Integrated Antenatal Care at Public Health Care

Integrated antenatal services are comprehensive and quality antenatal services provided to all pregnant women; in which they are integrated with other programs that require intervention during pregnancy. This study aimed to analyze the integrated antenatal care team of Public Health Care (Puskesmas) in the Sidoarjo Regency using the Input-Process-Output approach. This study was observational and descriptive with a cross-sectional research design. Data collection was done using a questionnaire and checklist. This study used a total population of 26 Public Health Care Integrated Antenatal Care Teams. The data collected were analyzed using descriptive analysis. The results show that there is a tendency in the team input that does not affect the process, and there are tendencies in the process that affect the output. Suggestions that can be done to improve cohesion are by placing the service rooms closely, conducting training on leadership/interprofessional practice/conflict management, giving rewards to team members who perform well

Integrated antenatal services are comprehensive and quality antenatal services provided to all pregnant women; in which they are integrated with other programs that require intervention during pregnancy. This study aimed to analyze the integrated antenatal care team of Public Health Care (Puskesmas) in the Sidoarjo Regency using the Input-Process-Output approach. This study was observational and descriptive with a crosssectional research design. Data collection was done using a questionnaire and checklist. This study used a total population of 26 Public Health Care Integrated Antenatal Care Teams. The data collected were analyzed using descriptive analysis. The results show that there is a tendency in the team input that does not affect the process, and there are tendencies in the process that affect the output. Suggestions that can be done to improve cohesion are by placing the service rooms closely, conducting training on leadership/interprofessional practice/conflict management, giving rewards to team members who perform well, and reviewing the existing policies.

INTRODUCTION
Factors contributing to maternal death can be broadly grouped into direct causes and indirect causes. The direct causes of maternal death are factors related to pregnancy complications, childbirth and the puerperium such as bleeding, preeclampsia/eclampsia, infection, obstructed labor and abortion. Indirect causes of maternal death are factors that aggravate the condition of pregnant women, such as four "too" (too young, too old, too frequent births and too close birth spacing) and three "too late" (to recognize danger signs and make decisions, late to reach health facilities and late in emergency treatment) (Ayu & Rizqi, 2019;Wolde et al., 2018). By giving a proper antenatal care at the onset of pregnancy may be beneficial in terms of providing various IEC (Information, Education, and Communication), training and support, as well as lowering childbirth fear (Miller et al., 2021;Swift et al., 2021;Tadesse, 2020;Warri & George, 2020) The high maternal mortality rate can indicate the low quality of health services. The reduction in the maternal mortality rate is also an indicator of the success of a nation's health status. The government is trying to make various strategies to reduce the Maternal Mortality Rate (Dinas Kesehatan Kabupaten Sidoarjo, 2018). The results of the performance evaluation of the Puskesmas at the Sidoarjo District Health Office fluctuated, the highest being 82.62/100,000 Live Births in 2017 and not reaching the target of 70/100,000 Live Births and the lowest being 62.63/100,000 KH in 2018. Efforts to improve the health mothers, newborns and children have become the government's main priority. One form of program policy to reduce MMR is the policy for antenatal care at Visit 1 (K1) and Visit 4 (K4). Antenatal care (antenatal care/ANC) is important to ensure the mother's health during pregnancy and to guarantee the mother to give birth in a health facility. Antenatal care is provided by health workers who work in government or private institutions. Antenatal services are also provided in health centers spread across Indonesia (Elvira et al., 2019).
Receivig quality antenatal care from skilled health workers and acccessible can detect risks in pregnancy, namely getting access to quality pregnancy care, getting opportunities for early detection of complications that may arise so that maternal deaths can be avoided (Ahrne et al., 2019;Woldeamanuel & Belachew, 2021). The program that is promoted in efforts to detect complications and risks during pregnancy is the implementation of integrated ANC as stated in the Regulation of the Minister of Health Number 97 of 2014 concerning Health Services before pregnancy, pregnancy, childbirth and the postpartum period, providing contraceptive services, as well as sexual health services (Bundarini & Fitriahadi, 2019). In integrated antenatal services, health workers should be able to ensure that the pregnancy proceeds normally, detect problems and diseases experienced by pregnant women early, intervene adequately so that pregnant women are ready to undergo normal delivery. To identify whether the pregnancy is proceeding normally or with complications, health workers, especially midwives, must carry out standard antenatal care (Harianis et al., 2020;Nuraisya, 2018). If it is not well-treated, pregnant women's anxiety may influence both physica; and psychological conditions of mother and fetus (Hariyati et al., 2019).
The Ministry of Health's Integrated antenatal guidelines (2010) state that performance indicators include integrated antenatal services including K1, K4 and Handling Complications (PK) (Kementrian Kesehatan Republik Indonesia., 2010). For this reason, these performance indicators can be used as a measure of team task performance, the results of achieving the target of antenatal service performance indicators compared to the minimum service standards (SPM) of Sidoarjo Regency show that the performance indicator for Pregnant Women Visits in K1 services has decreased in 2017 by 100% to 99 .09% in 2018, K4 decreased in 2017 by 99.60% to 96.74 in 2018, and the handling of obstetric complications was still below the target of 99.31% of what was expected. Not achieving the Minimum Service Standards (SPM) target can be interpreted as having an ineffective team, one of its characteristics is a decrease in team performance (Levi D, 2014), namely a decrease in performance or not achieving the expected results, the performance of antenatal care is assessed from the completeness of the services received by the mother pregnant.
In previous studies, it was shown that the results of the analysis of the socialization process of Norms, Standards, Procedures and Criteria (NSPK), the implementation of integrated antenatal services in health facilities and facilities, as well as the use of supporting logistics were still considered insufficient. The output analysis shows that integrated antenatal services have not been fully implemented in health facilities and facilities according to standards. The system for implementing an integrated antenatal service program is still not on target. The process of socialization and implementation requires improvement in order to increase public interest. This study will analyze the factors that influence the effectiveness of the integrated antenatal care team at the Community Health Center in Sidoarjo District.

