Mother and Child Health Services in North Central Timor District Through the Mother and Child Love Movement Program (Border Area Studies Republik Indonesia-Republica Democratica De Timor Leste)

The maternal, infant and toddler mortality rates in North Central Timor Regency as the Indonesia-Timor Leste border area have fluctuated in the last 5 years (2013-2017). The Mother and Child Love Movement program has not been able to reduce the maternal, infant and toddler mortality rates so that the level of health mothers and children at TTU do not yet comply with national health standards. The elements analyzed include elements of structure/input, environment, process and output. specialists, general practitioners, nurse midwives and other health workers, the quality and quantity of health facilities and equipment, limited health budgets and the culture of the TTU community which is contrary to medical regulations. So that maternal and child health services in TTU Regency through the Mother and Child Love Movement program can be To reduce the mortality rate of mothers, babies and toddlers, the efforts that must be made by the government are the addition of specialist doctors at the Kefamenanu Regional Hospital, there must be a permanent doctor at every community health center in TTU, the addition of permanent midwives at the Regional Hospital and Community Health Centers, increasing the number and quality of health facilities and equipment such as community health centers, pustu, polindes, laboratories and pharmacies, health budget allocation according to community needs, improving the quality of antenatal, delivery and neonatal/postpartum care, slowly eliminating the culture/tradition of se'i, tattoos and slow decision making in referring patients to community health centers and hospital. The recommended model for maternal and child health services at TTU is the model of empowering women through safe motherhood (family planning, antenatal care, clean delivery and obstetrical services) and empowering posyandu, poskesdes, posbindu and standby villages as community-based health efforts by community health centers


INTRODUCTION
The Sayang Ibu Movement/GSI or Safe Motherhood Program is a program carried out in Indonesia since 1996.The scope of GSI includes advocacy and social mobilization.In its implementation, GSI promotes activities related to the Sayang Ibu District and the Sayang Ibu Hospital, to prevent three types of delays, namely: 1) delays at the family level in recognizing danger signs and making decisions to immediately seek help; 2) delays in reaching health facilities; 3) delays at health service facilities to get the help needed.Activities related to Sayang Ibu District are trying preventing first and second delays, while activities related to the Sayang Ibu Hospital are preventing third delays (National Reference Book: Maternal and Neonatal Health Services: 2009;8) In its activities, GSI synergizes with multi-stakeholders between government, community organizations, women's organizations, professional organizations and society in general, in order to increase collective knowledge, awareness and concern.GSI has performance measures, namely: (1) Collecting data on pregnant and giving birth women, (2) Gender Education, (3) Maternal and Child Health Services, (3) Self Governing Community (SGC), (4) Blood Donation Services, and ( 5) Intensity of health workshops in a region.
In the last three years, cases of exogenous infant deaths in TTU Regency have decreased significantly, where in 2013 there were 101 cases of death from 5,124 live births to 61 cases from 5,101 live births.The infant mortality rate in 2016 was 18 per 1,000 live births or 98 deaths.So in total, the number of infant deaths in 2017 was 29 cases or 5.73 deaths/1,000 live births.The under-five mortality rate in TTU Regency has decreased over the last three years, where in 2013 there were 23 cases (4.5 per 1,000 live births), in 2014 there were 17 cases (3.32 per 1,000 live births) and in 2015 it increased again to 54 cases (10.59 per 1,000 live births), in 2016 it fell again to 28 cases (5 per 1,000 live births).Under-5 mortality cases and Under-five Mortality Rate (AKABA) per 1,000 live births.
The fluctuating maternal, infant and toddler mortality rates in TTU Regency require the government to continue making efforts to reduce the maternal, infant and toddler mortality rates.The efforts made by the TTU Regency government are to improve the quality of health services for mothers and infants which is emphasized in Regional Regulation Number 4 of 2012 concerning the Health of Mothers, Newborns, Infants and Toddlers (KIBBLA).Even though these efforts have been made, to date the mortality rate for mothers, infants and toddlers is still fluctuating.Therefore, other efforts are needed so that this problem can be resolved .
