The Association Between the Characteristics of Pregnant Women with Knowledge and Attitudes Toward Midwifery Care Based on Gender Sensitivity

Respectful maternity care must be ensured that all pregnant women can accept it. It is necessary to understand all pregnant women receiving midwifery care with a gender-sensitive approach to prevent the possibility of mistreatment, harassment, or violence during midwifery practice. This study aimed to assess the association between the characteristics of pregnant women and the knowledge and attitudes regarding gender-sensitive midwifery care. This was a cross-sectional study on 200 pregnant women who came to get antenatal care services at independent practice midwives. The sample was selected using a purposive sampling technique. Multivariate logistic regression analysis was performed to obtain the odds ratio and 95% confidence interval, and p for trend to assess the strength of the association. Data was collected using a questionnaire that was developed and has been assessed for validity and reliability. Pregnant women who actively participate in community activities have an association with good knowledge of midwifery care with a gender sensitivity approach (OR = 1.51, OR = 1.16-1.97, p-value = 0.03), and pregnant women with higher education levels have an association with a good attitude of midwifery care with gender sensitivity approach (OR=2.02, 95%CI=1.01-4.05, p-value= 0.04). Pregnant women who participate in community activities are associated with good knowledge about midwifery care with a gender sensitivity approach, and pregnant women with higher education levels are associated with good attitudes about midwifery care with a gender sensitivity approach (p value < 0.001). The role of midwives and other health workers is needed to provide health education for pregnant women in all of health facilities at every antenatal visit and also at community activities such as the village community health center.


INTRODUCTION
Respectful maternity care (RMC) is an essential aspect of women's reproductive health services.RMC is every woman's human right, which is often not a concern, causing gender inequality. 1 Gender inequality in prenatal care can occur because pregnant women do not have information about the importance of conveying their wishes to midwifery service providers.As a result, many services are lost or not provided as needed, harassment, discrimination, and even violence in midwifery services occur. 1 Based to the World Health Organization (WHO), 2018, every pregnant woman and newborn has the right to receive quality services during pregnancy to the postnatal period. 2 Reproductive rights are the rights of every woman to obtain services related to reproductive health, including during pregnancy at any time. 3A systematic review on the utilization of health facilities in sub-Saharan Africa states that women who have full autonomy in decision-making and control over economic resources will increase health services utilization. 4In addition, a high level of education is closely related to the choice of a place of delivery and a professional birth attendant. 4This study illustrates that the level of higher education will guarantee the knowledge and attitude of a woman to choose the best place of delivery and professional birth attendant for herself. 4 Indonesia, it is known that the utilization of maternal health services is closely related to age, education, distance to health facilities, and insurance ownership. 5The use of gender-sensitive women's health services is now also a major need for women and is fundamental to women's health. 6nder-sensitive health services will be able to provide higher quality services with a particular understanding that women have different needs and require more attention to their health conditions. 6oviding gender-sensitive reproductive services is very useful for increasing the coverage of reproductive health services for women, especially for women's health and reproductive health. 7Even so, currently in Indonesia, differences in residence in rural and urban areas as well as areas that are difficult to reach, are still one of the causes of the low access of pregnant women to get quality midwifery services and with a gender-sensitive approach. 8od knowledge for women about reproductive health services from a gender perspective, especially midwifery services, is very much needed.With sufficient understanding, it is hoped that it will affect their attitude toward gender-sensitive midwifery services.Gender-based services should be the main factor that must be taken into account in providing reproductive health services for women. 7w health services can be utilized and effect on women's health is closely related to factors including the knowledge and attitudes of women and their partners to take advantage of these services. 9formation on the characteristics of pregnant women is needed, which relates to the use of midwifery care with the gender sensitivity approach that pregnant women get and its relation to the knowledge and attitudes of pregnant women towards midwifery care.For this reason, this study aims to assess the association between the characteristics of pregnant women and their knowledge and attitudes regarding gender-sensitive midwifery care.

METHODS
This was an analytic study with a cross-sectional design conducted on 385 pregnant women in the DKI Jakarta and South Kalimantan Province as a population.They came for antenatal check-ups at independent practice midwives in 2019-2020.The reason for choosing DKI Jakarta and South Kalimantan as research sites was because some of the midwives had received training on gender-based midwifery care.So that these two places were used as research sites.This study used pregnant women as research samples to assess the characteristics of respondents and associated them with their knowledge and attitudes towards midwifery care-based gender sensitivity.The sample was selected using a purposive sampling technique.The sample was selected using inclusion and exclusion criteria.
The inclusion criteria were pregnant women with no abnormalities, gestational age in the second and third trimesters, and minimum two repeat visits at the same midwifery practice.The exclusion criteria were first trimester gestational age, pregnant women with complications, and early antenatal care visits.The number of samples used based on the purposive sampling technique was 100 people per research location.The total sample used was 200 pregnant women.
The characteristics of the pregnant women as an independent variable that were assessed included: maternal age (<25 and >25, 20-35 years), level of education (basic-middle, high), occupation (worked, not worked/homemakers), resource of family income (husband/ joint, wife), community activity (not participated, participated), parity (primipara, multipara), and history of antenatal care (poorly, good).Meanwhile, the dependent variable that is examined in this study was the knowledge (poorly, good) and attitudes (poorly, good) of pregnant women in midwifery care-based gender sensitivity.
Data were taken using a questionnaire developed by the authors, and the validity and reliability of the questionnaire were measured using Pearson's product moment.
Multivariable logistic regression analysis was used to examine the effect of correlation between variables assessed by measuring the odds ratio (OR) and 95% confidence interval (CI) and p for trend to measure the significance of the association of each variable.Data were analyzed using SPSS 21 (SPSS Inc.Chicago USA).
In this study, each respondent has given informed consent to be a research subject.This research has received ethical approval by the ethics committee of the Jakarta III Health Polytechnic No. KEPK-PKKJ3/246/V/2019.

