Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia

Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia Alinda Rahmani, Nareswari Cininta, Qurrata Akyuni, Bayu Priangga, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7380825/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Global cesarean section (CS) rates have nearly doubled in the past two decades, with many countries exceeding the 10–15% threshold recommended by the WHO as medically necessary. While CS can be life-saving in certain obstetric emergencies, its unnecessary use increases maternal and neonatal risks and burdens health systems. In Indonesia, the influence of delivery facility type on CS rates among low-risk pregnancies remains underexplored. Methods We conducted a cross-sectional analytical study using routinely collected maternal health data from a primary health care facility (Puskesmas) and a secondary-level referral hospital in Surabaya, Indonesia, from January 2023 to December 2024. All singleton pregnancies with a recorded Kartu Skor Poedji Rochjati (KSPR) score and documented delivery outcomes were eligible. Descriptive analyses were performed on the full cohort, while comparisons of CS and low birth weight (LBW) outcomes were restricted to women classified as low risk. Pearson’s Chi-square test and multivariable logistic regression were used to compare outcomes and estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Despite being classified as low risk, most women delivered in secondary or tertiary facilities rather than in primary care. Maternal and neonatal outcomes did not significantly differ between facility types; however, delivery in tertiary facilities was independently associated with higher odds of CS (aOR 2.22; 95% CI 1.06–4.63) compared to primary facilities. No significant association was found between facility type and LBW. Conclusion Facility level—not only clinical risk profile—appears to influence intervention rates in low-risk pregnancies. Strengthening the capacity, quality, and public trust in primary-level maternity care could help align service utilization with the intended referral system, reduce unnecessary interventions, and preserve higher-level resources for women with genuine obstetric risks. Background Over the last two decades, global cesarean section (CS) rates have nearly doubled—from around 12% in 2000 to over 21% by 2015—with some regions such as Latin America seeing rates above 40% ( 1 ). While CS can be life-saving in cases of obstetric complications, its routine or non-medically indicated use is associated with increased maternal and neonatal risks, including endometriosis ( 2 ), placenta accreta( 3 ) and also contributes to escalating healthcare costs ( 4 ). Clinical guidelines estimate that CS rates beyond 10–15% may reflect overuse rather than need ( 5 ). In Indonesia and similar low-middle income settings, ensuring that CS is reserved for genuine clinical need—especially in low-risk pregnancies—is critical but under-examined. The place of antenatal care (ANC) and delivery—primary healthcare centers ( Puskesmas ) versus higher-level hospitals—not only determines clinical management options but may also influence delivery mode due to infrastructure, provider availability, and referral patterns. Fragmented ANC and poor integration between facility tiers can undermine quality care and lead to defaults toward CS in higher-level settings( 6 ) This study examines differences in caesarean section (CS) rates and birth outcomes among low-risk pregnancies delivered in Puskesmas and hospital settings. It explores maternal characteristics by facility type, compares the prevalence of CS and low birth weight (LBW) between the two settings, and evaluates the association of these outcomes with selected predictors. Method Study design and setting A cross-sectional analytical study was conducted using routinely collected maternal health data from two sources in Surabaya, Indonesia: ( 1 ) a primary health care facility ( Puskesmas) and ( 2 ) a secondary-level referral hospital. The datasets were synchronized and merged in SPSS version 27 (IBM Corp., Armonk, NY, USA) with a binary indicator variable for facility type. Consecutive sampling was applied, meaning all available pregnancy records from routine service registers and electronic medical records between January 2023 and December 2024 were included if they met eligibility criteria. Inclusion criteria were singleton pregnancies with a recorded Kartu Skor Poedji Rochjati (KSPR) score at the first antenatal care visit and documented delivery outcomes. Both low- and high-risk pregnancies (per KSPR classification) were included in the descriptive analysis to characterize the overall population. For analyses addressing the primary study objectives—comparison of cesarean section and low birthweight outcomes—only women classified as low-risk were analyzed. Records missing delivery mode or birthweight data were excluded from all analyses. Study population The target population comprised pregnant women classified as low obstetric risk according to the Kartu Skor Poedji Rochjati (KSPR), a standardized Indonesian antenatal risk scoring system that identifies high-risk pregnancies based on maternal history, clinical findings, and obstetric factors ( 7 ). For brevity, KSPR will be used throughout the manuscript. Women with documented high-risk features at booking—including obesity, previous uterine surgery, gestational hypertension, preeclampsia, or gestational diabetes mellitus (GDM)—were excluded from the low-risk analytic subgroup. Statistical analysis Descriptive statistics were computed for all study variables. Categorical variables were summarized as frequencies and column percentages. Because the Puskesmas and hospital groups had unequal sample sizes, proportions rather than raw counts were emphasized in descriptive comparisons. Comparisons between Puskesmas and hospital groups were assessed using Pearson’s Chi-square test for categorical variables. All descriptive analyses were performed on the full dataset. For the primary analysis, we conducted a subset analysis restricted to women classified as low risk according to the KSPR criteria. In this subset, bivariable comparisons were performed between facility groups, followed by multivariable binary logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for each outcome. The two outcomes of interest were: ( 1 ) Caesarean section delivery (vs. vaginal birth) and ( 2 ) low birth weight (vs. birth weight ≥ 2500 g). Predictors included in the regression models were antenatal care (ANC) site, birth facility type, maternal age category, parity, and mid-upper arm circumference (MUAC). Reference categories were set as: Puskesmas for ANC site, primary facility for birth facility type, MUAC > 23.5 cm, age < 20 years, and nulliparous status for parity. All statistical tests were two-tailed, and p-values < 0.05 were considered statistically significant. Analyses were conducted using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Table 1 Baseline maternal sociodemographic, clinical characteristics, and outcomes by facility type Characteristic Puskesmas (n = 641) Hospital (n = 245) χ 2 p-value Age < 20 y.o 45 (7%) 7 (2.9%) 15.423 35 y.o 109 (17.1%) 68 (27.6%) Parity Nulliparous 172 (27.4%) 54 (22.0%) 2.998 0.223 Primiparous 192 (30.6%) 76 (28.4%) Multiparous 263 (41.9%) 115 (46.9%) BMI Underweight 41 (6.9%) 3 (1.3%) 51.899 < 0.001* Normal 257 (43%) 65 (27.3%) Overweight 183 (30.6%) 72 (30.3%) Obesity 117 (19.6%) 98 (41.2%) MUAC 23.5 529 (87.1%) 115 (92%) Anemia Normal 374 (72.5%) 178 (72.7%) 3.640 0.303 Mild 116 (22.5%) 