Comparative analysis of diploma and undergraduate midwifery students’ perceptions of inclusive maternity care in Indonesia, 2024–2025

Amalia, Rizki; Agus Salim, Lutfi; Indriani, Diah; Cherry Mustamu, Alva; Hafni Hasim, Nur

doi:10.48307/nms.2025.512623.1588

Comparative analysis of diploma and undergraduate midwifery students’ perceptions of inclusive maternity care in Indonesia, 2024–2025

Document Type : Original Article

Authors

Rizki Amalia ¹

Lutfi Agus Salim ²

Diah Indriani ²

Alva Cherry Mustamu ³

Nur Hafni Hasim ³

¹ Department of Doctoral Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya, East Java, Indonesia AND Department of Midwifery, Faculty of Nursing and Midwifery, Universitas Nahdlatul Ulama Surabaya, East Java, Indonesia

² Department of Epidemiology, Biostatistics and Behavioural Science, Faculty of Public Health, Universitas Airlangga, Surabaya, East Java, Indonesia

³ Department of Nursing, Ministry of Health Polytechnic of Sorong, Sorong, Papua, Indonesia

10.48307/nms.2025.512623.1588

Abstract

Background: Inclusive maternity care is critical for achieving equitable health outcomes, particularly in remote regions where access and cultural barriers persist. Midwifery education plays a central role in preparing students to deliver such care; however, comparative evidence between diploma and undergraduate programs in Indonesia remains limited.
Objectives: This study aimed to compare final-year diploma and undergraduate midwifery students’ perceptions of inclusive maternity care in Southwest Papua.
Methods: A cross-sectional survey was conducted between June 2024 and January 2025 among 143 students (68 diploma, 75 undergraduate) selected via stratified random sampling. Data were collected using a validated questionnaire that assessed inclusivity across six domains: accessibility, equality and non-discrimination, respect and dignity in care, effective communication, patient-centred care, and cross-sectoral collaboration. Data were analyzed with independent t-tests and chi-square tests.
Results: Undergraduate students demonstrated significantly higher scores in understanding (mean 4.2 vs. 3.8, P=0.02) and preparedness (mean 4.0 vs. 3.7, P=0.04) for inclusive care, whereas diploma students more frequently reported limited hands-on training as a primary barrier (73.5% vs. 60.0%, P=0.04). No significant differences were observed across the six domains, though both groups identified communication -particularly with patients with disabilities- as the weakest aspect, with agreement rates of 62.7% (undergraduate) and 55.9% (diploma).
Conclusion: Educational level influences students’ readiness but does not significantly affect overall attitudes toward inclusivity. Enhancing practical exposure, disability-sensitive communication skills, and institutional support is essential to translating inclusive maternity care policies into practice in Indonesia’s underserved regions.

Keywords

Midwifery education

Culturally competent care

Maternal health services

Students

Health occupations

Subjects

Midwifery

1. Ven C, Marella M, Vaughan C, Slade S, Devine A. Factors influencing the capacity of healthcare providers to deliver disability-inclusive maternity care services: A scoping review. Midwifery. 2025;143:104321. doi:10.1016/j.midw.2025.104321.

2. Bolarinwa O, Mohammed A, Igharo V, Shongwe S. Leveraging artificial intelligence for inclusive maternity care: enhancing access for mothers with disabilities in Africa. Women’s Health (Lond Engl). 2025;21. doi:10.1177/17455057251326675.

3. Yadav RK, Kaphle HP, Yadav DK, Marahatta SB, Shah NP, Baral S, et al. Health related quality of life and associated factors with medication adherence among tuberculosis patients in selected districts of Gandaki Province of Nepal. J Clin Tuberc Other Mycobact Dis. 2021;23:100235. doi:10.1016/j.jctube.2021.100235. PMID:33997309; PMCID:PMC8095181.

4. Kaphle S, Vaughan G, Subedi M. Respectful maternity care in south Asia: What does the evidence say? Experiences of care and neglect, associated vulnerabilities and social complexities. Int J Womens Health. 2022;14:847-79. doi:10.2147/IJWH.S341907. PMID:35837023; PMCID:PMC9273984.

