Program Evaluation of Antenatal Classes

Noviati Fuada

and Nurhandayani Utami

Health Research and Development Center, Magelang, Indonesia Ministry of Health,

Kavling Jayan Borobudur, Magelang Jateng 56553, Indonesia

Center for Research and Development of Public Health Efforts, Indonesia Ministry of Health, Jakarta, Indonesia

Keywords: Antenatal Classes, Pregnant Women, Maternal, Child, Mortality.

Abstract: Background: Antenatal classes Program has been launched since 2009. Antenatal Classes (KIH) was formed

as part of an effort to reduce maternal and child mortality, and also to improve the health knowledge of

pregnant women. That’s means to learn together about health for pregnant women, in the form of group

discussion. Purpose; The research aims to examine the implementation of KIH. The study was conducted in

2014 in Bogor Regency. Method: Qualitative. Data is collected by in-depth interviews, observation and

documentation. Data collection is carried out at the central level (Indonesian Ministry of Health), NGOs,

public health centers, health services, as well as to pregnant women and immediate family. The analysis was

done using the process input and output approach. Results: The implementation of the Antenatal classes was

good enough but needed to be improved. Input aspects. Namely participation of pregnant women participants,

materials (guidelines and KIH tool packages), place of implementation, facilitators, implementation funds.

Process aspects: family support, learning methods, quality of facilitators, is still lacking. Output: Number of

attendees, number of implementations, coverage of K1-4, less than maximum. Conclusion: The

implementation of KIH is not yet stable, it needs support in aspects of the process.

1 INTRODUCTION

Class Pregnant women have become a world trend.

The development was inspired, in 1950, when the

National Childbirth Trust formed an antenatal class

for prospective parents, as did the NHS. In 1960, the

NHS began to develop. The class of pregnant women

in Indonesia is based on Government Regulation No.

25 of 2014 concerning child health efforts. As a

realization of these goals since 2009, the Class

Pregnant Mother program has been launched.

Pregnant Women Class is a joint health learning

facility for pregnant women. Forms of group learning

to improve the knowledge and skills of mothers

regarding pregnancy, pregnancy care, childbirth,

puerperal care, newborn care, myths, infectious

diseases and birth certificates (Kemkes, 2011).

Maternal and Child Health is an important aspect,

to be addressed immediately. Millennium

Development (MDG’s) sets the Maternal and Child

Health (MCH) to be one of the targets to be achieved.

The goal, reduce child mortality and improve

maternal health. However, maternal and child health

problems in the last 10 years still need attention. The

maternal mortality rate is still at 305 per 100,000 live

births in 2015 (Kemkes, 2019 and BPS, 2015), even

the figure is far above the country of Malaysia

(Asean, 2017).

The Antenatal classes consist of a maximum of 10

participants. Participants are pregnant women with

gestational age, between 4 weeks to 36 weeks (before

delivery). The antenatal class aims to increase

knowledge, change the attitudes and behavior of

mothers to understand about pregnancy, body

changes and complaints during pregnancy, pregnancy

care, childbirth, childbirth care, postpartum birth

control, postnatal birth care, newborn care,

myths/beliefs/local customs, sexually transmitted

diseases and birth certificates.

The material in the Class of pregnant women is

given in full and planned. Before discussing the

material, experts can be brought in to provide an

explanation of a particular topic, when the discussion

of the material becomes effective because the pattern

of presentation of the material is well structured.

Continuous implementation, evaluation of health

workers in providing presentation materials, so as to

improve the quality of the learning system.

Pregnant mothers class is a learning process.

Good learning can be assessed from the input,

process, output, impact, evaluation and environment.

Fuada, N. and Utami, N.

Program Evaluation of Antenatal Classes.

DOI: 10.5220/0009571801650172

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 165-172

ISBN: 978-989-758-454-1

165

There are four groups of factors that influence the

success of a training/learning, namely, material

factors, physical environment, learning instruments,

individual subject conditions (Sukiarko, Edi., 2007).

The implementation of Antenatal Classes (KIH),

is still being improved. A review of the

implementation of classes for pregnant women in

Indonesia in 2015, was carried out using SWOT

analysis, based on literature study data. This shows,

the position of Antenatal Classes (KIH), which is in

quadrant III, a weak position but has the opportunity

to continue to develop (Fuada, N and Budi Setyawati,

2015).

