Use of antenatal care, maternity services, intermittent presumptive

treatment and insecticide treated bed nets by pregnant women in

Luwero district, Uganda

Mpungu S Kiwuwa1* and Patrobas Mufubenga2

* Corresponding author: Mpungu S Kiwuwa skiwuwa@med.mak.ac.ug

Equal contributors

Author Affiliations
1
Clinical Epidemiology Unit, Faculty of Medicine, Makerere University, Uganda
2
Ministry of Health Headquarters, National Malaria Control Programme, Uganda

For all author emails, please log on.

Malaria Journal 2008, 7:44 doi:10.1186/1475-2875-7-44

The electronic version of this article is the complete one and can be found online at:
http://www.malariajournal.com/content/7/1/44

Received: 23 August 2007

Accepted: 1 March 2008

Published:1 March 2008

2008 Kiwuwa and Mufubenga; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Abstract

Background

To reduce the intolerable burden of malaria in pregnancy, the Ministry of Health in Uganda
improved the antenatal care package by including a strong commitment to increase
distribution of insecticide-treated nets (ITNs) and introduction of intermittent preventive
treatment with sulphadoxine-pyrimethamine for pregnant women (IPTp-SP) as a national
policy in 2000. This study assessed uptake of both ITNs and IPTp-SP by pregnant women as
well as antenatal and maternity care use with the aim of optimizing their delivery.

Methods

769 post-partum women were recruited from a rural area of central Uganda with perennial
malaria transmission through a cross-sectional, community-based household survey in May
2005.

Results

Of the 769 women interviewed, antenatal clinic (ANC) attendance was high (94.4%); 417
(57.7%) visiting initially during the 2nd trimester, 242 (33.5%) during the 3rd trimester and
266 (37.1%) reporting 4 ANC visits. About 537 (71%) and 272 (35.8%) received one or 2
IPTp-SP doses respectively. Only 85 (15.8%) received the first dose of IPTp-SP in the 3rd
trimester. ITNs were used by 239 (31.3%) of women during pregnancy and 314 (40.8%)
delivered their most recent pregnancy outside a health facility. Post-partum women who
lacked post-primary education were more likely not to have attended four or more ANC visits
(odds ratio [OR] 3.3, 95% confidence interval [CI] 1.29.3).

Conclusion

These findings illustrate the need to strengthen capacity of the district to further improve
antenatal care and maternity services utilization and IPTp-SP uptake. More specific and
effective community health strategies to improve effective ANC, maternity services
utilization and IPTp-SP uptake in rural communities should be undertaken.

Background

Uganda is one of the countries in sub-Saharan Africa with high maternal and neonatal
morbidity and mortality rates. According to the Uganda Demographic Health Survey (UDHS)
2001, the maternal mortality ratio is estimated to be 504 per 100,000 live births, with a
neonatal mortality rate of 40 per 1000, and these indicators have barely changed for the last
two decades. Over 90% of the population live in highly endemic areas with perennial
transmission while the 10% live in low transmission areas which are prone to malaria
epidemics. Children are most vulnerable to malaria, with mortality rates being highest among
children under five years of age. Malaria during pregnancy contributes to high maternal
morbidity and mortality as a result of its contribution to severe anaemia, low birth weight,
foetal loss and still births [1].

The threat of malaria in pregnancy to maternal and neonatal survival in Uganda is well-
recognized by local communities in the country. Occult malaria in pregnancy (womb fever) is
known by the local communities to be responsible for spontaneous abortions and foetal
deaths. Consequently, these complications are believed to be responsible for some of the
women's emotional stress, stigma, superstition, self-hatred, indulgence, divorce and
ostracization in society [2]. One study in the country estimated the prevalence of malaria
parasitaemia in pregnancy to be 62.1% [3], while severe maternal anaemia (Hb < 8 gdl-1) and
low birth weight were found to be 18% and 12.4% respectively [2]. Sleeping under an
insecticide-treated bed net (ITN) can reduce the risk of a pregnant woman being infected with
malaria and reduce the risks of maternal anaemia and low birth weight [4]. Another
preventive measure of intermittent preventive therapy with Sulfadoxine-pyrimethamine for
malaria in pregnancy (IPTp-SP) in areas of high or seasonal transmission has been has been
shown to increase both maternal haemoglobin levels and the infants' birth weight [5-8].
Sulphadoxine-pyrimethamine may act by treatment or prevention of new infections. The
World Health Organization (WHO) recommends that all pregnant women in areas of stable
malaria transmission should receive at least two doses of IPT after quickening (first noted
movement of the foetus) during regularly/routinely scheduled antenatal clinic visits.

The Uganda Reproductive Health (RH) policy guidelines of 2000 recommend a schedule of a
minimum four ANC visits [9], in which a complete antenatal care package can be delivered
appropriately. According to this recommendation, a woman with an uncomplicated
pregnancy is expected to make ANC visits; once in each of the first and second trimesters,
and twice in the 3rd trimester. The current antenatal care package includes: health education
and counselling on pregnancy and emergency preparedness, nutrition, hygiene, birth plan,
postpartum care, breast feeding, sexually-transmitted infection prevention and family
planning. It also involves antenatal examinations, inter-current disease treatment, routine
screening for syphilis, voluntary counselling and testing for HIV, prevention of mother to
child transmission of HIV (PMTCT), periodic de-worming, nutrition supplementation and
tetanus immunisations [10]. The National Malaria Control Programme priority intervention
areas in 2001 included (IPTp-SP), vector control with emphasis on promoting large-scale use
of insecticide-treated materials, indoor residual spraying and improved appropriate case
management. Through this strategy the country expects to achieve a target of 75% pregnant
women receiving complete IPTp-SP, 70% of households each with an insecticide treated net
(ITN), and 100% clinical malaria cases receiving appropriate case management by the year
2010 [10]. It was observed that on average women make only two ANC visits during
pregnancy and often at late gestational ages (>28 weeks) irrespective of parity, education or
economic status [11], resulting in poor uptake of RH services by communities [12]. This is
demonstrated by the fact that two years after implementation of the malaria in pregnancy
control strategy, the two dose IPTp-SP coverage stood at only 5% in the central region
despite efforts to improve these services (Quarterly PHC Monitoring Report January 2002).
Pregnant women from rural areas are more likely to have placental malaria compared to
women from urban areas [13], thus the need for more studies on antenatal care performance
and IPTp-SP coverage in rural settings. A baseline community household survey was
therefore conducted in rural central Uganda among women who had recently delivered to
assess the use of antenatal care, maternal services, IPTp-SP and ITNs with the aim of
improving uptake of an optimal antenatal care package.