Limited infrastructure facilities such as public transportation, highways connecting villages, sub-districts and districts, communication and information facilities, health personnel resources, budget, health facilities and equipment, geographical and topographical conditions and the quality of human resources are inhibiting factors for the government.North Central Timor Regency in providing maternal and child health services in the Indonesia-Timor Leste border area.Therefore, the problem of maternal and child health services in North Central Timor is a very complex problem so that cross-program and cross-sector cooperation is needed because health services Mothers and children are not only the responsibility of the North Central Timor Health Service but are the responsibility of all elements in the area, namely the government, private and community sectors.

LITERATURE REVIEW
In general, the Mother and Child Love Movement program in North Central Timor Regency (TTU) as the Indonesia-Timor Leste border area has been implemented by the TTU District Health Service since it was launched by the government but until 2018 it had not achieved the target of improving the health status of mothers and children in the area.This can be seen from the fluctuating maternal, infant and toddler mortality rates in the last five years (2013)(2014)(2015)(2016)(2017), where in 2017 in TTU Regency there were 2 cases of maternal death or the equivalent of 39.50/100,000 live births.The maternal mortality rate tends to fluctuate, indicating that the maternal mortality rate cannot be controlled properly.After soaring high in 2012, the maternal mortality rate slowly decreased until 2014, but increased again in 2015 and decreased again in 2016.The maternal mortality rate in TTU Regency of 39.50/100,000 live births has reached the Term Development Plan target.Middle Regional, namely 192.95 deaths per 100,000 live births.

METHODOLOGY
The method used in the research is a qualitative approach, namely research that uses techniques to obtain in-depth information about the opinions, perceptions and feelings of informants about maternal and child health services in TTU Regency (Lapau Buchari;2012;45).Data collection in this research is observation, in-depth interviews and document study.
The key informants were the head of the Napan Community Health Center and the Wini Community Health Center which are located right in the Indonesia-Timor Leste border area, the Head of the TTU District Health Service and the Director of the Kefamenanu Regional General Hospital.Supporting informants consist of people in charge of maternal and child health at the Wini Health Center, Napan Health Center, Kefamenanu Regional General Hospital and the perinatology room.There are also patients from pregnant women, childbirth and postpartum, general practitioners, pediatricians, obstetricians and gynecologists, midwives and nurses, laboratory assistants, physiotherapists at the Napan, Wini health centers and the Kefamenanu Regional General Hospital, village midwives, posyandu cadres, active family planning acceptors and several general patients.To find out about cross-program and cross-sector collaboration, the heads of North Insana and Bikomi sub-districts were also interviewed.Utara as regional head of the Napan and Wini Health Centers.

RESULTS AND DISCUSSION
Maternal death is the death of a woman caused directly by the process of pregnancy, childbirth up to 42 days after giving birth which is not caused by an accident or incident (Retnaningsih;2013;37).Infant death is a death that occurs between the time after the baby is born until the baby is not yet old.exactly 1 month (28 days).
The causes of the high maternal mortality rate in Indonesia are three late, namely: 1) late recognizing danger signs and making the decision to refer to health facilities (puskesmas and hospitals); 2) delay in reaching health facilities due to transportation problems from the patient's home to the health center or hospital which is influenced by geographical conditions and road facilities; 3) delay in obtaining adequate help at the health center or hospital due to inadequate health facilities (Sulaeman E. Sutisna;2011;278).Apart from that, the indirect causes of maternal death are influenced by the Four Too (too young, too old, too often and too many) during pregnancy and childbirth (Syaifudin, 2009;6).