In this paper, Antenatal Classes (KIH) in Bogor

Regency will be analyzed, input, output process, with

Qualitative methods. Respondents consisted of

carried out at the central level (Directorate of

Nutrition, maternal and child health Ministry of

Health), NGOs, health centers, health services,

pregnant women and immediate family. Research

conducted in Bogor Regency in 2014 (Fuada, N, et

al., 2014)

2 RESULT

2.1 Input

The overall implementation of KIH in 2014 did not

yet have a specific legality aspect. KIH is part of the

Maternal and Child Health program, so its

implementation is based on the minister's regulations.

As stated by the central agency informant

“Sudah dimasukkan dan dalam proses. Kalau dulu

KIA masuk, sedang dibuatkan permen ..”

(It has been included and is in the process. In the past,

Maternal and Child Health entered, ministerial

regulations were being made).

Implementation in the regions was strengthened

by the Regent's circular. This aspect of legality is a

fundamental put in place for the implementation of

Antenatal classes (KIH). Input other support in

addition to legal aspects is, community support.

Standard Operating Procedures (SOP), technical

guidelines and operational guidelines that have been

provided by the government. The SOP has two sides,

between structured guidelines so that activities are

organized and planned. But the implementation in the

field is not easy. Constraints midwives are busy, and

the number of participants is not appropriate. This

was stated by the stake holder Wahana Visi Indonesia

(Wvi) :

“Dengan mengikuti itu (pedoman KIH) ada 2

bagusnya, bagusnya adalah terstruktur. Tapi di

masyarakat kesulitannya yaitu: Pertama, bidannya

suka tidak datang; yang kedua, cakupannya juga

kecil; akhirnya mereka tidak bisa strict harus datang

4 kali. Jadi, hampir tidak ada keberhasilan.” (By

following it (KIH guidelines) there are 2 good points,

good is structured. But in the community the

difficulties are: First, the midwife likes not to come;

secondly, coverage is also small; finally they can not

strict must come 4 times. So, almost no success).

The needs of the community, for the

implementation of KIH, are based on getting

integrated services, starting from pregnancy check-

ups, health education and also pregnancy exercise

activities for pregnant women. While other support is

from non-governmental organizations (NGOs), the

Indonesian Midwives Association. they provide

support in the training of KIH facilitators. Another

support, is World Vision Indonesia (WVI), they

provide KIH guidelines. On the contrary,

commitment from the village, sub-district, and local

governments is lacking, both in terms of funding and

monitoring. The Village Hall is considered too far

away, so that the implementation of KIH is not

monitored by the Village apparatus.

Activities are affected by operational costs. The

implementation of KIH is funded by the State

Revenue and Expenditure Budget (central

government) through the Health Operational

Assistance (BOK) and partly through the Regional

Budget. According to the respondents, if they rely on

central funds, this does not cover the cost of

implementation. Puskesmas are expected to be able to

innovate if BOK funds are insufficient. As one

respondent said at the district level:

“Harusnya kelas ibu hamil ini dari, oleh dan untuk

masyarakat sehingga ada, .. tiada dana BOK itu

mereka masih bisa jalan gitu”. (Should the Antenatal

classes be from, by, and for the community, so that

there is BOK funding, or there is no such fund, they

should keep going).

However, during an evaluation from the province,

it was described that the implementation of Antenatal

classes (KIH) was very dependent on BOK funds, so

the number of meetings was still very limited.

One village, which was observed, had 6 antenatal

classes. Each KIH consists of more than 10

participants who are pregnant women. there were 13

people recorded and usually reached 15 pregnant

women. Antenatal classes in the village are managed

ICOH 2019 - 1st International Conference on Health

166

by one village midwife. However, the midwife is only

a substitute midwife, so that the implementation of

antenatal classes is lacking. The activity involved

four posyandu cadres. Cadres are not helpful, because

they lack coordination.

Facilitator who has been trained, she moved to

work in another place. meanwhile, a substitute

midwife, has never been trained. He was able to

antenatal classes, based on reading and knowledge

while still in college. Village midwives have never

received antenatal class training. Antenatal classroom

training conducted by the district office is only

attended by the coordinating midwife. Other input

factors are limited quantity, quality of facilitators and

personality of village midwives.