Methods

Study setting

Luwero district in rural central Uganda was purposively selected for study because of its
malaria endemicity, ethnic homogeneity and social stability. Luwero district borders Kiboga,
Wakiso, Nakasongola and Mukono districts with a longitudinal location of 32. It has a total
area of 5,773.53 square km, with a total population of 474,627, and 24,681 annual expected
pregnancies (National Census 2002). The district is sub-divided into 4 counties and 20 sub-
counties. The national health policy (1999) established the health sub-district (HSD) as a
functional subdivision, or service zone, of the district health system to bring quality essential
care closer to the people. Within the HSD, exists a hierarchy of lower level health units. The
leadership of the HSD is located in an existing hospital or a HC IV (Public or Private not for
profit) located within the HSD. The HSDs in Luwero district include; Nakaseke, Katikamu
North, Katikamu south, and Bamunanika. The district has 68 recognized health units able to
offer antenatal care services. However, only 43% (59/136) of the parishes have at least one
health unit, which shows limited access to health care. Currently ANC services are offered at
all levels of care right from parish level (Health centre II) up to the national level (National
and regional hospitals), complemented by private domiciliary clinics at village level. At
public health units pregnant women get free ANC services. However ITNs are dispensed at
subsidies ranging between 0 and 100%, as determined by local authorities, social marketing
strategies or development partners.

Antenatal care services are offered by various categories of health care workers including
private midwives and traditional birth attendants. SP is administered as directly observed
therapy from the ANCs. The district has a hot and wet type of climate, with an average
rainfall of 1,300 mm resulting into malaria transmission all year round (hyperendemic area).
Malaria infections and morbidity have seasonal peaks after rains in March-May and in
September-December. The district populace largely depends on agricultural earnings. Prior to
the survey, the project team visited the study area and met the district local leaders and health
team so as to establish dialogue and sensitize the community about the project. Permission to
carry out the study was granted by Uganda National Council of Science and technology
(UNCST) the national ethical board.

Study design

A cross-sectional community survey of two health sub-districts of Luwero district namely

Bamunanika and Kapeka, was conducted in May 2005. All post-natal women who had
delivered their baby within the preceding five months were eligible for inclusion in the study.
Bamunanika and Kapeka sub-counties were purposively selected based on similarity in
population size, health unit number and annual expected pregnancy rates. The populations of
Bamunanika and Kapeka were estimated at 24,848 and 24,068 respectively (Uganda
population census 2002). It was estimated that a sample size of 384 mothers in each sub-
county was required to calculate the true proportion of those using IPT within 5% points and
assuming a 50% prevalence of at least four ANC visits. The research team comprised of six
trained research assistants and two field supervisors. The study population was obtained
using a multi stage sampling technique in which all parishes in the two chosen HSDs were
sampled. In each HSD data was collected for a total duration of five days. With the help of
field guides, the centre of each parish was identified and a bottle spinned to determine the
initial direction where the sample was drawn. Households were consecutively visited and one
eligible woman per household was interviewed until a pre-determined number of respondents
per parish was obtained. Where more than one eligible woman was present in a household, a
respondent among them was selected randomly.

Data collection instruments

Participants were interviewed using a pre-tested semi structured questionnaire. A

questionnaire was administered in the local language to each participant after obtaining
informed consent. The questionnaire collected information about: a) Socio-demographic
variables including age, religion, occupation, education level, distance to health units, marital
status: b) antenatal care service utilization including number of antenatal care visits, health
units visited, IPT intake and ITN use: c) maternity services including delivery process and
place of delivery. Antenatal clinic cards were routinely requested from the participants to
corroborate information provided by self report. Complete IPT uptake was defined as
provision of at least two or more SP doses given at the ANC to women who were not sick
[14]. The field supervisors regularly cross-checked on the completeness the data collected on
a daily basis. Limitations of the study may include imprecise estimates of gestational ages
and IPT intake during ANC visits due to potential recall bias and in some instances, lack of
ANC cards to corroborate some of the information obtained by self report.

Data analysis

Data was double entered into a computer using Epi info version 2000 and analysed using
SPSS version 10.0. Continuous data was presented as means (standard deviation) SD and
medians. Comparison of continuous data was done using the independent t-test and
nonparametric tests (Mann-Whitney U test) where the assumptions of normality were unmet.
Proportions were analysed using the Chi-square test or Fisher's exact test. Odds ratios and
95% confidence intervals (CI) were determined. Statistical significance was taken as P <
0.05.
Results

Socio-demographic characteristics of the study population

Seven hundred and sixty nine post-partum women participated in the study and their
characteristics are shown in (Table 1). The mean age (standard deviation [SD]) of the
participants was 24.7 (5.9) years. The group was predominantly made up of married women
in the 2029 years age-group 459 (59.7%); and 186 (24%) having attained post primary level
of education. It is noted that there were high rates of unemployment amongst this study
population 674 (87.6%); with only 31 (4%) engaged in subsistence farming. The majority of
the mothers 625 (81.3%) had recently delivered within the previous four months. In terms of
access to health care, the mean distance to the nearest ANC clinic was 3.9 km (SD) 3.2. Only
82 (10.7%) of the participants had been visited by a community health worker during their
previous pregnancy.

