How Much Time Do Midwives Spend on Antenatal Care? Assessment of Antenatal Care (ANC) in Six Districts/cities of West Java-indonesia

Background: The government makes various policies to improve the health of pregnant women, which in turn has an impact on reducing maternal mortality and infant mortality. Antenatal care (ANC) is the most important strategy to improve the health of pregnant women. Distric/city governments must ensure the availability of antenatal services for their communities in primary health facilities (PHF). Midwives are the primary provider of antenatal care at PHF. This study describes the time required for midwives to provide standardized antenatal care. Methods: This study was a time study method, which analyzes the average time of ANC Services by midwives in PHF. The study observed fty-eight midwives who gave ANC services to ve hundred fty-two pregnant women in six districts in West Java. The data collection was carried out in January-February 2019. Results: In this study, it was found that the time to ANC varied widely; for ANC-I, the average is 30.34 minutes (Min 25 minutes- Max 50 minutes; lower mean 56,7%), ANC-II 23.12 minutes (Min 17 minutes Max 36 minutes; Lower mean 63,5%), and ANC-T 26.9 minutes (Min 23 minutes - Max 35 minutes; lower mean 53,2%). The order of service time is as follows: ANC-I, ANC-T and ANC-II. Conclusions: The time used for ANC is still signicantly less than that recommended by the WHO for pregnant women's visits (40 minutes per visit). The reason will undoubtedly affect the quality of ANC services. It is hoped that District/City Administrative and Health Authorities will pay more attention to the duration time of ANC visits by developing a standard time of visit per patient or increasing the number of midwives in carrying out ANC services at that location.


Background
In 2017, nearly 810 women died every day from preventable conditions related to pregnancy and childbirth. Nevertheless, there has been a successful reduction in maternal mortality between [2000][2001][2002][2003][2004][2005][2006][2007][2008][2009][2010][2011][2012][2013][2014][2015][2016][2017] in the world by 30%. The world must note that almost 94% of maternal deaths occur in lower-middleincome countries, such as Indonesia. The governments of these countries should also perceive those deaths from complications as very common in young adolescents (ages [10][11][12][13][14]; Therefore, the program to improve the quality and quantity of midwives must be a priority because the mothers' life is very dependent on them. . This data shows that reducing maternal mortality has not successfully achieved the standard at least below ASEAN countries. With this situation, the government must evaluate the program's quality being implemented to accelerate maternal mortality resolution.  information provided by the midwife will signi cantly affect the behavior of the mother during pregnancy and the period of child-rearing up to Five years. However, ANC counselling, in addition to the short duration of time and not accompanied by lling out health records during pregnancy in the MCH Handbook lling out the information in this book accompanied by education for pregnant women will signi cantly affect the mother's knowledge about pregnancy, childbirth, and child care, especially during the immunization period. (Baequni et al., 2016;Yanagisawa et al., 2015) This paper describes the current performance of the length of time and components of antenatal care by midwives at PHF. The implementation of antenatal care carried out is then compared with the applicable standards.

Methods
The study was conducted in six districts/cities in West Java Province, namely Bogor District, Cianjur District, Cirebon District and Sumedang District, Depok City and Tasikmalaya City. The locations of these districts/cities are spread over the area of West Java Province. In each district/city, two subdistricts were taken, with the criteria for the number of inhabitants and the distance of the location of the sub-district from the capital of the district/city.
This study was a time study method, which was carried out by observing the work of midwives when

Results
At the time of data collection, Antenatal care or ANC were grouped into three visits, namely the rst visit (ANC-I), the second visit (ANC-II) and the last visit (ANC-T). ANC-I was the rst visit. ANC-II is a repeat visit for pregnant women, which consists of a second, third, and so on. ANC-T is the last visit before delivery.
In this study, it was found that the time to ANC varied widely; for ANC-I, the average is 30.34 minutes (Min 25 minutes-Max 50 minutes; lower mean 56,7%), ANC-II 23.12 minutes (Min 17 minutes -Max 36 minutes; Lower mean 63,5%), and ANC-T 26.9 minutes (Min 23 minutes -Max 35 minutes; lower mean 53,2%). The order of service time is as follows: ANC-I, ANC-T and ANC-II (see Table 2).  The physical examination at the rst visit that was examined was height, upper arm circumference (LILA), blood pressure, and weight, as well as general physical conditions, such as whether the face of the pregnant woman looks pale or not. At the next visit, only blood pressure and weight were measured, plus other examinations related to problems that had been identi ed at the previous visit, such as whether or not there was swelling in the pregnant woman's legs. The variation in the average time of physical examination between ANC1, ANC2, and ANC-T was not too large, namely 0.84 minutes (1.98 -2.82 minutes).