Materials such as, antenatal class (KIH) toolkit /

flip sheets, gymnastic CDs, mattresses were brought

in the fields / facilitators moved. While the KIH

package material consisted of flip sheets, gymnastic

CDs, matras at the puskesmas there was only one

package, used by six midwives the region. The

distribution of teaching materials in the form of KIH

toolkits is still a problem. The distribution of KIH

packages only reaches the Regency, so the Puskesmas

must be able to take the package in the Regency. The

price is expensive to make the KIH package

limitations in the field.

In addition to procuring toolkits from the center,

the regions also provide them. The district prints a flip

sheet. The district government has endeavored that at

least all puskesmas have all KIH material packages.

They distribute to AKBID, hospitals, clinics.

Likewise, the MCH book is sufficient for pregnant

women. However, for pregnancy exercise mat

mothers are only partially held only for stimulants.

The distribution of antenatal class tools to health

centers, depends on regional conditions. Regional,

there are those who are prone to be given more

toolkits, so that not all KIH can get one set. One

package worth Rp.550,000. In general, it is still

lacking and quite expensive, as well as said by

speakers from the central :

“Telah di cetak Kit KIH. Dan tahun2014 sedang

dipersiapkan kurikulum KIH dan Kelas Ibu

balita.jadi paket kelas ibu hamil itu sebenar kita

adakan dipusat juga, kemudian daerah beberapa

sudah melakukan pengadaan juga paket kelas ibu

hamil tetapi memang paket itu sangat kurang

terbatas. Sedangkan buku KIA tidak menjadi

kendala” (KIH Kit has been printed. And in 2014 the

curriculum of KIH and Mother's Classes for toddlers

is being prepared. So the package for pregnant

mothers is actually being held at the center, then

some regions have already procured a package of

classes for pregnant women but the package is very

limited. While the KIA book is not an obstacle)

“Sudah ada pedoman, leaflet, lembar balik, lengkap

semua.. CD senam, dalam waktu dekat permenkes,

Keterbatasannya ya kebutuhan daerah lumayan

mahal 550 satu paket..” (There are guidelines,

leaflets, leaflets, complete all ... CD gymnastics, in

the near future Permenkes, the limitations are quite

expensive regional needs 550 one package).

The place for the implementation of antenatal

classes is quite good, on average, it is carried out at

posyandu in the local hamlet. The place is quite clean

and spacious. However, the implementation of KIH is

done in conjunction with posyandu activities. Class

Pregnant women do after weighing children under-

five. The consideration is, the village midwife

/facilitator is effective in her duties. It is enough to

save the transportation costs of the facilitator.

However, this situation is more often a factor in the

failure of the implementation of the antenatal class.

Pregnant women can't wait for the children under-five

weighing event to finish, so the event isn't over yet,

participants have left the class first.

All participants in antenatal classes have unequal

gestational age. Pregnant women already have a

Maternal and Child Health book (MCH book). But

there were also those who did not bring it, they were

mostly new participants. They did not bring it because

they were not told to bring the Mother and Child

Health book.

Distance of the position of residence of pregnant

women participants with the position of the

implementation of antenatal classes far apart. the

location of the house where they are scattered. this

affects the routine of arrival at KIH implementation.

In addition, new participants rarely attended because

they did not know that there was a KIH

implementation. On the other hand there are people

who do not respond other than because of economic

factors. Time is used to make a living. Another reason

is that the program is not socialized in the community

or KIH to community leaders. As quoted from

respondents of pregnant mother parents said (N,

Fuada., Et al., 2014):

R: “Tidak tahu...” (I Don't know )

P: Jika tidak mengapa ? bisa di ceritakan (If not

know, its why? canyou tell us).

R: “Tidak ada yang memberi tahu”. (Nobody told

me)

P: Apakah ibu sering pergi ? (did you often not in

place)

Program Evaluation of Antenatal Classes

167

R: ”Ente...ada wae.. tapi ya ente aya... tidak ada yang

memberi tahu, biasanya kader memberi tahu

posyandu saja”. (No ... I was there at the time ... but

I didn't know ... Nobody told me, usually cadres, but

only told the Posyandu for children under-five).

The same thing was said by Pregnant Women:

“Duka … Te aya kabar. Bulan lau datang ke bidan

Yani, tidak dikabari” ( I Don't know ... Nobody gives

news. One month ago, we went to midwife Yani, but

she did not give news).

The same thing was said by the husband of the

respondent:

“Tidak tahu...saya nyupir. Tapi kalo ada mah hayo

aja.. boleh ikut” (I don't know ... I'm driving. But if

told, I'm willing to come to the antenatal class).

