[Vulnerable to mental health problems: Pregnant women and husband's perception in Surakarta, Indonesia]. / Vulnerabilidad a los problemas de salud mental: Percepción de las mujeres embarazadas y de sus maridos en Surakarta, Indonesia.

OBJECTIVE: This study aims to explore the perception of women and their husbands on the vulnerability of pregnant women to mental health disorders. METHOD: Qualitative study using a phenomenological approach. The inclusion criteria were pregnant women of the second and third-trimester gestation (13-35 weeks). The exclusion criteria were pregnant women with complications and who had a family record of mental disorders. Data was collected using focus group discussion and in-depth interviews at four Primary Health Cares in Surakarta, Indonesia. Then, the data were analyzed through thematic analysis, which was supported by the OpenCode 4.02® software. RESULTS: This study uncovered two main topics, firstly the factors that trigger the vulnerability of pregnant women to experience mental disorders and secondly perceived barriers to managing mental health during pregnancy and postpartum. Pregnant women and husbands recognize that they need to get mental health information. CONCLUSION: Unstable emotions during pregnancy are considered normal and neglected by their surroundings. Lack of knowledge about mental health in pregnancy justifies the need to increase education in this area in order to prevent prenatal and postpartum depression.

Vulnerabilidad a los problemas de salud mental: Percepción de las mujeres embarazadas y de sus maridos en Surakarta, Indonesia / Vulnerable to mental health problems: Pregnant women and husband's perception in Surakarta, Indonesia

Objetivo: Este estudio tiene como objetivo explorar la percepción de las mujeres y sus maridos sobre la vulnerabilidad de las mujeres embarazadas a los trastornos de salud mental. Método: Estudio cualitativo con enfoque fenomenológico. Los criterios de inclusión fueron mujeres embarazadas en el segundo y tercer trimestre de gestación (13-35 semanas). Los criterios de exclusión fueron las embarazadas con complicaciones y las que tenían antecedentes familiares de trastornos mentales. Los datos se recogieron mediante grupos de discusión y entrevistas en profundidad en cuatro centros de atención primaria de Surakarta (Indonesia). A continuación, los datos se analizaron mediante un análisis temático, con el apoyo del programa OpenCode 4.02®. Resultados: Este estudio descubrió dos temas principales: en primer lugar, los factores que desencadenan la vulnerabilidad de las mujeres embarazadas a experimentar trastornos mentales y, en segundo lugar, las barreras percibidas para gestionar la salud mental durante el embarazo y el posparto. Las mujeres embarazadas y los maridos reconocen que necesitan obtener información sobre salud mental. Conclusión: Las emociones inestables durante el embarazo son consideradas normales y son desatendidas por el entorno. El desconocimiento sobre salud mental en el embarazo justifica la necesidad de aumentar la educación en esta área con el fin de prevenir la depresión prenatal y posparto.(AU)

Objective: This study aims to explore the perception of women and their husbands on the vulnerability of pregnant women to mental health disorders. Method: Qualitative study using a phenomenological approach. The inclusion criteria were pregnant women of the second and third-trimester gestation (13–35 weeks). The exclusion criteria were pregnant women with complications and who had a family record of mental disorders. Data was collected using focus group discussion and in-depth interviews at four Primary Health Cares in Surakarta, Indonesia. Then, the data were analyzed through thematic analysis, which was supported by the OpenCode 4.02® software. Results: This study uncovered two main topics, firstly the factors that trigger the vulnerability of pregnant women to experience mental disorders and secondly perceived barriers to managing mental health during pregnancy and postpartum. Pregnant women and husbands recognize that they need to get mental health information. Conclusion: Unstable emotions during pregnancy are considered normal and neglected by their surroundings. Lack of knowledge about mental health in pregnancy justifies the need to increase education in this area in order to prevent prenatal and postpartum depression.(AU)

"Sharp downward, blunt upward": district maternal death audits' challenges to formulate evidence-based recommendations in Indonesia - a qualitative study.

BACKGROUND: Indonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality. METHODS: A qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7-8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation. RESULTS: The district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of "sharp downward, blunt upward"; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee' skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death's local avoidable factors. CONCLUSION: A productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.