METHODS
This type of research is descriptive observational with a cross-sectional research design. The population as well as the study sample were integrated antenatal teams at Community Health Centers throughout Sidoarjo Regency, consisting of 26 integrated antenatal teams with research time from September 2019 -September 2020.
The integrated antenatal team consists of general practitioners, dentists, midwives, nutritionists and analysts who handle pregnant women in integrated services only at the Primary Health Center. In addition, to get an overview of antenatal care, it is necessary to have a coordinating midwife at the Health Center and related officers at the Sidoarjo District Health Office.
This study consists of 3 kinds of variables, namely independent, intermediate and dependent. The independent variables consist of team composition (completeness of service personnel) and team diversity/demographic diversity (gender and age). Intermediate variables consist of cohesion (task & social), coordination (frequent communication, timely communication, accurate commonation, problem solving communication, shared goals, shared knowledge and mutual respect) and conflict (tasks, relationships & processes). While the dependent variable consists of team effectiveness (team task performance, team viability and member satisfaction).
Retrieval of independent variable data using a questionnaire filled out by the coordinating midwife. Intermediate variables used interviews based on a questionnaire with a 4-point Likert scale. The dependent variable uses a combination of two methods, namely the questionnaire and document study. Retrieval of input data (team composition, team diversity) through checklists and questionnaires, process data (cohesion, coordination and conflict) and output (effectiveness, especially the dimensions of team viability and member satisfaction). Retrieval of team effectiveness data on the dimensions of team task performance. Data collection was carried out by studying the medical record documents of pregnant women who had received integrated antenatal care as many as 10 files in each Puskesmas. A document study was conducted to determine the completeness of the services received by pregnant women. The questionnaire used has been tested for validity and reliability and the data is processed using editing, scoring and tabulation data processing techniques which are then analyzed with data processing software, univariable analysis aims to determine the distribution and proportion of the independent variables and the dependent variable. The data obtained is collected and presented in tabular form, then the data results are interpreted. The results of the analysis are categorized from the number of composite values. Data from the calculation results are then categorized into several classifications according to operational definitions. Data analysis using frequency distribution and cross-tabulation was then interpreted according to the research objectives.

Analysis of the Effect of Team Input (Team Composition and Team Diversity) on Process (Coordination, Cohesion and Conflict)
The results showed that there was a tendency for low diversity (team diversity) to have low conflict and low cohesion. Pelled's opinion (1996), explains that even though diversity can provide positive results if the organization or company is able to implement a system that is good and fair for this diversity, diversity can also be a source of conflict when differences between workers cannot be controlled by the organization or company (Pelled, 1996). The previous study found several barriers during integrated ANC implementations and one of them was process of care and organisation and management support (Afrizal et al., 2020).  Table 1 shows that incomplete team composition has very good coordination of 66.7%. There is a tendency for incomplete team composition to have very good coordination. The team with low diversity had very good coordination of 50.0%, while the team with high diversity had very good coordination of 66.7%. There is a tendency for high diversity teams to have very good coordination. Based on table 2, it is known that incomplete team composition has a very strong cohesion of 66.7%, while a team with complete cohesion has a very strong cohesion of 91.3%. There is a tendency for a complete team composition to have very strong cohesion. Based on table 2, it is known that the Puskesmas integrated antenatal team with low diversity has a very strong cohesion of 100.0%. Meanwhile, a high diversity team has a very strong cohesion of 75.0%. There is a tendency for low team diversity to have very strong cohesion.  Based on table 3 it is known that a complete team composition has a low conflict of 100.0%. There is a tendency for a complete team composition to have low conflict. Based on table 3 it is known that the integrated antenatal team at the Community Health Center with low diversity has a low conflict of 100.0%. There is a tendency for low team diversity to have low conflict.