In North Central Timor Regency, maternal and child health services through the Mother and Child Love Movement program have been implemented with follow-up from the Regency Government through Regional Regulation Number 4 of 2012 concerning the Health of Mothers, Newborns, Infants and Toddlers (KIBBLA).However, the figures Maternal, infant and under-five mortality continues to fluctuate as shown in the following table : Table 1.Maternal, Infant and Toddler Mortality Rates in TTU Regency 2013-2017 Source: TTU Health Profile, 2017 Table 1 explains that the maternal, infant and under-five mortality rates were still fluctuating in 2013-2017.This shows that the level of maternal and child health in TTU Regency as a border area has not yet met national standards, therefore cross-program and cross-sector cooperation is needed.to resolve the issue.
The cause of the fluctuating maternal, infant and under-five mortality rates in TTU is that all pregnant women have not had their pregnancies checked by a midwife at the village clinic, health center or hospital.This can be seen in the coverage of K1 and K4 pregnancy visits for every pregnant mother.In 2017, K1 coverage was 85% and K4 as much as 67% where the coverage of pregnant women's visits has not reached the national target because there are still pregnant women who trust traditional birth attendants or families more than checking their pregnancies with midwives.Apart from that, all births have not been assisted by midwives, where in 2017 births were assisted.75% were assisted by midwives, the remaining 25% were still helped by birth attendants and families.Meanwhile, postpartum services in 2017 reached 74.8%, the remainder did not have the awareness to access services at health facilities.
Maternal and child health services at TTU through the Gearakan Sayang Mother and Child program in reducing maternal and child mortality are analyzed from structural/input, environmental, process and output/output elements.
Structural/input elements are all things needed in the implementation of health services which include personnel, funds and facilities (Azrul Azwar;2010;53).Doctors, midwives, nurses and other health workers have provided services for maternal and child health based on minimum service standards However, the provision of services is not yet optimal because the number of medical personnel is not yet proportional to the population.Not all community health centers have doctors, of which 18 community health centers have doctors and 8 other community health centers do not have doctors and all community health centers do not have specialist doctors.In general hospitals The Kefamenanu area has 8 specialist doctors (2 pediatricians, 2 obstetricians and obstetricians, 2 surgeons and 1 internal medicine doctor) so that patients who need the services of a specialist doctor must bring a referral letter from the community health center.On average, doctors at TTU are non-permanent doctors (contract) assignment from the central government with a work period of 1 year which can be extended as needed.Meanwhile midwives and nurses are proportional to the population but there is not yet equal distribution in all health centers, there is a buildup in certain health centers, especially in the health centers which are closer to the Kefamenanu city.The average level of education for nurses is at bachelor's level, while midwives are still at diploma three (D3) and some even have diploma one (D1).The health budget allocation from the 2017 Regional Revenue and Expenditure Budget (APBD) is 12, 85%, there is also a central government budget from the State Expenditure and Revenue Budget (APBN) in the form of General Allocation Funds (DAU), Special Allocation Funds (DAK), maternity insurance, public health insurance and Health Operational Assistance (BOK).Health budget from APBN used for health services, while the budget from the APBD is used for the procurement of medicines and medical equipment.In relation to health facilities, health facilities and equipment in TTU are still limited because it has 1 regional general hospital which is assisted by 26 community health centers spread evenly in each sub-district which has a service area.exactly the same as the area of the sub-district, but on average the health centers at the border are non-PONED and PONED (Basic Emergency Neonatal Obstetric Services) which are capable of serving only normal deliveries so that patients with complications and high risks must be referred to a general hospital Areas that still have limited medical facilities and equipment certainly make it difficult for patients to get help.This is described in detail in table 2 and table 3 as follows:  2 explains that on average the health centers in TTU are non-PONED and PONED health centers which serve normal deliveries only, so that in the case of pregnant women and women giving birth in the category of complications and high risk, the patient must be referred to a regional hospital in the district capital which is quite far from residential areas.public.