Table 1. Socio-demographic characteristics of the participants (N = 769)*

Antenatal care services utilization

Of the 769 participating women, 722 (94.4%) reported having visited an antenatal clinic
during their most recent pregnancy (Table 2). Antenatal clinic attendance was verified among
344 (86%) participants who presented ANC records at the time of the interview. The mean
number of self reported antenatal clinic visits during the recent pregnancy was 3.0 range (1
10). Antenatal clinic attendance did not differ among those who lived within a distance of 4
km from the nearest formal health unit compared to those living beyond, P = 0.84.
Approximately 88% of the women made more than one ANC visit. The frequency of 4 or
more self reported antenatal care visits among ANC attendees was 266 (37.1%). The majority
of the women 417 (57.7%) reported attending the ANC for the first time in the second
trimester, while 242 (33.5%) commenced in the third trimester. Women who had not attained
post-primary education, 39 (90.7%), were almost three times more likely not to have visited
an ANC compared to women who had completed primary education, 4 (2.2%); (OR 3.3, 95%
CI 1.29.3). Of the ANCs visited by the women, the health centre III level was the most
commonly attended locality. However, only 12 (1.6%) acknowledged visiting traditional
birth attendants for antenatal care services.
Table 2. The use of Antenatal clinics, and IPT by pregnant women*

IPT uptake at the antenatal clinics

Approximately 544 (71.7%) of the postpartum women had taken at least one dose of SP
while they were pregnant (Table 2). All SP treatments were presumptive (taken when they
were not sick), and, they were all administered at an ANC. However fewer mothers 272
(35.8%) received at least two doses of IPTp-SP at an ANC visit. Only 417 (57.7%) reported
taking the first dose of IPTp-SP within the second trimester of pregnancy (47 mo) and
occasionally in 9% of women, it was given during the first trimester (<4 mo). Consumption
of other preventive anti-malarials through mechanisms other than IPTp-SP was uncommon
(1.5%) in this study population. More primigravidae 52 (19.1%) took two or more doses of
IPTp-SP compared to multigravidae 47 (17.8%), however the difference did not reach
statistical significance, P = 0.69. Lack of post primary education was associated with failure
to use at least one dose of IPTp-SP; OR 2.2, 95%CI (1.43.3).

Bed net use

Only 239 (31.3%) of women stated that they used a bed net during their previous pregnancy,
and only 116 (48.5%) reported a net re-treatment with an insecticide within the last 6 months.
Most nets were obtained from the commercial sector with no long-lasting impregnated nets
(LLINs) available on the market. The mean gestational age at inception of net use was 2.5
months. Women experiencing pregnancy for the first time, 47 (34.6%), were more likely to
report using a bed net compared to the multigravidae 191 (30.5%); however this difference
did not reach statistical significance, P = 0.356.

Maternity services

Most women delivered in health centers (28.7%); 193 (26.4%) delivered from home, 133
(18.2%) in private maternity homes and 101 (13.8%) in a hospital (Table 3). Approximately
455 (59.2%) women gave birth with a skilled attendant present. Others delivered either by
themselves or with the help of relatives, friends or traditional birth attendants.

Table 3. Maternity services utilization*

Discussion
The study indicates a high rate of antenatal care attendance as similarly observed in other
African countries with IPTp-SP policy implementation [15] and offers the potential for
implementing the nationally recommended approaches to the prevention and control of
malaria. Six years after the introduction of IPT in Uganda, only a small percentage of women
in this rural area are benefiting from this policy. More than two thirds of women attending
antenatal care and delivering from formal health units received at least one dose, but fewer
than 40% received the recommended full two dose SP regimen. These findings are similar to
studies done else where in Africa, where six years after the introduction of this policy, a
hospital-based study in urban Kisumu, Kenya reported (43.4%) receiving one dose of SP and
(23.7%) receiving two doses [13]; a hospital-based study in urban Malawi reported 45.1%
receiving one dose and 30.6% receiving two doses [6]; a community-based study in rural
Malawi reported 75.7% receiving one dose and 43.7% receiving two or more doses [16]; and
a nation wide survey reported 67.5% receiving one dose and 29.3% receiving two or more
doses (National Statistical Office Malawi 2001).

It is noteworthy that ANC cards may not be routinely available after a woman has delivered,
suggesting that the reported use of malaria preventive measures in our study might be an
overestimate. In this rural setting, the coverage of pregnant women with the recommended
malaria preventive measures (ITNs and IPT) in 2005 was <5% of the targets set by Roll Back
Malaria movement for 2005. Only 30% of women slept under a bed net and only 36.2%
received two or more doses of SP as presumptive treatment, and these tended to be mutually
exclusive with only 13% of women being covered by both these malaria preventive measures.
Primigravidae were more likely to sleep under a net compared to multigravidae, although this
finding has not been consistent in studies done elsewhere [17-19]. The community
perceptions regarding malaria as an important complication among vulnerable groups such as
primigravidae may possibly explain this observation. Previous studies in Uganda have
revealed that perceiving malaria as an important complication in pregnancy appears to be an
important factor in motivating pregnant women to participate in a program [3,20]. The
majority of the mothers reported receiving antenatal care from formal health units, however
approximately 60% delivered their most recent pregnancy outside a formal health facility.
Similarly in Hoima district of western Uganda, approximately 60% of women delivered
outside a health facility [21]. Other studies have reported 55% of women delivering from
home [3], only 58% delivering from hospital in Malawi [7], 51% delivering from a health
institution and 49% had delivered under TBA care in Nigeria [22]. The possible reasons for
low deliveries at formal health units could be related to costs, cultural factors, health worker's
attitudes towards pregnant women and the perceived quality of care at the health units
[3,21,23]. Given the projected absence of adequate cadres of skilled birth attendants in many
countries for years to come calls for innovative approaches to improve perinatal health in this
community. The newly initiated scaling-up of provision of free LLINs to vulnerable groups
countrywide is part of Ugandan commitment to improve access to ITNs for pregnant women
as a whole. It is hoped that through community health initiatives such as health education and
promotion, some of the socio-economic inequalities that hinder access of rural communities
to healthcare service utilisation will be addressed.

Conclusion

In conclusion, this baseline survey confirms that ANC attendance and delivery of a full IPT
regimen are sub-optimal. This results in limited access to information on malaria prevention
in pregnancy, such as the benefits of IPT and ITNs. Given findings of this baseline study and
others to come in Uganda it is important to identify strategies to increase IPTp-SP uptake in
rural areas. Optimising IPT uptake during ANC services would be the most rational option
given high attendance rates of the formal health sector. To this end, the malaria control
programme of the Ministry of Health, Uganda, designed a programme to strengthen the
capacity of the district for improved ANC performance and hence IPT uptake. Through the
use of trained community owned resource persons, pregnant women are periodically made
aware about the consequences of malaria in pregnancy and the necessity of an early ANC
visit so as to benefit from administration of a full IPT regimen. The implementation of such a
strategy is subject to further evaluation.

Authors' contributions

PM conceived of the study, participated in it's design, coordination of the data collection
process and draft of the manuscript. MSK participated in the design and coordination of the
study, performed the statistical analysis and drafted the manuscript. All authors read and
approved the final manuscript.
Acknowledgements

We thank the participating mothers who gave their precious time to inform the survey. We
thank the Luwero District Directorate of Health services and the local leaders for their
cooperation and help. We thank the research assistants who participated in the study. This
work was supported by MIM WHO-TDR, Geneva Switzerland.