New antenatal classes, attended by participants of

pregnant women, have not yet been attended by

supporters, such as husbands, mothers, or other

families. In some areas, customs / culture is still

constrained. most pregnant women are willing to take

part in the KIH. In fact, the community is quite

enthusiastic to take part in the natal classes, but what

is needed is the innovation of the village midwife, to

be creative in the classroom, so that the pregnant

woman is not bored

2.2 Process

The process of class antenatal activities (KIH) begins

with the implementation of the facilitator training in

stages. all coordinator midwives have been trained,

private midwives and hospital midwives and

midwifery Academy lecturers. Training Adjusted

targets, annually, so that there are already 3 forces

within 3 years. While from the Wahana Visi

foundation, they conducted training, with participants

including midwives and posyandu cadres. However,

posyandu cadres are still not permitted to become

single facilitators in antenatal classes.

The implementation schedule adjusts to the time

available by the village midwife. If the village

midwife is busy with other tasks, then antenatal class

activities, will not work. Unlike the Children under-

five weighing activities, even though no village

midwife/facilitator was present, the posyandu activity

for the Children under-five continued. Because

Posyandu cadres are skilled in weighing Children

under-five. Meanwhile, village midwives are

sometimes very busy with many holding program

responsibilities by the puskesmas.

The implementation of antenatal classes is

adjusted according to the posyandu weighing

schedule. The district midwife said;

“Duh sempet ga ya..penyuluhan, hari ini

pemeriksaan 15 bumil” (Oh, yeah ... did the

counseling, today's examination was 15 pregnant

women).

And other midwives answered:

“Ditempat saya kemarin (bulan kemarin) tidak bisa

ah... ada pak wali datang, besok kalo kader sempet

ya kita adakan” (At my place last month I could not

carry out classes. Because we have the mayor

coming. Tomorrow, if the cadres posyandu have time,

we will carry out the class).

There seems to be no schedule commitment from

the parties concerned. Impressed the implementation

was not well planned.

The implementation of Antenatal classes is

carried out simultaneously with the implementation

of weighing at posyandu. This makes pregnant

women sometimes impatient to wait, so the event is

not over yet, participants have already left class.

The process of KIH activities in the villages that

were observed, appeared to have not been carried out

pretest and posttest according to Standard Operating

Procedures. The learning process, using one-way

communication (counseling). The way to convey a

message is still seen using mass communication.

There is no visible adult learning, where participants

actively talk and discuss.

The facilitator conveys using a flipchart, there is

no question and answer session. However, when the

researchers invited the discussion, asking about the

motivation of KIH participation, it seemed very

enthusiastic. The discussion widened asking about the

food menu of pregnant women, dietary restrictions,

and others. This shows, the interest of pregnant

women to attend antenatal classes (KIH). As

expressed in the discussion, that the average KIH

participant joined the class because he wanted to

increase knowledge. Feeling happy when taught

gymnastics for pregnant women (two months ago the

material was gymnastics for pregnant women).

Evaluation monitoring system that is still weak.

This was acknowledged both by central, regional

resource persons and from NGOs. Central monitoring

is routinely carried out in the regions. Monitoribg is

carried out to see the management and

ICOH 2019 - 1st International Conference on Health

168

implementation, at the provincial and district levels.

Monitoring is carried out through integrated

evaluation, evaluation of classes of pregnant women

and also evaluations of other maternal health

programs.

The central ministry collects how many regions

have implemented KIH, discussion and delivery of

targets for the formation of KIH. However, it was

recognized that feedback from monitoring to the

provinces was not optimal. This is constrained by

time and cost. While at the district level supervision

was conducted after the training so to see, their

orientation results were quite varied. Monitoring is

carried out using assessment instruments including,

what has been done, for example, attendance list,

whether there is a companion or not, how the

implementation, schedule and frequency of activities.

Good antenatal classes if attended by participants

in a row 4 times. Three times not a pregnancy

semester but three months in a row. The mechanism

of implementation is up to the puskesmas not

determined up to them but we can copy the schedule,

usually with the posyandu.

The schedule as an example and the formation of

KIH has been made in the guidebook. But the

implementation, the schedule is adjusted in the field.

So that the material presented is tailored to the needs

of participants. The schedule is more often done in

conjunction with posyandu activities.