The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis.

BACKGROUND: Maternal Death Reviews (MDR) can assist in formulating prevention strategies to reduce maternal mortality. To support MDR, an adequate MDR instrument is required to accurately identify the underlying causes of maternal deaths. We conducted a systematic review and meta-analysis to determine the reliability of maternal death instruments for conducting the MDR process. METHOD: Three databases: PubMed, ProQuest and EBSCO were systematically searched to identify related research articles published between January 2004 and July 2019. The review and meta-analysis involved identification of measurement tools to conduct MDR in all or part of maternal audit. Eligibiliy and quality of studies were evaluated using the Modified Quality Appraisal of Diagnostic Reliability (QAREL) Checklist: Reliability Studies. RESULTS: Overall, 242 articles were identified. Six articles examining the instrument used for MDR in 4 countries (4 articles on verbal autopsy (VA) and 2 articles on facility-based MDR) were included. None of studies identified reliability in evaluation instruments assessing maternal audit cycle as a comprehensive approach. The pooled kappa for the MDR instruments was 0.72 (95%CI:0.43-0.99; p < 0.001) with considerable heterogeneity (I2 = 96.19%; p < 0.001). Subgroup analysis of MDR instruments showed pooled kappa in VA of 0.89 (95%CI:0.52-1.25) and facility-based MDR of 0.48 (95%CI:0.15-0.82). Meta-regression analysis tended to show the high heterogeneity was likely associated with sample sizes, regions, and year of publications. CONCLUSIONS: The MDR instruments appear feasible. Variation of the instruments suggest the need for judicious selection of MDR instruments by considering the study population and assessment during the target periods.

Human Papillomavirus (HPV) Health Savings as an Alternative Solution: HPV Vaccination Behavior in Adolescents.

OBJECTIVE: This study aimed to measure the effects of reproductive health savings (tabungan kesehatan reproduksi, Takespro) on human papillomavirus (HPV) vaccine initiation program and the quality of the decision making to get vaccinated, as measured by knowledge, attitudes, beliefs, and self-efficacy toward HPV vaccination. METHODS: This quasi-experimental study was conducted on 128 students randomly allocated to intervention and control groups. This research was conducted in junior high schools. The intervention group received the health education "Takespro HPV" intervention through videos and booklets for 6 months at school. Participants in the control group received usual care from the school. Data were collected using a questionnaire of knowledge, attitudes, beliefs, and self-efficacy about HPV vaccination modified by researchers based on previous research and tested for validity and reliability. Data were analyzed using Mann-Whitney test and independent t-test. RESULTS: A total of 40 participants were actively enrolled in the intervention group, and 88 were passively enrolled in the control group. The health education that was part of the Takespro HPV intervention improved the knowledge (p < 0.05) and self-efficacy (p < 0.05) of the intervention group compared with the control group. The attitude and belief variables showed no significant difference (p > 0.05). Forty students exhibited the health reproduction savings behavior at schools. However, the savings amount was insufficient to get HPV vaccination at the initiation phase. CONCLUSION: "Takespro" HPV intervention can be considered an alternative to increasing the coverage of HPV vaccination in adolescents in Yogyakarta.
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Need vs. Financing Capability: Human Papillomavirus Vaccinations among Adolescents.

BACKGROUND: The incidence of Human Papillomavirus (HPV) infection and cervical cancer in adulthood may be prevented by HPV vaccination in adolescence. Currently, the HPV vaccination coverage rate in developing countries is about 15%. The reason for this low vaccination coverage is most likely due to a lack of information among adolescents and adults. PURPOSE: To explore adolescents, parents and teachers' needs, obstacles, and expectations around the HPV vaccination. METHODS: This research used a qualitative method with a focus group discussion. The research participants were divided into three groups: 21 female students, 17 parents, and 20 teachers. This research was conducted in junior high schools that have programs run by their adolescent reproductive health counseling information centers. The data were analyzed by employing content analysis. RESULTS: HPV vaccination has not been made a priority for adolescents because: 1) There is a lack of available education about HPV and HPV vaccinations for adolescents, parents, and teachers. 2) The high cost for parents to vaccinate their children. 3) Adolescents, parents and teachers believe that the HPV vaccine needs to be administered to adolescents, but they feel that the vaccine is not affordable. CONCLUSION: It is important to consider a program which will provide accurate information about the HPV vaccination to the community, especially adolescents. Financial management, such as insurance or vaccination savings schemes, may be one way to overcome the problem of the HPV vaccination's cost.

