International Journal of Public Health Science (IJPHS)

International Journal of Public Health Science (IJPHS) Vol. 14, No. 4, December 2025, pp. 1765~1778 ISSN: 2252-8806, DOI: 10.11591/ijphs.v14i4.26820  1765 Journal homepage: http://ijphs.iaescore.com Optimization of maternal healthcare at the village level in reducing maternal mortality in Bali, Indonesia Panca Dwi Prabawa1,2, I Ketut Widnyana2, Ni Putu Pandawani2, Wayan Maba2 1BPS-Satistics Bali Province, Denpasar, Indonesia 2Postgraduate Program in Regional and Rural Planning, Mahasaraswati Denpasar University, Denpasar, Indonesia Article Info ABSTRACT Article history: Received Jul 25, 2025 Revised Sep 11, 2025 Accepted Nov 3, 2025 Although maternal mortality rates in Bali have declined, the achievement remains below the government’s target, highlighting the need to strengthen the role of villages as the frontline of development. This study aims to identify alternative strategies to accelerate maternal mortality reduction by examining the supply of maternal healthcare services and the demand reflected in women’s utilization of these services at the village level. Using the analytic hierarchy process (AHP) to map accessibility across villages and SERVQUAL model to evaluate women’s perceptions of maternal healthcare services provided through integrated services post (posyandu) and village health post (poskesdes), the study reveals significant disparities in accessibility across villages, particularly in Tabanan, Bangli, and Karangasem Regencies. While overall perceptions of healthcare quality are positive, the largest and most significant service quality gaps occur in tangibility and responsiveness. Based on these findings, the study recommends prioritizing villages with limited access to maternal healthcare services by ensuring health coverage for pregnant women from low-income households and guaranteeing the availability of midwives in villages through incentive schemes, while adopting community-based approaches to effectively reach migrant populations and improve their utilization of maternal healthcare services. Keywords: Analytic hierarchy process Healthcare accessibility Healthcare quality SERVQUAL model Village level This is an open access article under the CC BY-SA license. Corresponding Author: Panca Dwi Prabawa BPS-Statistics Bali Province Puputan (Renon) Street No. 1, Denpasar, Bali-80226, Indonesia Email: [email protected] 1. INTRODUCTION Women during pregnancy and childbirth face specific health risks, which, if not appropriately addressed, can lead to the worst-case scenario of maternal mortality. Maternal mortality is globally recognized as one key indicator of health and socio-economic development [1]. Maternal mortality reflects the overall status of women, their access to maternal healthcare, and the healthcare system's response to their needs. Reducing maternal mortality is a priority agenda outlined in the Sustainable Development Goals (SDGs)'s third goal, "Ensure Healthy Lives and Promote Well-Being for All at All Ages." According to target 3.1 of the third goal, it is agreed that "by 2030, the global maternal mortality rate should be reduced to less than 70 per 100,000 live births" [2]. Based on the results of the 2020 Indonesian Population Census, the maternal mortality ratio (MMR) in Bali is 85 per 100,000 live births. However, Bali's MMR must still be prioritized to meet the target outlined in the Bali Regional Development Plan for 2024-2026: to reduce MMR to 65 per 100,000 live births by 2026 or  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1765-1778 1766 meet the SDGs target by 2030 (see Figure 1). It still needs to be a priority to reduce the MMR in Bali, at least to achieve the target. Hence, various strategic and collaborative actions is necessary to enhance maternal health. To ensure the achievement of the MMR target in Bali, attention must be given to women who are at high risk. Risks during pregnancy and childbirth can be prevented when women receive the necessary maternal healthcare. According to [3], there are three delays closely related to maternal mortality events: the delay in deciding to seek maternal healthcare, the delay in accessing maternal healthcare facilities, and the delay in receiving adequate maternal healthcare. Access to healthcare is not only measured by distance but also by the quality of that healthcare [4]. In other words, unequal access to maternal healthcare contributes to maternal mortality, making the equal distribution of maternal healthcare essential to prevent maternal mortality, especially for those at high risk. To accelerate the reduction of maternal mortality and improve the health status of women, the Indonesian government has focused on health programs starting at the village level. By empowering villages as the lowest level of government representation that directly interacts with the community, health initiatives can prevent maternal mortality risks even from the pre-pregnancy period [5]. However, some health initiatives at the village level, particularly in rural areas, are not yet optimal in fulfilling their preventive and curative roles due to a lack of health workers and inadequate healthcare facilities. Research by Titaley et al. [6] indicates that cost and distance are primary factors influencing women's decision to access maternal healthcare. Additionally, this decision cannot be separated from personal preferences. The behavior of utilizing healthcare is influenced not only by motivation but