The Effect of Digitally Enabled District (DED 2.0) Ecosystem on the Completeness and Timeliness of Maternal and Neonatal Services in Primary Health Care

Completeness of ANC services within the gestational-age window, in accordance with the recommended schedule and standard:

Trimester 1 (1 visit, 1 ultrasound, 1 physician examination); Trimester 2 (2 visits); Trimester 3 (3 visits, 1 ultrasound, 1 physician examination).

Binary, individual-level: 1 = received all scheduled ANC contacts within the nationally recommended gestational-age windows; 0 = otherwise. Denominator = all eligible pregnant women registered at the cluster in that cluster-period. Analysed via generalised linear mixed model with a cluster random effect and categorical calendar period as a fixed effect (Hussey & Hughes, 2007). This is the study's single registered primary outcome; ANC "12T" completeness, PNC completeness, and PNC standard-assessment completeness are secondary outcomes.

Proportion of pregnant women for whom mandated ANC visits are documented within the correct gestational-age window (per trimester schedule) in routine facility records (KuApps and Legacy Apps). Coded 1 = Timely; 0 = Not timely

Proportion of postpartum women for whom all four scheduled PNC contacts are documented by a health worker in routine facility records (KuApps and Legacy Apps):

PNC1 (6 hours-2 days), PNC2 (3-7 days), PNC3 (8-28 days), PNC4 (29-42 days). Coded 0 = Incomplete, 1 = Complete.

Proportion of postpartum women with all 14 mandated components of the Book of KIA standard PNC assessment, documented in routine facility records (KuApps and Legacy Apps). Components include breast examination (assessment of lactation/breastfeeding), bleeding assessment, examination of the birth canal/perineum, Vitamin A administration, postpartum family planning, mental health screening, counselling, and case management. Documented in routine facility records (KuApps and Legacy Apps)

Proportion of neonates for whom all three neonatal visits (KN1, KN2, and KN3) fully documented in routine facility records (KuApps and Legacy Apps). Classified as incomplete if one or more visits are not documented.

Coded 0 = Incomplete, 1 = Complete.

Proportion of neonates for whom all required essential neonatal care components are documented in routine facility records (KuApps and Legacy Apps). Assessing the completeness of all required essential neonatal care components documented, comprising eye antibiotic ointment, Vitamin K administration, umbilical cord care, early initiation of breastfeeding, and exclusive breastfeeding.

Coded 0 = Incomplete, 1 = Complete.

Completeness of the standard neonatal examination, comprising: KN1: weight measurement, length measurement, head circumference measurement, breastfeeding assessment, umbilical cord care, Vitamin K1 administration*, eye ointment/drops*, Hepatitis B immunisation, congenital hypothyroidism screening (after 24 hours), congenital heart disease screening, triple elimination screening. KN2: breastfeeding assessment, umbilical cord examination/care, danger-sign assessment, jaundice identification, Hepatitis B immunisation*, congenital hypothyroidism screening (if not yet given), triple elimination screening. KN3: breastfeeding assessment, umbilical cord examination/care, danger-sign assessment, jaundice identification, congenital hypothyroidism screening (if not yet given), triple elimination screening.

Coded 0 = Incomplete, 1 = Complete.

Proportion of neonates for whom each neonatal visit is documented within the appropriate age window in routine facility records (KuApps and Legacy Apps): KN1 (6-48 hours), KN2 (3-7 days), KN3 (8-28 days). Coded 1 = Timely; 0 = Not timely.

Proportion of recorded pregnancies resulting in a live birth and non-live birth (such as stillbirth or miscarriage/abortion), ascertained at delivery from routine facility records (KuApps and Legacy Apps). Coded 0 = Death/stillbirth, 1 = Miscarriage/abortion, 2 = Live birth

Proportion of live-born neonates with birth weight ≥ 2,500 g, measured in grams using a calibrated infant scale and recorded in routine facility records (KuApps and Legacy Apps). Coded 1 = ≥ 2,500 g; 0 = < 2,500 g (low birth weight)

Proportion of deliveries occurring at a health facility, ascertained from routine facility records (KuApps and Legacy Apps). Coded 1 = Facility-based delivery; 0 = Delivery outside a health facility

Personnel who assisted the delivery process, ascertained from routine facility records Coded 0 = Non-health-worker, 1 = Health worker

Proportion of participants with a documented obstetric complication for whom a documented set of clinical actions and care is recorded in routine facility records (KuApps and Legacy Apps). Coded 1 = Documented management; 0 = Not documented.