Adolescent mothers' experiences of the transition to motherhood: An integrative review.

A woman experiences heightened vulnerability and faces tremendous challenges when transitioning to motherhood. This is exacerbated for young mothers and studies have shown that adolescent mothers experience an increased burden of responsibility during the transition to motherhood. Recent research addressing the experiences of adolescent mothers has increased. However, the current literature on this topic is still fragmented. The aim of this study was to conduct an integrative review of the literature to explore adolescent mothers' experiences of transition to motherhood and identify associated factors. The literature was searched using electronic databases: Medline, Cumulative index to Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and PubMed. Relevant articles published in English from February 2005 to 2018 were included. Eighteen articles were included in the analysis. Based on this review, factors influencing a successful to transition to motherhood for adolescents included physical problems related to birth and breastfeeding, psychological well-being, ability to care for their baby, social support, education and economic strain and the provision of healthcare. The literature indicated a relationship between social supports and the development of positive maternal identity in the transition period for adolescent motherhood. Future healthcare interventions for adolescent mothers during the transitional period should aim to provide social support and the increase ability of adolescent mothers to manage the physical and psychological challenges of young motherhood, and enhance new mothers' knowledge about caring for babies.

Exploring Indonesian adolescent women's healthcare needs as they transition to motherhood: A qualitative study.

BACKGROUND: Marriage and underage childbirth is a phenomenon of increasing incidence globally. Adolescent mothers simultaneously encounter multiple developmental challenges related to transition into adulthood, marriage, pregnancy and mothering responsibilities. Despite this, studies investigating postpartum care needs for adolescent mothers are limited. AIMS: The aim of this study was to explore adolescent mothers' postnatal inpatient experiences and healthcare needs as they moved towards their maternal roles. METHODS: A descriptive qualitative design was adopted to better understand experiences of adolescent mothers during their transition to becoming mothers. Data were collected using in-depth interviews with eleven adolescent mothers in hospital settings in South Sulawesi, Indonesia and analysed using thematic analysis. RESULTS: Four major themes emerged: (1) breastfeeding problems, (2) disempowerment in caring for the baby, (3) health care encounters, and (4) health care needs for adolescent motherhood transition. DISCUSSION: Breastfeeding problems and feeling disempowered in caring for their babies after birth was experienced by all adolescent mothers in this study. Furthermore, the health care provided was limited to mandatory hospital tasks with staff failing to recognize adolescent mothers' broader needs. The findings suggest that adolescent mothers need compassionate health education, support and psychological care from midwives in the postpartum ward before hospital discharge. CONCLUSION: The results highlight important issues in postnatal care provision for adolescent mothers in improving their maternal roles during the transition period. Specific, appropriate interventions for adolescent mothers are needed to support their transition and adaptation to their new roles.

A qualitative study on barriers in the prevention of anaemia during pregnancy in public health centres: perceptions of Indonesian nurse-midwives.

BACKGROUND: Anemia in pregnancy remains a major problem in Indonesia over the past decade. Early detection of anaemia in pregnancy is one of the components which is unsuccessfully implemented by nurse-midwives. This study aims to explore nurse-midwives' experiences in managing pregnant women with anaemia in Public Health Centres. METHODS: We conducted a qualitative study with semi-structured face to face interviews from November 2011 to February 2012 with 23 nurse-midwives in five districts in Yogyakarta Special Province. Data analysis was thematic, using the constant comparison method, making comparison between participants and supported by ATLAS.ti software. RESULTS: Twelve nurse-midwives included in the interviews had less than or equal to 10 years' working experience (junior nurse-midwives) and 11 nurse-midwives had more than 10 years' working experience (senior nurse-midwives) in Public Health Centres. The senior nurse-midwives mostly worked as coordinators in Public Health Centres. Three main themes emerged: 1) the lack of competence and clinical skill; 2) cultural beliefs and low participation of family in antenatal care programme; 3) insufficient facilities and skilled support staff in Public Health Centres. The nurse-midwives realized that they need to improve their communication and clinical skills to manage pregnant women with anaemia. The husband and family involvement in antenatal care was constrained by the strength of cultural beliefs and lack of health information. Moreover, unfavourable work environment of the Public Health Centres made it difficult to apply antenatal care the pregnant womens' need. CONCLUSIONS: The availability of facilities and skilled staffs in Public Health Centre as well as pregnant women's husbands or family members contribute to the success of managing anaemia in pregnancy. Nurse-midwives and pregnant women need to be empowered to achieve the optimum result of anaemia management. We recommend a more comprehensive approach in managing pregnant women with anaemia, which synergizes the available resources and empowers nurse-midwives and pregnant women.