5. Syairaji M, Nurdiati DS, Wiratama BS, Prüst ZD, Bloemenkamp KWM, Verschueren KJC. Trends and causes of maternal mortality in Indonesia: a systematic review. BMC Pregnancy Childbirth. 2024;24(1):515. doi:10.1186/s12884-024-06687-6. PMID:39080562; PMCID:PMC11290122.

6. Suparji S, Nugroho HSW, Sunarto S, Prayogi AS. High maternal mortality rate in Indonesia: a challenge to be addressed immediately. PAMJ One Health. 2024;14:13. doi:10.11604/pamj-oh.2024.14.13.44464.

7. Laily D, Prasetyo B, Jayanti RD. Correlation between parity and residence with maternal mortality due to miscarriage and abortion in Papua Province in 2020. J Health Sci (Univ Nahdlatul Ulama Surabaya). 2025;18(1):12-8. doi:10.33086/jhs.v18i01.6901.

8. Bonifasius, Kayika IPG, Madjid OA, Adjie JMS, Rumopa HIM. Effectiveness of telemedicine on maternal health practices among pregnant women in rural areas. Indones J Obstet Gynecol. 2024; 12 (3):179-85. doi:10.32771/inajog.v12i3.2100.

9. Safitri DL, Handayani S, Prasetyo B, Jayanti RD. Maternal, socioeconomic and healthcare factors associated with postpartum maternal mortality in Papua Province, Indonesia, based on secondary data analysis of IDHS 2020. J Obstet Ginekol Indones. 2025;33(2):97-104. doi:10.20473/mog.V33I22025.97-104.

10. Yihune Teshale M, Bante A, Gedefaw Belete A, Crutzen R, Spigt M, Stutterheim SE. Barriers and facilitators to maternal healthcare in East Africa: a systematic review and qualitative synthesis of perspectives from women, their families, healthcare providers, and key stakeholders. BMC Pregnancy Childbirth. 2025;25(1):111. doi:10.1186/s12884-025-07225-8. PMID:39901111; PMCID:PMC11792318.

11. Tilahun BD, Ayele M, Alamaw AW, Lake ES, Abate BB, Yilak G, et al. Determinants of traditional birth attendant utilisation among reproductive age women in Ethiopia: a multilevel analysis of the 2019 Ethiopian Demographic and Health Survey. BMJ Open. 2024;14(12):e087290. doi:10.1136/bmjopen-2024-087290. PMID:39653564; PMCID:PMC11628947.

12. Ven C, Marella M, Vaughan C, Devine A. "I feel like I'm not confident enough": A qualitative study of Cambodian midwives' experiences in disability-inclusive maternity care. Midwifery. 2025;148:104472. doi:10.1016/j.midw.2025.104472. PMID:40466528.

13. Solanky P, Shah H. Determinants of place of delivery among women in indigenous communities of western India: A mixed-methods exploratory study. J Prev Complement Med. 2025; 4(3): 157-166. doi: 10.22034/jpcm.2025.532275.1229

14. Adnani QES, Okinarum GY, Muchlis M, Susanti AI, Gumilang L, Adepoju VA, et al. Scope, significance and sustaining the midwifery profession in Indonesia: Commentary. Midwifery. 2025;142:104286. doi:10.1016/j.midw.2025.104286. PMID:39837155.

15. Graham K, Colquhoun S, LaBond C, Housen T, Mohale H, Campbell S, et al. The preparedness and readiness of rural and remote primary care midwives working in low- and middle-income countries: A scoping review. Women Birth. 2025;38(2): 101866. doi:10.1016/j.wombi.2024.101866. PMID:39952195.

16. Adnani QES, Chairiyah R, Argaheni NB, Khuzaiyah S, Widyasih H, Telfer M. Decoding newly graduated midwives: a value-based philosophy of vocational and professional midwifery program in Indonesia. Midwifery. 2025;141:104239. doi:10.1016/j.midw.2024.104239.

17. Adnani QES, Gilkison A, McAra-Couper J. Strengthening midwifery education through clinical experience: Findings from a qualitative study in Indonesia. Women Birth. 2022;35(1):87-95. doi:10.1016/j.wombi.2022.04.005. PMID:33745822.