Table 3. Number and Ratio of Health Workers in TTU Regency, 2017 Source: TTU Health Profile, 2017 Table 3 shows that the number of medical and non-medical personnel at TTU is still limited.Doctors and specialist doctors are still limited.There are still 18 community health centers doctors, while 7 specialist doctors only serve at Kefamenanu Regional Hospital, therefore patients need services from doctors.The specialist must bring a referral letter from the local health center.Environmental elements are surrounding conditions that influence health service policy, organization and management.The implementation of maternal and child health services also requires coordination between the TTU Health Service and the management organization sub-district and village level health because coordination saves costs, prevents waste, saves time, energy and materials (M.Fais Sastrianegara-Sitti Saleha; 2014; 50).There is good coordination between the TTU District Health Service and regional general hospitals, health centers , auxiliary health centers, village maternity polyclinics and integrated service posts in health services.Environmental influences that hinder maternal and child health services are local community culture such as the tatobi/compress, se'i/grill culture and the tradition of slow decision making in referring patients.Apart from The geographical conditions make it quite difficult for people to access health services because the settlements are far from the health center and road facilities are less supportive, especially during the rainy season, it is difficult to reach them by motorbike or car.For example, the Inbate Health Center which is directly adjacent to the Ambenu district of Timor Leste, during the rainy season, the health center staff and The community had to brave floods when referring patients to the regional general hospital in Kefamenanu because there was no bridge connecting the Inbate Community Health Center to the city of Kefamenanu as the district capital.
The process element is the organization of the program and implementation of health services which includes anamnesis, physical examination, medical support examination, drug prescribing, health education and referring patients (Donabedian in Imbalo S. Pohan; 2010; 251).The process of maternal and child health services has been implemented based on minimum service standards starting from antenatal services, delivery services and neonatal/postpartum services.All pregnant women who visit the village clinic, health center and hospital receive 6T (tension, fe tablets, TT immunization, body weighing and fundal height and interview) however There are still pregnant women who have not had a pregnancy check-up at a health facility because K1 coverage has only reached 85.87% and K4 is 67.59%.The main contributing factors are the low level of compliance of pregnant women in checking their pregnancies with midwives and low public awareness of accessing health services.during pregnancy.Apart from that, cultural factors still influence the perception of pregnant women who still trust traditional birth attendants rather than midwives.Childbirth care has also been carried out according to minimum service standards, but not all mothers giving birth are assisted by midwives because the coverage of births assisted by midwives has only reached 75.77The remaining 24.23% are still helped by traditional birth attendants and families.In the neonatal service midwives make home visits after postpartum twice which are intended to determine the health development of the mother and baby including preventive measures, detecting abnormal conditions and seeking medical assistance and taking emergency measures.emergency.Apart from that, in immunization services for babies, as many as 80% of babies in TTU have received complete immunization, the remaining 205 have not received complete immunization due to the negligence of parents who did not take their children to the integrated service post.
The output/input element is the appearance of medical and non-medical health services (Azrul Azwar; 2010; 54).In maternal and child health services through the Garakan Sayang Ibu dan Anak program, the output/output elements include: 1) collecting data on pregnant women and women giving birth ;2) gender education; 3) maternal and child health services; 4) self-governing community; 5) blood donation services; 6) intensity of health workshops.The aim of collecting data on pregnant and giving birth women is to find out the number in the health center area every month so as to early detect pregnant and giving birth women with high risk complications in Government Regulation no.7/2017 concerning Blood Services states that blood donation and blood processing are carried out by the Blood Donor Unit (UDD) organized by a social organization, namely the Indonesian Red Cross (PMI).That the government is responsible for implementing blood services that are safe, easily accessible and in accordance with community needs and guaranteeing government funding through subsidies to the UDD, APBN, APBD and other assistance.Organizing blood donations and processing blood donations at TTU is carried out by the Blood Transfusion Installation (ITD) at Kefamenanu Regional Hospital because there is no PMI organization, which hampers blood services at TTU.This can be seen from the situation in TTU where all health centers in TTU do not have blood banks.Likewise, in regional hospitals, blood supplies are limited, so when patients need blood donation services, officers usually ask for help from the family to find their own blood donors from the family or community.