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HUBUNGAN DUKUNGAN SUAMI TERHADAP
MENINGKATNYA KUNJUNGAN ANC PADA IBU HAMIL DI
WILAYAH KERJA PUSKESMAS LINGKAR TIMUR KOTA
BENGKULU TAHUN 2011 (Djusmalinar, Erli Zainal, Elvina
Desmayanti)
Senin, 19 Maret 2012 11:45
HUBUNGAN DUKUNGAN SUAMI TERHADAP MENINGKATNYA KUNJUNGAN
ANC PADA IBU HAMIL DI WILAYAH KERJA PUSKESMAS LINGKAR TIMUR
KOTA BENGKULU TAHUN 2011

Djusmalinar, Erli Zainal, Elvina Desmayanti

Akademi Kesehatan Sapta Bakti Bengkulu

High and low coverage of pregnant women to visit health facilities seen by the mother in
obedience to antenatal care. One factor that could affect the ANC's visit is support her
husband. The notion that the husband did not want to take his wife to their pregnancy to
health center or other health services because busy and say it is the women's affairs so that
the objectives of this study was to determine the relationship of husband's support of ANC
visits increased in the Lingkar Timur Health Center of Bengkulu City in 2011. The research
was conducted in Lingkar Timur Health Center of Bengkulu City in April-June 2011. This
type of research is an analytical study, using cross-sectional design. In this study using
primary and secondary data. The sampling technique was accidental sampling from the
population numbered 82 people. The results of univariate analysis that the husband's support
of ANC visits increased in pregnant women at health centers in 2011 East Circle largely
classified as good (70.7%) and was conducted in full (63.4%). The results of the calculation
of Chi square test statistic obtained value p value = 0.000 < ? = 0.05 means that there is a
significant relationship between a husband to support the increase in health center visits ANC
Lingkar Timur Health Center 2011. From the results of this study are expected health care
workers should be able to increase knowledge about the importance of providing support her
husband in his wife during their pregnancy through health education and consulting, and is
expected ANC examination in pregnant women can be made in full so that maternal and
infant mortality could be reduced.

Key word : Support, visit ANC

Kehamilan adalah sebuah impian dan cara untuk mencapai kepuasan tertinggi untuk prestasi
seorang ibu dan suami. Kehamilan dimulai dari pembuahan dan berakhir dengan kelahiran
manusia baru. Kehamilan dan persalinan merupakan proses yang alami, tetapi bukannya
tanpa resiko dan merupakan beban tersendiri bagi seorang wanita. Namun demikian tidak
semua hasil persalinan dan kehamilan akan menggembirakan seorang suami, ibu dan bayi
lahir sehat. Ibu hamil bisa menghadapi kegawatan dengan derajat ringan sampai berat yang
dapat memberikan bahaya terjadinya ketidak nyamanan, ketidak puasan, kesakitan, kecacatan
bahkan kematian bagi ibu hamil resiko tinggi, maupun rendah yang mengalami komplikasi
dalam persalinan (Saifudin, 2002).

Saat ini angka kematian ibu di Indonesia masih tetap tinggi di kawasan ASEAN. Hasil
Survey Demografi dan Kesehatan Indonesia (SDKI) 2007, menunjukkan Angka Kematian
Bayi (AKB) 34/1000 Kelahiran Hidup (KH), Angka Kematian Balita (AKBA) 44/1000 KH
dan Angka Kematian Ibu (AKI) 228/100.000 KH. Target pencapaian sasaran di tahun 2015
yaitu AKB 23/1000 KH dan AKBA 32/1000 KH. Salah satu upaya yang dilakukan
Departemen Kesehatan dalam rangka mempercepat penurunan angka kematian ibu dan bayi
adalah pendekatan pelayanan kesehatan maternal dan neonatal yang berkualitas, yaitu
melakukan kunjungan pemeriksaan kehamilan atau Antenatal Care (ANC). Tujuan dari ANC
sendiri menurut Depkes RI (2008) adalah untuk menjaga agar ibu hamil dapat melalui masa
kehamilan, persalinan dan nifas dengan baik dan selamat, serta menghasilkan bayi yang
sehat.

Kunjungan ANC yang teratur dan pengawasan yang rutin dari bidan maupun dokter selama
masa kehamilan tersebut diharapkan komplikasi yang mungkin terjadi selama hamil,
termasuk riwayat penyakit secara umum dapat dikenali secara lebih dini. Hal ini dapat
mengurangi resiko kematian ibu hamil. Menurut Depkes RI (2008) faktor yang
mempengaruhi pencapaian kunjungan KI dan K4 ibu hamil diantaranya adalah faktor internal
(paritas dan usia) dan eksternal (pengetahuan, sikap, ekonomi, sosial budaya, geografis,
informasi dan dukungan). Dampak dari ibu hamil yang tidak mengikuti ANC adalah :
meningkatnya angka mortalitas dan morbilitas ibu, tidak terdeteksinya kelainan-kelainan
kehamilan dan kelainan fisik yang terjadi pada saat persalinan tidak dapat dideteksi secara
dini.

Cakupan pelayanan ANC dapat dipantau melalui pelayanan kunjungan baru ibu hamil (KI)
untuk melihat akses dan pelayanan kesehatan ibu hamil sesuai standar paling sedikit 4 kali
(K4) dengan distribusi sekali pada trimester pertama, sekali pada trimester kedua dan dua kali
pada trimester ketiga. Menurut data Dinas Kesehatan Propinsi Bengkulu pencapaian KI dan
K4 pada tahun 2009 adalah 95,20% dan 87,69% dan pada tahun itu juga tercatat ibu yang
meninggal sebanyak 51 orang yang terdiri dari ibu hamil sebanyak 3 orang, ibu bersalin
sebanyak 35 orang dan ibu nifas sebanyak 13 orang (Profil Kesehatan Kota, 2010). Dari 19
puskesmas yang ada di kota Bengkulu, ibu hamil yang memeriksakan kehamilannya paling
banyak terdapat pada Puskesmas Lingkar Timur, yaitu sebanyak 818 ibu hamil dengan
kunjungan KI mencapai 89,24% dan K4 mencapai 85,94% yang dapat kita lihat pada tabel
berikut :
Tabel 1.1Kunjungan Ibu Hamil (KI, K4) Kota Bengkulu Tahun 2010