also by adequate knowledge, the presence of barriers, and how this behavior is perceived as important and becomes a habit [7]. Karkee et al. [8] emphasize the importance of studying women's awareness of maternal healthcare and their perceptions of its quality in increasing utilization. Therefore, while addressing issues related to adequate availability of maternal healthcare is a priority, there also needs to be a focus on the necessity of utilizing maternal healthcare, particularly in enhancing knowledge and awareness of women and the broader community. Reducing maternal mortality is a priority. Strategies for reducing maternal mortality need to be examined both from the perspective of providing adequate maternal healthcare and utilizing maternal healthcare. Considering the potential differences in MMR across regions and villages, which are crucial for development, it is interesting to analyze the accessibility and quality of maternal healthcare across villages in Bali further. This study aims to comprehensively investigate maternal healthcare services at the village level in Bali. Three primary objectives guide the research: first, to map and analyze the inter-village disparities in access to maternal healthcare; second, to assess the quality of village-level maternal healthcare services by examining the perceptions and expectations of users; and third, to develop evidence-informed strategic recommendations for enhancing both the accessibility and quality of maternal healthcare delivery at the village level. Ultimately, this research seeks to provide a nuanced understanding of the current maternal healthcare landscape and contribute actionable insights to assist policymakers and healthcare providers in addressing geographical inequities and improving maternal health outcomes across Bali. Figure 1. Maternal mortality ratio achievement and targets in Bali Int J Public Health Sci ISSN: 2252-8806  Optimization of maternal healthcare at the village level in … (Panca Dwi Prabawa) 1767 2. LITERATURE REVIEW 2.1. Access to healthcare and maternal mortality The condition of maternal mortality reflects not only the women’s health status during pregnancy and childbirth but also access to and quality of healthcare, behaviors in utilizing healthcare, as well as the socio-economic status of women, households, and communities in the area [4]. Socio-economic status influences the incidence of maternal mortality but only explains a slight difference across provinces in Indonesia. Access to maternal healthcare is the leading cause of disparities in MMR [9] and should be considered in efforts to reduce maternal mortality [10]. Easily accessible and quality healthcare during pregnancy and childbirth reduces the risk of maternal mortality and morbidity [11]. According to Thaddeus and Maine [3], the condition of healthcare facilities being far away and limited has the potential to delay women from reaching them and obtaining adequate healthcare. Delays in reaching health facilities are primarily caused by long distances resulting from the uneven distribution of locations, particularly the tendency for facilities to be concentrated in urban areas [12], [13]. On the other hand, delays in receiving adequate healthcare are mainly caused by limited resources at health facilities, which are unable to handle complex pregnancy and childbirth complications. In addition to long distances and limited services, conditions in rural areas are exacerbated by a lack of awareness of maternal health, leading to delays in deciding to seek healthcare. 2.2. Women's perception of healthcare quality The quality of healthcare is a crucial consideration when deciding whether to seek care. Findings by [3] show that when women have access to healthcare facilities, their perception of healthcare quality tends to be prioritized over distance. This condition cannot be separated from the women's assessments based on their experiences or the information they receive. Thus, women's decisions to utilize maternal healthcare are connected to healthcare quality. This can be understood as women are more likely to have a high intention to return if they feel satisfied with the quality they received [14]. Therefore, assessing women's perceptions can serve as an evaluation for healthcare providers to improve and enhance the quality of their healthcare [15]. According to Donabedian [16], healthcare quality can be assessed through a model consisting of three interconnected categories: structure, process, and outcome. The Donabedian model is one of the recommended models for assessing healthcare quality, as recommended by [17], and serves as a systematic and flexible guideline for evaluating healthcare quality. In the context of health, according to the Donabedian model, outcomes encompass not only improvements in physical health conditions but also subjective aspects, such as patients' perceptions and experiences. Therefore, women's satisfaction with healthcare and their desire to return are important factors in evaluating healthcare quality. A positive perception indicates that healthcare meets their expectations. Women's perceptions of healthcare quality will affect healthcare utilization in the future and indirectly influence the reduction of maternal mortality. 