A person's average blood pressure in the arteries during one complete cardiac cycle recorded as a continuous variable in mmHg. An additional ordinal variable derived from MAP, categorising the continuous value into clinical groups:

0 = Normal (<90 mmHg)

• = Elevated (≥90-<92)
• = Stage 1 hypertension (≥92-<96)
• = Stage 2 hypertension (≥96)

The pressure inside the artery when the heart contracts and pumps blood through the body. the "top number" of a blood pressure reading. Recorded as a continuous variable in mmHg in routine facility records (KuApps and LegacyApps). An additional ordinal variable derived from systolic blood pressure for systolic status:

0 = Normal (<130 mmHg)

• = Stage 1 hypertension (≥130-<140 mmHg)
• = Stage 2 hypertension (≥140 mmHg)

The pressure inside the artery when the heart is at rest. Recorded as a continuous variable in mmHg. the "bottom number" of a blood pressure reading, recorded in routine facility records (KuApps and Legacy Apps). Reported as a continuous variable. An additional ordinal variable derived from diastolic blood pressure for diastolic status:

0 = Normal < 80 mmHg

• = Stage 1 hypertension (80-89 mmHg)
• = Stage 2 hypertension (>90 mmHg)

Vertical distance from the soles of the feet to the top of the head of a person standing upright

Maternal's total amount of fluid, fat, muscle, and bone mineral in the human body, as measured using a scale, expressed in kilograms (kg)

Maternal BMI which considered as an index used to determine ideal body weight based on the ratio of weight to height. Reported as a continuous variable. Descriptive categorisation:

underweight <18.5 normal 18,5-22,9 overweight 23-24.9 obesity type 1: 25-29.9 obesity type 2: >30

Maternal upper arm circumference measured in centimetres using a standard non-elastic MUAC measuring tape at the first ANC contact, recorded in routine facility records (KuApps and Legacy Apps). Reported as a continuous variable.

Proportion of pregnant women are classified as having Chronic Energy Deficiency (CED) if their Mid-Upper Arm Circumference (MUAC) is < 23.5 cm, measured at the first Antenatal Care (ANC) visit

Occurrence of at least one day of unavailability (recorded stock = 0) during the observation month for essential ANC medications and supplements, such as Iron-Folic Acid (IFA) tablets, calcium, and folic acid, ascertained from monthly Puskesmas pharmacy and logistics records. Coded 1 = At least one stock-out day during the month; 0 = No stock out

Aggregate score of Puskesmas (Community Health Centre) service performance, ascertained from the Ministry of Health's Puskesmas Performance Assessment (Penilaian Kinerja Puskesmas, called PKP) monthly tabulations. Reported as a continuous score per Puskesmas per observation month

Number of pregnant women served per health worker (midwife or cadre) per Puskesmas per observation month, computed from routine service records (KuApps and Legacy Apps) divided by the roster of active ANC providers per Puskesmas. Reported as a continuous count

Proportion of documented ANC contacts recorded by cadres compared with the total number of ANC contacts documented during the period, ascertained from KuApps and Legacy Apps entry logs. Reported as a continuous proportion (0-100%).

Proportion of registered health workers and cadres per Puskesmas who actively used the KuApps application at least once during the observation month, ascertained from KuApps user activity logs (log-in timestamps and data entry events). Reported as a continuous proportion (0-100%) per Puskesmas per month.

Availability of supporting devices and connectivity (computers/tablets, internet connection) at health facilities. This is ascertained by facility inventory checklist adapted from the Digital Readiness Assessment (DRA). Coded 1 = Fully available (device + connectivity); 0 = Not fully available

Connectivity status of the Puskesmas recording system with the national Electronic Medical Record system (SATUSEHAT), ascertained by facility inventory checklist and confirmed via SATUSEHAT integration logs. Coded 1 = Integrated; 0 = Not integrated

Proportion of routine Puskesmas reports (monthly ANC, PNC, and neonatal reports) submitted by the established Dinas Kesehatan deadline during the observation month, ascertained from Dinas Kesehatan report intake logs. Reported as a continuous proportion (0-100%)

Total cost of training healthcare workers using the DED (trainer's fee, healthcare worker training time, materials, transportation), per Puskesmas. Reported in Indonesian Rupiah (IDR)

Hardware and network costs (such as tablets/mobile phones, servers/cloud, internet) measured based on economic lifespan, attributable to the DED ecosystem, annualised over economic lifespan, ascertained from a prospective cost inventory. Reported in Indonesian Rupiah (IDR)

Annualised development and licensing costs of the KuApps application and PWS dashboard attributable to the DED ecosystem, ascertained from a prospective cost inventory. Reported in Indonesian Rupiah (IDR)

Costs of RME and AI-OCR integration attributable to the DED ecosystem, ascertained from a prospective cost inventory. Reported in Indonesian Rupiah (IDR)

Ongoing operational costs of HealthComm, Tableau, PWS, and KuApps dashboard servers per period, ascertained from a prospective cost inventory. Reported in Indonesian Rupiah (IDR)

Cost of providing ANC, PNC, delivery, and referral services per service unit, ascertained from a prospective service costing exercise (facility-based micro-costing). Reported in Indonesian Rupiah (IDR) per service unit

The timeframe over which costs are calculated covering the identification of incurred costs and the duration (time horizon) of the study, as well as costs categorized by source and expenditure period. Reported as a structured cost inventory in Indonesian Rupiah (IDR), stratified by source and expenditure period

Difference in the number of documented services and visits delivered between the intervention and control periods, ascertained from routine facility records (KuApps and Legacy Apps). Reported as a continuous count

Number of mothers documented as completing the full continuum: ANC (per standard), delivery, and PNC (all four contacts), ascertained from routine facility records (KuApps and Legacy Apps). Reported as a continuous count.

Incremental cost of the DED ecosystem per DALY averted, computed by linking observed improvements in maternal and neonatal care coverage to modelled reductions in mortality and morbidity risk using published transition-model parameters. Reported as IDR (Indonesian Rupiah) per DALY averted.