IBU HAMIL
NO PUSKESMAS
JUMLAH KI % K4 %
1 Jembatan Kecil 323 322 99.69 295 91.33
2 Jalan Gedang 362 339 93.65 303 83.70
3 Lingkat Barat 200 188 94.00 177 88.50
4 Lingkar Timur 818 730 89.24 703 85.94
5 Sidomulyo 199 198 99.50 149 74.87
6 Kuala Lempuing 113 107 94.69 103 91.15
7 Nusa Indah 508 504 99.21 492 96.85
8 Sawah Lebar 505 446 88.32 440 87.13
9 Anggut Atas 363 334 92.01 324 89.26
10 Penurunan 362 271 74.86 256 70.72
11 Pasar ikan 385 277 71.95 375 97.40
12 Kampung Bali 279 271 97.13 248 88.89
13 Sukamerindu 370 369 99.73 358 96.76
14 Ratu Agung 275 255 92.73 192 69.82
15 Beringin Raya 337 310 91.99 247 73.29
16 Basuki Rahmad 619 605 97.94 596 96.28
17 Betungan 298 285 95.64 237 79.53
18 Kandang 298 271 90.94 241 80.87
19 Padang Serai 253 180 71.15 154 60.87
Jumlah Kota 6.867 6.262 91.19 5.890 85.77

Sumber : Dinkes Kota Bengkulu, 2010

Dari berbagai faktor yang mempengaruhi pencapaian kunjungan KI dan K4 diatas,

keberhasilan upaya kesehatan ibu dan anak khususnya pemeriksaan kehamilan selain
tergantung kepada petugas kesehatan, ada dukungan suami yang ikut serta dalam
mengingatkan pemeriksaan kehamilan. Wanita hamil selama masa kehamilannya mengalami
perubahan fisik dan juga psikologis. Penelitian Werner (2001) menyebutkan bahwa
perubahan fisik dan psikologis yang terjadi pada wanita hamil meningkatkan dependency
need /kebutuhan. Penelitian tersebut juga menunjukan kebutuhan akan perhatian yang lebih
besar, keinginan memastikan bahwa bantuan yang dibutuhkan telah tersedia dan keinginan
akan keterlibatan teman dan keluarga. Hal ini diperkuat dengan penelitian Marks & Kumar
(2001) yang menunjukan bahwa kecemasan yang dialami oleh wanita hamil lebih banyak
terdapat pada mereka yang kurang mendapat dukungan sosial.

Faktor yang dapat mengurangi kecemasan yang terjadi pada wanita hamil adalah adanya
dukungan suami yang didapat dari suami, keluarga atau saudara lainnya, orang tua, dan
mertua. Dukungan suami yang didapatkan calon ibu akan menimbulkan perasaan tenang,
sikap positif terhadap diri sendiri dan kehamilannya, maka diharapkan ibu dapat menjaga
kehamilannya dengan baik sampai saat persalinan. Menurut BKKBN (2001) partisipasi suami
dalam asuhan kebidanan dapat ditunjukkan dengan memberikan perhatian dan kasih sayang
kepada istri, mendorong dan mengantar istri untuk memeriksakan kehamilan ke fasilitas
kesehatan minimal 4 kali selama kehamilan, memenuhi kebutuhan gizi bagi istrinya agar
tidak terjadi anemi, menentukan tempat bersalin (fasilitas kesehatan) bersama istri,
melakukan rujukan ke fasilitas kesehatan sedini mungkin bila terjadi hal-hal menyangkut
kesehatan selama kehamilan dan menyiapkan biaya persalinan. Dengan adanya dukungan
suami diharapkan wanita hamil dapat mempertahankan kondisi kesehatan psikologisnya dan
lebih mudah menerima perubahan fisik serta mengontrol gejolak emosi yang timbul.

Dukungan suami yang tinggi disebabkan adanya dukungan emosional, dukungan

insrumental, dukungan informasional, dan penilaian yang baik yang diberikan dari keluarga
kepada ibu hamil, yang mampu menumbuhkan terjalinnya hubungan yang baik antara
keluarga dan ibu hamil dan mencegah kecemasan yang timbul akibat perubahan fisik yang
mempengaruhi kondisi psikologisnya (Safarino, 2003). Penelitian yang dilakukan Retnowati
(2007) menyebutkan bahwa sebanyak 61,9 % ibu hamil mendapat dukungan dari suami
mempunyai motivasi yang tinggi terhadap pemeriksaan ANC, penelitian ANC serupa
dilakukan oleh Nurul Hidayati (2008) menunjukkan bahwa partisipasi suami dalam asuhan
kehamilan dipengaruhi oleh tingkat pengetahuan suami terhadap asuhan kehamilan.

Pada kasus psikologis atau kelainan jiwa yang berat perlu dorongan dan dukungan dari orang
terdekat dalam keluarga. Pengaruh faktor psikologis atau kelainan jiwa terhadap kehamilan
adalah ketidakmampuan pengasuhan kehamilan dan mempunyai potensi melakukan tindakan
yang membahayakan terhadap kehamilan (Kusmiyati, 2008). Dari hasil studi pendahuluan, 3
dari 10 ibu hamil yang datang untuk memeriksakan kehamilannya mengatakan bahwa
suaminya mau membantu pekerjaan di rumah tetapi tidak mau mengantar istri periksa ke
Puskesmas karena sibuk atau mengatakan hal ini merupakan urusan perempuan.

Berdasarkan fenomena yang terjadi maka perlu untuk dilakukan penelitian lebih lanjut
tentang Hubungan Dukungan Suami Terhadap Meningkatnya Kunjungan ANC pada Ibu
Hamil di Wilayah Kerja Puskesmas Lingkar Timur Tahun 2011.

METODE PENELITIAN

Populasi adalah keseluruhan dari suatu variabel penelitian yang menyangkut masalah yang
diteliti (Nursalam, 2008). Populasi dalam penelitian ini adalah seluruh suami yang
mempunyai ibu hamil dan masih terdaftar di Puskesmas Lingkar Timur Kota Bengkulu

Sampel adalah sebagian yang diambil dari keseluruhan objek yang diteliti dan dianggap
mewakili keseluruhan populasi (Nursalam, 2008).