The community health center mini workshop is an effort to mobilize and monitor various community health center activities through meetings where this mini workshop covers cross-programs and cross-sectors (Ministry of Health of the Republic of Indonesia, 2006).The puskesmas mini workshop is held at the end of every month to evaluate health services in the puskesmas service area.With cross-program community health centers, there can be cooperation between health workers internally at the community health center, including community health centers and village midwives, while with cross-sectors, it can increase community participation and support from the sector concerned in implementing health development because health development is not the responsibility of the community health center alone but involves many sectors.Others related to it are society, NGOs, the education sector, agriculture, religion, socio-culture and so on.Therefore, all sectors involved in health development must work together in maternal and child health services so that they can improve the level of maternal and child health in TTU.The inhibiting factor in health workshops at TTU is that in 2017 and 2018 the frequency of workshops on health in general and the health of mothers and children in particular is uncertain (2-3 months) because most of the budget is allocated to preparation for accreditation of regional hospitals and several community health centers.Apart from that, the mini health center workshop that was carried out was only crossprogram as an evaluation of the activities of the health center in 1 month without involving other related sectors such as elements of society, NGOs, the Department of Agriculture, BP2KB, the Department of Religion, the Department of Education and academics as well as other sectors that had direct contact.with KIA services.The mini puskesmas workshop was only attended by the TTU Health Service and the puskesmas concerned so there was a lack of feedback from the community as users of health services from the puskesmas.
Improving the quality of maternal and child health services in TTU Regency is not only the responsibility of the Health Service and its staff but requires cross-program and cross-sector collaboration involving government, the private sector and the community.Community empowerment in efforts to improve the level of maternal and child health is more focused on empowerment women through safe motherhood which includes family planning, antenatal care, safe delivery and essential obstetric care.Family planning ensures that every child of childbearing age has access to information on family planning services so that they can plan the right time for pregnancy, determine the spacing of pregnancies and the number of children so that there are no more unwanted pregnancies by married couples who fall into the 4 too pregnancy category (too young, too old, too often and too many).Antenatal care is intended to detect as early as possible the complications and high risks of obstetric pregnancy and childbirth so that they can prevent things that are undesirable for pregnant women, birth mothers and families such as maternal death, babies and cases of abortion.Safe delivery to ensure that births are assisted by midwives who have knowledge and skills in childbirth care and tools to provide birth assistance are sterile.(safe and clean) and have competence in providing postpartum care for mothers and babies.Essential obstetric services are intended to ensure that obstetric services for pregnant women and those giving birth at high risk and complications are available for mothers who need them.These four things need to be implemented through basic health services without there is discrimination because all mothers have the same rights to obtain health services.
Apart from empowering women through safe motherhood, improving the quality of maternal and child health services at TTU can be done through empowering integrated service posts (posyandu), village health posts (poskesdes), integrated coaching posts (posbindu) and alert villages as community-based health efforts by community health centers.There are many Community Resource Health Efforts (UKBM) in TTU.Up to 2017, there were 88 alert villages, 16 village health posts (poskesdes), 58 integrated development posts (posbindu) and 498 integrated service posts (posyandu).The UKBM was formed by the community health center together with the community but it was more of a mobilization nature so that the community was less proactive with the activities that had to be organized by the UKBM because this UKBM had to be from the community, by the community and for the community.Community empowerment is very important in UKBM so that the community takes ownership of the UKBM.The Community Health Center is limited to facilitating the formation of UKBM in the community, but the activities must come from community initiative because the community itself is aware of the importance of UKBM for itself and for the community in general.
Many UKBMs were formed by puskesmas together with the community, such as village alert, poskesdes, posbindu and posyandu but were not empowered for maternal and child health services.For example, there are 498 posyandu which are 92.97%active.The community only understands posyandu as a place to weigh children and get additional food for pregnant women and malnourished babies and toddlers.In fact, posyandu not only carries out activities like that, but also carries out a lot related to maternal and child health services, namely family planning, maternal and child welfare, improving family nutrition, immunization and preventing diarrhea.Apart from that, people are less aware of the importance of posyandu for mothers and children, mothers who come to posyandu are dominated, more people attend when their children are about to receive immunizations and usually if their child has received complete immunization, the mother does not want to take her child to posyandu again.According to the rules, children and toddlers should not go to posyandu again after the age of 5 years.

