Maternal health literacy as an effort to reduce maternal mortality

The Karawang Regency's progress in reducing maternal mortality through an expanding (EMAS) program does not inherently reduce maternal mortality. The change in the incidence of postpartum mother mortality has led the Government of the Karawang Regency to a breakthrough by implementing an appreciation of the level of mothers’ comprehension during the postpartum period between fathers. This research investigated the extent of the father's communication process in Kelas Bapak (Lit: Father Class) to improve the father's awareness of maternal health over the postpartum. This study employs descriptive qualitative methods of research. The study results found that Kelas Bapak inspired families to treat maternal health at the Regional General Hospital of Karawang Regency during the postpartum period. This study concludes that one of the causes of a father's lack of understanding about his mother is that his mother's health is unconcerned during the postpartum period. Keywords; kelas bapak; health family literation; childbirth literation; family health


INTRODUCTION
WHO noted that eight hundred and ten women died in one day of pregnancy and childbirth in 2017; 94 per cent of deaths occurred in developing countries (Sochas, 2019), one of them in Indonesia. WHO records maternal mortality rates in ASEAN as follows in Figure 1, and Indonesia is the second country in Southeast Asia with the highest maternal mortality rate.
The 189 Heads of State and their representatives, who are members of the UN, announced a Millennium Development Goal, one of the targets of which was to reduce mothers' mortality and infant mortality, and a program which ended in 2015, was expected to reduce maternal mortality and rates. Child mortality can only advance slower than other deals (Smith & Hunsmann, 2019). The aim of reducing maternal mortality and mortality for children is also set out in the Sustainable Development Goals (SDS), the purpose of which is to reduce the world maternal mortality rate by less than 70 deaths per 100,000 births by 2030. The success of maternal health efforts, among others, can be seen from the Maternal Mortality Rate (MMR) indicator. MMR is the number of maternal deaths during pregnancy, childbirth and postpartum caused by pregnancy, childbirth and the puerperium or its management but not due to other causes such as accidents or falls in every 100,000 live births.
This indicator can assess maternal health programs and the degree of public health because of its sensitivity to improvements in health services, both accessibility and quality. In general, there was a decrease in maternal mortality during the 1991-2015 period. There was a decrease in MMR in Indonesia from 390 in 1991 to 305 in 2015. An illustration of the maternal mortality rate in Indonesia from 1991 to 2015 can be seen in Figure 2.
Several studies have been conducted regarding the causes of maternal death during childbirth, including delivery at home without being accompanied by competent health workers (Gamlin & Osrin, 2020), skills of health workers (Li, 2020), pregnancy complications (Murphy, 2021) and lack of family knowledge about the health conditions of the mother and the baby in the womb (Murphy, 2021 program, which is expected to reduce maternal and neonatal mortality by 25%. This program is implemented in provinces and districts with many maternal and neonatal deaths, namely North Sumatra, Banten, West Java, Central Java, East Java and South Sulawesi. The basis for selecting the province was because 52.6% of the total maternal deaths in Indonesia came from these six provinces. So that by reducing the maternal mortality rate in these six provinces, it is hoped that will significantly reduce the maternal mortality rate in Indonesia.
Karawang Regency is one of the EMAS vanguard loci focuses along with Bogor Regency, Indramayu Regency, Bandung Regency, Cirebon Regency and Bogor Regency. The presence of the EMAS Program in Karawang Regency as a program to reduce infant mortality and maternal mortality is a breath of fresh air for the world of health, especially Karawang Regency, which is one of the districts contributing to infant mortality and infant mortality rates in West Java. The high infant mortality rate and maternal mortality rate in Karawang Regency can be seen in the data obtained from the Karawang District Health Office as follows in figure 3.