Analisis univariat digunakan untuk memperoleh gambaran distribusi frekuensi dan proporsi
dari variabel yang diteliti.

Analisis ini untuk menguji hipotesis hubungan antara dukungan suami dengan meningkatnya
kunjungan ANC pada ibu hamil dengan uji Chi-Square.
HASIL PENELITIAN

Penelitian ini dilakukan untuk mengetahui hubungan dukungan suami terhadap meningkatnya
kunjungan ANC pada ibu hamil di Wilayah Kerja Puskesmas Lingkar Timur tahun 2011.

Tabel 4.1 Distribusi frekuensi dukungan suami di Wilayah Kerja

Puskesmas Lingkar Timur dari bulan April-Mei tahun 2011.

No Dukungan suami (F) (%)

1. Baik 58 70,7

2. Cukup 18 22,0
Dari
3. Kurang 6 7,3 tabel
Jumlah 82 100,0 4.1
di
atas dapat disimpulkan bahwa sebagian besar (70,7%)

dukungan suami baik.

Tabel 4.2 Distribusi frekuensi kunjungan ANC pada ibu hamil di Wilayah Kerja

Puskesmas Lingkar Timur dari bulan April-Mei tahun 2011.

No Kunjungan ANC (F) (%)

Lengkap 52 63,4
Dari
1. tabe
l 4.2
Tidak Lengkap 30 36,6
di
atas
2. dida
Jumlah 82 100,0 patk
an
bahwa sebagian besar (63,4%) kunjungan ANC oleh ibu hamil yang dilakukan secara
lengkap.
Tabel 4.3 Hasil analisis hubungan dukungan suami terhadap meningkatnya kunjungan
ANC di Wilayah Kerja Puskesmas Lingkar Timur dari bulan April-Mei tahun 2011.

Kunjungan ANC
Dukungan Total
Lengkap Tidak Lengkap X2 P Value
suami
(F) (%) (F) (%) (F) (%)
Baik 45 54,9 13 15,9 58 70,7
Cukup 3 3,7 15 18,3 18 22,0 Dari
22,003 0,000
Kurang 4 4,9 2 2,4 6 7,3 tabel
Jumlah 52 63,4 30 36,6 82 100 di
atas didapatkan bahwadari 82 responden, sebagian besar (70,7%) dukungan suami kategori
baik dengan kunjungan ANC mencapai (54,9%) sudah dilakukan dengan lengap. Serta
sebagian kecil (7,3%) dukungan suami katagori kurang dengan kunjungan ANC mencapai
(4,9%) sudah dilakukan dengan lengkap.

PEMBAHASAN

Dari tabel 4.1 dan 4.2 di atas didapat hasil sebanyak 70,7 % dukungan suami kategori baik
dan sebanyak 7,3% dukungan suami kategori kurang, pada umumnya dukungan suami
terhadap kunjungan ANC pada ibu hamil di wilayah kerja Puskesmas Lingkar Timur tahun
2011 sebagian besar (70,7%) tergolong baik. Dukungan suami yang baik akan
menyebabkan kunjungan ANC pada ibu hamil semakin lengkap dengan demikian ibu akan
merasa tenang, nyaman, aman dan kehamilan pun akan sehat, sehingga harapan bahwa ibu
dan bayi lahir sehat akan tercapai.

Hal ini sejalan pendapat Suryaningsih (2007) yang mengatakan bahwa dengan peran keluarga
khususnya suami, sangat diperlukan bagi seorang wanita hamil. Keterlibatan dan dukungan
yang diberikan suami kepada kehamilan akan mempererat hubungan antara ayah anak dan
suami istri. Dukungan yang diperoleh oleh ibu hamil akan membuatnya lebih tenang dan
nyaman dalam kehamilannya. Hal ini akan memberikan kehamilan yang sehat. Dukungan
yang dapat diberikan oleh suami misalnya dengan mengantar ibu memeriksakan kehamilan,
memenuhi keinginan ibu hamil yang mengidam, mengingatkan minum tablet besi, maupun
membantu ibu malakukan kegiatan rumah tangga selama ibu hamil. Walaupun suami
melakukan hal kecil namun mempunyai makna yang tinggi dalam meningkatkan keadaan
psikologis ibu hamil ke arah yang lebih baik.

Hasil penelitian ini didukung juga oleh Sakinah (2005) yang menyatakan bahwa tinggi
rendahnya cakupan kunjungan ibu hamil ke fasilitas kesehatan terlihat dengan kepatuhan ibu
dalam melakukan antenatal care. Dukungan sosial memberikan peranan penting dalam setiap
perkembangan

kehidupan manusia. Dukungan suami yang tinggi disebabkan adanya dukungan emosional,
dukungan insrumental, dukungan informasional dan penilaian yang baik yang diberikan dari
keluarga kepada ibu hamil, yang mampu menumbuhkan terjalinnya hubungan yang baik
antara keluarga dan ibu hamil dan mencegah kecemasan yang timbul akibat perubahan fisik
yang mempengaruhi kondisi psikologisnya. Dalam penelitian ini juga terdapat dukungan
suami yang kurang dan ini berarti bahwa terdapat faktor-faktor yang mempengaruhi baik atau
tidaknya dukungan suami terhadap kunjungan ANC bagi ibu hamil.

Sesuai dengan pendapat Harymawan (2007) yang mengatakan bahwa terdapat beberapa
faktor yang mempengaruhi dukungan suami dalam perlindungan kesehatan reproduksi istri
(ibu), seperti faktor budaya, dimana diberbagai wilayah di Indonesia terutama di dalam
masyarakat yang masih tradisional (patrilineal) menganggap istri adalah konco wingking,
yang artinya bahwa kaum wanita tidak sederajat dengan kaum pria, dan wanita hanyalah
bertugas untuk melayani kebutuhan dan keinginan suami saja. Anggapan seperti ini
mempengaruhi perlakuan suami terhadap kesehatan reproduksi istri, misal : kualitas dan
kuantitas makanan yang lebih baik dibanding istri maupun anak karena menganggap
suamilah yang mencari nafkah dan sebagai kepala rumah tangga sehingga asupan makanan
untuk istri kurang, suami tidak empati dan peduli dengan keadaan ibu yang sedang hamil
maupun menyusui anak, dan lain-lain.

