ANALYSIS OF DETERMINANTS RELATED TO PUBLIC HEALTH VISITS FOR POST-PARTUM MOTHER DURING THE COVID-19 PANDEMIC ANALISIS

Postpartum visits are highly recommended for postpartum mothers to determine their health condition. The postpartum visit target that has not been achieved is influenced by several factors, predisposing, enabling, and reinforcing factors. The problem of postpartum visits if not treated immediately will have an impact on the occurrence of postpartum complications. The purpose of the study was to determine the factors related to the behavior of postpartum visits during the COVID-19 pandemic at Dysmenorrhea Health Center. Methods: this type of research is quantitative with cross-sectional and descriptive correlational design. The populations were all post-partum mothers normally at the Dysmenorrhea Health Center, in June - July 2022 with total 35 people. Samples were 32 postpartum mothers normally at Dysmenorrhea Public Health Center which were taken using a purposive sampling technique. Results: most of the respondents made postpartum visits during the COVID-19 pandemic as many as 23 (71.9%).test results in Fisher exact obtained p-value of age (0.013), education (0.003), parity (0.022), knowledge (0.003), attitude (0.006) and belief/culture (0.035), distance to health facilities (0.006), and family support (0.000) or (p<0.05). Conclusion: There is a relationship between predisposing, enabling, and reinforcing factors with postpartum visit behavior during the COVID-19 pandemic at Dysmenorrhea Health Center. Suggestion: It is hoped that postpartum mothers can improve postpartum visit behavior by the time to get early treatment if there are health problems during the postpartum period.


INTRODUCTION
The puerperium is the period that begins after the placenta comes out and ends when the uterine organs return to their original state (before pregnancy). The existence of problems with the mother will also have an impact on the welfare of the baby born because the baby will not receive maximum care from his mother. Thus, infant mortality and morbidity will also increase (Sulistyawati, 2015).
Maternal mortality and morbidity are serious health problems in developing countries. According to the World Health Organization (WHO) report, the world's maternal mortality rate is 289,000 people and Indonesia's maternal mortality rate is 214 per 100,000 live births (WHO, 2018).
Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) are one of the indicators of health development in the 2015-2019 RPJMN and SDGs. According to IDHS data, the Maternal Mortality Rate has decreased to around 307 per 100,000 live births, this figure has not met the target of the SDGs (Sustainable Development Goals) in 2030, namely reducing maternal mortality to below 70 per 100,000 live births (Kemenkes RI, 2015).
The maternal mortality rate (MMR) in Central Java during the COVID-19 pandemic has again increased, namely previously in 2019 as many as 416 cases and then increasing in 2020 to 530 cases of AKI. One of the reasons for the increase in AKI cases in Central Java is that pregnant women are afraid to check or visit health facilities because of the increasing transmission of the COVID-19 virus (Sholikah, 2021).
Based on a report from the Tegal District Health Office, in 2020 out of 26,895 deliveries in Tegal, there were 28 cases of AKI. In the early semester period of 2021, namely in January -July 2021, there were 20 cases of AKI in Tegal Regency, and 5 of those AKI cases were from Dismenorea Health Center (Tegal Regency Health Office, 2020).
Postpartum visits are highly recommended for postpartum mothers to determine their health condition. Postpartum visits are visits made by postpartum mothers to health workers during the postpartum period, which starts after the birth of the placenta and ends when the uterine equipment is like before pregnancy, the postpartum period lasts for approximately 6 weeks (Bahiyatun, 2015). Postpartum visit behavior is influenced by several factors, namely predisposing factors such as knowledge, attitudes, education, parity, beliefs, beliefs, values, enabling factors such as the availability and distance of health facilities, and reinforcing factors) such as attitudes, behavior, and support from family or health workers (Notoatmodjo, 2012).
If the postpartum visit problem is not treated immediately, it will have an impact on the occurrence of postpartum complications. Programs and technical policies during the postpartum period, there are at least three times according to the recommended schedule, namely at six hours to three days postpartum, from day 4 to day 28 postpartum, and from day 29 to day 3. 42nd post (Kemenkes RI, 2015).
Strict monitoring and counseling by health workers to mothers and families will be very helpful in preventing maternal deaths. All postpartum mothers are recommended to do a postpartum checkup at a health facility or to be visited at home even if delivery assistance is provided by other health workers. Postpartum visits are carried out to assess the mother's condition, and detect and deal with problems that may occur (Ambarwati & Wulandari, 2017).
A preliminary study conducted by researchers at the Dismenorea Health Center, Tegal Regency, obtained data that in the June-August 2021 period there were 224 postpartum mothers, Post-partum visit 1 until 3 achievements were 100%, Post-partum visit 4 90% with 3 cases of maternal mortality. Based on the results of interviews with health workers, SJKB 2022DOI: http://dx.doi.org/10.34310/sjkb.v9i2.693 pISSN: 2301-6213, eISSN: 2503 116 midwives at the Dismenorea Health Center said that the achievement of postpartum visits had met the target, but due to the pandemic factor, visits were made via video call or online. This is considered less effective because of the limited knowledge of technology in postpartum mothers and the delivery and receipt of information are not optimal so if there are obstacles in the online process, it will also affect the success of the postpartum visit program. This is also influenced by the assumption that during the 4th postpartum visit period, usually the mother often has no puerperal complications, so if the postpartum woman on the 1st, 2nd, and 3rd visits is declared healthy and there are no signs of symptoms that lead to postpartum complications, the postpartum visit 4th is not done.
The results of interviews conducted with 10 postpartum mothers at the Dismenorea Health Center, Tegal Regency, showed that there were several factors related to postpartum mothers' visits to the District Health Center, including 6 mothers (60.0%) who did not know related to the postpartum period and postpartum services, 4 people mothers (40%) are not good with regards to health services during the puerperium, that is, on average, their answers respond that they check themselves and visit the District Health Centre during the puerperium if only complaints are found, not because of their awareness, which should require intensive care during the puerperium. Post-delivery, 5 mothers (50%) responded that they were afraid of contracting COVID-19 or felt COVID-19 if they were honest with the complaints that led to Covid, and as many as 5 mothers (50%) stated that there was a lack of support from their families for postpartum visits. Based on the above background, the researchers are interested in researching "Analysis of factors related to postpartum visit behavior during the COVID-19 pandemic at Dismenorea Health Center."