As shown in Figure 3, in the condition of the maternal mortality rate and infant mortality rate in 2008, there were 43 cases of maternal mortality and 205 cases of infant mortality. 2010 was the beginning of the declaration and implementation of the MDGs, the maternal mortality rate reached 47 cases, and the infant mortality rate was at 191 cases. Various efforts have been made by the Karawang regency government, such as initiating Basic Emergency Obstetric Neonatal Care service, using maternal and child health books and childbirth insurance programs. In 2012, the Government of Karawang Regency was beginning to be intervened by USAID through the USAID expanding maternal and neonatal survival program, which ended in 2015, and the West Java Provincial Health Office took the expanding maternal and neonatal survival program. When viewed fundamentally, maternal, and infant mortality is influenced by various factors, including socio-economic, demographic and geographic, and the reach of services to the community. Through cooperation between health workers and families, community leaders, including forums to care for maternal and child health, it is hoped that the problem of midwifery services can be gradually overcome.
Thus, the health problems of pregnant women and babies are not only focused on health workers but also on active family and community participation through community-based partnerships. As the smallest organization in society, the family is a supporting system that dramatically influences the behaviour of family members (Mirzanezhad, 2020). Family communication is necessary to divide roles and carry out their respective roles so that each family member has responsibility and supports and strengthens each other. This division of roles indeed results in a rule that will be different in each family; these rules are then communicated and carried out by other members to create a communication pattern to achieve mutually agreed goals.
Since the government has made a breakthrough by opening up the Kelas Bapak (Lit: Father Class) to provide health literacy to mothers and babies during the postpartum period, which is concerned with efforts to avoid mothers and neonates' deaths, the father class is a family health Angka Kematian Ibu Angka Kematian Bayi literacy forum that emphasises the role of the father as the person most responsible for protecting his family members. In a patriarchal society, the father's role as the person in charge of the family (Minuchin, 2019) is considered the highest and most respected role. Therefore, a father needs to have sufficient knowledge to support the mother's health condition during postpartum. It is hoped that the knowledge possessed by the father will be conveyed to other family members or used as part of the decisions that will be taken (Sciffmann, 2000). Kelas Bapak is a government-based preventive initiative by West Java EMAS mentors through community contact, showing the husband's position as a family leader who is ultimately accountable for family health. In some cases of deaths in pregnancy and childbirth, the impotence of thinking in making decisions independently of their health management was caused by women (Sochas, 2019). Thus, this research has shown how the communication mechanism in Kelas Bapak activities leads to fathers becoming active in the postpartum initiative to avoid maternal mortality. This study uses a qualitative analysis approach with case studies, while research work will take place in Karawang Regency, West Java, Indonesia.

METHODOLOGY
This research uses a qualitative research method with a case study approach; a case study is a research method that emphasizes human interpretation of variations in norms that exist in society, beliefs, and scientific theories (K. Yin, 2015). Yin said that a case study is a study that analyses and analyses a case in order to achieve an in-depth research result. The focus of case studies is on variations between phenomena and current contexts (K. Yin, 2015). In the analysis, the selected case was a single case, namely the efforts of the Karawang regency government to reduce maternal mortality and infant mortality rates through the father class.
The speakers in this research are policymakers, policymakers and policy recipients. The following are the sources for this report, as seen in the table 1. Data collection was carried out through formal interviews, where the study had already been planned, and each resource individual received the same questions (Crozier et al., 1994). Structured interviews were conducted to gather each person's views in the same situation, including saving mothers and newborns through Kelas Bapak.

RESULTS AND DISCUSSION
Talking about maternal health in a patriarchal community does not only speak about a specific woman who is healing but also about the general social norms within society and the family itself. The specific social patterns of postpartum mothers are often not in line with health sciences, and health workers' cooperation and hard work in educating mothers and family members around them are therefore required.
The Karawang District Health Office has engaged in several partnerships, such as private and government midwives, Taraji or traditional birth attendants, with community leaders to carry out socialisation and education related to maternal health during pregnancy, childbirth and postpartum. We have some breakthroughs, such as collecting the mother to give birth from the hospital and bringing her home. We also have a midwife monitoring group to pick up; midwives must prove the condition of the postpartum mother after arriving home by sending a picture that the mother has arrived home and has been handled through WhatsApp Group under the leadership of the Karawang District Health Off. (Result of an interview with Yayuk, 1 July 2019).