CONCLUSIONS
Maternal and child health services have not been able to accelerate the reduction in maternal and child mortality rates in TTU Regency due to several reasons, namely: 1.There are limited specialist doctors and not all health centers have doctors.On average, the doctors at TTU are non-permanent doctors or contract doctors on special assignments from the Ministry of Health with a contract period of 1 year which can be extended further as needed.2. On average, midwives have a three-diploma degree and there are still some who have a first-diploma degree.3. Limited number and quality of health facilities and equipment at the village police, health center and Kefamenanu regional general hospital.4. On average, the health centers in TTU are non-PONED and PONED health centers which can only provide normal delivery services.5. Limited health budget allocation from the Regional Revenue and Expenditure Budget.6.Not all pregnant women have their pregnancies checked and not all births are attended by midwives, either midwives at village clinics, community health centers or general hospitals.7.There are still pregnant women and women giving birth who have not reported to village midwives and posyandu cadres, especially those who are pregnant out of wedlock, making it difficult for health officers to collect data every month.8. Community culture and behavior are still influenced by the Three Late Factors (late in recognizing danger signs and making decisions to refer to health centers and hospitals; late in reaching health facilities due to transportation problems from the patient's home to the health center or hospital which are influenced by geographical conditions and road facilities; delay in getting adequate help at the health center or hospital due to inadequate health facilities Four Too (too young, too old, too often and too much.9. Lack of public awareness in empowering posyandu, alert villages, village health posts and posyandu as community-based health efforts in accessing maternal and child health services.

RECOMMENDATIONS
1.There is a need for additional specialist doctors and general practitioners at TTU.Every community health center must have a general practitioner and the doctors on duty at TTU must be permanent doctors so that these doctors are more effective in providing maternal and child health services.2. It is necessary to increase the formal education of midwives from diploma to bachelor's level so that midwives who work in village clinics, community health centers and hospitals are more professional in antenatal care, delivery care and the care of postpartum mothers, babies and toddlers.3. Increasing the quality and quantity of health facilities and equipment at the village police, community health center and Kefamenanu regional general hospital.4. Increasing the status of health centers from non-PONED health centers to PONED health centers and PONED health centers to PONEK health centers so that not all high-risk deliveries and complications have to be referred to Kefemenanu or Atambua public hospitals.5. Increase the health budget allocation from the Regional Revenue and Expenditure Budget to 20% in 2019.6. Increasing gender education and health workshops so that all pregnant women and women giving birth have the awareness to have their pregnancies checked and give birth at the village police, health centers and hospitals with professional midwives and doctors.7. Increase health education and promotion so that it can reduce maternal and child mortality rates due to culture and community behavior which are influenced by factors three too late and four too.8. Empowerment of posyandu, poskesdes, posbindu and alert villages as community-based health efforts in accessing maternal and child health services.

FURTHER STUDY
This research still has limitations, so it is necessary to carry out further research related to the topic of Mother and Child Health Services in North Central Timor District Through the Mother and Child Love Movement Program in order to improve this research and add insight to readers.
Policies that support maternal and child health services are Law Number 36 of 2009 concerning Health, the Mother Love Movement program, the public health insurance program, East Nusa Tenggara Governor Regulation Number 42 of 2009 concerning the Maternal and Child Health Revolution, North Central Timor Regency Regional Government Regulation Number 4 of 2012 concerning the Health of Mothers, Newborns, Infants and Toddlers, vision and mission of the North Central Timor Regency Health Service for 2017-2021.Policies This helps the TTU Regency government in providing health services to mothers and children based on minimum service standards in order to accelerate the reduction of maternal and infant mortality through the Mother and Child Compassionate Movement program.

Table 2 .
Health Facilities and Ratio of 100,000 to Population in 2017 Source: TTU Health Profile, 2017