METHOD
This research uses a quantitative method with a cross-sectional and descriptive correlational design. The population of all postpartum mothers is normal at Dismenorea Health Center in June -July 2022 with an estimated 35 postpartum mothers.
The sampling technique was purposive sampling with inclusion criteria (mother in conscious condition (good orientation of people, time and place); mother with normal delivery at Dismenorea Health Center; willing to be a respondent in the study; able to communicate verbally well; mother's age 20-45 years) and exclusion criteria (normal postpartum mothers with postpartum hemorrhage, so mothers need immediate medical attention; mothers who die after childbirth). Sample is 32 postpartum mothers. This research data collection was carried out for 1 month (June -July 2022). The research instrument was a questionnaire to assess age, education, parity, distance to health services, knowledge, attitudes, beliefs/culture, family support, and postpartum visits.
The results of the validity of the questionnaire about knowledge, attitudes, beliefs/culture, family support, and postpartum visits obtained a value of r count > r table (0.44) with a significance of 0.05% which means that all of the questionnaires are valid. The results of the reliability test for all questionnaires are reliable because of the results of Cronbach's Alpha > alpha table (0.60). Types of questionnaires about the level of knowledge, postpartum visits, and postpartum visit behavior are favorable and unfavorable, while the types of questionnaires about trust/visit and family support are favorable. Univariate data analysis used the frequency distribution of each variable and bivariate data analysis used an analysis test with fisher exact. Table 1. shows that the majority of postpartum mothers made postpartum visits during the postpartum period, namely 23 people (71.9%) and those who did not visit postpartum as many as 9 people (28.1%).  Table 2. shows the results of research on predisposing factors according to the age of respondents, mostly not at risk, namely 21 people (65.6% ) and 11 people at risk (34.4%). According to the education of the respondents, the majority were high school educated as many as 22 people (68.8%), while the junior high school students were 6 people (18.8%) and the college students were 4 people (12.5%). According to the parity history, most of the respondents were multiparous mothers as many as 18 people (56.3%), while 14 people were primiparous (43.8%).