The efforts to reduce maternal and infant mortality by the Karawang District Health Office in partnership with the Ministry of Health and USAID through the Expanding Maternal and Neonatal Survival (EMAS) program started in 2012. They ended in 2017, resulting in substantial results in the form of a reduction in mortality in five years, as high as 25%, as we can see in Figure 3.
EMAS is a program to reduce maternal and infant mortality rates that focuses on enhancing service efficiency, employee transparency and synergy between government and community through civil society forums. The EMAS program has been in service since 2012 and will conclude in 2017. The West Java Province and the Karawang Regency Government are committed to continuing the EMAS program because the program is considered capable of reducing maternal mortality and infant mortality by 25 per cent over five years. According to data from the Karawang District Health Office, 43 cases of maternal mortality and 162 cases of infant death occurred in 2018.25 mothers died during the puerperium, six mothers died during childbirth, and 12 mothers died during pregnancy.
During the introduction of the EMAS program, it has since been strengthened in terms of resources and skills of health workers to ensure that all emergencies affecting mothers and newborns have been adequately treated, carried out in health facilities funded and monitored by the community through civil society forums. After the introduction of the EMAS program, cases of maternal death occurred during the puerperium, i.e., postpartum and home treatment, the cause of this condition was the level of awareness of mothers and families regarding low maternal and newborn care and insufficient cultural or community practices or should not be done during puerperium (Result of an interview with Ning Nurul Safitri, 4 July 2019).
So far, there are many myths in society about what food, drinks and activities should and should not be done to mothers and newborns. Some of these myths are often ridiculous and violates medical laws, need cooperation between family members, especially husbands and wives, in convincing mothers to carry out medical advice activities, mainly to reassure the mother-in-law and her family. The communication pattern between family members is also related to the specific role functions carried out by each individual. The role functions that are usually associated with the roles of husband and wife are divided into several parts, namely: (1) providing clothing and shelter needs; (2) managing houses, household budgets, enforcing rules; (3) nurturing, providing support and guide, (4) develop abilities and talents; (5) meet the sexual needs of partners and become role models for children (Galvin, Kathleen M & Bernard J, 1986). In Indonesia, which is thick with a patriarchal culture, the father's role is vital and dominant in providing support in running all businesses that can make the mother feel comfortable during the postpartum period so that the mother's health can be adequately maintained.
To date, studies in the field of mothers have died due to rebleeding or other causes. This disorder is due to a lack of awareness of the family's health during postpartum, from wound care to nutritional issues. Sometimes while in the village, there are several prohibitions, such as the postpartum mother who is not permitted to eat meat, eggs, or chicken, she claims it will make them itchy, or their wound will not heal. Mothers who have just given birth are also forbidden from taking a nap because later blood flow will go to the brain and other prohibitions that sometimes the mother can only follow. After all, those behaviours, whether they like it or not, must be followed. The mother's state becomes more complicated as she still must live with her in-laws or the husband's family. (Results of an interview with Ning Nurul Safitri, 4 July 2019).
Focusing on efforts to reduce maternal mortality during the puerperium, the Karawang District Health Office, through the Karawang Regional Hospital, has made a breakthrough in the education of postpartum mothers to improve maternal health and maternal comfort during the postpartum era.
We are trying to approach the father, a man, who is a leader in the family, is supposed to play a more role and care more for the wellbeing of his mother or wife. Men are typically more obeyed by their families, mainly if they live in their parents-in-law or the house of the male's family, so we try to educate men or the writer as family leaders. (Result of an interview with Ning Nurul Safitri, 4 July 2019).
The father of the class is expected to be one of the efforts of men g educate families in regard to the welfare of mothers and newborns. Kelas Bapak is a company started by an EMAS mentor who works as a midwife at Karawang Hospital. Mentors are health professionals who have the additional responsibility of transmitting good practices from attempts to save mothers and newborns; mentors are prepared to assist and inspire health workers to make every effort to support the community, in particular by carrying out rescue efforts for mothers and newborns (Nursanti, 2018).