49 (20%) Moderate 26 (5%) 17 (6.9%) Severe 0 (0.0%) 1 (0.4%) Gestational Diabetes Mellitus (GDM) Yes 1 (0.2%) 18 (7.3%) 43.677 < 0.001* No 640 (99.8%) 227 (92.7%) Albuminuria Yes 79 (12.3%) 68 (27.8%) 97.977 < 0.001* No 433 (67.6%) 76 (31%) History of Uterine Surgery Yes 80 (12.5%) 128 (14.5%) 157.106 < 0.001* No 561 (87.5%) 116 (47.5%) Gestational Hypertension (GHt) Yes 16 (2.5%) 72 (29.4%) 143.287 < 0.001* No 625 (97.5%) 173 (70.6%) Preeclampsia/Eclampsia Yes 30 (4.7%) 25 (10.2%) 9.289 0.002* No 611 (95.3%) 220 (89.8%) KSPR Low risk 229 (35.7%) 34 (13.9%) 40.535 < 0.001* High risk 412 (64.3%) 211 (86.1%) Delivery at the same place as ANC Yes 128 (20.0%) 245 (100%) 465.747 < 0.001* No 452 (79.5%) 0 (0.0%) Birth Facility Type for Labour Primary 131 (20.4%) 0 (0.0%) 177.773 < 0.001* Secondary 336 (61.4%) 245 (100%) Tertiary 114 (17.8%) 0 (0.0%) Mode Delivery Caesarean section (CS) 265 (45.3%) 172 (72.2%) 49.600 < 0.001* Vaginal Birth (VB) 320 (54.7%) 67 (27.8%) Low Birth Weight (LBW) Yes 65 (10.2%) 29 (12.3%) 0.805 0.370 No 574 (89.8%) 207 (87.7%) BMI (Body mass index). ANC (Antenatal Care). MUAC (Middle Upper Arm Circumference) Among 886 participants, 641 (72.3%) received antenatal care (ANC) at Puskesmas and 245 (27.7%) at hospitals (Table 1 ). Age distribution differed significantly between groups (p 35 years (27.6% vs. 17.1%) and a lower proportion aged < 20 years (2.9% vs. 7.0%). Parity distribution was not significantly different between groups (p = 0.223). BMI categories differed significantly (p < 0.001), with obesity more common in the hospital group (41.2% vs. 19.6%) and underweight more common in the Puskesmas group (6.9% vs. 1.3%). No significant difference was found in MUAC distribution (p = 0.129) or anemia severity (p = 0.303). However, gestational diabetes mellitus (GDM) was more prevalent in the hospital group (7.3% vs. 0.2%, p < 0.001). Similarly, albuminuria, history of uterine surgery, gestational hypertension, and preeclampsia/eclampsia were significantly more frequent in the hospital group (all p < 0.01). KSPR risk classification also differed (p < 0.001), with high-risk pregnancies more common in the hospital group (86.1% vs. 64.3%). All hospital deliveries occurred at the same facility as ANC, while most Puskesmas patients delivered elsewhere (p < 0.001). Regarding facility type for delivery, all hospital group deliveries occurred in secondary-level facilities, whereas Puskesmas patients delivered across primary (20.4%), secondary (61.4%), and tertiary (17.8%) facilities (p < 0.001). Caesarean section rates were higher in the hospital group (72.2% vs. 45.3%, p < 0.001), while low birth weight prevalence did not differ significantly (p = 0.370). Table 2 Birth outcomes among low-risk pregnancies by facility type Outcome (in low risk pregnancy) Puskesmas (n = 229) Hospital (n = 34) (χ²) p-value Birth Facility Type Primary 56 (24.6%) 0 (0.0%) 24.155 < 0.001* Secondary 123 (53.5%) 34 (100%) Tertiary 50 (21.9%) 0 (0.0%) Delivery Mode Caesarean section (CS) 96 (41.6%) 18 (54.8%) 1.937 0.164 Vaginal Birth (VB) 133 (58.4%) 16 (45.2%) Low Birth Weight (LBW) Yes 20 (8.7%) 6 (16.1%) 1.718 0.190 No 209 (91.3%) 28 (83.9%) In the subset of low-risk pregnancies (n = 263), facility type for delivery differed significantly between groups (p < 0.001) (Table 2 ). All hospital patients delivered in secondary-level facilities, whereas Puskesmas patients delivered in primary (24.6%), secondary (53.5%), and tertiary (21.9%) facilities. Mode of delivery did not differ significantly (p = 0.164), although caesarean section was more frequent among hospital patients (54.8% vs. 41.6%). Similarly, the prevalence of low birth weight was higher in the hospital group (16.1% vs. 8.7%) but did not reach statistical significance (p = 0.190). Table 3 Multivariable Logistic Regression Results for low risk pregnancy outcome Caesarean section (CS) Low Birth Weight (LBW) Predictor Adjusted OR 95% CI Lower 95% CI Upper p-value Adjusted OR 95% CI Lower 95% CI Upper p-value ANC site Puskesmas (Ref) - - - - - - - - Hospital 0.549 0.165 1.833 0.517 0.439 0.081 2.386 0.341 Birth Facility Type Primary (Ref) - - - - - - - - Secondary 0.997 0.00 0.00 - 0.946 0.258 3.467 0.933 Tertiary 2.217 1.062 4.628 0.034* 0.459 0.136 1.547 0.209 MUAC > 23.5 (Ref) - - - - - - - - < 23.5 0.797 0.308 2.061 0.640 1.483 0.313 7.036 0.620 Age < 20 (Ref) - - - - - - - - 21–34 0.645 0.199 2.094 0.466 1.362 0.273 6.785 0.706 Parity Nullipara (Ref) - - - - - - - - Primipara 1.176 0.524 2.639 0.694 0.825 0.246 2.771 0.756 Multipara 1.132 0.503 3.548 0.764 0.964 0.314 2.966 0.950 Multivariable binary logistic regression (Table 3 ) adjusting for ANC site, birth facility type, MUAC, age, and parity showed that, among low-risk pregnancies, delivering in a tertiary facility was associated with higher odds of caesarean section compared with primary facilities (adjusted OR = 2.217, 95% CI 1.062–4.628, p = 0.034). No other predictors were significantly associated with either caesarean section or low birth weight. Discussion In this study, we compared maternal characteristics and birth outcomes between Puskesmas and hospital settings, with a specific focus on low-risk pregnancies. In the full cohort, significant differences in maternal age distribution, BMI, and antenatal complications were observed, with hospitals managing a higher proportion of women aged > 35 years, those with obesity, and those with conditions such as gestational diabetes, albuminuria, or hypertensive disorders. These differences align with the intended role of hospitals in the Indonesian referral system, where higher-level facilities are designed to manage complex or high-risk pregnancies ( 8 ). When the analysis was restricted to low-risk pregnancies, the characteristics of women became more comparable across facility types. However, an interesting pattern emerged regarding their choice of delivery location: even without identifiable medical risk factors, most low-risk women delivered in secondary facilities, and a notable proportion in tertiary hospitals, rather than primary care settings. This trend may reflect perceptions of higher safety and better resources in larger hospitals. For instance, studies suggest that women often prefer hospitals due to better availability of medications, improved care for both mother and baby, cultural norms around childbirth, or limited confidence in the capacity of primary care facilities to manage delivery. ( 9 – 11 ). Such utilization patterns may contribute to overburdening higher-level facilities and reducing efficiency in the referral system ( 12 ). In terms of outcomes, caesarean section rates remained higher in hospitals (54.8%) compared to Puskesmas (41.6%) among low-risk women, although this difference was not statistically significant ( p = 0.164). Low birth weight prevalence was also slightly higher in hospital deliveries (16.1% vs. 8.7%), but again without significant difference. Multivariable analysis indicated that tertiary facility delivery was independently associated with increased odds of caesarean section (aOR 2.22; 95% CI 1.06–4.63) compared to primary facilities, whereas ANC site, MUAC, age, and parity were not significant predictors for either outcome. These results suggest that facility level—not just patient risk profile—may influence intervention rates. Although we cannot always predict complications that may arise during normal labor—such as obstructed labor, fetal distress, or abnormal presentation—that could ultimately require a cesarean section, awareness of these potential risks is essential for planning safe deliveries. ( 13 ). The persistence