Pregnant Women's Satisfaction with Antenatal Care (ANC) Services at Puriala Public Health Center, Konawe District

Background: Quality health services are Public health Center that can provide satisfaction for every user of health services in accordance with the level of satisfaction of the average population, the implementation of which is in accordance with established professional standards and ethical codes. Fulfilling customer expectations for satisfactory quality of health services is one of the biggest challenges in providing health services. This study aims to determine the factors related to the level of satisfaction of pregnant women with Antenatal Care (ANC) services at the Puriala Public Health Center, Konawe Regency, in 2022. Method: This research is an analytic survey research with a cross sectional study approach. The sample of this research is 68 with the sampling technique that is Accidental Sampling. Data analysis techniques with univariate and bivariate using the Chi-Square test. Results: The results of the Chi-Square statistical test at the 95% confidence level (0.05) showed that p value = 1,000 so that p value = <0.05, bivariate analysis obtained reliability (p value = 0.001), responsiveness (p value = 0.218), empathy (p value = 0.022), assurance (p value = 0.945), and tangibles (p value = 0.006). Conclusion: There is no relationship between satisfaction of pregnant women with responsiveness and assurance, while there is a relationship between satisfaction of pregnant women with reliability, empathy, and tangibles.


INTRODUCTION
Indonesia is one of the countries in the Association of South East Asian Nations (ASEAN) which has a high maternal mortality rate (MMR).The 2017 Indonesian Demographic and Health Survey (IDHS), the MMR in Indonesia was 359 per 100,000 population, an increase of around 57 percent compared to conditions in 2007, which was 228 per 100,000 population (1).Human Development Report data shows that the MMR in Indonesia is higher than several countries in ASEAN such as Singapore, Thailand, Brunei Darussalam, Malaysia, the Philippines, and even Vietnam (2,3).In 2020, the Maternal Mortality Rate will reach 245 deaths per 100,000 live births; The Neonatal Mortality Rate reaches 19 deaths per 1000 live births; The infant mortality rate is 33 deaths per 1000 live births and the under five and child mortality rate is 45 deaths per 1000 live births (4).Public health centers include planning, implementation, evaluation, recording, reporting, and set forth in a system (5).The efficient delivery of high-quality health services is a cornerstone of the global agenda to achieve universal health coverage.WHO, health service delivery is considered to function well when there is equitable access to a wide range of high quality health services (6).
The quality or quality of health services can be seen from several perspectives, namely the perspective of health service providers, the perspective of funders, the perspective of owners of health service facilities and the perspective of patients.There are five criteria that determine the quality of a service, namely: Reliability, namely the ability to perform services as promised, accurately and satisfactorily.Responsiveness, namely the ability to help customers to serve well Assurance, namely knowledge of the courtesy of officers and their trustworthy nature.Empathy, namely a sense of caring to give individual attention to customers, understanding customer needs and ease of contact.Tangibles (physical evidence), which includes physical facilities, employee equipment and communication suggestions (7).
One of the main indicators to measure the quality of health services is to assess the level of satisfaction of service users, namely patients who visit health institutions.Patient satisfaction is the level of satisfaction experienced by patients after using the service (8).In providing quality services, the Public health centers still has several obstacles that are often complained of by most patients, one of which is ANC services.ANC is a preventive effort in the obstetric service program to optimize the contribution of mothers and babies through a series of routine follow-up activities during pregnancy (9).ANC examinations are very beneficial for pregnant women themselves because apart from being able to get services according to the procedure, they can also get or seek information about their pregnancy, starting from gestational age, nutritional status, blood pressure, and so on.And the most important of the benefits of the ANC examination is that it can prevent the risk of maternal death (9, 10).Indonesia's Health Profile In 2021, the compliance level of pregnant women performing ANC services in Indonesia for K1 is 88.13%, while the coverage for K4 is 88.8% (11).Meanwhile, the Southeast Sulawesi Health Profile for 2021 shows a K1 coverage of 93.2% and a K4 coverage of 74.8% in Southeast Sulawesi.There are 9 districts/cities that have reached the target, while 8 other districts/cities have not yet reached the target.The highest K1 coverage is in Kendari City, which is 97.53% and K4 coverage is 94.39%, while the lowest coverage is in Konawe Regency, namely K1 coverage is 87.89% and K4 coverage is only 76.75%.(12).
The level of compliance of pregnant women carrying out ANC services in Konawe Regency in 2019 recorded K1 coverage of 69.00% and K4 coverage of 60.32%.Meanwhile, in 2020, the K1 coverage was 87.89% and the K4 coverage was 76.75% in Konawe district.Increasing the coverage of K4 is expected to increase the coverage of deliveries by health personnel, as well as reduce maternal and infant mortality (13,14).Health Profile of Konawe Regency in 2020, the level of adherence of pregnant women in carrying out ANC services recorded the number of K1 and K4 coverage in several Public health centers, namely the Unaaha Health Center had a total coverage of K1 of 84.9% and a coverage of K4 of 77.27%, the Uepai Health Center had a total coverage K1 is 84.52% and K4 is 74.61% and the Soropia Health Center has K1 coverage is 92.56% and K4 is 83.88%.(13).This is different from the Puriala Public Health Center, which in 2019 recorded ANC coverage for K1 of 93.51% and for K4 of 82.68%.Whereas in 2020 there was a decrease in ANC coverage for K1 visits, namely 79.72%.However, for K4 visits there was an increase of 88.68%.Even though there has been an increase in K4 coverage, this is still below the national target of 90%.(4,14).
The decrease in the coverage of ANC visits and the target not being achieved indicates the possibility of patient dissatisfaction with the services provided by health workers, especially ANC services at the Puriala Public Health Center, Konawe Regency.There are also several factors that can affect the decrease in the coverage of ANC inspection visits such as level of knowledge, trust, economy and time issues.Based on this, the researchers wanted to know more about "Factors Associated with the Level of Satisfaction of Pregnant Women with Antenatal Care (ANC) Services at the Puriala Health Center, Konawe Regency in 2022".

