, there are limitations to
consider. The reliance on secondary data may lead to gaps in coverage or biases in data
collection. Establishing direct causal relationships between variables can be challenging. The
research is geographically focused on Papua, limiting the generalizability of the results to
other areas in Indonesia. Moreover, there may be unmeasured factors influencing infant
mortality that the dataset does not capture. Finally, the data represents a snapshot from 2017,
which might not reflect current trends or changes. Despite these drawbacks, the study aims to
make a significant contribution to efforts to reduce infant mortality in Papua.

Conclusion
This study underscores the significant impact of residential building quality on infant
mortality rates in Papua Province. It identifies that while factors such as maternal age,
antenatal care, and Tetanus Toxoid immunization are relevant, they do not show a direct
correlation with infant mortality. Deliveries in healthcare facilities are linked to lower
mortality rates, highlighting the necessity of access to quality maternal healthcare services.
Furthermore, the physical condition of living environments plays a crucial role, with
inadequate housing contributing to increased risks for infants. Overall, improving healthcare
access, enhancing living conditions, and promoting maternal health education are essential
steps needed to reduce infant mortality in Papua and similar regions.

Disclosures
Conflict of Interests
The authors declare that there are no conflicts of interest regarding this research. All authors
have contributed to, reviewed, and approved the final manuscript for publication.

Funding
This research did not require or receive any funding and was solely supported by the
researchers, ensuring the independence and impartiality of the research findings and
conclusions. Informed consent was obtained from all participants involved in this study.
Author Contributions
The authors were actively involved in the data collection, screening, and analysis process,
ensuring a comprehensive and detailed evaluation of the research findings. All authors have
approved the final version of the manuscript, collectively ensuring its accuracy and integrity.
They have agreed to the published version, upholding rigorous academic standards and
ensuring the credibility and reliability of the work.

References