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Midwives’ role in drop-out antenatal care at second visit: Therapeutic and interactive communication in the Lombok Tengah District, Indonesia

Visiting health center for getting ANC service, at least four times during pregnancy consisting of the first visit (K1) during the first trimester, the second visit (K2) during the second trimester, and K3 and K4 visit during the third trimester must be done by pregnant women in Indonesia. The objective of this research is to analyze therapeutic and interactive communication by midwives during ANC service. This observational research used cross sectional design. The sample size is 30 women with babies under six months old from 3 PHCs working areas in Lombok Tengah District. Among all therapeutic and interactive communication indicators performed by the midwives, only responsive indicator in therapeutic communication showed insignificant influence on K4 of pregnant women. The other indicators showed significant impact. More than 50% of respondents said that midwives providing ANC had poor attending skill, respect, responsiveness, empathy, informing, persuading, and reminding. The conclusion is that the worse the pregnant women perception of midwives communication behavior is, the higher the chance for the pregnant women to drop-out during K4 is.


Introduction
Antenatal care (ANC) is health care service by health workers throughout pregnancy in the form of observation, education and medical treatment for pregnant women which comply with ANC standards. The purpose of ANC is to achieve a safe and satisfactory pregnancy and delivery. 1 ANC can be delivered by professionals such as midwifery specialist, general practitioner, midwife or nurse in the period of the pregnancy compliant with the minimum antenatal service standards. 2,3 The law mandates that every pregnant woman at least did four ANC check-ups throughout pregnancy, con-sisting of the first visit (K1) in the first trimester, the second visit (K2) in the second trimester, and the third and fourth visits (K3 and K4) respectively during the third trimester. 4 ANC can detect signs of highrisk pregnancy or complications in delivery to enable fast and accurate prevention and help.
The problem was that the drop-out rate from ANC of pregnant women at Public Health Centers (PHCs) in Lombok Tengah District was over 10% in 3 (three) respective years, 2010 (20%), 2011 (44%), and 2012 (28%). Based on the PHC Performance Appraisal Guidelines, the tolerance limit of the average of ANC drop-out is less than 10%. 5 A high drop-rate indicates that ANC service quality needs to be improved.
Midwives are the backbone of ANC services in PHCs. Although technical competence of a midwife greatly influences the success of ANC, interaction skill cannot be overlooked. Midwives providing ANC should deliver satisfactory service to pregnant women with different individual characteristics.
One of the efforts to enhance the quality of services is to improve the communication process between midwife and pregnant women. According to Zeithalm and Bitner, 6 a service requires three forms of marketing, those are internal marketing, external marketing, and interactive marketing. Kotler and Keller stated that interactive marketing describes the skills of employees in serving the clients. 7 Supriyanto says that the essence of interactive marketing is communication. In this study, interactive marketing deals more with therapeutic communication and interactive communication during contact between pregnant women and midwives in PHCs. 8 Midwives must have therapeutic and interactive communication skill to deliver good services. Therapeutic communication is a professional communication intentionally done with the goal of patient recovery. 9 Meanwhile, interactive communication is the interaction of individual, patient, caregiver, or professional with or through a communication technology to give health information or to receive guidance and support about health. 10 The objective of this research was to analyze the influence of therapeutic and interactive communication by midwives during ANC service on K4 visit of pregnant women.

Materials and Methods
This research was an observational study using cross-sectional design. The population comprised women with babies under six months old. The sampling used multistage sampling technique. The sample was drawn in two stages. First, PHCs in Lombok Tengah District was divided into three categories according to their drop-out rate: high, medium and low. From each category, one PHC was randomly selected to obtain three PHCs (Kopang, Aikmual, and Muncan).
The next stage was to sample women Lombok Tengah District Health Officer for their helps and support to this work. Authors are also thankful to the respondents of the study for providing valuable information regarding the midwive's communication capacity.
Contributions: the authors contributed equally.
Conflict of interests: the authors declare no potential conflict of interests.
Funding: there is no funding support this study.
Clinical trials: the study is not involved any clinical trials.
Conference presentation: part of this paper was presented at the 3 rd International Symposium of Public Health, 2018 October 31-November 1, Universitas Airlangga, Surabaya, Indonesia.
Dedication: the article is dedicated to all midwives in Indonesia who already committed to accelerate the decreasing number of maternal mortalities. with newborn babies (under six months old) who had check-up during the first month of the data collection. The sample was taken by choosing respondents from each PHC who presented to the PHC during the data collection period. As many as 30 respondents who meet the inclusion criteria (having baby under 6 months old) were obtained, 12 from Kopang PHC, 11 from Muncan, and 7 from Aikmual.
Primary data was directly collected from respondents through interview using questionnaire guide. The questionnaire was tested beforehand to meet validity and reliability standards. The secondary data, the Local Area Monitoring Report-Women and Children Health, was obtained from Health Office of Lombok Tengah District. The data was statistically analyzed using logistic regression test to examine the influence of therapeutic communication and interactive communication on K4 visit in PHCs.