of higher CS rates in tertiary facilities, even for low-risk women, may be influenced by the greater availability of surgical capacity, differing clinical practices, and possibly defensive medicine. International literature has documented that higher-level hospitals often have lower thresholds for intervention, particularly when specialist obstetric care is readily available( 14 ). While this may be beneficial in emergencies, it raises concerns about the potential overuse of caesarean delivery in populations where vaginal birth is safe and recommended. A study showed that Indonesian women generally preferred vaginal delivery, promotional messaging about enhanced recovery after cesarean (ERACS) framed CS as an “advanced” procedure offering comfort and faster recovery, influencing some to view it as equal or superior to vaginal birth. Changes in delivery preferences near birth were often driven by obstetricians’ recommendations, with many women reporting insufficient information on the risks and benefits of each mode and feeling disappointed when their actual birth did not match their preferences ( 15 ). These findings have important implications for maternal health policy and service delivery. Strengthening public confidence in primary-level birth facilities—through adequate staffing, equipment, and training—may encourage low-risk women to utilize these settings. Concurrently, standardized clinical guidelines and consistent monitoring across all facility levels are needed to ensure that caesarean sections are performed only for clear medical indications. Reducing unnecessary utilization of secondary and tertiary facilities for low-risk births could improve system efficiency, lower healthcare costs, and ensure that higher-level resources remain available for women who truly require specialized care. Strengths and Limitations This study focuses exclusively on low-risk pregnancies, reducing confounding from maternal comorbidities and allowing clearer assessment of facility type and ANC site in relation to birth outcomes. Including both primary and higher-level facilities provides insight into service utilization patterns across the referral network. The use of multivariable logistic regression allowed adjustment for ANC site, maternal age, parity, MUAC, birth facility type. Several limitations should be acknowledged. Facility-based research in low- and middle-income countries (LMICs) is often constrained by variations in record-keeping systems, non-standardized variable definitions, and inconsistent data-entry practices. In this study, hospital data export restrictions and incomplete primary care records reduced the available sample size, necessitating a complete-case analysis. These limitations may have reduced statistical power, particularly for less common outcomes. Additionally, as an observational study, residual confounding from unmeasured factors—such as socioeconomic status or patient preference—cannot be ruled out. This study also lacked data on complications arising during cesarean sections in low-risk pregnancies. Future research would benefit from standardized, interoperable data systems and prospective data collection to enhance robustness and comprehensiveness. Conclusion This study found that, despite being classified as low risk, most women in our cohort delivered in secondary and tertiary facilities rather than in primary care settings. While maternal and neonatal outcomes did not significantly differ by facility type, delivery in tertiary facilities was associated with higher odds of caesarean section. These patterns suggest that factors beyond clinical risk—such as patient preference, perceived quality, and health system organization—are shaping delivery site choices and intervention rates. Strengthening the capacity, quality, and public trust in primary-level maternity care could help align service utilization with the intended referral system, optimize resource use, and ensure that higher-level facilities remain accessible for women with genuine obstetric risks. Abbreviations CS Caesarean Section ANC Antenatal Care KSPR Kartu Skor Poedji Rochjati (Poedji Rochjati Score Card) aOR Adjusted Odds Ratio CI Confidence Interval MUAC Mid-Upper Arm Circumference y.o. Years Old BMI Body Mass Index GDM Gestational Diabetes Mellitus GHT Gestational Hypertension VB Vaginal Birth LBW Low Birth Weight LMIC Low- And Middle-Income Countries Declarations Acknowledgement The authors would like to thank all the participants, staff at Puskesmas and hospitals involved in this study, and colleagues who provided guidance and support throughout the research process. Authors Contribution AR: Conceptualization, Methodology, Formal analysis, Writing – original draft, Project administration. NC: Data curation, Validation, Writing – review & editing. QA: Investigation, Resources, Data curation. BP: Supervision, Visualization, Writing – review & editing. EG: Supervision, Writing – review & editing. All authors have read and approved the final manuscript. Funding This research received no specific funding. Data Availability Data is provided within the manuscript. Ethics approval and consent to participate This study was approved by the Airlangga University Dental Medicine Health Research Ethical Clearance Commission (Approval No. 0118/HRECC.FODM/II/2025, issued on February 6, 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki. Given the retrospective design that relied solely on existing medical records, written informed consent was not applicable, and the requirement for informed consent was formally waived by the Ethics Committee. Consent for Publication Not Applicable Competing Interest The authors declare that they have no competing interests. References Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Health. 2021;6(6). Zhang P, Sun Y, Zhang C, Yang Y, Zhang L, Wang N, et al. Cesarean scar endometriosis: Presentation of 198 cases and literature review. BMC Women’s Health. Volume 19. BioMed Central Ltd.; 2019. Alavi SM, Arjmandnia MH, Feizollahjani M, Noori E, Yousefi M. Placenta Accreta Spectrum; Risk Factors, Complications, Advantages and Disadvantages to Decrease Maternal Morbidity and Mortality. J Obstet Gynecol Cancer Res. 2024;9(5):516–21. Haider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM. Ever-increasing Caesarean section and its economic burden in Bangladesh. PLoS ONE. 2018;13(12). World Health Organization. WHO Statement on Caesarean Section Rates. 2015. 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Konlan KD, Baku EK, Japiong M, Dodam Konlan K, Amoah RM. Reasons for Women’s Choice of Elective Caesarian Section in Duayaw Nkwanta Hospital. J Pregnancy. 2019;2019. Murray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Soc Sci Med [Internet]. 2006;62(9):2205–15. Available from: https://www.sciencedirect.com/science/article/pii/S0277953605005514 Abebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: A retrospective record review. Volume 13. Reproductive Health: BioMed Central Ltd.; 2016. Glantz JC. Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less. 2012. Zahroh RI, Hazfiarini A, Martiningtyas MAD, Ekawati FM, Emilia O, Cheong M et al. Rising caesarean section rates and factors affecting women’s decision-making about mode of birth in Indonesia: a longitudinal qualitative study. BMJ Glob Health. 2024;9(6). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 28 Sep, 2025 Reviewers agreed at journal 20 Sep, 2025 Reviewers invited by journal 18 Sep, 2025 Editor assigned by journal 15 Sep, 2025 Editor invited by journal 25 Aug, 2025 Submission checks completed at journal 24 Aug, 2025 First submitted to journal 24 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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08:41:32","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76941,"visible":true,"origin":"","legend":"","description":"","filename":"5972482c642f40a6a59aa059f36607bb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7380825/v1/79b6cab0f510fe039fc95f6f.xml"},{"id":92391889,"identity":"3af788ae-8b33-4665-a33c-d0bce0cc6ad6","added_by":"auto","created_at":"2025-09-29 08:41:35","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83263,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7380825/v1/92ccd9b617daf9e6ae954f2f.html"},{"id":92392184,"identity":"361a6d68-cf60-4abb-b414-4488597ff610","added_by":"auto","created_at":"2025-09-29 08:48:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":966588,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7380825/v1/9edb8ad1-3b07-4b25-a47e-a2b95761f442.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the last two decades, global cesarean section (CS) rates have nearly doubled\u0026mdash;from around 12% in 2000 to over 21% by 2015\u0026mdash;with some regions such as Latin America seeing rates above 40% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). While CS can be life-saving in cases of obstetric complications, its routine or non-medically indicated use is associated with increased maternal and neonatal risks, including endometriosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), placenta accreta(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and also contributes to escalating healthcare costs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Clinical guidelines estimate that CS rates beyond 10\u0026ndash;15% may reflect overuse rather than need (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Indonesia and similar low-middle income settings, ensuring that CS is reserved for genuine clinical need\u0026mdash;especially in low-risk pregnancies\u0026mdash;is critical but under-examined.\u003c/p\u003e\u003cp\u003eThe place of antenatal care (ANC) and delivery\u0026mdash;primary healthcare centers (\u003cem\u003ePuskesmas\u003c/em\u003e) versus higher-level hospitals\u0026mdash;not only determines clinical management options but may also influence delivery mode due to infrastructure, provider availability, and referral patterns. Fragmented ANC and poor integration between facility tiers can undermine quality care and lead to defaults toward CS in higher-level settings(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) This study examines differences in caesarean section (CS) rates and birth outcomes among low-risk pregnancies delivered in \u003cem\u003ePuskesmas\u003c/em\u003e and hospital settings. It explores maternal characteristics by facility type, compares the prevalence of CS and low birth weight (LBW) between the two settings, and evaluates the association of these outcomes with selected predictors.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eA cross-sectional analytical study was conducted using routinely collected maternal health data from two sources in Surabaya, Indonesia: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a primary health care facility (\u003cem\u003ePuskesmas)\u003c/em\u003e and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) a secondary-level referral hospital. The datasets were synchronized and merged in SPSS version 27 (IBM Corp., Armonk, NY, USA) with a binary indicator variable for facility type. Consecutive sampling was applied, meaning all available pregnancy records from routine service registers and electronic medical records between January 2023 and December 2024 were included if they met eligibility criteria.\u003c/p\u003e\u003cp\u003eInclusion criteria were singleton pregnancies with a recorded Kartu Skor Poedji Rochjati (KSPR) score at the first antenatal care visit and documented delivery outcomes. Both low- and high-risk pregnancies (per KSPR classification) were included in the descriptive analysis to characterize the overall population. For analyses addressing the primary study objectives\u0026mdash;comparison of cesarean section and low birthweight outcomes\u0026mdash;only women classified as low-risk were analyzed. Records missing delivery mode or birthweight data were excluded from all analyses.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe target population comprised pregnant women classified as low obstetric risk according to the \u003cem\u003eKartu Skor Poedji Rochjati\u003c/em\u003e (KSPR), a standardized Indonesian antenatal risk scoring system that identifies high-risk pregnancies based on maternal history, clinical findings, and obstetric factors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For brevity, KSPR will be used throughout the manuscript. Women with documented high-risk features at booking\u0026mdash;including obesity, previous uterine surgery, gestational hypertension, preeclampsia, or gestational diabetes mellitus (GDM)\u0026mdash;were excluded from the low-risk analytic subgroup.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were computed for all study variables. Categorical variables were summarized as frequencies and column percentages. Because the \u003cem\u003ePuskesmas\u003c/em\u003e and hospital groups had unequal sample sizes, proportions rather than raw counts were emphasized in descriptive comparisons. Comparisons between \u003cem\u003ePuskesmas\u003c/em\u003e and hospital groups were assessed using Pearson\u0026rsquo;s Chi-square test for categorical variables. All descriptive analyses were performed on the full dataset.\u003c/p\u003e\u003cp\u003eFor the primary analysis, we conducted a subset analysis restricted to women classified as low risk according to the KSPR criteria. In this subset, bivariable comparisons were performed between facility groups, followed by multivariable binary logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for each outcome. The two outcomes of interest were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Caesarean section delivery (vs. vaginal birth) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) low birth weight (vs. birth weight\u0026thinsp;\u0026ge;\u0026thinsp;2500 g). Predictors included in the regression models were antenatal care (ANC) site, birth facility type, maternal age category, parity, and mid-upper arm circumference (MUAC). Reference categories were set as: \u003cem\u003ePuskesmas\u003c/em\u003e for ANC site, primary facility for birth facility type, MUAC\u0026thinsp;\u0026gt;\u0026thinsp;23.5 cm, age\u0026thinsp;\u0026lt;\u0026thinsp;20 years, and nulliparous status for parity. All statistical tests were two-tailed, and p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. Analyses were conducted using SPSS version 27 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e maternal sociodemographic, clinical characteristics, and outcomes by facility type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ePuskesmas\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;641)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital (n\u0026thinsp;=\u0026thinsp;245)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20 y.o\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (2.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e15.423\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;34 y.o\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e487 (75.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e170 (69.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;35 y.o\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e109 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68 (27.