METHOD
This research is an analytic survey research with a cross sectional study approach.The population in this study were all pregnant women who visited the Puriala Health Center for check-ups in 2022, namely 212 pregnant women.Sampling was done by accidental sampling technique.The number of samples is 68 respondents.This study uses a questionnaire research instrument.Analysis using the Chi-Square test.

RESULTS AND DISCUSSION
This study analyzed factors related to the level of satisfaction of pregnant women with antenatal care (ANC) services.Table 1 shows that out of 68 respondents, 12 (17.6%)respondents were aged 16-20 years, 21-25 years were 28 (41.2%)respondents, 26-30 years were 23 (33.8%) respondents , and 31-35 years as many as 5 (7.4%) respondents.The more mature, the level of maturity and strength of a person will be more mature in thinking and working.While the age of pregnant women is the age of the mother obtained through filling out a questionnaire.In the period of healthy reproduction, it is known that the safe age for pregnancy, childbirth and breastfeeding is 20-35 years.Mother's age is one of the determining factors from the process of pregnancy to delivery.Those who are less than 20 years old are feared to have a close risk to their reproductive health (15).
Table 1 of 68 respondents it was found that 4 (5.9%)respondents had the last education level Elimentary School, 12 (17.6%)junior high school respondents, 21 (30.9%)Senior high School and Bachelors as many as 31 (45.6%)respondents.Education is very important for self-development, the higher a person's education, the higher the level of knowledge.In general, mothers with higher education behaved differently from mothers with lower education.Mothers who are well educated know more about the importance of maintaining health, especially during pregnancy.Educated women tend to be more aware of the existence of antenatal care services and the benefits of using them.Educated women are said to be more aware of health problems, more aware of the availability of health services, and use information more effectively than uneducated women (18).Table 2 shows that of the 31 respondents who received poor service reliability, 23 respondents (74.2%) felt unsatisfied and the remaining 8 people (25.8%) were satisfied.While of the 37 respondents who received good service reliability, as many as 15 people (40.5%) felt unsatisfied and the remaining 22 people (59.5%) were satisfied.

