Mix Method Analysis of Factors Affecting Implementation of Antenatal Care (ANC) in Pregnant Women in the Work Area of the Medan Deli Health Center, Medan Deli District, Medan

Mix Method Analysis of Factors Affecting Implementation of Antenatal Care (ANC) in Pregnant Women in the Work Area of the Medan Deli Health Center, Medan Deli District, Medan Elya Rosa, Razia Begum Suroyo, Aida Fitria Master of Public Health Science, Helvetia Institute of Health, Medan, Indonesia Lecturer of Master's Degree in Public Health Sciences, Helvetia Institute of Health, Medan, Indonesia Lecturer of Master of Public Health Sciences, Helvetia Institute of Health, Medan, Indonesia


Introduction
Antenatal care is health care provided to pregnant women by health professionals. It covers physical and emotional health in order to ensure the health of mothers and infants during pregnancy, delivery, and the postpartum period. Prenatal care information may be documented in writing in the mother and child health book (MCH) if its usage has been established (McKinney et al., 2017). Clients who are unable to read may request assistance from other family members after receiving an explanation from the midwife. Mothers with hearing loss or a lack of education may comprehend the contents of the book (Astuti (2017).
According to the World Health Organization (WHO), about 303,000 women and girls died in 2015 from pregnancy and childbirth-related problems, while 2.6 million stillbirths occurred in the same year. Ninety-nine percent of maternal fatalities (99%) and 98 percent of infant deaths (98%) occur in low-and middle-income nations. Indonesia's infant mortality rate was 34/1,000 live births in 2012, nearly five times that of Malaysia (6/1,000 live births), two times that of Thailand (11/1,000 live births), and 1.3 times that of the Philippines (8/1,000 live births), Brunei Darussalam (6/1,000 live births), and Singapore 2/1,000 live births. This maternal mortality might have been avoided if pregnant women and teenage girls had access to highquality prenatal care (ANC). Sixty percent (1.46 million) of stillbirths occurred during the antepartum period, mostly as a result of untreated maternal infection, hypertension, and inadequate fetal development.
Reduce worldwide maternal mortality to fewer than 70 per 100,000 live births, in accordance with the 2030 Sustainable Development Goals (SDGs). In 2015, 303,000 women died as a result of pregnancy or delivery problems. Almost majority of these fatalities happened in nations with low and medium incomes (99 percent). Maternal mortality reduction is largely reliant on women having access to high-quality care before to, during, and after delivery (Rachmawati et al., 2017).
In Minister of Health Number 52 of 2017, the Indonesian Ministry of Health stated that all pregnant women who had their prenatal examinations were required to be screened for HIV, Syphilis, and Hepatitis B as part of integrated antenatal care and were supported by promotional and preventive efforts in health care/KB services that would support the National Program for the Elimination of (Ppia KEA, 2017).
MMR is defined in the 2018 Indonesian Health Profile as the number of maternal fatalities during pregnancy, delivery, and postpartum that are caused by pregnancy, childbirth, or postpartum or their treatment, but not by other causes such as accidents or falls. In 2018, North Sumatra Province recorded 185 maternal fatalities, with 38 of them being pregnant mothers. Indirect reasons include pregnant women who have pre-existing illnesses or problems, such as hypertension, anemia, or infections. These complications are actually preventable with proper prenatal care (Indonesian Ministry of Health, 2017).
Medan Deli Health Center is one of the health facilities situated in Medan City. This health center currently has K1 and K4 coverage levels that are below than the goal, which is 100% K4 coverage. According to statistics from the Medan Deli Health Center, there were five subdistricts in 2019 between January and December with a target number of pregnant women of 2854 with K1 (87 percent) and K4 coverage (66 percent ).
Information is a significant element in pregnant women's desire to attend Antenatal Care; moms with a high level of knowledge about pregnancy health view ANC (Antenatal Care) appointments as a need for their pregnancy (World Health Organization, 2004) Pregnant women's attitudes about prenatal care services have an effect on their compliance with ANC (Antenatal Care) appointments. A positive attitude or a positive reaction demonstrates their care for their own and their fetus's health, which increases the frequency of visits, while a negative attitude demotivates pregnant women to visit (World Health Organization, 2018).
On the basis of these issues, researchers are interested in conducting an analysis of "Analysis of Mix Method Factors Influencing the Implementation of Antenatal Care (ANC) for Pregnant Women in the Work Area of the Medan Deli Health Center, Medan Deli District, Medan City in 2020."