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNulliparous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172 (27.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (22.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e2.998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.223\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimiparous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e192 (30.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (28.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiparous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e263 (41.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115 (46.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderweight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (6.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e51.899\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e257 (43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65 (27.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverweight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e183 (30.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (30.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObesity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e117 (19.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98 (41.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMUAC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;23.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78 (12.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.305\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.129\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;23.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e529 (87.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115 (92%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnemia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e374 (72.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e178 (72.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e3.640\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.303\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (22.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (6.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational Diabetes Mellitus (GDM)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (7.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e43.677\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e640 (99.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e227 (92.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAlbuminuria\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (12.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68 (27.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e97.977\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e433 (67.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (31%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHistory of Uterine Surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128 (14.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e157.106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e561 (87.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e116 (47.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational Hypertension (GHt)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (29.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e143.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e625 (97.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e173 (70.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePreeclampsia/Eclampsia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (4.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (10.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e9.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e611 (95.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e220 (89.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKSPR\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e229 (35.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (13.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e40.535\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e412 (64.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e211 (86.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDelivery at the same place as ANC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e128 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e245 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e465.747\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e452 (79.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth Facility Type for Labour\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e131 (20.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e177.773\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e336 (61.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e245 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114 (17.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode Delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaesarean section (CS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e265 (45.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e172 (72.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e49.600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal Birth (VB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e320 (54.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (27.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLow Birth Weight (LBW)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65 (10.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (12.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.805\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.370\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e574 (89.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e207 (87.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (Body mass index). ANC (Antenatal Care). MUAC (Middle Upper Arm Circumference)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong 886 participants, 641 (72.3%) received antenatal care (ANC) at \u003cem\u003ePuskesmas\u003c/em\u003e and 245 (27.7%) at hospitals (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Age distribution differed significantly between groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the hospital group having a higher proportion of mothers aged\u0026thinsp;\u0026gt;\u0026thinsp;35 years (27.6% vs. 17.1%) and a lower proportion aged\u0026thinsp;\u0026lt;\u0026thinsp;20 years (2.9% vs. 7.0%).\u003c/p\u003e\u003cp\u003eParity distribution was not significantly different between groups (p\u0026thinsp;=\u0026thinsp;0.223). BMI categories differed significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with obesity more common in the hospital group (41.2% vs. 19.6%) and underweight more common in the \u003cem\u003ePuskesmas\u003c/em\u003e group (6.9% vs. 1.3%).\u003c/p\u003e\u003cp\u003eNo significant difference was found in MUAC distribution (p\u0026thinsp;=\u0026thinsp;0.129) or anemia severity (p\u0026thinsp;=\u0026thinsp;0.303). However, gestational diabetes mellitus (GDM) was more prevalent in the hospital group (7.3% vs. 0.