Team Composition
Analysis of the Effect of Team Process (Coordination, Cohesion, and Conflict) on Output Effectiveness (Team Task Performance, Team Viability, and Member Satisfaction) The results showed that there was a tendency for good coordination to have team task performance, very good team viability, very satisfied member satisfaction and strong cohesion to have very good team task performance. The results of this study are in line with research conducted by Syauqi (2019) explaining that there is an effect of a relationship between coordination on employee performance. Coordination can be carried out through proper delegation of authority, clear division of labor, and good communication between team members (Syauqi, 2019). Coordination is a very important thing, in achieving its goals, if the leader (leader) cannot implement good coordination then there will be chaos, disputes and job vacancies so that work effectiveness is not achieved. Establishing a mechanism in an activity is very important for coordinating work or organizing a harmonious unit and the strength of a team depends on its ability to organize its existing resources to achieve a goal (Hasibuan, 2016). Research conducted by Larasati et al (2018) found that cohesiveness has a significant effect on employee performance. Each working group has goals and objectives that must be achieved, these goals may not necessarily be fully accepted by the members of the group. The level of agreement of members on group goals and the degree of mutual acceptance of other group members shows the degree of cohesiveness of the group, the more members are attracted to each other and the more members agree on group goals and objectives, the more cohesive the group is, the higher the cohesiveness of the group the higher it is group commitment to achieving goals (Larasati et al., 2018). Cohesiveness is usually considered as a strength, cohesiveness binds all group members to remain in the group and counteracts influences that pull members out of the group and a cohesive group consists of individuals who are mutually attracted to one another (Pratama & Prasetya, 2017). An efficient and effective approach during the implementation of integrated ANC in public healthcare was using clinical information system (Afrizal et al., 2020).  Based on table 4, it is known that the Integrated Health Center antenatal team with fairly good coordination had a very good team task performance of 100.0%. Meanwhile, the team with very good coordination also had a very good team task performance of 93.3%. There is a tendency for good coordination to have a very good team task performance.
Based on table 4 it is known that the Integrated Health Center antenatal team with strong cohesion has a very good team task performance of 100.0%. Meanwhile, a team with very strong cohesion had a very good team task performance of 87.0%. There is a tendency for very strong cohesion to have very good team task performance.
Based on table 4 it is known that the integrated antenatal team at the Community Health Center with low conflict has a very good team task performance of 84.6%. There is a low tendency for conflict to have a very good team task performance.
The results of the study show that there is a low tendency for conflict to have very good team task performance and very satisfied member satisfaction. The results of the research are in line with research conducted by Tidajoh, et al (2017) which says there is a very strong relationship between conflict on employee performance. Conflict is ensured that there will always be in a team because the team consists of several personnel who of course have different thoughts and for this it requires coordination for its resolution and conflicts occur because of interactions called communication, this is intended if you want to know conflict means you have to know communication skills and behavior . All conflicts contain communication but not all conflicts are rooted in poor communication. Conflict is not only expressed verbally but also expressed nonverbally, such as facial expressions, gestures that express conflict and conflict which do not always have a bad connotation but can also be a source of positive experiences. Conflict does not always have a bad impact, but also provides lessons and wisdom behind the conflict between related parties and that lesson can be in the form of how to avoid the same conflict so that it does not recur (Tidajoh et al., 2017). These findings support the research conducted by Alfiah, J (2013) which found that conflict has a significant and negative effect on job satisfaction (Alfiah, 2013). Han and Harms (2010), explain conflict as disagreement and different points of view on something. Conflict within the organization/team has both positive and negative impacts on the team/organization, positively the existence of conflict increases work rhythm, makes work done quickly and increases employee discipline. Meanwhile, negatively, conflict within the team/organization can cause job stress, decreased job satisfaction, decreased organizational commitment and desire to leave (Han & Harms, 2010).  Based on table 5, it is known that the Integrated Health Center antenatal team with good coordination has a team viability of 100.0%. Meanwhile, the team with very good coordination had a very good team viability of 93.3%. There is a tendency for good coordination to have very good team viability.