Methods
This is a mixed methods study, which mixes quantitative and qualitative techniques. A progressive explaining approach will be utilized (Creswell, 1999).
Qualitative research data supplement quantitative data in this investigation. This research method starts with the gathering and analysis of quantitative data and continues with the collection and analysis of qualitative data that is based on the quantitative findings. This approach places a high premium on quantitative data. In this approach, the research process begins when the first quantitative findings influence the qualitative data collecting procedure, ensuring that the two kinds of data are distinct but yet linked.
A quantitative method is a kind of retrospective study that entails the gathering of statistical data in order to do calculations. The quantitative method used questionnaires to informants with the goal of evaluating how pregnant women's prenatal care is implemented. The qualitative method is fundamentally an investigative process like to detective work; throughout the course of the inquiry, both primary and secondary data will be gathered. Qualitative data are mostly derived from words and acts. In-depth interviews were conducted utilizing interview guidelines to elicit more information on the implementation of prenatal care for pregnant women (Sugiyono, 2013).
The study will be performed in August 2020 at the Medan Deli Health Center Work Area, Medan Deli District, Medan City. The population for this research included pregnant women who received prenatal care checks in December 2019 in the Medan Deli Health Center Work Area, Medan District. Medan City Deli employed 195 workers. The sampling method employed in this study was incidental sampling, or sampling of individuals who happened to be present at the time of the investigation, and it was based on the Slovin formula. Pregnant ladies who underwent an antenatal care examination in December 2019 in the Medan Deli Health Center Work Area, Medan Deli District, Medan City. The sample is qualitative and includes two more informants: the spouse and a health care professional.
To ascertain which variables have a greater impact on the application of ANC in pregnant women. The Chi-Square test was used to evaluate the survey data in this research, and the Logistics Regression test was used to identify the most dominating component in the ANC implementation.   Based on the results of the Chi-Square test using the chi-square test, the chi-square test shows that the p-value is 0.004 <0.05, which means that there is a relationship between health services and the implementation of antenatal care (ANC) for pregnant women in the Medan Deli Public Health Center. Medan Deli District, Medan City in 2020.    Based on the results of the interview, it was found that the level of knowledge of mothers about pregnancy in the area where the study was conducted was good, but some still did not understand the importance of ANC, especially mothers with low education, mothers who were pregnant for the first time. If I'm here, I often provide information according to the mother's ability to absorb information. A research conducted in a rural region found that some women had excellent understanding of pregnancy in the area under investigation, but that others did not comprehend the significance of antenatal care, particularly among moms with low levels of education and those who were expecting for the first child. In the event that I am there, I often give information based on the mother's capacity to assimilate new knowledge. Report 2 "This is our fourth child." 3 Report 3 "The fifth is Ma'am." 4 Report 4 "Third child ma'am" Based on the table above, from the results of the depth interview, it is known that the number of children (parity) owned by the informant is between 3-5 people. 2 Report 2 "I am a housewife and help help at the somay sales house" 3 Report 3 "I am a housewife" 4 Report 4 "I am a housewife" It is known to informant 1 that the informant's work status is that of a housewife who assists family in the sale of chicken. This is based on the findings of the depth interview. Informant 2 is a housewife who assists her husband in the sale of meatball from their home. It was discovered that those interviewed said that health-care professionals gave easy-tounderstand explanations, pleasant treatment, and the services were trustworthy because of what was said by informants 1, 2, 3, and 4. Report 4 "support, support like to take medicine, always cheered" Based on the table above, from the results of the depth interview, it is known that the informant stated that the husband had provided support to his wife in order to know the state of the In accordance with the findings of the depth interview, it can be concluded that all informants stated that health workers provide support for their wife's pregnancy in order for pregnant women to undergo timely examinations, prevent pregnancy complications by understanding symptoms or complaints during pregnancy, and ensure that their wife has a healthy pregnancy. Bivariate analysis revealed that there is a positive connection between knowledge and the implementation of Antenatal Care (ANC) for Pregnant Women in the Work Area of the Medan Deli Health Center in the Medan Deli District, Medan City in the year 2020.