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, albuminuria, history of uterine surgery, gestational hypertension, and preeclampsia/eclampsia were significantly more frequent in the hospital group (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eKSPR risk classification also differed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with high-risk pregnancies more common in the hospital group (86.1% vs. 64.3%). All hospital deliveries occurred at the same facility as ANC, while most \u003cem\u003ePuskesmas\u003c/em\u003e patients delivered elsewhere (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eRegarding facility type for delivery, all hospital group deliveries occurred in secondary-level facilities, whereas \u003cem\u003ePuskesmas\u003c/em\u003e patients delivered across primary (20.4%), secondary (61.4%), and tertiary (17.8%) facilities (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Caesarean section rates were higher in the hospital group (72.2% vs. 45.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while low birth weight prevalence did not differ significantly (p\u0026thinsp;=\u0026thinsp;0.370).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBirth outcomes among low-risk pregnancies by facility type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003cp\u003e(in low risk pregnancy)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ePuskesmas\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;229)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(χ\u0026sup2;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eBirth Facility Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56 (24.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e24.155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e123 (53.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (21.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDelivery Mode\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaesarean section (CS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96 (41.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (54.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.937\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.164\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal Birth (VB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133 (58.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (45.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLow Birth Weight (LBW)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (8.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (16.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.718\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e209 (91.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (83.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the subset of low-risk pregnancies (n\u0026thinsp;=\u0026thinsp;263), facility type for delivery differed significantly between groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All hospital patients delivered in secondary-level facilities, whereas \u003cem\u003ePuskesmas\u003c/em\u003e patients delivered in primary (24.6%), secondary (53.5%), and tertiary (21.9%) facilities.\u003c/p\u003e\u003cp\u003eMode of delivery did not differ significantly (p\u0026thinsp;=\u0026thinsp;0.164), although caesarean section was more frequent among hospital patients (54.8% vs. 41.6%). Similarly, the prevalence of low birth weight was higher in the hospital group (16.1% vs. 8.7%) but did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.190).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariable Logistic Regression Results for low risk pregnancy outcome\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eCaesarean section (CS)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eLow Birth Weight (LBW)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdjusted OR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI Lower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI Upper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted OR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI Lower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95% CI Upper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANC site\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePuskesmas\u003c/em\u003e (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.549\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.833\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.517\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.439\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.386\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.341\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth Facility Type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.997\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.946\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.258\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3.467\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.933\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.628\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.034*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.459\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.209\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMUAC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;23.5 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;23.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.797\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.640\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.483\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e7.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.620\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.466\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.785\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.706\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNullipara (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimipara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.524\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.639\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.771\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.756\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultipara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.503\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.548\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.764\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.964\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.966\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.950\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultivariable binary logistic regression (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) adjusting for ANC site, birth facility type, MUAC, age, and parity showed that, among low-risk pregnancies, delivering in a tertiary facility was associated with higher odds of caesarean section compared with primary facilities (adjusted OR\u0026thinsp;=\u0026thinsp;2.217, 95% CI 1.062\u0026ndash;4.628, p\u0026thinsp;=\u0026thinsp;0.034). No other predictors were significantly associated with either caesarean section or low birth weight.