2.3. The role of villages in improving maternal health Maternal health initiatives aim to maintain women’s health so they can give birth to healthy and quality generations while reducing maternal mortality. To help accelerate the achievement of optimal maternal health, community involvement is necessary, tailored to the specific conditions and needs of the local population. One way to empower the community is through active participation in community-based health initiatives (UKBM), which serve as a platform for villagers’ empowerment established based on their needs, managed by, for, and with them, prioritizing a promotive and preventive approach (Regulation of the Ministry of Health of the Republic of Indonesia Number 21 of 2021). Villages play a crucial role in providing healthcare, which can be facilitated through the management of UKBM. The implementation of UKBM in the village supports enhancing maternal health during pre-pregnancy, pregnancy, childbirth, and postpartum periods through integrated services post (posyandu) and village health post (poskesdes). At the village level, there is also a village-based midwife (bidan desa) program, which aims to ensure every village has a midwife assigned to practice midwifery as part of the network connected to the community health center (puskesmas). On the other hand, the Indonesian government has committed to initiating development at the village level. According to Law of the Republic of Indonesia Number 6 of 2014, villages are recognized as having the authority to organize their governance and implement initiatives for village development, community development, and community empowerment based on their initiatives and local customs. This recognition of authority is accompanied by providing financial resources to villages through the village fund (dana desa) policy. With dana desa, the implementation of development can be more aligned with the specific needs of each village. One of the priority uses of the dana desa is education and training for maternal health as part of health promotion and the healthy living community movement (Regulation of the Ministry of Village, Development of Disadvantaged Regions, and Transmigration of the Republic of Indonesia Number 7 of 2023).  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1765-1778 1768 3. METHOD 3.1. Operational framework This study is a field-based quantitative investigation employing a cross-sectional, observational design. Primary data were collected directly in the field and supplemented with secondary sources to support a comprehensive analysis. Conducted as an exploratory inquiry, the research aims to generate new insights into a relatively underexplored phenomenon. The findings are expected to enrich the existing literature and to inform future scholarly discourse and research. This research examines the in-depth relationship between maternal mortality and healthcare from two sides: supply and demand. Theoretical and empirical studies indicate that maternal mortality is intricately linked to the framework of healthcare services. Specifically, access to quality maternal healthcare during the antenatal, intrapartum, and postpartum periods is a critical preventive factor against maternal mortality [9], [18], [19], [20]. From the supply side, the research emphasizes the accessibility of maternal healthcare. Meanwhile, from the demand side, it considers women's perceptions of maternal healthcare quality, which serves as the basis for their decision to utilize. Given the important role of villages in health development, this study looks at accessibility from a village perspective and women's perception of community-based health initiatives at the village level. Socio-economic and cultural factors are not specifically examined in this study, which is a limitation, as these factors indirectly impact maternal mortality [4], [9] and have a relatively limited influence on healthcare utilization [21]. The conceptual framework linking these factors to maternal mortality is illustrated in Figure 2. Figure 2. Conceptual framework linking maternal healthcare utilization to maternal mortality 3.2. Research design The scope of this research is the villages in Bali Province. Accessibility reflects how women in villages can access maternal healthcare. Meanwhile, quality reflects how community-based maternal health initiatives— posyandu and poskesdes—are utilized in the villages. Thus, there are two areas of analytical objects: the village as a territorial unit and the women living within it. This research encompasses all 717 villages in Bali [22]. This research conducts two integrated analyses. To describe the accessibility level of maternal healthcare, the research applies the analytic hierarchy process (AHP) method. AHP determines priority criteria through questionnaire interviews with stakeholders and uses them to create a thematic map using secondary data available at the village level. To measure the quality of posyandu/poskesdes, this research employs the SERVQUAL model through self-enumerated questionnaires completed by women as service users. The results from both analyses are subsequently analyzed in depth using a TOWS matrix to formulate strategies for improving the accessibility and quality of maternal healthcare. To analyze maternal healthcare accessibility, 14 selected respondents represent the triple helix collaboration between the government (health department at the provincial level and regency/municipality level), academics, and the community (Indonesian Midwives Association, Indonesian Planned Parenthood Association). The criteria selection to determine priority is based on variables derived from the Village Potential Data (Podes) data and is relevant to