Perceptions of pregnant woman on monetary and time sacrifice for satisfaction based on health workers roles in antenatal services to reduce the risk of maternal death at Gowa district

Background: The Maternal Mortality Rate (MMR) is one indicator of health development in Indonesia. Efforts to accelerate the reduction of MMR can be done by ensuring that every mother can access quality maternal health services. Antenatal care is utilized properly, maternal health can be monitored continuously from pregnancy to delivery. Methods: The study design was observational with a cross sectional study design. The population in this study were all pregnant women who had a gestational age of 7-9 months in Gowa Regency as many as 122 people. A sample of 93 people was taken using accidental sampling technique. Results: Pregnant women who have a perception of small monetary sacrifice and say the role of the health workers is lacking in antenatal care 90.0%. Pregnant women who have a perception of monetary sacrifice are very small and say the role of health workers is less as much as 83.1%. Pregnant women who have the perception of the sacrifice of big time and say the role of health workers lacking in antenatal care as much as 100%. Pregnant women who have a perception great monetary sacrifice and say the role of health workers is lacking in antenatal care 90.2%. Conclusion: Satisfaction of pregnant women towards the role health workers in antenatal care based on perception monetary sacrifice does not show correlation while based on time sacrifice shows there is a correlation. Need to increase the speed of the process of pregnancy examination services for pregnant women by health workers. (Health Science Journal of Indonesia 2019;10(2):111-8)


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Every year around the world, an estimated 358,000 maternal deaths occur and around 99% of those deaths occur in poor developing countries including Indonesia. 1 Maternal death is a complex event caused by various causes that can be distinguished by determinants of close, between, and far. 2 Close determinants that are directly related to maternal death are obstetric disorders such as bleeding, preeclampsia/ eclampsia, and infections or illnesses suffered by the mother before or during pregnancy that can worsen pregnancy conditions such as heart, malaria, tuberculosis, kidney, and acquired immunodeficiency syndrome. Close determinants are directly affected by determinants between those related to health factors, such as maternal health status, reproductive status, access to health services and the behavior of using health facilities. Determinants are far related to demographic and sociocultural factors. 3 The success of maternal health efforts can be seen from the indicators of Maternal Mortality Rate (MMR). The MMR is the number of maternal deaths during pregnancy, childbirth and childbirth caused by pregnancy, childbirth, and post partum or its management but not due to other causes such as accidents or falls in every 100,000 live births.
Efforts to accelerate the reduction of MMR can be done by ensuring that every mother can access quality maternal health services, such as health services for pregnant women, delivery assistance by trained health workers in health care facilities, postpartum care for mothers and babies, special care and referrals if there are complications, ease of getting maternity and maternity leave, and family planning services. 4,5 The World Health Organization (WHO) recommends that the obligation to visit ANC during normal pregnancy is 4 visits during pregnancy with a predetermined standard and time. K1 was increased but K4 is decreased.According to the Indonesian Health Profile in 2015, ANC coverage in Indonesia for K1 was 95.75% and K4 coverage was 87.48% (Ministry of health, 2015). According to Indonesia's Health Profile in 2017, ANC coverage in Indonesia for K4 in 2016 was 85.35% and K4 coverage in 2017 was 87.3%. 6,7 The coverage of K4 health services for pregnant women by Province in 2017 was 76%. However, of all the provinces in Indonesia, there are 11 provinces that have not reached the target of the strategic plan. Constraints faced in the implementation of health services for pregnant women are not only in terms of access. The quality of services provided must also be improved, including the fulfillment of all components of health services for pregnant women must be provided at the visit. In terms of availability of health facilities, up to December 2017 there were 9,825 health centers. The existence of an ideal health center must be supported by good accessibility. This of course is closely related to geographical aspects and the ease of transportation infrastructure. In supporting outreach to the community in its working area, Health Center has also applied the concept of satellite by providing auxiliary health center. 8 The The population in this study were all pregnant women who had a gestational age of 7 to 9 monthsin Gowa Regency during the study period of 122 people. The sample in this study were pregnant women who had a gestational age of 7 to 9 months in Gowa Regency taken using accidental sampling, which is a sampling technique based on chance. 9 Where pregnant women found at the Gowa District Health Center by chance were determined as samples. The sample size was determined using the Slovin formula of 93 people.
Information: n = Sample Size N = Large Population e = Standard Error (0.05) So that it gets: to assess the role of health workers in antenatal care based on perceptions of monetary sacrifice and the time of pregnant women to reduce the risk of maternal death.