RESULTS
According to the knowledge of the respondents, most of them were sufficient as many as 13 people (40.6%), while those who lacked knowledge were 11 people (34.4%), and those who had good knowledge were 8 people (25.0%). According to the attitude of the majority of respondents, there were 20 people (62.5%) who had a positive attitude, while 12 people (37.5%). According to belief/culture, the majority are believers, as many as 21 people (65.6%) and 11 people who don't believe (34.4%).
Based on enabling factors, according to the distance of respondents to health facilities, most of them were less than 3 km, namely 20 people (62.5%) and 12 people (37.5%). Based on the reinforcing factors according to family support, the majority of respondents received good family support, namely 13 people (40.6%) while those with sufficient family support were 10 people (31.3%), and those who lacked family support were 9 people (28.1 %).  Table 3. Showing the results of the cross-tabulation calculation, it can be seen that 9 postpartum women (42.9%). The results of statistical analysis with Fisher's exact obtained a p-value of 0.013 (p < 0.05). Most postpartum mothers with junior high school education did not visit postpartum as many as 5 people (83.3%). The results of statistical analysis with Fisher's exact obtained a p-value of 0.003 (p < 0.05). Postpartum mothers with a history of primiparous parity and who had postpartum visits were 7 people (50.0%), and postpartum mothers with a history of multiparous parity were mostly 16 people (88.9%). 118 The results of statistical analysis with Fisher's exact obtained a p-value of 0.022 (p < 0.05). The results of the cross-tabulation showed that the majority of postpartum mothers with sufficient knowledge made postpartum visits to as many as 11 people (84.6%). The results of statistical analysis with Fisher's exact obtained a p-value of 0.003 (p < 0.05). Postpartum mothers with a positive attitude made up 18 postpartum visits (90.0%). The results of statistical analysis with Fisher's exact obtained a p-value of 0.006 (p < 0.05).
The majority of postpartum mothers who believed in the benefits of postpartum visits made postpartum visits to as many as 18 people (85.7%). The results of statistical analysis with Fisher's exact obtained a p-value of 0.035 (p < 0.05).

The behavior of Postpartum Visits to Postpartum Mothers during the COVID-19 Pandemic at Dismenorea Health Center.
The results showed that most of the postpartum mothers made postpartum visits during the postpartum period, namely 23 people (71.9%) and 9 people who did not visit postpartum (28.1%). This is evidenced by the behavior of postpartum mothers who visited or examined postpartum at least 3 times during the postpartum period as many as 21 people (65.6%). The time of the visit carried out by postpartum mothers is also following the predetermined time where the first examination is 6 hours -3 days after delivery. The second examination is from day 4 to day 7 after delivery. The third examination was carried out on the 2nd week after delivery, as well as the fourth examination at 15 days -6 weeks after delivery for as many as 21 people (65.6%). The results of this study are supported by previous research on the factors that influence postpartum visits to mothers who have babies aged 2-12 months in the working area of the Nambo Kendari Health Center. The results of the study stated that of the 36 respondents, most of them adhered to postpartum visits, namely 29 people (80.6%) (Wolio, 2017). Supported by the theory which states that the behavior of postpartum visits is needed as an action for further postpartum examinations. Postpartum visits are planned in collaboration with the family and are scheduled based on need. Postpartum care is needed in this period because it is a critical period for both mother and baby (Saifuddin, 2013). Postpartum visits can be part of hospital services, private doctors, public health departments, or Private Practice Midwives (BPS) who provide maternity services at home (Mansyur, 2014).