Faktor pendapatan yang rata-rata 75%-100% penghasilannya dipergunakan untuk membiayai

keperluan hidupnya bahkan banyak keluarga prasejahtera yang setiap bulan bersaldo rendah.
Sehingga pada akhirnya ibu hamil tidak diperiksakan ke pelayanan kesehatan karena tidak
mempunyai kemampuan untuk membayar. Atas dasar faktor tersebut di atas maka prioritas
kegiatan GSI (Gerakan Sayang Ibu) ditingkat keluarga dalam pemberdayaan suami tidak
hanya terbatas pada kegiatan yang bersifat anjuran (advocacy) saja seperti yang selama ini.
Akan tetapi lebih bersifat holistic. Secara konkrit dapat dikemukakan bahwa pemberdayaan
suami perlu dikaitkan dengan pemberdayaan ekonomi keluarga sehingga kepala keluarga
tidak mempunyai alasan untuk tidak memperhatikan kesehatan istrinya karena permasalahan
keuangan.

Hasil analisis bivariat didapat hasil penelitian bahwa dukungan suami yang baik
menyebabkan kunjungan ANC pada ibu hamil dilakukan secara lengkap, namun dukungan
suami yang kurang juga bisa menyebabkan kunjungan ANC pada ibu hamil dilakukan secara
lengkap, dari hasil observasi peneliti ini terjadi karena kunjungan ANC pada ibu hamil
dipengaruhi oleh beberapa faktor diantaranya yaitu pengetahuan ibu hamil tentang
pentingnya pemeriksaan kehamilan yang lengkap, ekonomi yang memadai dan juga
keterbukaan dan kemudahan informasi yang didapat, sehingga tidak membatasi seorang ibu
hamil untuk mengetahui pentingnya akan pemeriksaan kehamilan yang lengkap.

Faktor yang mempengaruhi pencapaian kunjungan KI dan K4 ibu hamil diantaranya adalah
faktor internal (paritas dan usia) dan eksternal (pengetahuan, sikap, ekonomi, sosial budaya,
geografis, informasi dan dukungan). Dampak dari ibu hamil yang tidak mengikuti ANC
adalah meningkatnya angka mortalitas dan morbilitas ibu, tidak terdeteksinya kelainan-
kelainan kehamilan dan kelainan fisik yang terjadi pada saat persalinan tidak dapat dideteksi
secara dini (Depkes RI, 2008).

Hasil penelitian ini diperkuat oleh Saifudin (2002) bahwa Informasi adalah keseluruhan
makna, dapat diartikan sebagai pemberitahuan seseorang, biasanya dilakukan oleh tenaga
kesehatan. Pendekatan ini biasanya digunakan untuk menggugah kesadaran masyarakat
terhadap suatu inovasi yang berpengaruh terhadap perilaku, biasanya melalui media massa.
Ibu yang pernah mendapatkan informasi tentang antenatal care dari tenaga kesehatan, media
massa, maupun media elektronik akan meningkatkan pengetahuan ibu hamil tentang
pentingnya melakukan antenatal care, sehingga ibu dapat teratur dalam melakukan kunjungan
antenatal care.
Hal senada juga diutarakan oleh Harymawan (2007) bahwa dukungan sosial suami yang
sangat diharapkan oleh sang istri antara lain suami mendambakan bayi dalam kandungan
istri, suami menunjukkan kebahagiaan pada kelahiran bayi, memperhatikan kesehatan istri,
mengantar dan memahami istrinya, tidak menyakiti istri, berdoa untuk keselamatan istri dan
suami menunggu ketika istri dalam proses persalinan.

Pengalaman melahirkan atau paritas serta usia ibu hamil yang matang akan menjadikan pola
pikir yang rasional dan matang tentang pentingnya melakukan pemeriksaan kehamilan,
begitupun juga dengan pengetahuan, sikap, ekonomi dan informasi serta dukungan yang
didapat pada ibu hamil. Dengan pengetahuan yang memadai, adanya sikap lebih baik tentang
ANC, ekonomi yang mendukung, informasi yang didapatkan akurat serta dukungan yang
baik dari keluarga, dengan kesemuanya itu berarti mencerminkan kepedulian ibu hamil
terhadap kesehatan dirinya dan janin (Depkes RI,2008).

KESIMPULAN

1. Sebagian besar (70,7%) dukungan suami terhadap meningkatnya kunjungan ANC

pada ibu hamil di Wilayah Kerja Puskesmas Lingkar Timur tahun 2011 tergolong
baik.
2. Sebagian besar (63,4%) Kunjungan ANC pada ibu hamil di Wilayah Kerja Puskesmas
Lingkar Timur tahun 2011 sudah dilakukan secara lengkap.
3. Ada hubungan bermakna antara dukungan suami terhadap meningkatnya kunjungan
ANC pada ibu hamil di Wilayah Kerja Puskesmas Lingkar Timur tahun 2011.

Diharapkan dapat dijadikan sebagai informasi khususnya para suami yang mempunyai istri
hamil agar dapat lebih memahami tentang pentingnya partisipasi atau dukungan dalam
pemeriksaan kehamilan, seperti dengan saling berbagi pengalaman dan pengetahuan antara
masyarakat dengan ibu hamil maupun bagi sesama ibu hamil, sehingga terjadi perubahan
perilaku seorang suami dan masyarakat untuk terus mendukung istrinya selama masa
kehamilan terutama dalam pemeriksaan kehamilan yang lengkap.

Diharapkan petugas kesehatan dapat selalu menginformasikan dan memberikan pengetahuan

yang baik melalui konsling atau penyuluhan kesehatan terutama dalam hal kunjungan ANC
oleh ibu hamil yang didukung oleh suaminya, dengan begitu pemeriksaan ANC pada ibu
hamil dapat dilakukan secara lengkap sehingga angka kematian ibu maupun bayi dapat
ditekan.
DAFTAR PUSTAKA

Arikunto, S. (2006). Metodologi Penelitian Kesehatan. Jakarta : Rineka Cipta

BKKBN. (2001). Panduan Antenatal Care. Jakarta : BKKBN (diakses pada tanggal 8 Maret
2011), diunduh dari http://.depkes.go.id

Depkes RI. (2008). Panduan Pelayanan Antenatalcare. Jakarta : Depkes RI

(diakses pada tanggal 8 Maret 2011), diunduh dari http://www.depkes.go.id

Dinkes Proponsi Bengkulu. (2010). Profil Kesehatan Kota Bengkulu 2010. Bengkulu: Dinkes
Kota Bengkulu

Harymawan. (2007). Dukungan Suami Dan Keluarga. (diakses pada tanggal 5 Maret 2011),
diunduh dari http://www.infowikipedia.com.