18. Gordon RD, Kishi A, Brown JA, Voisin C, Thomas N, Riley SR, et al. Rural maternal health interventions: A scoping review and implications for best practices. J Rural Health. 2025;41(1):e70007. doi:10.1111/jrh.70007. PMID:40029019; PMCID:PMC11874679.

19. Hazfiarini A, Akter S, Homer CSE, Zahroh RI, Bohren MA. 'We are going into battle without appropriate armour': A qualitative study of Indonesian midwives' experiences in providing maternity care during the COVID-19 pandemic. Women Birth. 2022;35(5):466-74. doi:10.1016/j.wombi.2021.10.003. PMID:34656517; PMCID:PMC9239738.

20. Adnani QES. Progress and challenges of midwifery education in Indonesia. Eur J Midwifery. 2021;5:50. doi:10.18332/ejm/142496.

21. Adnani QES, Gilkison A, McAra-Couper J. The interplay of structural and external factors for strengthening midwifery education in Indonesia. Sex Reprod Healthc. 2022;33:100734. doi:10.1016/j.srhc.2022.100734. PMID:35640525.

22. Kubota S, Ando M, Murray J, Khambounheuang S, Theppanya K, Nanthavong P, et al. A regulatory gap analysis of midwifery to deliver essential reproductive, maternal, newborn, child and adolescent health services in Lao People's Democratic Republic. Lancet Reg Health West Pac. 2023;43:100960. doi:10.1016/j.lanwpc.2023.100960. PMID:38146489; PMCID:PMC10749282.

23. Koksoy Vayisoglu S, Aydin Besen M, Oncu E. Perspectives of midwifery and nursing students on recommending the COVID-19 vaccine to women of reproductive age and factors influencing counseling competency: a cross-sectional study. J Prev Complement Med. 2024; 3(1): 1-11. doi: 10.22034/ncm.2023.418212.1133

24. Staples N, Collett J, Gild M, Hong J, Huq F, Shone J, et al. Variation in students' experiences and approaches to learning during early clinical immersion. Clin Teach. 2025;22(4):e70156. doi:10.1111/tct.70156. PMID:40676814; PMCID:PMC12271669.

25. Santos-Costa P, Paiva-Santos F, Graveto J, PrevInf Group. Nursing students' perceptions of a novel education approach to prevention and control of healthcare-associated infections: Insights from PrevInf Pilot Study. Nurs Rep. 2024;14(2):1494-1503. doi:10.3390/nursrep14020112. PMID:38921722; PMCID:PMC11206788.

26. Kubota S, Ando M, Khambounheuang S, Theppanya K, Nanthavong P, Tengbriacheu C, et al. A gap analysis of midwifery competency, pre- and in-service education for reproductive, maternal, newborn, child and, adolescent health in Lao People's Democratic Republic. Lancet Reg Health West Pac. 2023;43:100959. doi:10.1016/j.lanwpc.2023.100959. PMID:38144445; PMCID:PMC10746507.

27. Jacob A, Seif S, Munyaw Y. Perceptions and experiences of diploma nursing students on clinical learning. A descriptive qualitative study in Tanzania. BMC Nurs. 2023;22(1):225. doi:10.1186/s12912-023-01362-1. PMID:37391811; PMCID:PMC10311861.

28. Amod HB, Ndlovu L, Brysiewicz P. Clinical mentorship of midwifery students: The perceptions of registered midwives. Health SA. 2024;29:2492. doi:10.4102/hsag.v29i0.2492. PMID:38726062; PMCID:PMC11079372.

29. Macad GL, Rocca-Ihenacho L. 'Just a Midwife': A qualitative study on perceived barriers and facilitators facing Filipino midwifery students in reaching ICM standards. Midwifery. 2025; 144:104355. doi:10.1016/j.midw.2025.104355. PMID:40043640.

30. Nguyen Q, Flora J, Basaviah P, Bryant M, Hosamani P, Westphal J, et al. Interpreter and limited-English proficiency patient training helps develop medical and physician assistant students' cross-cultural communication skills. BMC Med Educ. 2024; 24 (1):185. doi:10.1186/s12909-024-05173-z. PMID:38395858; PMCID:PMC10893691.

31. Navas-Bonilla CR, Guerra-Arango JA, Oviedo-Guado DA, Murillo-Noriega DE. Inclusive education through technology: a systematic review of types, tools and characteristics. Front Educ. 2025;10: 1527851. doi:10.3389/feduc.2025.1527851.