maternal mortality incidents related to a study by [23], which summarizes the territorial factors influencing maternal mortality from various previous studies. This data source was selected because Podes is conducted as a census covering all administrative areas at the village level, to provide data on the existence and development of village potential, including aspects of social, economic, infrastructure, and public facilities. According to [24], the AHP method is used to structure the territorial variables into a hierarchy (see Figure 3) and then analyze them to determine priority. To analyze maternal healthcare quality, a total of 149 sample respondents, married women aged 15– 49 years, were selected and proportionally distributed across all districts in Bali to assess the quality of Int J Public Health Sci ISSN: 2252-8806  Optimization of maternal healthcare at the village level in … (Panca Dwi Prabawa) 1769 services at posyandu/poskesdes using a self-administered questionnaire. The samples were collected using a non-probability sampling technique with the quota sampling method. This approach was selected because the study explores respondents' perspectives in a preliminary context, rather than aiming to estimate or generalize the population. The sample size was determined using Cochran's formula [25] for finite populations and proportionally distributed across all districts in Bali Province according to the number of women of reproductive age. The questionnaire was developed based on the SERVQUAL model, integrated with the Donabedian model [26]. The Donabedian model provides a framework for evaluating service quality through its components, while the SERVQUAL model examines patients' perceptions and expectations. Respondents were asked to rate each statement on a scale from 1 (strongly disagree) to 7 (strongly agree) for each statement, both based on the healthcare that has been received (perception) and the healthcare that should be received (expectation), where values from 2 to 6 are not assigned specific labels [27]. The questionnaire has undergone prior validity and reliability testing to ensure that it is fit for use. The complete list of questionnaire statements is presented in Table 1. Figure 3. Hierarchical structure of maternal healthcare accessibility Table 1. Explanation of perception-based assessment variables on the quality of village-level maternal healthcare Dimensions Explanations Questionnaire item descriptions Tangible Respondents evaluated the physical conditions, facilities, and availability of health workers prior to receiving healthcare 1. Having complete facilities and services 2. The available medical equipment is clean and safe to use 3. The health information provided is straightforward to understand 4. There are sufficient health workers Assurance Respondents assessed the background and professional attitude of health workers, as well as their initial impressions of the service process 5. Health workers are professionals in their field 6. The healthcare provided are safe and reliable 7. The healthcare process is straightforward to understand 8. The healthcare is provided on time Reliability Respondents evaluated the health workers’ ability to provide care and support during the service process 9. Health workers have good health knowledge 10. Health workers have adequate experience 11. Health workers provide services correctly and accurately 12. Health workers can communicate well and politely Responsiveness Respondents assessed the responsiveness of health workers to their needs during the service process 13. Health workers deliver services promptly 14. Health workers show concern to help 15. Health workers will not neglect even when they seem busy Empathy Respondents evaluated whether health workers demonstrated empathy toward their feelings during the service process 16. Health workers deliver services promptly 17. Health workers empathize with complaints and expressions 18. Health workers strive to provide solutions Medical output Evaluation of respondents based on the impact of the services received and their overall satisfaction with the care they have received 19. Health complaints improve and can be handled well 20. Satisfaction with the healthcare provided  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1765-1778 1770 Statistical tests were conducted to assess the significance of the quality gap score, quantifying the discrepancy between patient expectations and perceptions of maternal healthcare quality at the village level, using a paired sample t-test. A larger positive gap indicates that perceived quality is substantially lower than expected, implying that the healthcare received fails to meet patients' expectations. Therefore, aspects demonstrating the most significant gaps should be prioritized for improvement to enhance overall service quality. Additionally, tests were performed to examine the significance of the relationship between perceived healthcare quality and output of the healthcare received (medical output) using the Pearson correlation test, identifying which aspects of maternal healthcare quality are most closely associated with maternal health outcomes and patient satisfaction. 