Manuaba. (2008). Ilmu Kebidanan, Kandungan dan KB. Jakarta : EGC

Notoatmodjo, S. (2005). Metodologi Penelitian Kesehatan, Jakarta : Rineka Cipta

Nursalam. (2008). Metodologi penelitian. Jakarta : Salemba Medika

Nurul. H. (2008). Hubungan Tingkat Pengetahuan Suami dengan Partisipasi Suami dalam
Asuhan kehamilan di Puskesmas 1 Toroh Kabupaten Grobogan Surakarta.(diakses pada
tanggal 6 Maret 2011), diunduh dari http://www.skripsi-KTI.com

Retnowati. (2007). Hubungan Antara Dukungan Suami Terhadap Motivasi ibu dalam
Memeriksakan Kehamilan di Puskesmas Bathi Dolopo Madiun Jawa Timur. (diakses pada
tanggal 6 Maret 2011), diunduh dari http://www.skripsi-KTI.com

Safarino. (2003). Dukungan suami. Jakarta : Salemba Medika. (diakses pada tanggal 5 Maret
2011), diunduh dari http://www.worpress.com.

Saifudin. (2002). Buku Acuan Pelayanan Kesehatan Maternal dan Neonatal. Yogyakarta :
Yayasan Bina Pustaka Pustaka Sarwono Prawirohardjo. (diakses pada tanggal 6 Maret 2011),
diunduh dari http ://www.Kesmas- unsoed.blogspot.com.

Sakinah. (2005). Antenatal Care. (diakses tanggal 5 Maret 2011), diunduh dari
http://www.info-wikipedia.com.

Slamet B. (2007). Psikologi Umum. Bandung : PT Remaja Rosdakarya

Suryaningsih. (2007). Antenatal Care. (diakses pada tanggal 6 Maret 2011), diunduh dari
http://www .lenterabiru.com.
Portal Journal Universitas Muhammadiyah Semarang (UNIMUS)
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Title Statement ANTE NATAL CARE (ANC) DALAM RESPREKTIF IBU HAMIL : GAMBARAN
KERENTANAN KESEHATAN REPRODUKSI PADA MASYARAKAT NELAYAN DI
KABUPATEN REMBANG

Added Entry - Soesanto, Edy

Uncontrolled Name Anggraini, Eny

Summary, etc. Latar belakang : Angka Kematian lbu (AKI) di idonesia menempati urutan
tertinggi di Asia Tenggara. Angka Kematian Bayi (AKB) Propinsi Jawa
Tengah tahun 2003 sebesar 8,29 per 1000 kelahiran hidup. AKB tertinggi
dialami oleh Kabupaten Rembang. Menurunnya setatus gizi dan<br
/>kesehatan ibu hamil menyebabkan resiko tinggi kehamilan mengalami
peningkatan. Resiko tinggi kehamilan ini sebenarnya dapat diantisipasi
pada saat ante natal care (ANC), Sehingga kondisi kesehatan ibu hamil
dapat dl pantau dan bila terjadi kegawat daruratan akan memudahkan<br
/>pengambilan tindakan. Amun kenyataannya ibu hamil yang melakukan
ANC masih sangat rendah. Berdasarkan data dari Profil Kesehatan
JawaTengah tahun 2003, cakupan K4 Kabupaten Rembang adalah 67,65%
(peringkat ke 33).<br />Tujuan dari penelitian ini adalah untuk melihat
sejauh mana pengetahuan, perilaku ibu hamil tentang Ante Natal Care,
riwayat kehamilan dan status gizi ibu hamil serta peranlpendukung suami
dalam pelaksanaan Ante Natal Care di Kabupaten Rmbang.<br
/>Metodologi : menggunakan metode Diskriptif dengan pendekatan
crosectional. Subyek peelitan ini ibu hamil trimester ke tiga di daerah
pantai di Kabupaten Rembang, sebanyak 88 orang, dengan metode
pengambilan sample Multitage Random Sampling. Penelitian ini
 dilakukan<br />pada bulan April 2007.<br />Hasil Penilitian menunjukka
bahwa: pengetahuan ibu hamil tentang Ante Natal Care (ANC) rerata
sebesar 77,27 + 8,435 serta denga tingkat pengetahuan yang baik tentang
ANC sebanyak 35 orang (39,5'A. Berata perilaku ibu hamil tentang Ante
Natal Care (ANC) sebanyak 77,a7<br />x. 7,99 dengan tingkat perilaku
tentang Ante Natal Care (ANC) yang tinggi sebanyak 30 orang (34,1W.
Gambaran status gizi ibu hamilterdapat I0rang (9,1%) mempunyai resiko
Kekurangan Energi Kronis (KEK), Dukungan positif suami terhadap istri
untuk proses lnle Natal Care (ANC)<br />seeDesar 49 orang (55,7Y")
dengan rerata sebesar 7,77 t 1,436.<br />Kesimpulan dan Rekonendasi
:Rekomendasi dari penelitian ini adalah perlunya pemberi dukungan,
informasi melalui penyuluhan, konseling tentang Ante Natal Care (ANC),
pemeriksaan kehamilan kehamilan yang paripurna kepada ibu hamil aat
ibu hamil melakukan pemeriksaanl<br />kunjungan ke pelayanan
kesehatan dalam upaya peningkata dan perubahan: (a) pengetahuan ibu
hamiltentang Ante Natal Care (ANC). (b) perilaku ibu hamil dalam
melakukan AC. (c) Gizi pada ibu hamil (d) Peranlpendukung suami
terhadap istri dalam melakukan ANC. Serta untuk<br />itu juga diperlukan
peningkatan keterampilan komunikasi interpersonal, teknik bimbingan
dan penguasaan tentang ANC oleh petugas kesehatan.<br />Kata Kunci;
status gizi, dukungan suami, Ante Natal Care.

Publication, FIKkeS
Distribution, Etc. 2012-03-09 10:10:16

Electronic Location and http://jurnal.unimus.ac.id/index.php/FIKkeS/article/view/240

Access

Data Source Entry FIKkeS; ##issue.vol## 2, ##issue.no## 2 (2009): Keperawatan, Kesehatan,

dan Kebidanan

Language Note en