Factors related to the behavior of postpartum visits during the COVID-19 pandemic at the Dismenorea Health Center.
The results showed that based on predisposing factors according to the age of the respondents, most of them were not at risk, namely 21 people (65.6%). Supported by the results of previous  (Rosita, 2018). Age is related to the nature of maturity and will have an impact on responsibilities. Older ages are generally more responsible, more orderly, more thorough, more moral, and more devoted than young people (Ahmadi, 2012). With increasing age, it will affect the level of vision, perception, and a person's ability to receive the information it will affect decision making. The ideal age for a woman to get pregnant and give birth is 21-35 years (Notoatmodjo, 2012).
The education level of the majority of respondents is high school education, namely as many as 22 people (68.8%). Supported by previous research by Rosita on the relationship between education, age, and parity of postpartum mothers with postpartum visits at BPM Suryati Palembang. The results of the research show that the results of the chi-square are known to 153 respondents with higher education. 50 (52.1%) respondents obtained a value (p = 0.000) < (0.05) (Rosita, 2018).
The parity history of the respondents was mostly multiparous mothers as many as 18 people (56.3%). My previous research by Aulia on factors related to postpartum maternal visits in the working area of the Samata Health Center, Gowa Regency. The results of the study showed that the results were known to 15 respondents with multipara parity status (63.2%). The results of statistical analysis with Fisher's exact stated that there was a relationship between parity and postpartum maternal visits to the Samata Gowa Health Center with a value (p = 0.038) < (0.05) (Aulia, 2021).
Most of the respondents' knowledge is sufficient as many as 13 people (40.6%). The results of this study are supported by previous research conducted by Prihanti regarding factor analysis of postpartum maternal visits in the working area of the Poned X Health Center. The results showed that the majority of respondents had high knowledge of postpartum, namely 117 people (73.6%) (Prihanti, 2019).
The attitude of the majority of respondents is positive, as many as 20 people (62.5%). The results of this study are supported by previous research by Hapsindori on factors related to postpartum visit compliance in mothers in the working area of Aek Batu Health Center, South Labuhanbatu Regency. The study showed the results that most of the mothers had a positive attitude towards the postpartum period and postpartum visits, namely 38 people (54.3%) (Haspindori, 2019).
Based on belief/culture, the majority are believers, as many as 21 people (65.6%). The results of this study are in line with previous research by Dahniar on the influence of community cultural values on the care of pregnant, maternity, and postpartum women in Teluk Pulau Hulu Village, Rokan Hilir Regency. The research shows the results that the respondent's habits are not supportive (41.2%), the respondent's customs are quite supportive (50.0%), the respondent's belief is quite supportive (58.6%), the respondent's knowledge is not supportive (55.2%), and the attitude of the respondents did not support (37.9%).
Based on enabling factors, according to the distance of respondents to health facilities, most of them are less than 3 km, namely as many as 20 people (62.5%). The results of this study are reinforced by previous research by Rahmawati who found that 36% of Cambodian women stated that distance to health facilities was the biggest obstacle for them to utilize postpartum services. [32] In another study by Hapsindori the results that mothers with easy access to health services were mostly obedient in conducting postpartum visits, namely 18 people (25.7%) (Haspindori, 2019).
Based on the reinforcing factors according to family support, most of the respondents received good family support, namely as many as 13 people (40.6%). The results of this study are strengthened by previous research by Prihanti which stated that in the family support variable some respondents showed a good category, namely 108 (67.9%) (Prihanti, 2019).