4. RESULTS AND DISCUSSION 4.1. Accessibility level of maternal healthcare at the village level Among the eleven criteria, maternal health insurance for low-income households received the highest score, indicating it is the top priority in assessing the accessibility of maternal healthcare in Bali. Providing health insurance not only increases the utilization of healthcare facilities but also improves the quality of care provided [28]. Health insurance reduces the financial burden of accessing healthcare, particularly for individuals with limited incomes [29], [30]. In addition, it encourages healthcare facilities to implement specific minimum service standards, which in turn enhances service utilization. A study by [31] found that maternal health insurance ownership positively influences the use of maternal healthcare. However, some villages may not provide maternal health insurance for low-income households because they are already covered under the National Health Insurance–Healthy Indonesia Card (JKN-KIS) program. The second priority variable is the availability of midwifery practice in the village. Midwives play a vital role in maternal healthcare, particularly in providing antenatal care, first aid, and early detection of complications during pregnancy, childbirth, and the postpartum period. Furthermore, midwives authorized to practice independently are graduates of professional education programs, equipping them with more advanced competencies (Law of the Republic of Indonesia Number 4 of 2019). Achieving universal coverage of midwifery services has the potential to prevent up to 67 percent of maternal mortality in lowand middleincome countries [32] and is also associated with reduced referral rates and fewer cases requiring complex interventions [33]. However, this must be supported by compliance with competency standards and the availability of an enabling practice environment. Additionally, midwives are often the preferred providers of maternal healthcare across socio-economic groups due to their accessibility in terms of distance and affordability [34]. The implementation of prenatal group classes and supplementary feeding programs for pregnant women with chronic energy deficiency (CED) is among the criteria with relatively high priority in improving maternal health. Participation in prenatal group classes is positively associated with increased utilization of adequate antenatal care and delivery assistance by trained health professionals at healthcare facilities [35]. Meanwhile, supplementary feeding programs contribute to improved nutritional intake and reduced morbidity among pregnant women, thereby lowering the risk of complications during pregnancy and childbirth [36]-[38]. These findings highlight that maternal health initiatives at the village level represent a key priority in enhancing access to maternal healthcare. Based on the priority scores shown in Figure 4, the accessibility level of maternal healthcare can be calculated for each village. A higher accessibility score indicates that maternal healthcare is more accessible in each area. Most villages in Bali Province exhibit relatively high accessibility. This is illustrated by the thematic map in Figure 5, which shows that 21.3% of villages fall into the category with the highest accessibility level (indicated in blue). These villages are predominantly located in the southern part of Bali, particularly in Gianyar Regency, and around the capitals of Jembrana and Buleleng Regencies. In contrast, only 10.6% of villages are classified as having the lowest accessibility level (indicated in red), primarily found in Bangli, Tabanan, and Karangasem Regencies. Villages in this lowest-accessibility group are typically characterized by the absence of midwifery services and the lack of maternal health insurance for low-income households. The accessibility of maternal healthcare across villages is negatively correlated with maternal mortality. As illustrated in Figure 6, villages with lower levels of accessibility, such as those in Bangli, Tabanan, and Karangasem Regencies, tend to have higher MMR. In contrast, areas with higher accessibility, such as Denpasar City, Badung Regency, and Gianyar Regency, generally exhibit lower MMR. The concept of accessibility extends beyond geographic distance; it also encompasses the ease with which pregnant women can obtain adequate and timely healthcare [4]. Improved access enables pregnant women to receive appropriate care throughout pregnancy, reduces the risk of complications, and ultimately contributes to lower MMR. Int J Public Health Sci ISSN: 2252-8806  Optimization of maternal healthcare at the village level in … (Panca Dwi Prabawa) 1771 Villages requiring priority attention for improving maternal healthcare accessibility have been further identified. As shown in Figure 7, several areas exhibit relatively low accessibility levels despite having high population densities. These villages are in Tabanan Regency (Kerambitan, Kediri, and Marga Districts), Bangli Regency (Susut, Bangli, and Tembuku Districts), and Karangasem Regency (Sidemen District). This suggests a high potential need for maternal healthcare in these areas, given the large number of female residents, yet significant barriers remain in accessing maternal healthcare. Efforts to improve accessibility should be directed toward villages with low accessibility levels; however, priority should be given to those with higher population densities, as interventions in these areas are likely to have a greater impact on reducing maternal mortality. Figure 4. Priority scores of accessibility criteria for maternal healthcare across villages Figure 5. Village-level spatial distribution of maternal healthcare accessibility in Bali  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1765-1778 