Reliability
The results of the Chi-Square statistical test at the 95% level of confidence (0.05) show that p value = 0.011 so that p value = <0.05.That is, H0 is accepted and Hα is rejected.This shows that there is a relationship between Reliability and satisfaction of pregnant women in ANC services at the Puriala Health Center in 2022.This is evidenced by filling out the reliability questionnaire, many respondents answered no to the question "Midwives provide timely services to pregnant women".The untimely service referred to by the respondent is that when visiting to carry out an examination the midwife is often not at the Public health centers or at the posyandu, therefore the respondent has to wait a long time for officers to come and serve pregnant women.Waiting time at health facilities can affect pregnant women's satisfaction with ANC.Pregnant women who wait less than 30 minutes at health facilities to get services have a higher satisfaction with ANC compared to pregnant women who wait more than 30 minutes (19).
In addition, many respondents answered no to the question "Registration officers are always there and can provide complete information."This is what causes pregnant women to be dissatisfied with the service.As we know, the higher the level of knowledge and skills of officers, the better the quality of health services.With high quality, patient satisfaction will increase.Reliability is used by customers in evaluating the quality of health services.If a health service is unreliable or unreliable, the patient will feel unsatisfied or dissatisfied.
Reliability will affect patient satisfaction, patients have the perception that if health workers are able to examine patients immediately then for them it is quality service.In addition, the first time they were treated, the officers received them without complicated procedures.This was in line with their view that quality is the speed of service (20).
Although most of the respondents gave an assessment that reliability was still lacking, the results of the study also showed that there were some respondents who were satisfied, namely as many as 37 (54.4%) of respondents, where these respondents felt the officers were able to show good reliability when providing services. .Respondents answered yes to the question "The midwife measures the mother's body temperature during a visit to carry out an examination".As we know that measuring body temperature is an important thing that must be done at every ANC visit as a management of early detection of complications that can occur in pregnant women and can harm pregnant women and the fetus (21).
Nurfadillah et al. ( 2019), which states that there is a relationship between reliability and satisfaction of pregnant women with ANC services.According to the researchers, there were still a number of pregnant women who were dissatisfied with the services provided by midwives in ANC services because there were still respondents who considered that midwives had not been able to take blood at their fingertips correctly, giving medication and injections not according to schedule, and the medicine given by the midwife did not make the respondent's health better (11).Suryadi (2017), that there is a relationship between reliability and satisfaction of pregnant women with ANC services, especially regarding the treatment of midwives in taking blood samples from the mother's fingertips for Hb examination (22).
Patients who come to the Health Center for pregnancy checks need the help of health workers to find out the condition of their pregnancy and the condition of the fetus in her womb.Patients hope that when they need health services in general and ANC services in particular, the service procedures are not too complicated (23).Table 3 shows that of the 17 respondents who received poor service responsiveness, 15 respondents (22.1%) felt unsatisfied and 2 (2.9%) were satisfied.Meanwhile, of the 51 respondents who received good service responsiveness, 23 people (33.8%) felt unsatisfied and the remaining 28 people (41.2%) felt satisfied.The Chi-Square statistical test at the 95% confidence level (0.05) shows that the p value = 0.218 so that the p value = > 0.05.That is, H0 is rejected and Hα is accepted.This shows that there is no relationship between responsiveness and satisfaction of pregnant women in ANC services at the Puriala Health Center.This was because respondents felt that it was the ability of midwives to always tell them things to avoid during pregnancy, so that when complaints occurred to pregnant women, midwives responded quickly to complaints that pregnant women felt during pregnancy.This is in accordance with the results of the questionnaire where many respondents answered Yes to the question "Midwives tell things to avoid during pregnancy" as well as to the question "Midwives provide health education when mothers carry out examinations".As we know, health education is very important for pregnant women to be able to know the important things that must be done during pregnancy and delivery which aims to increase awareness and ability to live a healthy life for pregnant women.Because without health education can increase maternal and child mortality.Other respondents also said that midwives always monitor the progress of the mother's pregnancy.Midwives do this to ensure the health of pregnant women and the growth and development of the fetus in their womb.Where, pregnant women really need monitoring during their pregnancy in improving their physical and mental health so that they are able to deal with childbirth, postpartum, prepare for exclusive breastfeeding, and return to reproductive health in a reasonable manner.