METHODS
This is an Observational research with cross sectional type, meaning that each research subject is only observed once and the measurement between independent and dependent variables is done at the same time. The population in this study were all pregnant women who had a gestational age of 7 to 9 monthsin Gowa Regency during the study period of 122 people. The sample in this study were pregnant women who had a gestational age of 7 to 9 months in Gowa Regency taken using accidental sampling, which is a sampling technique based on chance. 9 Where pregnant women found at the Gowa District Health Center by chance were determined as samples. The sample size was determined using the Slovin formula of 93 people.
Information: n = Sample Size N = Large Population e = Standard Error (0.05) So that it gets: Data were obtained directly using a questionnaire for pregnant women found at the Gowa District Health Center and were willing to participate in the study.Samples were interviewed after having ANC at the health center.
The health workers in this studied include all the people that give services to pregnant women to get antenatal care in health center like that administrative staffs, midwives, nutritionist for nutrition, nurses, K4 visits for pregnant women are the most important visits to be done by pregnant women because at K4 visits pregnant women get complete services as they should according to the standards set. This study aims to assess the role of health workers in antenatal care based on perceptions of monetary sacrifice and the time of pregnant women to reduce the risk of maternal death.

METHODS
This is an Observational research with cross sectional type, meaning that each research subject is only observed once and the measurement between independent and dependent variables is done at the same time.
Gowa District Health Center data for 2017, from the target of 257 pregnant women for K1 coverage to 254 people (98.8%) while for K4 coverage to 244 people (95%), for 2018 with 252 pregnant women targeting for K1 coverage 257 people (102%) while K4 coverage reached 241 people (95.6%), for 2019 in February the number of pregnant women was recorded at 258. While for K1 coverage were 47 people (18.2%) and for K4 coverage was 40 people (15.5%). While the expected health center target is 100% per year.
The population in this study were all pregnant women who had a gestational age of 7 to 9 monthsin Gowa Regency during the study period of 122 people. The sample in this study were pregnant women who had a gestational age of 7 to 9 months in Gowa Regency taken using accidental sampling, which is a sampling technique based on chance. 9 Where pregnant women found at the Gowa District Health Center by chance were determined as samples. The sample size was determined using the Slovin formula of 93 people. Data were obtained directly using a questionnaire for pregnant women found at the Gowa District Health Center and were willing to participate in the study.Samples were interviewed after having ANC at the health center.
The health workers in this studied include all the people that give services to pregnant women to get antenatal care in health center like that administrative staffs, midwives, nutritionist for nutrition, nurses, Data were obtained directly using a questionnaire for pregnant women found at the Gowa District Health Center and were willing to participate in the study. Samples were interviewed after having ANC at the health center.
The health workers in this studied include all the people that give services to pregnant women to get antenatal care in health center like that administrative staffs, midwives, nutritionist for nutrition, nurses, public health workes for health promotion, doctor for qualified ANC in which one of the visit should be examined by the doctor. Monetary sacrifice and time are measured on a Likert scale and Scoring is done on each item with a total number of questions of 10 (ten) questions. Each answer is given a score. Very small (4), small (3), big (2), and very large (1). Use the interval formula as follows: Highest score = 10 x 4 = 40 (100%) and Lowest score = 10 x 1 = 10 (10 / 12x100% = 25%) Range = highest score -lowest score = 100% -25% = 75% Then, Information: I = interval R = Range (highest score -lowest score) K = Number of categories "I" = R / K = "I" = 75/4 = 18.75% The desired score is: Highest score -Interval = 100% - 18 Satisfaction Pregnant Women to The Role of Health Care Workers in Antenatal Care are measured on a Likert scale and Scoring is done on each item with a total number of questions of 10 (ten) questions. Each answer is given a score. Very Satisfied (4), Satisfied (3), Not Satisfied (2), and very dissatisfied (1). Use the Arrange as above: Highest score = 10 x 4 = 40 (100%) Lowest score = 10 x 1 = 3 (3 / 12x100% = 25%) Range = highest score -lowest score = 100% -25% = 75% Then, Information: I = interval R = Range (highest score -lowest score) K = Number of categories "I" = R / K "I" = 75/2 = 37.5% Health Science Journal of Indonesia Dewi et al.

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The desired score is: Highest score -Interval = 100% -37.5% = 62.5% Objective Criteria: Good: If the score obtained by respondents >62.5% Not Good: If the score obtained by respondents <62.5% Analysis of the data in this study is Correlation analysis with pearson correlation test. Correlation is a tool used to measure the level of closeness of the relationship between independent variables with the dependent variable. Analysis data also use chi square test. The presentation of data is done in the form of frequency and percentage distribution tables accompanied by an explanation.