32. Khazaei A, Safdari A, Vardanjani MM, Farahmandnia H, Afshari A. Bridging the gap: summative content analysis of barriers in elderly patient education from nurses’ perspectives. BMC Nurs. 2025;24(1):509. doi:10.1186/s12912-025-03118-5.

33. Fatima F, Siddiqui FA, Ali S, Fatima S, Zahoor A, Alvi A. Association between empathy and assertiveness of undergraduate students of medical colleges of Punjab. Front Psychiatry. 2025;16:1543308. doi:10.3389/fpsyt.2025.1543308. PMID:40809853; PMCID:PMC12345292.

34. Abed MG, Abed LG, Shackelford TK. Attitudes towards and communication with people with disabilities in Saudi Arabia: towards the sustainability of a healthy citizenry. Sustainability. 2024;16(22):10061. doi:10.3390/su162210061.

35. Menezes P, Guraya SY, Guraya SS. A systematic review of educational interventions and their impact on empathy and compassion of undergraduate medical students. Front Med (Lausanne). 2021;8:758377. doi:10.3389/fmed.2021.758377. PMID:34820397; PMCID:PMC8606887.

36. Angerbauer K, Van Wagoner HP, Keplinger K, Halach T, Vogelsang J, Hube N, et al. Inclusive avatars in the metaverse: learning from the lived experiences of people with disabilities. J Strateg Inf Syst. 2025; 34(4):101935. doi:10.1016/j.jsis.2025.101935

37. Bachfischer A, Barbosa MC, Rojas AAR, Bechler R, Schwienhorst-Stich EM, Kasang C, et l. Implementing community based inclusive development for people with disability in Latin America: a mixed methods perspective on prioritized needs and lessons learned. Int J Equity Health. 2023; 22(1):147. doi:10.1186/s12939-023-01966-8. PMID:37542266; PMCID:PMC10403844.

38. Purdy E, Symon B, Marks RE, Speirs C, Brazil V. Exploring equity, diversity, and inclusion in a simulation program using the SIM-EDI tool: the impact of a reflexive tool for simulation educators. Adv Simul (Lond). 2023;8(1):11. doi:10.1186/s41077-023-00250-7. PMID:37004091; PMCID:PMC10067255.

39. Safari K, McKenna L, Davis J. Midwifery in Middle Eastern and North African countries: A scoping review. Women Birth. 2021; 34(6):503-13. doi:10.1016/j.wombi.2020.11.002. PMID:33199188.

40. Susanti AI, Ali M, Hernawan AH, Rinawan FR, Purnama WG, Puspitasari IW, et al. Midwifery continuity of care in Indonesia: initiation of mobile health development integrating midwives' competency and service needs. Int J Environ Res Public Health. 2022;19(21):13893. doi:10.3390/ijerph192113893. PMID:36360772; PMCID:PMC9653760.

41. Cox A, Ip A, Watkin S, Matuska G, Bunford S, Gallagher A, et al. Implementing and evaluating resources to support good maternity care for parents with learning disabilities: A qualitative feasibility study in England. Midwifery. 2024;133:104001. doi:10.1016/j.midw.2024.104001. PMID:38643599.

42. Nakatabira M, Ekirapa-Kiracho E, Aanyu C, Tan HL, Apolot RR, Zia N, et al. Improving access to skilled maternal health services among pregnant women with disabilities in Uganda: defining disability-responsive maternal health services. SSM Health Syst. 2025;5:100087. doi:10.1016/j.ssmhs.2025.100087.

43. Bolarinwa O, Mohammed A. Bridging gaps in maternity care for women with disabilities: a scoping review of access and utilisation in sub-Saharan Africa adopting the WHO health systems framework. Contracept Reprod Med. 2025;10(1):58. doi:10.1186/s40834-025-00395-y. PMID:40999541; PMCID:PMC12465681.

44. Polat F, Karakuş M, Helmer J, Malone K, Gallagher P, Mussabalinova A, et al. Factors affecting multi-stakeholder perspectives towards inclusive early childhood education in Kazakhstan. Child Youth Serv Rev. 2023;155:107224. doi:10.1016/j.childyouth.2023.107224.