Results and Discussion
The results showed characteristics of respondents, respondents' knowledge about ANC Service, therapeutic communication of midwives throughout ANC checkup and the influence of therapeutic communication towards K4 Visit in Kopang PHC, Aikmual PHC and Muncan PHC in Year 2013. Table 1 shows that most of the respondents were under 35 years old and only received either primary or primary and secondary education. They are farmers or housewives whose income is mostly less than 2 million IDR per month. Table 2 shows that generally, respondents' knowledge related to ANC was categorized as poor because the highest correct score was only 76.7%. This research analyzed communication skills of midwives in delivering ANC services using indicators of therapeutic communication and interactive communication. Therapeutic communication indicators consist of attending skill, respect, responsiveness, and empathy while the interactive indicators comprise informing, persuading, and reminding. None of those indicators was categorized as good (See Table 3 and Table 4). The best score achieved was only in fair criteria, while the responsiveness got the worst score. Interactive communication can be measured based on the perception of pregnant women of how informing, persuading and reminding the midwife was during the ANC serv-   ice. It shows that none of the three indicators were categorized as good. Moreover, persuading and reminding indicators show bad and very bad score. The result of regression test indicates that there was a significant influence of attending skill, respect, and empathy on K4 visit. However, responsiveness indicator did not show significant influence. Table 5 shows that all indicators of interactive communication had a significant influence on K4 visit of pregnant women. Thus, the low rate of K4 visit of pregnant women was influenced by the poor midwives' skill to deliver interactive communication while providing health care service for pregnant women.

Article
In general, respondents' knowledge related to ANC was categorized as poor and quite lot respondents that did not understand about the types of service at antenatal care (ANC). Likewise, the score of respondents' knowledge about the benefits of ANC was also categorized as low. Only 56.7% of the respondents understand about the benefits of ANC. This is probably due to lack of information regarding benefits of ANC or complex language and method used to communicate. According to Supriyanto & Ernawaty, the better one's knowledge about a product is, the bigger the chance for him/her to use the product is. 11 The low K4 visit in this study can be attributed to, among other things, the lack of midwives' ability to communicate with pregnant women during ANC services. 12 There was a significant influence of attending skill, respect, and empathy on K4 visit, yet responsiveness indicator did not show significant influence. This may be due to the relatively similar answers from the respondents. Most pregnant mothers, both respondents attending K4 visit and not, felt that the midwives' responses when giving ANC services were poor. In addition, they thought that poor responses of midwives was normal and should not be considered a problem.
There are four barriers that health workers typically encounter in communicating with the patients, perception of not having enough time, the desire to avoid a flood of strong feeling, fear of empathy being emotionally exhausting and leading to burnout, and the lack of training in empathic communication as it relates to awareness of opportunity and appropriate response. 13 Those barriers were the leading cause of poor communication by the midwife, so the midwives' attending skill, respect, responsiveness, and empathy were assessed in a fair and bad category by the patients.
It is widely accepted that effective clinical communication enhances the health care worker-patient relationship. Studies agree that improved communication increases both health care worker and patient satisfaction, decrease malpractice risk, and improves diagnostic accuracy. 13 The poor value of interactive communication indicators can be due to the midwives are not considering the information gap between her as a health worker and a pregnant woman as a patient. This must be the case in the communication process between health personnel and patients because of the difference in information held between them. Therefore, health personnel needs to explain in detail to the patient about matters related to health services that include the benefits of the process of examination, examination results, and so forth. Bad score for persuading indicator shows that midwife often did not repeat or put further emphasis related to ANC. Very bad score on reminding indicator shows that midwives often did not remind mothers to make another ANC visit. Moreover, midwives often did not contact pregnant mothers if they were missing their previous ANC visit.

Conclusions
This study shows that midwives' communication skills are one of the important aspects in addition to the skill and experience they have in providing ANC services. The results show that based on therapeutic communication indicators, none of the indicators achieved a good score. The results of statistic test show that 3 of 4 indicators are related to K4 visit of pregnant women. Based on the interactive communication indicators, midwives' ability to communicate interactively was poor and all indicators had a significant effect on K4 visits of pregnant women. This suggests that high drop-out rates can be attributed to poor midwives' communication skills to pregnant women during the ANC service process. Therefore, training or improvement efforts to enhance the communication skills of midwives are needed.