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we compared maternal characteristics and birth outcomes between \u003cem\u003ePuskesmas\u003c/em\u003e and hospital settings, with a specific focus on low-risk pregnancies. In the full cohort, significant differences in maternal age distribution, BMI, and antenatal complications were observed, with hospitals managing a higher proportion of women aged\u0026thinsp;\u0026gt;\u0026thinsp;35 years, those with obesity, and those with conditions such as gestational diabetes, albuminuria, or hypertensive disorders. These differences align with the intended role of hospitals in the Indonesian referral system, where higher-level facilities are designed to manage complex or high-risk pregnancies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhen the analysis was restricted to low-risk pregnancies, the characteristics of women became more comparable across facility types. However, an interesting pattern emerged regarding their choice of delivery location: even without identifiable medical risk factors, most low-risk women delivered in secondary facilities, and a notable proportion in tertiary hospitals, rather than primary care settings. This trend may reflect perceptions of higher safety and better resources in larger hospitals. For instance, studies suggest that women often prefer hospitals due to better availability of medications, improved care for both mother and baby, cultural norms around childbirth, or limited confidence in the capacity of primary care facilities to manage delivery. (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Such utilization patterns may contribute to overburdening higher-level facilities and reducing efficiency in the referral system (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn terms of outcomes, caesarean section rates remained higher in hospitals (54.8%) compared to \u003cem\u003ePuskesmas\u003c/em\u003e (41.6%) among low-risk women, although this difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.164). Low birth weight prevalence was also slightly higher in hospital deliveries (16.1% vs. 8.7%), but again without significant difference. Multivariable analysis indicated that tertiary facility delivery was independently associated with increased odds of caesarean section (aOR 2.22; 95% CI 1.06\u0026ndash;4.63) compared to primary facilities, whereas ANC site, MUAC, age, and parity were not significant predictors for either outcome. These results suggest that facility level\u0026mdash;not just patient risk profile\u0026mdash;may influence intervention rates. Although we cannot always predict complications that may arise during normal labor\u0026mdash;such as obstructed labor, fetal distress, or abnormal presentation\u0026mdash;that could ultimately require a cesarean section, awareness of these potential risks is essential for planning safe deliveries. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe persistence of higher CS rates in tertiary facilities, even for low-risk women, may be influenced by the greater availability of surgical capacity, differing clinical practices, and possibly defensive medicine. International literature has documented that higher-level hospitals often have lower thresholds for intervention, particularly when specialist obstetric care is readily available(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). While this may be beneficial in emergencies, it raises concerns about the potential overuse of caesarean delivery in populations where vaginal birth is safe and recommended. A study showed that Indonesian women generally preferred vaginal delivery, promotional messaging about enhanced recovery after cesarean (ERACS) framed CS as an \u0026ldquo;advanced\u0026rdquo; procedure offering comfort and faster recovery, influencing some to view it as equal or superior to vaginal birth. Changes in delivery preferences near birth were often driven by obstetricians\u0026rsquo; recommendations, with many women reporting insufficient information on the risks and benefits of each mode and feeling disappointed when their actual birth did not match their preferences (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings have important implications for maternal health policy and service delivery. Strengthening public confidence in primary-level birth facilities\u0026mdash;through adequate staffing, equipment, and training\u0026mdash;may encourage low-risk women to utilize these settings. Concurrently, standardized clinical guidelines and consistent monitoring across all facility levels are needed to ensure that caesarean sections are performed only for clear medical indications. Reducing unnecessary utilization of secondary and tertiary facilities for low-risk births could improve system efficiency, lower healthcare costs, and ensure that higher-level resources remain available for women who truly require specialized care.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study focuses exclusively on low-risk pregnancies, reducing confounding from maternal comorbidities and allowing clearer assessment of facility type and ANC site in relation to birth outcomes. Including both primary and higher-level facilities provides insight into service utilization patterns across the referral network. The use of multivariable logistic regression allowed adjustment for ANC site, maternal age, parity, MUAC, birth facility type.\u003c/p\u003e\u003cp\u003eSeveral limitations should be acknowledged. Facility-based research in low- and middle-income countries (LMICs) is often constrained by variations in record-keeping systems, non-standardized variable definitions, and inconsistent data-entry practices. In this study, hospital data export restrictions and incomplete primary care records reduced the available sample size, necessitating a complete-case analysis. These limitations may have reduced statistical power, particularly for less common outcomes. Additionally, as an observational study, residual confounding from unmeasured factors\u0026mdash;such as socioeconomic status or patient preference\u0026mdash;cannot be ruled out. This study also lacked data on complications arising during cesarean sections in low-risk pregnancies. Future research would benefit from standardized, interoperable data systems and prospective data collection to enhance robustness and comprehensiveness.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that, despite being classified as low risk, most women in our cohort delivered in secondary and tertiary facilities rather than in primary care settings. While maternal and neonatal outcomes did not significantly differ by facility type, delivery in tertiary facilities was associated with higher odds of caesarean section. These patterns suggest that factors beyond clinical risk\u0026mdash;such as patient preference, perceived quality, and health system organization\u0026mdash;are shaping delivery site choices and intervention rates. Strengthening the capacity, quality, and public trust in primary-level maternity care could help align service utilization with the intended referral system, optimize resource use, and ensure that higher-level facilities remain accessible for women with genuine obstetric risks.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCaesarean Section\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntenatal Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKSPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eKartu Skor Poedji Rochjati\u003c/em\u003e (Poedji Rochjati Score Card)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eaOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMUAC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMid-Upper Arm Circumference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ey.o.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eYears Old\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGestational Diabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGHT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGestational Hypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVaginal Birth\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLBW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow Birth Weight\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow- And Middle-Income Countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants, staff at Puskesmas and hospitals involved in this study, and colleagues who provided guidance and support throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAR: Conceptualization, Methodology, Formal analysis, Writing \u0026ndash; original draft, Project administration.