The original idea came from completing the EMAS activities; the 2018 report shows that maternal mortality rates are decreasing, while not absolute to zero will at least not increase the quality of mortality, no more mothers' giving birth is not a health facility. Maternal support and clear intervention because the scheme was working well, but it turns out there is a change now there is still unfinished homework that maternal mortality in puerperal mother dies l even after home. After collecting data, the cause of death, one of which is the habit of the community during the postpartum period, if only the mother's education is not enough, we try to approach the head of the family, namely the father (Result of an interview with Ning Nurul Safitri, 4 July 2019).
The implementation of the Kelas bapak itself is not like traditional classes, as in the ordinary education system, the Kelas Bapak is planned to be an interactive contact room for midwives, husbands, postpartum mothers, and their families.
The first time they come to the hospital to give birth, the pregnant woman will meet her sibling midwife, her brother, in Indonesia. The term local content is used by the manager of the Karawang Regional Hospital to create an intimate relationship between family and health workers at the hospital.
We try to offer a welcoming picture to pregnant women and their families by using the word "dulur" or a pregnant mother's relative who comes to the hospital. That is done with the intention of building intimacy between health workers and pregnant women, so far it is believed in the community that if they have relatives in the hospital, the service will be different and more relaxed, so we strive to make pregnant women and their family's brothers to the midwives who provide services. To build a positive relationship between mothers and health workers so that there is a successful communication relationship and a shift in the impression that hospitals are terrifying (Results of Interview with Dwi Susilo, 7 July 2021).
The interpersonal partnership between health workers and pregnant women is expected to be successful in interacting and making it easier for health workers and pregnant women to exchange knowledge and help each other for the service process and maternal comfort if the mother feels secure. It is hoped that emergencies in the mother can be resolved immediately.
The first time the midwife came to the hospital, she immediately asked where her husband was, and she introduced herself and gave a phone number and WhatsApp to make it easier to find details and urgent support for mothers and babies (Results of an interview with Akbar, 1 November 2020).
The mother and her family experience the warmth of having relatives in the hospital. Establishing good contact between mothers, families and health workers may benefit the creation of efficient contact between communication actors to save mothers and newborns. Pregnant women are not patients, which means that they come to the hospital in a stable state, and there are only psychological changes that usually occur in mothers. Hormonal shifts that occur in mothers cause emotional instability, which can impede the identification of emergencies that occur, and thus there is a need to improve comfort on the part of the nurse, the family of the patient and health workers.
The lack of awareness of changes in life on the mother's side can cause distress, which is thought to affect the mother's health. Therefore, serious education is required to develop an awareness of mothers and their immediate environment regarding mothers 'and newborns' health literacy. There are a variety of areas of knowledge literacy. Furthermore, the newborns take place in the parent's class, followed by the baby, parent, health worker and midwife's "dulur" concerned, and follow the procedure from the time the mother enters the hospital until the mother returns home.
The existence of women and health in women's bodies in a patriarchal culture is not wholly-owned by women; women own only 10 per cent of rights to their bodies, including their health (Saptandari, 2013). One of the studies conducted in Brebes stated that maternal mortality is caused by the belief in the community that women must obey their husbands and families (Kusumo Hapsari dan Sumardiyono, 2016), the level of mother's education and family knowledge of maternal health, and the vibrant health of health workers in carrying out health literacy towards mothers and their families (Prihartanti, 2017). The maternal mortality rate in Indonesia is relatively high, and one of the causes is the lack of literacy in the health of the mother, family, and the immediate environment (Aeni, 2013). The understanding of some people who think that the task of getting pregnant, giving birth, and raising children is one of the main tasks and functions of women in Indonesia (Zahrok & Suarmini, 2018) is one of the reasons why fathers, as the head of the family, feel they do not have to participate in women's domestic affairs in the household.
Health literacy for mothers and newborns is not enough to only be given to mothers as the centre of childbirth and breastfeeding activities; it takes cooperation between husbands and families to provide support and increase knowledge regarding the health of mothers and babies during the postpartum period. The results of the study Junaidi and his friends found that the public has not that being a housewife is a profession and an occupation requiring joint support of all parties, especially husbands and means families, because it is the duty of women and a mother take care of her, and the baby was born (Junaedi, 2017). Based on the research conducted by women regarding Parent educations, it was found that women experience Partum stress due to childbirth (Daman & Salat, 2015). Therefore, as the leader of the father's household, they must participate in the care of mothers and newborns.