Table 3, Result of observation service components in each level of Antenatal Care (ANC) Services
Obstetric examination consists of measuring the height of the top of the uterus (fundus uteri), determining the presentation of the fetus and calculating the Fetal Heart Rate (FHR). The average time of this examination tends to increase with increasing gestational age, namely ANC1 for 6.04 minutes, ANC2 for 7.13 minutes, and ANC-T for 7.9 minutes. At the last ANC (ANC-T), midwives must be more careful in examining the womb of pregnant women because of the preparation for delivery. Midwives must be able to detect if there are abnormalities or if pregnant women need a referral for delivery.
Provision of supplements to pregnant women in the form of blood-added tablets and PMT (Supplementary Feeding) for pregnant women. Drugs are given to pregnant women according to complaints. When giving supplements or medicines, the midwife also explains how to take them and the side effects. In ANC-I and ANC-II, all pregnant women (100%) received supplements or medicines, but in ANC-T only 2 (two) pregnant women (1.2%). The average service time ranges from 1.54-1.57 minutes in ANC-I, ANC-II and ANC-T.
The mean consultation time for ANC1, ANC2, and ANC-T were 9.26 minutes, 7.29 minutes, and 12.00 minutes, respectively. During the consultation, the midwife explains to pregnant women about (a) pregnancy and its complications, (b) diet and nutrition, (c) rest and exercise during pregnancy, (d) personal hygiene, (e) danger signs in pregnancy, (f) use of drugs in pregnancy,(g) impact of STI/HIV/AIDS, (h) voluntary counselling and HIV testing, (i) breastfeeding, (j) symptoms/signs of labour, (k) birth plans (emergency preparedness, transportation, place of delivery, (l) nancial arrangements, (m) postpartum care plan, (n) family planning, (p) dangerous habits (e.g. smoking, drug abuse, alcoholism). Especially for ANC-T, the midwife must explain the preparation for delivery to pregnant women, so that the average consultation time is the longest.
The large range between the longest and the shortest consultation times is due to the interaction between the midwife and pregnant women. The ability of the midwife to explain affects whether or not pregnant women easily understand the midwife's explanation. On the other hand, the ability of pregnant women to understand the explanations of the midwives varies greatly, some quickly understand, but some take a long time or nd it di cult to understand the midwife's explanation.
Referral cases were found in ANC2 and ANC-T. In ANC2, there were 10 pregnant women who needed referral services or 2.4% of the total observations. This pregnant woman was referred to an secondary health facility for further examination from an obstetrician. Meanwhile, in the last ANC (ANC-T), pregnant women who received referrals meant that pregnant women needed delivery services at secondary health facilities.
Our The results of the study by Magoma, Moke, et al (2011) regarding the timing of ANC services in Tanzania gave different results in the control group and the intervention group. Time requirements per ANC in the intervention group are 40.1 minutes for an ANC rst visit and 23.3 minutes for an ANC Revisit. In the control group, Time requirements per ANC are 19.9 minutes for an ANC rst visit and 10.3 minutes for an ANC Revisit. The factor that causes the difference in service time between the two groups is the time for consulting services (health education and counseling). Consultation service time at an ANC rst visit was 24.5 minutes in the intervention group and 10.5 minutes in the control group. Meanwhile, the consultation service time for ANC Revisit was 13.8 minutes in the intervention group and 4.5 minutes in the control group. The results of this study obtained the following consultation service times: ANC-I (an ANC rst visit) for 9.26 minutes, ANC-II (an ANC Revisit) for 7.29 minutes, and ANC-T (an ANC Revisit) for 12 minute Antenatal care is an important service to monitor the physical development of the mother and fetus. Consultation conducted during ANC is the midwife's way of providing education for pregnant women, This lack of time also impacts recording maternal records in the MCH Handbook, which is a standard book for education for pregnant women in Indonesia. Education by using MCH Handbooks will increase the mother's knowledge of knowledge and better practices during pregnancy, delivery, and child health care. (Baequni et al., 2016;Baequni & Nakamura, 2012) Technically, the length of time ANC will affect the quality of the ANC given to pregnant women. However, it would be better if the District/City Administrative and Health Authorities conducted a thorough evaluation of the implementation of ANC at PHF, namely evaluating the availability of tools, medical and non-medical materials, and health personnel (midwives). The evaluation also needs to include the quality of the ANC provided by the midwife, such as the ability of midwives to measure blood pressure accurately, detecting pre-eclampsia in pregnant women, and conducting empathetic communication.

Conclusions
The time used for ANC is still signi cantly less than that recommended by the WHO for pregnant women's visits (40 minutes per visit). The reason will undoubtedly affect the quality of ANC services. It is hoped that the District/City Administrative and Health Authorities will pay more attention to the duration time of ANC visits by developing a standard time of visit per patient, evaluate the implementation of ANC, or if needed add a midwife in carrying out ANC services at that location.