It was discovered through the study's findings that there was a statistically significant relationship between knowledge and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, Medan Deli District, Medan City in 2020, with a p value of 0.032 0.05 for the relationship between knowledge and implementation of ANC. With an Exp (B) value of 3.688, the knowledge variable indicates that respondents with excellent information are 3.6 times more likely than respondents with less knowledge to adhere to the implementation of prenatal care (ANC), according to the data.
According to researchers, when a mother has more than three children and the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place. When a mother has more than three children and the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place, and when the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place. Women with parity 3 children who are not following standards because they lack knowledge about the importance of routine pregnancy visits, as well as women with parity 3 children who are following standards because they are still fearful because they have less experience with pregnancy and therefore are concerned about the condition, have been identified. If the mother does not come in for a pregnancy check, the fetus is at risk. Among the variables associated with implementation of antenatal care (ANC) in pregnant women, the parity variable is the most significant.
When it comes to prenatal care (ANC), knowledge is one of the most significant markers of a person's willingness to act. Knowledge is also an essential element that affects pregnant women's desire to attend antenatal care (ANC) appointments (Lee et al., 2018). For women who have a strong understanding of pregnancy health, prenatal care appointments are no longer simply a means of fulfilling responsibilities, but have evolved into a need for their pregnancy.
According to studies, the more the information a mother has, the greater her awareness of and willingness to have her pregnancy checked is. Having knowledge about the significance of prenatal care influences the behavior of mothers when it comes to doing antenatal care exams, which helps to prevent the risks of pregnancy from becoming apparent. The mother will be aware of the need of doing a thorough ANC examination as a result of the information she has gained.
In accordance with the findings of the research conducted using bivariate analysis, it can be concluded that the relationship between attitudes and the implementation of Antenatal Care (ANC) for Pregnant Women in the Work Area of the Medan Deli Health Center, Medan Deli District, Medan City in 2020 will be positive.
Following the findings of this research, it was discovered that there was a statistically significant relationship between attitudes and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, in the Medina Deli District of Medan City in 2020, with an adjusted p value of 0.0218 0.05. With an Exp (B) = 11.522, the attitude variable indicates that individuals with a positive attitude are 11.5 times more likely to adopt prenatal care than those who have a negative attitude.
According to the study, pregnant women's attitudes about prenatal care services have an impact on their willingness to participate in antenatal care (ANC) appointments. A positive attitude or a positive reaction shows their care for their own health and the health of their fetus, which may lead to an increase in the frequency of visits, while a negative attitude causes pregnant women to lose their desire to visit.
Bivariate analysis revealed that there is a positive connection between parity and the implementation of Antenatal Care (ANC) for pregnant women in the Medan Deli Work Area, Medan Deli District, and Medan City in the year 2020 according to the findings of the study.
Following the study's conclusion, it became clear that there was a statistically significant relationship between parity and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, in the Medina Deli District of Medan City in 2020, as determined by a p value of 0.0080.05. The attitude variable has a value of Exp(B) = 0.0062, which means that respondents with a parity more than three have a probability of being involved in the execution of prenatal care one more time than respondents with a parity less than three.
According to researchers, when a mother has more than three children and the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place. When a mother has more than three children and the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place, and when the standard of care is not followed, the mother assumes that the baby and mother will remain in good health until the delivery process takes place. Women with parity 3 children who are not following standards because they lack knowledge about the importance of routine pregnancy visits, as well as women with parity 3 children who are following standards because they are still fearful because they have less experience with pregnancy and therefore are concerned about the condition, have been identified. If the mother does not come in for a pregnancy check, the fetus is at risk. Parity is the most significant variable in the application of antenatal care (ANC) in pregnant women, and it is the most prevalent variable in the study.
Bivariate analysis revealed that there is a positive connection between health services and the implementation of Antenatal Care (ANC) for Pregnant Women in the Work Area of the Medan Deli Health Center, Medan Deli District, and Medan City by 2020 based on the findings of this study.
Following the study's conclusion, it was discovered that there was a statistically significant relationship between health services and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, the Medin Deli District, and the city of Medan in 2020, as indicated by the p value of 0.016-0.05. Exp(B) = 12,048 for the health service variable, indicating that respondents who get health services have 12 times the chance to implement prenatal care compared to respondents who do not. In the opinion of researchers, good health services are provided but not implemented in accordance with standards because many mothers regard their pregnancies as trivial or indifferent, and they assume that if there are complaints, pregnant women will come to check on their pregnancies. Good health services are provided in accordance with standards because mothers understand the importance of visiting and are satisfied with the the lack of health services and their non-implementation in accordance with standards are due to mothers' dissatisfaction with the health-care system, and the lack of healthcare services and their non-implementation in accordance with standards are due to mothers' awareness of the importance of scheduling prenatal visits (Buisman& García-Gómez, 2015).
