Maternal and Infant Mortality Rates’s Contributing Factors Description and Its Prevention in Kencong Healthcare Center, Jember Regency : A Descriptive Study

Background: Maternal Mortality Rates (MMR) and Infant Mortality Rates (IMR) are two of the indicators on the success of health programs in Indonesia. Jember has become the district with the highest rate of maternal and infant deaths throughout 2020-2021. Methods: This research assessed the contributing factors of MMR and IMR in Puskesmas Kencong, Jember Regency. This study uses a qualitative descriptive research design. Data in this study were taken by conducting interviews to fill out questionnaires to mothers who had given birth at least once and the Coordinating Midwife and Head Midwife of PONED (Basic Emergency Neonatal Obstetrics Services) at the Puskesmas Kencong. Then the data from the questionnaires and interviews will be processed and then explained in the narrative. Results: . Based on data


Introduction
Maternal Mortality Rates (MMR) is one of the indicators on the success of health programs in Indonesia.MMR can be defined as all deaths during pregnancy, childbirth, and puerperium.
Maternal mortality rates in Indonesia tends to decrease every year, but the number is still insignificant and hasn't met the target of Sustainable Development Goals (SDGs).MMR, which was initially progressively decreasing throughout the year, had increased again in 2020 and reached its peak in 2021.MMR in 2021 was mainly caused by COVID-29 infection followed by post-partum bleeding and hypertension in pregnancy 1 .Infant Mortality Rate (IMR) is all infant deaths in the age of 0-59 months.This mortality rate along with MMR is also one of SDGs targets of 2021.The number of infant deaths in 2021 was 27.566, which had decreased from 2020, which was 28.158 deaths.Even though we can see the decrease in numbers, this decrease is still not significant and has not met the SDGs target of 25 deaths per 1.000 births 1 .

The Maternal Mortality Rate in Jember
Regency in 2021 had increased to 115 cases from 61 cases in 2020.This figure had brought Jember Regency to become the district with the highest Maternal Mortality Rate in East Java Province in 2021.This was due to the lack of complete pregnancy checks so that high risk pregnancies were left undetected.There were 9 cases of maternal mortality in Jember Regency in 2021 caused by bleeding, 15 cases of hypertension during pregnancy, 1 case of infection, and 90 other cases.Jember Regency also became the highest Infant Mortality Rate (IMR) in East Java Province with 300 cases in 2021.The most cases of infant mortality in Jember Regency were caused by low birth weight as many as 88 cases. 23skesmas Kencong is one of the health centers in the Jember Regency with a working area covering Delays in reaching referral sites may be due to difficulties in transportation facilities, while delays in obtaining services may occur due to a lack of medical equipment facilities, limited operating rooms, and limited blood supplies.The delay in service in this case refers to services at referral hospitals, and this factor has the greatest impact on maternal mortality, because not all facilities provide emergency obstetric services, so that it becomes a separate problem for the health care system 5 .In addition, internal factors or 4T include too young in maternal age (< 20 years), too old in maternal age (> 35 years), too close in pregnancies interval (< 2 years), and too many children (more than four) can affect MMR 67 .IMR is closely related to factors that affect MMR because the baby is directly related to the mother in terms of nutrition, immunity, and so on 8 .
The high MMR and IMR are the main focus of this research.The risk factors that influence the occurrence of AKI and IMR, especially in Jember, which is the highest contributor to MMR and IMR in East Java, need to be studied and found out so that prevention and mitigation efforts can be made.