KIH implementation is supported by village

midwives. The village midwife learned how to

manage KIH from the coordinating midwife who had

been trained at the district level, therefore, each

facilitator had different abilities, even though they

were provided with a KIH management manual.

They were use use of the one-way counseling method.

As stated by the coordinating midwife:

“Masih menjadi kendala karena teman teman masih

harus belajar, karena kebanyakan masih satu arah”

.(Still an obstacle, because the village midwife friends

still have to learn, because they still use the one-way

counseling method).

Leveled socialization from the central to the

provincial level has been carried out to all districts.

However, socialization at the lower level of decision

and implementation depends on the Puskesmas.

“Kerja sama dengan produk susu hami sari husada,

tapi untuk teman teman di puskesmas silakan bebas

berkreasi. Sosialisai pada kader melalui bidan

kelurahan” (Collaboration with Husada sari

products, milk for pregnant women. but for friends at

the health center please be free to be creative.

Socialization of cadres through village midwives).

Socialization at the district level is carried out

through the health promotion sector. Collaboration

with radio stations is carried out when there are

broadcast schedules and other meetings involving

community health centers and the community.

2.3 Output

The output resulting from the implementation of KIH

can be seen in the number of participants and the

achievements of visits of pregnant women to the local

health service during the first pregnancy for up to four

months, or commonly termed visit 1 - visit 4 (K1-K4).

However, the indicator was deemed unfit to describe

the successful implementation of KIH.

The respondent said if he had analyzed the data,

comparing the area with the number of health centers

that carry out classes of pregnant women with the

number of achievements K1-K4. The results did not

have a significant impact. There is a K4 area down,

but KIH is running well. In addition, because pre-tests

and post-tests were not carried out, so it is not known

to what extent participants gained the benefits of

adding knowledge. Even so, there are several areas of

high KI-K4 coverage relevant to KIH

implementation.

There are areas where KIH is quite active, but

there are still those who deliver through a dukun.

Conversely, there are also areas where KIH is

running, giving birth to health workers is increasing.

Each region is different, therefore the size of the k1-

k4 outs cannot yet be described, so the puskesmas

measure the implementation of KIH with the number

of participants coming in a row at least four times.

Observations, the average KIH participants at the

location only attended 1-2 meetings.

The community is directed to participate in

assisting. It also becomes an output of success. It is

seen that KIH's community participation in

supporting is still lacking. Must be creative in each

region/region, especially for funding the

implementation of KIH, do not be top-down.

3 DISCUSSION

As a concept "Class" that transfers knowledge, is

expected to change behavior. The government

actually has done a fairly clear model. Training has

been carried out in stages, providing funding and

procurement of toolkit material, although it cannot

Program Evaluation of Antenatal Classes

169

meet the whole. This effort is quite a positive thing

for the development of KIH.

The observations said that the material toolkit in

the form of a mat for pregnancy is very limited. This

was recognized by both central and regional

informants. Triangulation at the lower level, pregnant

women informants are interested in joining KIH,

because they want to take part in gymnastics.

Gymnastics are believed to expedite the birth process,

which is most feared by pregnant women. KIH

participants have a hope that the birth process will run

smoothly so that the cesarean section can be avoided.

Like research in Italy, the antanatal class can

significantly reduce the rate of cesarean section and

is a potential factor (Cantone, D., 2018).

KIH participants and support from the community

were not optimal, this was possible because the

socialization was not enough to convince the public

of the benefits of KIH. Support from village and

family governments is still lacking. This needs to be

improved considering that from the results of several

studies it is proven that the support group and

implementation time have a significant relationship

with the small class antenatal which can reduce stress

in 37 weeks pregnant women. (Koushede, V., et al,

2017). Likewise in other studies, it also provides

information on participation in classes of pregnant

women significantly with maternal stress levels

(Runjati, et al., 2017).

KIH is still not needed by families of pregnant

women. Whereas promotion of the family has been

proven to increase participation in a program, such as

the promotion of the HEALTHY program to families

proven to be acceptable in diverse ethnic families

(Venditti, EM., Et al., 2009). Offering the benefits of

KIH will be a promotional attraction. As informed

that pregnant women who follow KIH, pregnancy

care is better than those who do not follow KIH

(Ummah, Faizatul, 2013). Besides that the effect of

participation on KIH is significant with the growth of

toddlers (Indria, GA., At al, 2016).