Based on table 5, it is known that the Integrated Health Center antenatal team with strong cohesion has a very good team viability of 100.0%. Meanwhile, a team with very strong cohesion had a very good team viability of 91.3%. There is a tendency for very strong cohesion with very good team viability.
Based on table 5, it is known that the integrated antenatal team at the Community Health Center with low conflict has very good team viability at 92.3%. There is a tendency for low conflict to have very good team viability.  Based on table 6, it is known that the Integrated Health Center antenatal team with good coordination has a satisfied member satisfaction of 100%. Meanwhile, the team with very good coordination had very satisfied member satisfaction of 66.7%. There is a tendency for very good coordination to have very satisfied member satisfaction.
Based on table 6, it is known that the Integrated Health Center antenatal team with strong cohesion has a satisfied member satisfaction of 11.5%. Whereas a team with very strong cohesion has a very satisfied member satisfaction of 65.2%. There is a strong cohesion tendency to have very satisfied member satisfaction.
Based on table 6, it is known that the integrated antenatal team at the Community Health Center with low conflict has very satisfied member satisfaction of 57.7%. There is a low conflict tendency to have very satisfied member satisfaction.
The results of the study show that there is a strong cohesive tendency to have very satisfied member satisfaction. Cohesiveness has a significant effect on job satisfaction and each individual has a different level of satisfaction, the higher the feeling of satisfaction of employees/members will spur the morale of employees/members. With a feeling of satisfaction, members/employees can carry out tasks with an honest heart and the tasks given are not a burden but an obligation that must be completed (Arifin, 2017;Larasati et al., 2018;Pratama & Prasetya, 2017). The important factors in the implementation ANC was patient satisfaction and the decrease complications among women (Hatta et al., 2022).  Based on table 7, it shows that the Integrated Health Center antenatal team with good coordination has a less effective team of 100%. Meanwhile, the team with very good coordination had a fairly effective team of 60.0%. There is a tendency for very good coordination to have a fairly effective team effectiveness.
Based on table 7, it is known that the Puskesmas integrated antenatal team with strong cohesion has a less effective team of 100%. Meanwhile, a team with very strong cohesion has a less effective team of 52.2%. There is a very strong cohesion tendency to have a fairly effective team effectiveness.
Based on table 7, it is known that the Puskesmas integrated antenatal team with low conflict has an effective team of 30.8%. Meanwhile, teams with sufficient conflict have less effective teams of 69.2%. There is a low conflict tendency to have a fairly effective team effectiveness.
The results showed that there was a very good trend of coordination on team effectiveness, which means that the better the coordination between integrated antenatal teams at the Community Health Center, the more effective and better the team will be. This is in line with research conducted by Sanusi and Feriyana (2019), which states that there is an influence of coordination on team effectiveness, which can be interpreted as coordinating with authority to move, harmonize, align and balance specific or different activities so that all directed at a specific goal. Meanwhile, functionally coordination is carried out in order to reduce the negative effects of specialization and streamline the division of labor (Sanusi & Feriyana, 2019). According to Hasibuan (2016), that effectiveness is a condition that shows the level of success of management activities in achieving goals, effective goals are accompanied by efficient management (Hasibuan, 2016). In a team, a good integration role of health care provider can be realized if the organisation has a good organisational context and leadership. Also, health system factors also influence integration of ANC with other services and may require restructuring of existing management, and financing, as well as monitoring and evaluation system (De Jongh et al., 2016;Diadjeng et al., 2018).
The results of the study show that there is a low conflict tendency to have a fairly good team effectiveness. The results of this study are in line with research conducted by Salim, NA et al (2017), that there is a significant positive effect between conflict on effectiveness. Conflict is a dynamic process that occurs because of conflict that is not only caused by other people but that conflict can also come from within oneself, therefore any form of conflict that occurs within an organization will definitely result in ineffective job execution and inefficient (Salim et al., 2017). For this reason, every leader and member of a team/organization must be able to resolve or at least assist in resolving conflicts that occur within a team or organization with the maximum form of conflict management.

LIMITATION OF THE STUDY
This study limited only in Sidoarjo Regency and the results may different in other cities.

CONCLUSIONS AND SUGGESTIONS
The conclusion of this study on team input there is a tendency not to affect the process and in the process there is a tendency to affect the output. To increase cohesion by bringing service rooms closer together, leadership training/workshops/interprofessional practice/conflict management, rewards for team members who perform well and review existing policies.