Methods
This study uses a qualitative descriptive

Results
The questionnaire given to the respondents was divided into several sections according to the question criteria.Respondent characteristics including place of residence, age, mother's educational background, ethnicity, and religion are shown in Table 1.The respondents we met were Javanese (73%), Maduranese (8.1%), and Javanese-Maduranese (5.4%), and all of them were Muslim.
We examined the characteristics of the respondents to determine the socio-cultural background of the respondents and their influence on habits that could increase MMR and IMR.
Mother's basic information can be seen in Table 2, .In this study, it was found that 20 out of 37 respondents were primigravidas, 12 out of 37 respondents had been pregnant twice.
Parity is the number of babies born alive by the mother 15 .Parity is said to have no relationship to maternal mortality but the higher the parity can have a negative impact on the mother.
Women with high parity can increase welfare and quality of life problems 16 .High parity will increase the mother's risk of developing cardiovascular disease and type 2 diabetes mellitus 17 .The results of this study found that 20 out of 37 respondents had given birth to a live birth once and 12 out of 37 respondents had given birth to a live birth twice.
Pregnant women are required to make antenatal care (ANC) visits at least four times during pregnancy.This visit is carried out at least once in the first trimester (K1), at least once in the second trimester (K2), and at least twice in the third trimester (K3 and K4).Examinations that must be carried out during ANC visits are known as 10T 18 .
Antenatal Care (ANC) must be carried out from the beginning of pregnancy so as to be able to detect early risk factors for pregnancy and childbirth so that proper prevention and management can be carried out 19 .Pregnant women are required to make ANC visits at least four times during their pregnancy because it can reduce maternal mortality through screening and early treatment 20 .
In professional health workers and at health service facilities.This is intended so that pregnant women receive quality and comprehensive services 18 .The results of this study found that 32 out of 37 chose to have a pregnancy check-up at the Independent Practicing Midwife, 26 out of 37 respondents gave birth with the help of a midwife, 11 out of 37 respondents gave birth at a Gynecologist.
Respondents have also conducted ANC pregnancy checks and deliveries at health care facilities.
Respondents said that carrying out examinations and deliveries at health facilities was safer so as to reduce maternal and infant mortality.In addition, the respondents made ANC visits and deliveries at health facilities as a result of good education by midwives in classes for pregnant women.This shows the low quality of maternal health services.WHO states that one of the important aspects of maternal and child health services is the existence of a close relationship with the health services that are above it.This close relationship is reflected through an effective referral system 9 .An effective health service referral system is one of the efforts to improve the quality of health services Kencong and Wonorejo Villages.Kencong District has an area of 5865.3 ha / 65.92 km2 with a total of 71,430 inhabitants.Kencong sub-district has 46 posyandu, two supporting health centers (puskesmas pembantu), and one village polyclinic (poliklinik desa) spread throughout the Kencong sub-district.The complications of pregnancy and childbirth that are most often encountered and referred to at the Puskesmas Kencong are premature rupture of membranes, severe preeclampsia, prolonged 1st stage of birth, premature parturition, and hepatitis B positive patients.Meanwhile, most neonatal referral cases are caused by giant babies, low birth weight babies, and severe asphyxia.In 2021, there were three cases of maternal death and one case of infant death at Puskesmas Kencong 23 .MMR can be caused by the 3T (3 Terlambat) or 3 Delays factors, namely Delay in Making Decisions, Delay in Referring, and Delay in Obtaining Services 4 .Delay in decision making is possible due to being late in realizing a complication or late in early detection of a complication, fear of the hospital, or lack of funds.
research design and has been approved by the Ethical Committee of Medical Faculty of Jember University.Data to determine the late decision factor in this study were taken by conducting interviews to fill out questionnaires on November 2022 to mothers who had given birth at least once from 2020-2022.Data to find out the late referral factor was carried out by conducting interviews with the Coordinating Midwife and Head Midwife of PONED (Basic Emergency Neonatal Obstetrics Services) at the Puskesmas Kencong.Then the data from the questionnaires and interviews will be assessed according to PONED Guidelines and then explained in the narrative.

Forms of family support
can be in the form of positive appreciation of individuals, encouragement, approval of individual opinions, as well as support and attention21 .Family support that plays a very important role is support from the husband who is the closest person to pregnant women22 .Family support plays an important role in influencing the motivation and psychology of mothers in carrying out health behaviors.From this research it can be seen that the respondents get support from the family.This can be seen from the assistance of respondents when carrying out ANC examinations and childbirth.During the ANC examination, 22 out of 37 respondents were accompanied by their husbands.During the delivery process, 36 out of 37 respondents were accompanied by their husbands and/or family.In addition, this family support can be seen from the majority of the husbands and/or families of the respondents who gave authority to the respondents to determine the place for ANC examinations and their own deliveries.The number of maternal deaths inIndonesia in 2021 has increased compared to 2020.

Table 2 .
Mother's Basic Information

s age at birth of last child
Based on the questionnaire data in Table2, the majority of respondents (83.8%) were housewives who did not work.Most of the respondents had been pregnant twice (51.4%), and following in second place were respondents with their first pregnancy (27%).Most of the respondents had given birth once (54.1%).The age of the mother at the time of giving birth to her last child was mostly in the age range of20-35 years

Table 3 .
Infant's Basic Information

Table 5 .
Basic Childbirth Information

Table 6 .
Basic Health Information