Background Most maternal and neonatal deaths occur in low- and middle-income countries and are largely preventable with quality care. In Indonesia, 98% of pregnant people receive antenatal care and birth commonly occurs in community settings or hospitals. Outside of high-income countries, few studies identify where women with pregnancy-related risk factors give birth. Accurate identification of pregnancy risk factors and referral to an appropriate birth setting is considered an essential element of quality antenatal care, though its efficacy in Indonesia is unknown. Methods This study aimed to identify suitable indicators of pregnancy risk factors for Indonesia and examine population-level patterns in pregnancy-related risk, care and appropriateness of birth setting. Risk factors in pregnancy based on internationally relevant referral guidelines were identified from literature search and mapped to available indicators. Using self-reported data from three waves of the Indonesian Demographic Health Survey (2007, 2012, 2017), a representative survey of women aged 15-49 years, we examined receipt of maternity care, prevalence of pregnancy risk factors and time trends in birth setting, overall and by presence of risk factors. Results In the weighted sample (n=43,846), one quarter of women reported pregnancy risk factors. From 2002-2017, numbers of births in hospitals have doubled and births at home have halved. However, the proportions of women with pregnancy risk in each setting remains largely unchanged. Discussion These findings identify opportunities for shifting care in Indonesia to ensure women are receiving the appropriate level of care at birth.

The authors have declared no competing interest.

This study is supported by an Australian Government Research Training Program (RTP) Scholarship provided to the first author. The Australian Government had no input into the topic, design or any other aspect of this research.

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This study received ethical approval from the chair of the Science and Medical Delegated Ethical Review Committee at the Australian National University on 2/10/2018. The protocol number is 2018/643.

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