1772 Figure 6. Scatter diagram of average village-level maternal healthcare accessibility and average reported MMR by regency/municipality in Bali Figure 7. Quadrant chart of average maternal healthcare accessibility and average female population density at the village-level by subdistrict in Bali 4.2. Women's perception of maternal healthcare quality at the village level Overall, the quality of services at posyandu/poskesdes in Bali is relatively good, as shown in Table 2. On a scale of 1 to 7, the average perception score reported by respondents was 6.160. However, the corresponding expectation score was higher, at 6.808, indicating a potential for improved maternal healthcare quality at the village level (posyandu/poskesdes). The statistical tests comparing perception and expectation scores (average gap quality score) reveal a significant difference, underscoring the gap between the maternal healthcare quality women currently receive and what they expect. Int J Public Health Sci ISSN: 2252-8806  Optimization of maternal healthcare at the village level in … (Panca Dwi Prabawa) 1773 Table 2. Average posyandu/poskesdes quality score based on women's perceptions SERVQUAL dimensions Average score of quality perception Average score of quality expectation The average gap quality score of expectation-perception Tangible 6.020 6.790 0.770* Assurance 6.208 6.817 0.609* Reliability 6.262 6.810 0.549* Responsiveness 6.132 6.799 0.667* Empathy 6.177 6.823 0.647* Overall 6.160 6.808 0.648* *Gap quality score of expectation-perception significant at 1% level (paired t-test) The most significant gap is observed in the tangible dimension (indicated by the largest gap quality score in Table 2, indicating that women face limitations in the physical aspects of maternal healthcare. The indicator with the widest gap relates to facilities and infrastructure, as well as the availability of health workers. This suggests that inadequate infrastructure and a shortage of health workers are the main barriers to meeting women's expectations. The second largest gap appears in the responsiveness dimension, indicating that health workers have not fully met expectations regarding readiness and speed in addressing women's needs. The most critical indicator within this dimension concerns the ability of health workers to provide services promptly and attentively, even when operating under high workloads. This highlights how limited staffing and excessive workloads can delay responses to women's needs, reducing their perception of service quality. Human resources and infrastructure shortages can create discomfort for users when accessing healthcare [39]. Moreover, high workloads among community health workers can negatively affect their productivity [40]. In addition to examining the quality gaps, this study also analyzes the relationship between each maternal healthcare quality dimension and medical output regarding improvements in women's health conditions and satisfaction with the services received. As shown in Table 3, the assurance and empathy dimensions exhibit the strongest associations with medical output, indicated by the largest Pearson correlation coefficient in Table 3. This suggests that women's trust and confidence in services are positively linked to better health outcomes. Conversely, although the tangible and responsiveness dimensions display larger quality gaps, their relationship with medical output is relatively weaker. In other words, even when facilities, infrastructure, and the responsiveness of health workers are perceived as inadequate, women tend to place greater value on how well they are supported and treated with empathy during service delivery. This supports the perspective that healthcare quality is shaped not only by physical components but also by users' psychological and emotional experiences [41]. These findings reinforce that posyandu/poskesdes are performing relatively well, contributing to improved health outcomes. Nevertheless, the substantial gaps in the tangible and responsiveness dimensions remain critical areas for improvement. Table 3. Pearson correlation between SERVQUAl dimensions and medical output in assessing posyandu/poskesdes quality SERVQUAL dimensions Pearson correlation coefficient Between quality perception and medical output Between the gap quality of expectationperception and medical output Tangible 0.664* -0.547* Assurance 0.682* -0.595* Reliability 0.636* -0.540* Responsiveness 0.649* -0.570* Empathy 0.673* -0.603* *Pearson correlation coefficient significant at 1% level (t-test) 4.3. Improving the accessibility and quality of maternal healthcare at the village level Based on the analysis of maternal healthcare accessibility and quality at the village level in Bali, this section formulates strategies using a TOWS matrix, which categorizes strategic options by combining internal factors (strengths and weaknesses) with external factors (opportunities and threats) [42], [43]. Regarding internal factors, maternal healthcare in Bali demonstrates a strong foundation in accessibility and service quality. Accessibility mapping indicates that distance and transportation are low-priority barriers. Perception assessments show narrow quality gaps in the assurance and empathy dimensions, suggesting that health workers at posyandu/poskesdes are competent and communicative. However, gaps persist in in-service distribution, particularly in providing maternal health insurance for low-income households and the