Responsiveness
The results of this study also show that there are still respondents aged 16-20 years where respondents at that age are still minimal or don't understand much about the risks during pregnancy and what to avoid during pregnancy until it's time to give birth.Responsiveness, namely the ability of midwives or other health workers to help patients or pregnant women and provide health services that are fast or responsive and appropriate.Where midwives are always there when patients need them and provide good responses to patient complaints so that patients feel satisfied with the services provided by midwives (24).
The responsiveness service is good, but there are still 23 (33.8%) respondents who are still not satisfied with the service.This is because the attitude of the officers at the Puriala Public Health Center is different.Pregnant women who were dissatisfied with the service gave reasons because there were several officers who seemed to care less about patients during visits to carry out examinations, this was in accordance with the answers of many respondents who answered Yes to the question "Midwives don't help mothers to walk when they feel difficult.".
The responsiveness of officers in serving patients will greatly affect the satisfaction of visiting patients.Where by giving a good attitude to the patient, the patient will also feel comfortable and be more open to officers to tell things that are felt during pregnancy so that information from the patient can be conveyed in full and can become important data for midwives to record information in the Card Book Towards Health (card to health) pregnant women.Sampouw (2019), which states that there is no relationship between responsiveness and satisfaction of pregnant women with ANC services due to aspects of good service responsiveness such as giving a positive response to patient complaints, providing fast assistance when patients need help, provide friendly service, and be responsive in providing information about treatment to patients or families (25) (26).were still unsatisfied and the remaining 17 people (63.0%) were satisfied.The Chi-Square statistical test at the 95% confidence level (0.05) shows that the p value = 0.022 so that the p value = <0.05.That is, Hα is accepted and H0 is rejected.This shows that there is a relationship between empathy (concern) and satisfaction of pregnant women in ANC services at the Puriala Health Center in 2022.

Emphaty
This happens because there are some officers who still discriminate against pregnant women based on their status or class.When performing midwife services, the midwife sometimes serves patients who have a higher status or class than other patients.As we know that midwives in carrying out their duties must provide optimal service to everyone, regardless of rank and position, class, or religion.It can be seen from the answers of many respondents who answered Yes to the question "Midwives discriminate between mothers based on status or class, religion and ethnicity when visiting to get an examination".
To date most of the research sheds light on inequalities in health service delivery.A number of studies have proven that certain population groups consistently tend not to have access to and use health services.These studies have revealed systematic inequalities for almost all coverage indicators.Nonetheless, differences in the quality of care received by disadvantaged people have not been systematically examined.Several studies have demonstrated an equitable rate of low-quality care, regardless of poverty status, educational level, and standing (27).
The officer's empathy is still lacking, but there are 13 (31.7%)respondents who are satisfied with the reason midwives are polite when communicating with patients.Respondents felt that midwives always listen well to every complaint of pregnant women and help solve them, midwives provide opportunities for pregnant women to ask questions about their pregnancy, midwives always discuss the possibilities that occur during pregnancy, midwives respect every question a mother has about pregnancy, and midwives help mothers in preparing for childbirth and respecting the mother's opinion about the place of delivery.ANC refers to pregnancyrelated services provided between conception and the onset of labour, which aim to improve pregnancy and maternal and child health outcomes, and provide information to patients and families regarding pregnancy, childbirth and healthy living.as well as suggestions for postpartum recovery (27).
Siregar.M et al. ( 2018), which states that there is a relationship between empathy (concern) and satisfaction of pregnant women.It can be seen that pregnant women are satisfied with aspects of service that do not look at patient status as evidenced by pregnant women who mostly use health insurance (BPJS) but still get antenatal care services which are no different from pregnant women who pay directly for examinations, and those who feeling dissatisfied resulted from the statement "Health workers immediately greeted pregnant women and asked about complaints during the service" (28).Suryadi (2017), which states that there is a relationship between empathy (concern) and satisfaction of pregnant women, especially by counter staff who do not provide friendly service, and counter staff who do not separate between general patients and MCH patients (20).Patient satisfaction is an important issue, because it affects the number of ANC visits if the patient is dissatisfied with the service Patient satisfaction is an important issue, because it affects the number of ANC visits if the patient is dissatisfied with the service (24).Table 5 found that of the 17 respondents who received poor service assurance, 13 respondents (19.1%) felt unsatisfied and 4 other people (5.9%) were satisfied.Meanwhile, of the 51 respondents who received good service assurance, as many as 25 people (37.0%) were still unsatisfied and as many as 26 people (63.0%) were satisfied.The Chi-Square test at the 95% confidence level (0.05) shows that the p value = 0.945 so that the p value = > 0.05.That is, H0 is rejected and Hα is accepted.This shows that there is no relationship between assurance and satisfaction of pregnant women in ANC services at the Puriala Public Health Center.Assurance in this study consisted of midwives' abilities and skills in providing services to pregnant women, not discriminating against patients, examinations were carried out comfortably, safely and politely.The results showed that on average pregnant women who visited to carry out ANC examinations were satisfied with the assurance services provided.The reason the respondents were satisfied was because the respondents felt that some of the officers at the Puriala Health Center served patients politely and kindly.Respondents also gave reasons that this was because the midwife was able to explain well about the state of the mother's pregnancy.This is supported by the results of filling out the questionnaire where the average respondent answered Yes to the question "Midwives provide clear and easy-to-understand information for pregnant women".