\u003c/p\u003e\n\u003cp\u003eNC: Data curation, Validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eQA: Investigation, Resources, Data curation.\u003c/p\u003e\n\u003cp\u003eBP: Supervision, Visualization, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eEG: Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Airlangga University Dental Medicine Health Research Ethical Clearance Commission (Approval No. 0118/HRECC.FODM/II/2025, issued on February 6, 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki. Given the retrospective design that relied solely on existing medical records, written informed consent was not applicable, and the requirement for informed consent was formally waived by the Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBetran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Health. 2021;6(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang P, Sun Y, Zhang C, Yang Y, Zhang L, Wang N, et al. Cesarean scar endometriosis: Presentation of 198 cases and literature review. BMC Women\u0026rsquo;s Health. Volume 19. BioMed Central Ltd.; 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlavi SM, Arjmandnia MH, Feizollahjani M, Noori E, Yousefi M. Placenta Accreta Spectrum; Risk Factors, Complications, Advantages and Disadvantages to Decrease Maternal Morbidity and Mortality. J Obstet Gynecol Cancer Res. 2024;9(5):516\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaider MR, Rahman MM, Moinuddin M, Rahman AE, Ahmed S, Khan MM. Ever-increasing Caesarean section and its economic burden in Bangladesh. PLoS ONE. 2018;13(12).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO Statement on Caesarean Section Rates. 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFabbro MRC, Wernet M, Baraldi NG, de Castro Bussadori JC, Salim NR, Souto BGA et al. Antenatal care as a risk factor for caesarean section: a case study in Brazil. BMC Pregnancy Childbirth. 2022;22(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSihotang J, Hidayatullah A. Kartu Skor Pedji Rochyati in the Indonesian Maternal Referral System. Journal of Obstetrics \u0026amp; Gynecology Science [Internet]. 2024;32(1):44\u0026ndash;53. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://e-journal.unair.ac.id/MOG/\u003c/span\u003e\u003cspan address=\"https://e-journal.unair.ac.id/MOG/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRyan LM, Mahmood MA, Mufiddah I, Yulianti M, Laurence CO. Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level. PLoS ONE. 2022;17(12 December).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhattacharyya S, Srivastava A, Roy R, Avan BI. Factors influencing women\u0026rsquo;s preference for health facility deliveries in Jharkhand state, India: A cross sectional analysis. BMC Pregnancy Childbirth. 2016;16(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEfendi F, Ni\u0026rsquo;Mah AR, Hadisuyatmana S, Kuswanto H, Lindayani L, Berliana SM. Determinants of facility-based childbirth in Indonesia. Scientific World Journal. 2019;2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKonlan KD, Baku EK, Japiong M, Dodam Konlan K, Amoah RM. Reasons for Women\u0026rsquo;s Choice of Elective Caesarian Section in Duayaw Nkwanta Hospital. J Pregnancy. 2019;2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Soc Sci Med [Internet]. 2006;62(9):2205\u0026ndash;15. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S0277953605005514\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S0277953605005514\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: A retrospective record review. Volume 13. Reproductive Health: BioMed Central Ltd.; 2016.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlantz JC. Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less. 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZahroh RI, Hazfiarini A, Martiningtyas MAD, Ekawati FM, Emilia O, Cheong M et al. Rising caesarean section rates and factors affecting women\u0026rsquo;s decision-making about mode of birth in Indonesia: a longitudinal qualitative study. BMJ Glob Health. 2024;9(6).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7380825/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7380825/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Global cesarean section (CS) rates have nearly doubled in the past two decades, with many countries exceeding the 10–15% threshold recommended by the WHO as medically necessary. While CS can be life-saving in certain obstetric emergencies, its unnecessary use increases maternal and neonatal risks and burdens health systems. In Indonesia, the influence of delivery facility type on CS rates among low-risk pregnancies remains underexplored.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e We conducted a cross-sectional analytical study using routinely collected maternal health data from a primary health care facility (Puskesmas) and a secondary-level referral hospital in Surabaya, Indonesia, from January 2023 to December 2024. All singleton pregnancies with a recorded Kartu Skor Poedji Rochjati (KSPR) score and documented delivery outcomes were eligible. Descriptive analyses were performed on the full cohort, while comparisons of CS and low birth weight (LBW) outcomes were restricted to women classified as low risk. Pearson’s Chi-square test and multivariable logistic regression were used to compare outcomes and estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Despite being classified as low risk, most women delivered in secondary or tertiary facilities rather than in primary care. Maternal and neonatal outcomes did not significantly differ between facility types; however, delivery in tertiary facilities was independently associated with higher odds of CS (aOR 2.22; 95% CI 1.06–4.63) compared to primary facilities. No significant association was found between facility type and LBW.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eFacility level—not only clinical risk profile—appears to influence intervention rates in low-risk pregnancies. Strengthening the capacity, quality, and public trust in primary-level maternity care could help align service utilization with the intended referral system, reduce unnecessary interventions, and preserve higher-level resources for women with genuine obstetric risks.\u003c/p\u003e","manuscriptTitle":"Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-29 08:40:13","doi":"10.21203/rs.3.rs-7380825/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-28T22:20:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4671116985071331388424939680620227907","date":"2025-09-20T12:29:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T08:10:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T15:43:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-25T12:06:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-24T05:02:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-24T04:59:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4488e2e-95fe-4eae-9d0f-b85d4b85fcd9","owner":[],"postedDate":"September 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T08:40:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-29 08:40:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7380825","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7380825","identity":"rs-7380825","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}