Relationship of Predisposing Factors (Age, Education, Parity, Knowledge, Postpartum Mother's Attitude and Belief/Culture) with Postpartum Visitation Behavior during the COVID-19 Pandemic at Dismenorea Health Center.
The results of statistical analysis with Fisher's exact obtained a p-value of 0.013 (p < 0.05). These results indicate that there is a relationship between age and postpartum visitation behavior during the COVID-19 pandemic at the Dismenorea Health Center. The postpartum period is no less important than the period of pregnancy and childbirth because at that time the reproductive organs are undergoing a recovery process after pregnancy and childbirth. Age also has an important role in access to health services. People with an older age tend to have higher needs because the risk of disease increases in line with a person's age (Sarwono, 2013).
There is a relationship between education and postpartum visit behavior during the COVID-19 pandemic at the Dismenorea Health Center with the fisher exact getting a p-value of 0.003 (p < 0.05). Education is a very important factor to provide the ability to think, analyze, and understand the information obtained with more rational considerations and better education will also provide a better ability to make decisions about family health (Azwar, 2012). People with higher formal education than people with lower levels of formal education will be more able and easier to understand the importance of health and the use of health services. Education can support knowledge for mothers. Health knowledge will affect behavior as a medium-term outcome of health education, then health behavior will affect the increase in public health indicators as a health education outcome (Notoatmodjo, 2012).
There is a relationship between parity and postpartum visit behavior during the COVID-19 pandemic at the Dismenorea Health Center with the fisher exact getting a p-value of 0.022 (p < 0.05). Parity can be defined as the number of children a mother has. The more children, the more visits during the postpartum period. The results of this study are to the theory of Wawan and Dewi that mothers who gave birth more than once had better knowledge and behavior than mothers who gave birth for the first time. The more often the mother gives birth, the mother will have a lot of experience with childbirth so that the mother has information about postpartum visits (Wawan, 2011).
There is a relationship between knowledge and behavior of postpartum visits during the COVID-19 pandemic at Dismenorea Health Center with the fisher exact obtained p-value of 0.003 (p < 0.05). Knowledge is one of the factors that influence or predispose to behavior change that provides rational thinking or motivation for an activity, as well as a factor that facilitates the occurrence of one's behavior (Notoatmodjo, 2012). In this study, the behavior that may be influenced by the level of knowledge is the behavior of the accuracy of postpartum visits at the Dismenorea Health Center.
There is a relationship between attitude and behavior of postpartum visits during the COVID-19 pandemic at Dismenorea Health Center with the fisher exact obtained p-value of 0.006 (p < 0.05). This is in line with the theory that attitudes will manifest in actions depending on the current situation, referring to the experiences of others, based on a person's much and little experience, and values in society (Notoatmodjo, 2012). Attitude is a readiness to react to an object in certain ways. Readiness referred to here is a potential tendency to react in a certain way when individuals are faced with a stimulus that requires a response (Azwar, 2012).
There is a relationship between belief/culture with postpartum visit behavior during the COVID-19 pandemic at Dismenorea Health Center with Fisher's exact obtained p-value of 0.035 (p < 0.05).
Culture and society are two sides that cannot be separated because culture is related to mind or reason. The condition of the family environment that is not supportive will affect the mother in checking herself during the postpartum period. The belief or family culture that does not allow a woman to leave the house to check her health during the postpartum period is a belief/culture that hinders regular visits by postpartum mothers to check the health of themselves and their babies (Syaifuddin, 2013).

.The Relationship of Enabling Factors (Distance to Health Facilities) with Postpartum Visit Behavior during the COVID-19 Pandemic at Dismenorea Health Center.
The results of statistical analysis with Fisher's exact obtained a p-value of 0.006 (p < 0.05). These results indicate that there is a relationship between the distance between health facilities and the behavior of postpartum visits during the COVID-19 pandemic at the Dismenorea Health Center. The results of this study are supported by previous research by Wolio which stated that there was a relationship between the distance from the place of residence to the place of health care and postpartum visits for mothers who had babies aged 2-12 months in the Working Area of the Nambo Health Center, Kendari City (Wolio, 2017). This is in line with the theory that generally postpartum mothers will seek health assistance at a health facility located near their place of residence. If for some reason the mother comes to a distant service place, the clinic staff must be able to help and explain the nearest health facility that can provide further health care and services. These health facilities must have reliable capabilities to serve various needs for recovering health conditions, adequate emergency assistance, or comprehensive contraceptive services for patients in need (Saifuddin, 2013).

The Relationship of Reinforcing Factors (Family Support) with Postpartum Visitation Behavior during the COVID-19 Pandemic Period at Dismenorea Health Center.
The results of statistical analysis with Fisher's exact results obtained a p-value of 0.000 (p <0.05). These results indicate that there is a relationship between family support and postpartum visit behavior during the COVID-19 pandemic at the Dismenorea Health Center. The results of this study are supported by previous research by Prihanti which showed that there was a relationship between family support and postpartum mother visits in the work area of the Poned X Health Center with a p-value of 0.04 < 0.05 (Prihanti, 2019). The family is a factor that influences the selection or use of the most important service in society. The family is a series of closely related and independent individuals and an individual's problems can affect other family members and the entire system. Family support refers to social support that is seen by family members as accessible/provided for the family (social support may or may not be used, but family members view that supportive people are always ready to provide help and assistance if needed) (Setiadi , 2018).