The Effectiveness of a New Model in Managing Pregnant Women with Iron Deficiency Anemia in Indonesia: A Nonrandomized Controlled Intervention Study.

BACKGROUND: Indonesia has a major problem with iron deficiency anemia among pregnant women. A new model named the Four Pillars Approach was designed to improve antenatal care for these women. This study aimed to measure the effectiveness of the model in managing pregnant women with iron deficiency anemia. METHOD: We used a nonrandomized controlled intervention study. The study, with the Four Pillars Approach as intervention versus usual care as its control, was conducted in two provinces in Java (Indonesia) during the period from March 2012 until May 2013. Main outcome measures were a difference of Hb level ≥ 0.5 g/dL, the number of women who attended five or more antenatal care visits, and birthing with a skilled birth attendant. RESULTS: Three hundred fifty-four participants were enrolled in the study. Participants in the intervention group had an adjusted odds ratio of 25.0 (95% CI 12.03-52.03, p = 0.001) for increased hemoglobin of ≥ 0.5 g/dL at 35-37 weeks of gestation, compared with the control group. In the intervention group, 95.0 percent of women had five or more antenatal care visits, compared with 57.2 percent (p = 0.001) in the control group. All births in both groups were assisted by skilled birth attendants. CONCLUSION: The Four Pillars Approach is effective in increasing the hemoglobin level and the frequency of antenatal care visits of participants when compared with the usual care for pregnant women with anemia.

A randomised controlled trial on the Four Pillars Approach in managing pregnant women with anaemia in Yogyakarta-Indonesia: a study protocol.

BACKGROUND: Anaemia is a common health problem among pregnant women and a contributing factor with a major influence on maternal mortality in Indonesia. The Four Pillars Approach is a new approach to anaemia in pregnancy, combining four strategies to improve antenatal and delivery care. The primary objective of this study is to measure the effectiveness of the Four Pillars Approach. The barriers, the facilitators, and the patients' as well as the midwives' satisfaction with the Four Pillars Approach will also be measured. METHODS/DESIGN: This study will use a cluster randomised controlled trial. This intervention study will be conducted in the Public Health Centres with basic emergency obstetric care in Yogyakarta Special Province and in Central Java Province. We will involve all the Public Health Centres (24) with emergency obstetric care in Yogyakarta Special Province. Another 24 Public Health Centres with emergency obstetric care in Central Java Province which have similarities in their demographic, population characteristics, and facilities will also be involved. Each Public Health Centre will be asked to choose two or three nurse-midwives to participate in this study. For the intervention group, the Public Health Centres in Yogyakarta Special Province, training on the Four Pillars Approach will be held prior to the model's implementation. Consecutively, we will recruit 360 pregnant women with anaemia to take part in part in the study to measure the effectiveness of the intervention. The outcome measurements are the differences in haemoglobin levels between the intervention and control groups in the third trimester of pregnancy, the frequency of antenatal care attendance, and the presence of a nurse-midwife during labour. Qualitative data will be used to investigate the barriers and facilitating factors, as to nurse-midwives' satisfaction with the implementation of the Four Pillars Approach. DISCUSSION: If the Four Pillars Approach is effective in improving the outcome for pregnant women with anaemia, this approach could be implemented nationwide and be taken into consideration to improve the outcome for other conditions in pregnancy, after further research. TRIAL REGISTRATION: Current Controlled Trials ISRCTN35822126.