Planning at the central and regional government

levels is good. However, the implementation process

at the village level has not been carried out according

to the SOP. Such as pretest and post-test activities

have not been done. Though this activity is significant

enough to measure changes in the level of knowledge

of participants. Like the participants of pregnant

women at KIH in one of the puskesmas in Semarang

City, knowledge of pregnancy problems increased by

more than 50% (Puspitasari. Lia., 2012).

The process of KIH constraints caused by, among

others, the high dependence of activities on the

village midwife facilitator, while the facilitator was

busy. Professional facilitators who handle KIH or a

complementary team are needed.

Teaching team, it appears that only one midwife

is active. Even though at the central level it has been

recommended that other than midwives be facilitated,

the facilitator team at the puskesmas level seems to be

still held by one village midwife/midwife (village

midwife). Taking into account the affordability of

pregnant women participants, it is better to form a

facilitator team consisting of, more than one person,

authorized by the relevant officials. If the facilitator

is a team, then there will be interrelations between

learning material contexts, this will further facilitate

the learning transfer process (Perkins, DN., 1992).

Village midwives have never received KIH

training. KIH training conducted by the city/district

office was only attended by the coordinating midwife.

Therefore, it is necessary to think about the

development of KIH modules through an effective

and efficient transfer of information, by not excluding

the possibility of online tutorials. Openness to change

in innovation and organizational culture has been

proven to have a positive relationship with the

relational channels and organizational self-

knowledge (Pastor, L., 2011).

The curriculum has been accommodated with the

antenatala class toolkit. The schedule, although

following the weighing schedule of the posyandu, at

least there was an effort to plan activities already

carried out. Similar information was also obtained

from the description of the implementation of KIH in

Jakarta, obtained from Wahana Visi Indonesia (WVI,

2014).

The reflection activity has done coaching by

trying out the model, cadres as facilitators and fully

responsible for the continuity of KIH implementation.

Where supervision is still carried out by regional

midwives. And Posyandu cadres have been selected

and trained by midwives, facilitated by the Wahana

Visi Indonesia NGO. An interesting finding from this

reflection is that cadres can be assisted as facilitators

of the pregnant mothers class to bring general

materials (such as in the MCH handbook) in the

pregnant mothers class. This is in line with the results

of research on nutrition class training activities at

posyandu cadres able to increase nutritional

knowledge about 80 percent (Tejasari, et al., 2015.)

Minimum implementation of pregnant women

during pregnancy according to Standard Operating

Procedures, followed by pregnant women at least 4

times a meeting. The meeting includes the first

material about pregnancy, the second material

preparation for childbirth and also the puerperium,

the third meeting about complications handling

ICOH 2019 - 1st International Conference on Health

170

complications and the fourth is care about newborns.

Other things will be more interesting if included

material on managing stress, emotions both for

pregnant women and post-partum mothers. Findings

in other countries inform that psychosocial and

psychological interventions are 22% less likely to

experience perinatal depression, compared to usual

care (Jardri, R., et al., 2006).

4 CONCLUSIONS

Reporting Class antenatal implementation, only the

number of classes in the area of the public health

center. Weak input aspects are participation of

pregnant women participants, place of

implementation, facilitators, implementation funds.

While what is already strong enough is the material

(class antenatal guidelines and tool kits, the number

of maternal and child health books) and the quality of

the facilitators, facilitator training. Process aspects, in

general, are still lacking. Process aspects include the

implementation of family support for pregnant

women, learning methods, and the quality of

facilitators. Output aspects as a result of input and

process, this aspect is also less than optimal. Consists

of, the number of attendees, the number of events, the

coverage of the first neonatal visit to the fourth. (K1-

K4).

4.1 Recommendation

Continue to be informed through greater media, the

benefits of KIH. It is compulsory for pregnant women

to attend KIH for government aid funders. Facilitators

should not be limited to village midwives. KIH must

enter the system. And it is really seen from the supply

and demand sides. The method is made as attractive

as the material as needed. The facilitator should not

only be a single village midwife. The facilitator

should be carried out by a team, consisting of

promkes, TPG, Religious instructors etc. The material

is delivered by each person who is interested in one

of these materials.

ACKNOWLEDGEMENTS

The author would like to thank the respondent

participants, and the local government. The author

also thanks, funders, Center for Research and

Development of Public Health Efforts, National

Institute of Health Research and Development,

Ministry of Health of the Republic ofIndonesia.

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