Ethical Declaration
This study has been approved by the Ethics Committee Health Research of Universitas Muslim Indonesia and Ibnu Sina YW-UMI Hospital number 095/A.1/KEPK-UMI/V/2019.

RESULTS
The results of research on the role of health workers in antenatal care based on perceptions of monetary sacrifice and time of pregnant women to reduce the risk of maternal death are shown as follows:  Table 1 showed that the majority of pregnant women are aged 20-35 years (87.1%), primigravid (26.9%) and multigravida (50.6%), the education level of the majority is middle school (38.7%), high school (26.9%), family income < 2.860.000 (51.8%), and husban jobs as labor (35.5%), farmers (24.7%), entrepreneurs (29.1%).  Table 2 showed that the majority of perceptions of pregnant women regarding the sacrifice of transportation costs fall into the small category (57%), the sacrifice of administrative services costs is very small (73.1%), and the sacrifice of photocopy costs falls into the very small category (91.4%).   Table 3 shows that the majority of perceptions of pregnant women regarding the sacrifice of Time/ Travel Lengthinto the small category (57%), the sacrifice of Long Time Queueis large (59.1%), and the sacrifice of long service time into the large category (45.2%). Table 4 shows that maternal satisfaction with the role of officers in antenatal care does not correlate with the perception of monetary sacrifice. On the other hand the satisfaction of pregnant women towards the role of officers in antenatal care correlates with the perception of sacrifice of time.

