Objectives: To examine the association between midwife density, other characteristics of midwifery provision and village contextual factors, and the percentage of births attended by a health professional and deliveries via caesarean section in two districts in West Java, Indonesia. Methods: Analysis of: (i) a census of midwives; (ii) a population-based survey of women who had delivered over a 2-year period; (iii) a census of all caesareans in the four hospitals serving the two districts; and (iv) data from National Statistical Office. Results: At an average density of 2.2 midwives per 10 000 population, 33% of births are with a health professional, and 1% by caesarean section. Having at least six midwives per 10 000 population was associated with a fourfold increase in caesareans [adjusted risk ratio (RR) 4.3: 95% confidence interval (CI): 3.3-5.5] and a threefold increase in the odds of having a health professional attend the delivery [adjusted odds ratio (OR) 2.88: 95% CI: 0.96-8.70]. The assigned midwife's professional status and the duration of her service in the village were also associated with higher rates of health professionals' attendance of delivery and caesareans. Regardless of the provision of services, women's education and wealth were strong predictors of delivery with a health professional. Conclusions: Promoting a stable workforce of midwives, better financial access for the poor and expanding female education are important for the achievement of the fifth Millennium Development Goal (MDG-5).
Tropical Medicine and International Health, doi:10.1111/j.1365-3156.2007.01957.x, volume 12, no. 12, pp. 1490-1497, 2007