Going through the postpartum period for a mother who has just given birth is not a manageable condition considering that during the postpartum period, the mother still remembers the pain she feels during childbirth (Taghizadeh et al., 2015), many changes occur in women during and after childbirth (Greenfield et al., 2016) in the form of fear and loss of control (Ayers et al., 2015) which often causes problems in the mental health of the mother during childbirth (Turkstra et al., 2015). Research conducted by Huang in China found that minimal family support for mothers during childbirth and childbirth is one of the causes of psychiatric disorders during the puerperium (Huang et al., 2019), loss of support from families due to mothers not being able to provide the sex that the family wants. Therefore, the support and cooperation of health workers (Silveira et al., 2019) are needed to provide health literacy to families related to the mother's condition after giving birth.
As the smallest organizational unit in society, the family is the first place a person learns to organize to meet the basic needs of each individual. The grief that occurs due to the death of a mother does not only talk about the father's grief; other griefs will be felt by children who have lost their mothers and parents of mothers who have lost their children (Stroebe et al., 2007). Losing a family member will leave an impression and trauma for each family member (Walder, 2010), especially if it was a mother who died. Mothers, the individuals tasked with getting pregnant, giving birth, and raising future nationals, are the first people a newborn will meet on this earth (Zahrok & Suarmini, 2018).
The success of reducing maternal mortality and infant mortality rates in Karawang Regency through the EMAS program has brought new problems, namely cases of maternal deaths that occur even during the postpartum period, which are not yet covered by the EMAS program. The Karawang District Health Office, through EMAS mentors, made a breakthrough as an effort to reduce cases of maternal mortality through Kelas Bapak as an effort to educate the public regarding maternal health during the postpartum period.
Midwives carried out the initiation of Kelas Bapak at the Karawang Regional Hospital to motivate the father as the head of the family to be responsible for taking care of mothers and babies during the postpartum period. The existence of Kelas Bapak, which is carried out in the form of a group simulation attended by a group of fathers, is expected to give birth to the father's understanding that mothers in the postpartum period also face a pretty heavy period, such as trauma during childbirth, wounds caused by childbirth that can still be felt. The mother's psychological changes, besides enduring pain, also have to breastfeed and take care of the baby.
As the primary communicator, the midwife gave directions to the father regarding the mother's condition, wound care, and explanation of social habits in society that were not in line with health recommendations. In-class activities midwife hospitals Karawang designing messages and packing messages using language quickly understood and delivered in a group discussion. Messages were conveyed using examples and the language commonly used by the community, namely Sundanese language typical of Karawang Regency, and occasionally midwives used Indonesian. The use of the local wisdom approach is expected to make fathers better understand and understand the message given by the midwife.
The communication process at the father's class is considered quite effective, considering that the message giver is a midwife who has quite good experience in educating mothers and their families. "Dulur" or sibling approach has its advantages in producing effective communication, the quality of communication between the midwife as a counsellor and the father as counselling is an advantage in the educational process.
The choice of messages and the use of the language conveyed by considering the mother tongue, namely Sundanese language, is easily understood and understood by the father and his family; the persuasion communication style makes the father not feel intimidated and fosters motivation from within the father to be involved in the care of maternal health during the postpartum period. The choice of education using group communication makes the father feel that he is not alone; many other fathers are being educated to be more concerned about maternal health during the postpartum period. Cohesion in a group is not an immediate form of action. Communicating in groups helps someone realize their position in society; communication in groups can prevent communication actors from isolating the communication freeze (Poole, 1994).
A fantasy chain event will not produce complete cohesion. In Kelas Bapak, there is a possibility that those who undergo and attend Kelas Bapak simply abort their obligations, considering that the discussion is held at the hospital where the mother and baby are born. Their fantasies had not been revealed at the time, so similarities had not been formed between all group members. In general, various fantasies will be expressed during group activities so that previously excluded members can find common ground in dealing with other group members. Creating cohesion in groups takes time because recognizing commonalities and developing a comfortable atmosphere takes place gradually and is a critical group process that must endure (Sovacool & Brossmann, 2010)