After conducting research using bivariate analysis, it was discovered that there is a positive relationship between husband support and the implementation of Antenatal Care (ANC) for pregnant women in the working area of the Medan Deli Health Center, located in the Medina del Deli District of Medan City in 2020, according to the findings.
Following the study's findings, it was discovered that there was a statistically significant relationship between husband's support and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, in the Medan Deli District, and Medan City in 2020 (p value 0.026-0.005). Exp(B) = 8.744 for the husband's support variable, which means that respondents who get husband's support have 8.7 times the chance to apply prenatal care compared to respondents who do not receive husband's help.
As stated by the researcher, the findings of this study demonstrate that a husband's support is significantly related to the implementation of antenatal care (ANC) for pregnant women in the working area of the Medan Deli Health Center, located in the Medan Deli District of Medan City, according to the researcher. Pregnant women will feel more confidence in their ability to carry their babies if their husbands support them throughout their pregnancy. Because of the husband's encouragement, the wife is always prepared to do a pregnancy test. Support may take the shape of a husband's readiness to accompany his wife to the doctor for a physical examination. In addition, financial assistance will encourage mothers to have their children checked for health problems since getting their children checked for health problems requires money for injections such as vitamin injections, TT injections, and other expenses associated with getting them checked. Additionally, according to the findings of this research, men did not give support to their spouses because they did not understand the significance of giving assistance to their wives during pregnancy. This may also have an effect on the wife's willingness to endure the pregnancy process if she does not get enough support from her spouse. Bivariate analysis revealed that there is a positive relationship between health worker support and the implementation of Antenatal Care (ANC) for Pregnant Women in the Medan Deli Health Center Work Area, which is located in the Medan Deli District of Medina City in 2020, according to the findings of the research.
Following the study's conclusion, it was discovered that there was a statistically significant relationship between the support of health workers and the implementation of antenatal care (ANC) in the Medan Deli Health Center Work Area, the Medan Deli District, and the city of Medan in 2020, as indicated by the p-value of 0.0410.05. With an Exp(B) value of 6.139, the husband's support variable indicates that respondents who get assistance from health professionals have a 6 times greater chance of putting in place prenatal care when compared to respondents who do not receive support from health workers. According to the researcher, receiving support from health workers encourages pregnant women to undergo an annual pregnancy examination (ANC) in accordance with the standard, which includes one examination in the first trimester, one examination in the second trimester, and two examinations in the third trimester, or the older the gestational age the better, as recommended. Pregnancy tests are administered to health-care professionals.
According to the chart above, it was discovered that the reason the mother did not complete antenatal care was because if there were any complaints, the pregnant woman came to check her pregnancy, and this was because the mother and fetus were healthy in the previous pregnancy, so the mother assumed that the mother and fetus were still in good condition for the next pregnancy. a condition of good health A lack of health services, such as being unfriendly and apathetic when reacting to concerns from patients, may cause people to feel uncomfortable while doing pregnancy tests. The lack of assistance provided by the spouse is due to the fact that the husband is very busy at work.
During her pregnancy examination, the midwife said that one of the reasons why the mother's information was lacking was because she did not understand the significance of doing a pregnancy checkup. The more the amount of information a mother has, the greater her awareness of and desire to have her pregnancy checked. Having knowledge about the significance of prenatal care influences the behavior of mothers when it comes to doing antenatal care exams, which helps to prevent the risks of pregnancy from becoming apparent. The mother will be aware of the need of doing a thorough ANC examination as a result of the information she has gained. Midwives have also been restricted in their ability to visit the homes of pregnant women who have not completed their pregnancy check-ups, which has caused them frustration.

Conclusion
The findings of this research indicate that there is a connection between Knowledge, Attitude, Parity of Health Services, Husband's Support, and Support of Health Workers, and that this association is significant. According to the findings of qualitative research based on in-depth interviews with informants, the high maternal parity rate results in mothers having prior pregnancy experience and only seeing the doctor when they are suffering symptoms of pregnancy-related illness.