Assurance
Pregnant women who are satisfied with the ANC services provided by midwives consider that midwives' communication when providing ANC services is clear and the performance of the health services they receive equals or exceeds their expectations, and conversely dissatisfaction or feelings of disappointment from patients will arise if the performance of the health services obtained is not according to his expectations.Communication is very important and useful for pregnant women.Good communication between midwives and pregnant women greatly influences the satisfaction of pregnant women in receiving services by midwives.So that mutual trust can be obtained between midwives and patients, judging that midwife communication when providing ANC services is clear and easily understood by pregnant women (29).Midwife service assurance at the Puriala Health Center is in the good category, meaning that good service assurance will affect the satisfaction of pregnant women in receiving ANC services.
WHO recommends that pregnant women feel comfortable during ANC services.Examinations and tests should be carried out at appropriate times.Teamwork between staff and patients is essential for the safety of pregnant women and their unborn children.All pregnant women are entitled to professionally recommended ANC services during pregnancy.Staff are trained not only to manage normal pregnancies, but also to recognize and treat complications, and to refer patients to hospital if further care is needed.Pregnant women, especially in rural areas, are most at risk of giving birth without adequate support (30,31). .Ndruru et al. (2019), which states that there is no relationship between assurance and satisfaction of pregnant women.Respondents thought that the knowledge and friendliness of the officers in providing good service and the ability of the officers to instill confidence and comfort in themselves so that respondents had no doubts in receiving the services provided (30,32).Table 6 found that of the 45 respondents who received less tangibles (physical evidence) of service, 31 respondents (68.9%) felt unsatisfied and 14 (31.1%)others were satisfied.Meanwhile, of the 23 respondents who received tangibles (physical evidence) of good service, as many as 7 people (30.4%) were still unsatisfied and as many as 16 people (69.6%) were satisfied.The Chi-Square test at the 95% confidence level (0.05) shows that the p value = 0.006 so that the p value = <0.05.That is, Hα is accepted and H0 is rejected.This shows that there is a relationship between tangibles (physical evidence) and the satisfaction of pregnant women in ANC services at the Puriala Health Center.

Tangibles
Based on the univariate results, the respondents answered No to the question "the MCH poly has a large room", services that are oriented to Public public health centers facilities, especially the MCH Poly also affect patient satisfaction.Facilities-oriented services include the appearance of physical facilities, equipment, personnel and communication media such as cleanliness, neatness and comfort of the room, interior and exterior arrangement, completeness, cleanliness of the appearance of the officers.Both the lack of Antenatal Care services provided by health workers to pregnant women can be seen from the patient's satisfaction based on

Table 1 .
Characteristics of Respondents for Pregnant Women at the Puriala Public Health Center, Konawe Regency in 2022

Table 2 .
Relationship between reliability and satisfaction of pregnant women in ANC services at the Puriala Public Health Center, Konawe Regency, in 2022

Table 3 .
The Relationship between Responsiveness and Satisfaction of Pregnant Women in ANC Services at the PurialaPublic Health Center, Konawe Regency, in 2022 ISSN:

Table 4 .
Relationship between Empathy (concern) and Satisfaction of Pregnant Women in ANC Services at the PurialaPublic Health Center, Konawe Regency, in 2022

Table 4
found that of the 41 respondents who had lack of empathy for service, 28 respondents (68.3%) felt unsatisfied and 13 (31.7%)felt satisfied.Meanwhile, of the 27 respondents who received good service empathy, as many as 10 people (37.0%) ISSN:

Table 5 .
Relationship between Assurance (guarantee) and Satisfaction of Pregnant Women in ANC Services at the PurialaPublic Health Center, Konawe Regency, in 2022

Table 6 .
Relationship between Tangibles and Satisfaction of Pregnant Women in ANC Services at Puriala Public Health Centers, Konawe Regency in 2022