RESULTS
Table 1 describes the association between pregnant women`s characteristics and knowledge of gender-sensitive midwifery care.From table 1, pregnant women with a high level of education (25.5%), worked (71.6%), family income comes from husband/joint (85.3%), participated in community activities (47.1), and multiparity (61.8%) has good knowledge about gender-sensitive midwifery care.The results of multivariable logistic regression found that pregnant women who participated in community activities had a significant association with a good knowledge of midwifery care with gender-sensitive (OR=1.51,OR=1.16-1.97,p value=0.03).Meanwhile, for pregnant women with a high level of education and multiparity, there was an increase in Odds, but it did not reach a significant level (p > 0.05).

DISCUSSION
Our research shows that pregnant women participating in community activities know well about gender-sensitive midwifery care.By participating in various community activities, women can increase their knowledge about how gender-sensitive midwifery care should be.This is in accordance with a mapping review of gender inequality in the context of mistreatment during childbearing. 1The study stated that pregnant women with insufficient information would not get their rights in respectful maternity care (RMC), which is known that RMC is closely related to midwifery care with gender sensitivity. 1

penelitian dari
In this study, community activities participated in by pregnant women proved beneficial in providing knowledge about the importance of midwifery care based on a gender perspective.This result is closely related to the effectiveness of public health interventions provided through existing activities in the community or the use of media to convey information.It is essential to increase knowledge of pregnant women by involving them in activities that develop in the community.High knowledge will increase good perceptions about health, especially pregnancy. 11Knowledge of midwifery care with a gender perspective that should get is essential for pregnant women.Concerning the model of midwifery care with a gender perspective, it is hoped that pregnant women can assess and feel the quality of care so that they can complain to the midwife or health worker as a provider if the service she gets is inappropriate.In addition, knowing the type of midwifery care with a gender perspective will prevent pregnant women from mistreating in the care they receive and from the possibility of ethical violations and abuse either physically or psychologically from health workers (unrespectful maternity care). 12Research in Iran on 88 pregnant women also stated that public participation followed by pregnant women increased the value of women getting birth assistance as naturally as possible and avoiding cesarean section without indications. 13Even though, from what is developing in society, women are always not confident participating in community activities. 14It is necessary to empower women, which midwives and health workers can assist as service providers to make them more confident in joining community activities to provide benefits in increasing their knowledge, especially about reproductive health. 14 this study, pregnant women with a high level of education and multiparity had an increased chance of 5-20 percent having good knowledge of midwifery care with a gender sensitivity approach.
However, it did not reach a significant level of association.When viewed from these characteristic factors, the level of education should indeed increase one's knowledge, in this case, pregnant women.
A strategic step in increasing women's knowledge about the importance of gender equity in every source of health is the opportunity to get an increase in education and socio-economics. 15The success of understanding gender issues in a woman is influenced by continued development of the economic, environmental, and social fields conducive to rationally supporting their needs. 15The ability of midwives to provide midwifery care with a gender-sensitive approach is also a benchmark for pregnant women in recognizing and understanding how important this model of care is for them to get. 16,17 this study, the higher education level in pregnant women was associated with a good attitude towards midwifery care with gender sensitivity.This study relates to pregnant women's understanding and acceptance of gender-sensitive midwifery care and whether it benefits them during this period of pregnancy.It is just that how midwifery care with gender sensitivity needs to be clearly understood by midwives or health workers as providers in order to be able to facilitate providing this midwifery care with gender sensitivity to all pregnant women. 16Pregnant women with low education are vulnerable to getting health services that are not under their needs.A trial study on 88 pregnant women in Iran explained that pregnant women with low education are prone to cesarean section during delivery even without indications. 13This is related to their knowledge and attitude towards the health services they get.One example of maternity care that does not use a gender sensitivity approach is delivery assistance by cesarean section without indications. 18This is a priority that must be eliminated, considering that cesarean section without indication is a medical intervention that does not respect the needs of women (unrespectful maternity care).By increasing women's education, it will increase women's attitudes to be better toward midwifery care based on the gender-sensitive approach they should receive, 18 and able to prevent women from being exposed to harassment or violence in the reproductive health services they receive. 19is research has several strengths, including research that is still rarely done.This research supports the importance of increasing the knowledge and attitudes of pregnant women better to recognize midwifery care with a gender-sensitive approach.However, this study still has limitations.
The characteristics of respondents that have not been measured, such as the husband's role, education, and occupation, need to be considered to be influential in increasing the knowledge and attitudes of pregnant women towards midwifery care with a gender sensitivity approach.

CONCLUSIONS
In conclusion, pregnant women participating in community activities are associated with good knowledge about midwifery care with a gender sensitivity approach (p-value = 0.03).Pregnant women with higher education levels are associated with good attitudes about midwifery care with a gender sensitivity approach (p-value = 0.04).The role of midwives and other health workers is needed to educate pregnant women about the importance of getting midwifery care services with a gendersensitive approach.Providing midwifery services with gender sensitivity is essential to ensure respectful maternity care for all pregnant women.

Table 1 .
The Association Between the Characteristic of Pregnant Women and Knowledge of Gender-Sensitive

Table 2 .
The Association Between Characteristic Respondents and Attitudes Of Gender-Sensitive Midwifery Care * Logistic regression analysis ** p for difference