DISCUSSIONS
Based on the results of the research and data processing that has been presented, this discussion will explain in accordance with the research objectives, namely: how the role of health workers in antenatal care based on the perception of monetary sacrifice and time of pregnant women as an effort to reduce the risk of maternal death.
1. The role of health workers in antenatal care as an effort to reduce the risk of maternal death Pregnancy Checkup or Antenatal Care is an activity given to the mother before giving birth or during pregnancy. Pregnancy examination is an effort made in the maintenance of the health of the mother and her womb. Pregnancy checks should be done at least four times during pregnancy, namely once in the first trimester, once in the second trimester, and twice in the third trimester. Pregnancy examination is needed because although in general the pregnancy develops normally and results in healthy births of the baby through the birth canal, sometimes it is not as expected. 10,11,12,13,14 Antenatal Care is a planned program in the form of observation, education, and treatment of medicines for pregnant women, with the aim to keep the mother healthy during pregnancy, childbirth and childbirth as well as maintain a healthy born baby, the process of pregnancy and childbirth that is safe and satisfying, monitoring the possible risks of pregnancy, and reduce maternal and fetal perinatal morbidity and mortality. 15,16 The results showed that the majority of respondents at 83.9% rated the role of health workers in antenatal services as good. The use of antenatal care (ANC) in health center is still low or underutilized. From the results of the study most of the respondents said they did not use the pregnancy check up at the health center. They preferred to have their pregnancy checked by the village midwife, because the distance to the village midwife is closer than to the health center. Besides, at the village midwife the pregnancy check-up process did not take so long, and there was no queue.
The results showed that the service that was not good according to pregnant women was that the waiting time to obtain antenatal services was very long, whether it was in the card room for administrative processes, the service room of midwives / doctors / other health workers, and in the medical waiting room. So that pregnant women feel a great sacrifice of time in obtaining antenatal care. So it needs efforts to improve service quality in terms of service time. The quality of ANC services based on the 10T standard is not optimal, there are still some services provided that are not in accordance with the 10T standard. The administrative process for registration is very complicated and complicated.
The results showed that the service that was good according to pregnant women was that the health staff's friendliness, facilities and infrastructure were quite adequate, the quality of the ANC was already good from the aspect of providing information about the ANC, the provision of the MCH handbook, the implementation of some good ANC standards.
2. The satisfaction of pregnant woman to the role of health workers in antenatal care based on perceptions of maternal monetary sacrifice in an effort to reduce the risk of maternal death Monetary sacrifice is a cost incurred by the customer to obtain goods or services that greatly affect customer satisfaction in utilizing the goods or services.Monetary sacrifice is the sacrifice of money that must be paid by customers to obtain products or services that will be used Kotler & Keller, 2009. Monetary sacrifice is related to the financial costs incurred by the customer in utilizing antenatal care. 17,18 The results of research on the relationship between satisfaction of pregnant women to the role of health workers in antenatal care based on the perception of maternal monetary sacrifice show the results of correlation analysis of 0.058 (p = 0.582) which means no correlation. Results of research on evaluating the perception of monetary sacrifice based on the role of health workers in antenatal care show that at a small monetary sacrifice of 90% stated the role of health workers in antenatal services is a good category. In a very small monetary sacrifice as much as 83.1% stated the role of health workers in antenatal services in the good category, and there were 16.9% included in the poor category.
Based on research results, they underestimate the problem of monetary sacrifice. because they say at the health center there is no charge if there is a BPJS and for those who do not have BPJS only the price of medicine is 10,000 and the average answer of 10,000 is not a burden for those who are important to get health services for their pregnancy well. And so is the transportation administration, most of them use ojeg to go to the health center at a price of 10,000, for those 10,000 for a motorcycle taxi at this time it is reasonable to return home from health center.
This study found that family income of pregnant women varies, family income greatly influences patient satisfaction with antenatal care, because if family income is high (51.8%) then the monetary sacrifice of pregnant women in obtaining antenatal care is not a problem, so in terms of monetary sacrifice it is categorized small. This research also found that husband jobs as a labor (35.5%), farmers (24.7%), entrepreneurs (29.1%), so they have enough money to get antenatal care.
This study is in line with the research of Lubis N & Martin (2009) which states that funding is not given much attention to the problem of getting optimal health services. Pregnant women are willing to pay more if health care providers improve the quality of services. Although the price is increasing every year, the patient is satisfied with the price of the room, the price of medicines. And others. This is because the higher price is also adjusted to the service so that patients get satisfaction and they are not price sensitive. People or the community will continue to use health services as long as price increases are also adjusted to the increase in services. 18,19,20,21 3. Satisfaction of pregnant woman to the role of health workers in antenatal care based on the perception of sacrifice of time as an effort to reduce the risk of maternal death Time sacrifice is the range of time that a customer must spend to obtain a product or service that they will use, or the amount of time that a customer needs to interact with a service company such as: whether fast or not is easy for customers to receive service from the company. 17 Sacrifice time is the length of time sacrificed to get the service used to find out how much the cost of the customer to get the service. 21 The results of research on the relationship between the role of health workers in antenatal care based on the perception of sacrifice of maternal time show the results of correlation analysis of 0.930 (p = 0.009) which means there is a correlation. The results of the study of assessing perceptions of time sacrifice based on the role of health workers in antenatal care show that at very large time sacrifices as much as 100% stated the role of health workers in the antenatal service category is not good. In big time sacrifice as much as 90.2% stated the role of health workers in the antenatal service category is not good, while in small time sacrifice as much as 75.8% stated the role of health workers in antenatal service is a good category.
Based on research, the sacrifice of time felt by respondents is large, because sometimes respondents have to queue and wait for about 60 minutes or even more to get a pregnancy check-up service. but this time can be said that the time is not too long because the standard time set by the 2008 Ministry of Health Regulation is 60 minutes. However this is one of the reasons they state the role of health workers in pregnancy examinations at the health center is not good. This shows that the greater sacrifice of time is felt, it will give respondents a tendency to use the pregnancy check up less at the health center.
This study found that the education of pregnant women in middle school (38.7%), and high school (26.9%). So that their understanding of the importance of antenatal care is better. High education can provide opportunities to take advantage of antenatal care services, even though they have to sacrifice a lot of time.
To increase the perception of pregnant women regarding the quality of antenatal services based on time sacrifice, namely by making the small sacrifice of time felt by pregnant women by speeding up the time of service provided to pregnant women and all midwives in the MCH room should take their respective roles for serving pregnant women so that optimal service can be created and quickly resolved while reducing long queues.
This study is in line with the research of Muhammad Yusri (2015), Aulia Utami Dewi (2015) which states that there is a tendency that the fast waiting time for registration will make the patient satisfied with the service, or the length of the waiting time for registration will make the patient dissatisfied with the service and will have an impact on utilization return to the hospital. 22,23 According to previous research, the relationship between waiting time of service and the level of patient satisfaction in the obstetric clinic and the content of Surakarta Hospital showed a positive relationship. 24 Researchers assume that the tendency of faster service waiting times increases patient satisfaction. 25,26 In conclusion, satisfaction of pregnant women towards the role of health workers in antenatal care based on monetary sacrifice does not show correlation while based on time sacrifice shows there is a correlation. Need to increase the speed of the process of pregnancy examination services for pregnant women by health workers.