The Change of Knowledge and Attitude of Bride and Groom Candidate After Reproductive Health Pre-Marital Course by KUA Officer Sri

Reproductive health in Indonesia is still very poor, as evidenced by the still high maternal mortality rate (MMR). MMR decline was slow, as well as in the province of Central Java. The highest is in Brebes Regency which has as many as 53 cases of maternal decease. One of the causes of high MMR is the lack of reproductive health sensitivity of bride and groom candidates. The purpose of this research is to analyze the influence of counseling on bride and groom candidates knowledge and attitude related to reproductive health. This research is a quasi experimental research with pre and post test without control group design. The population was bride and groom candidates listed in KUA of Brebes Regency in July and August of 2017, with a sample of 100 pairs selected according to the inclusion criteria. The interventions in the form of a one-day course by KUA officers on reproductive health with Bride and Groom Candidates Reproductive Healt booklet and flipcharts as the tools. The data of knowledge and attitude are obtained by interviewing the bride and groom candidates. Analysis is conducted with Wilcoxon Match Paired Test. The results showed that there is a difference of bride and groom candidates knowledge and attitude before and after intervention (p <0,05), with mean value increased 2.58 points (knowledge) and 3,21 points (attitude). Recommended advised are the pre-marital program socialized by KUA officers is expanded and multiplication of the booklet as a tool for the officers in pre-marital courses implementation.


Introduction
Reproductive health in Indonesia is still an apprehensive matter.Based on the 2007 IDHS survey (1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), the MMR is still at 228 per 100,000 live births and in 2012 at 359 per 100,000 live births, whereas the 2015 MDG target is to reduce MMR to 102 per 100,000 live births and the target seems to fail to meet.Observing the slow downward trend of MMR, it is feared that the target of SDGs will not be reached.In 2014 the absolute mortality rate in Indonesia reaches 4925 and in 2015 was 4809.
reproductive health quality of the bride and groom.
The purpose of this research is to analyze the difference of knowledge and attitude of the bride candidate related to reproductive health before and after being given intervention in the area of Office of Religious Affairs of Brebes Regency.

Method
The research uses quantitative approach, with pre and post test design in one group without control.Interventions were given for a day (3 to 4 hours) of a pre-marital Reproductive Health Course on KUA prepared by a previously trained KUA Officer.The course tools are the reproductive health booklets and feedback sheets for the bride and groom candidate.The target of the intervention is the bride and groom candidate registered in the KUA of Brebes District in July-August 2017.Samples are selected purposively as many as 100 candidates according to the inclusion criteria, which are willing to attend and not pregnant at the time of the course.At the beginning and end of the research, the measurement of knowledge and attitudes of bride and groom related to their behavior about reproductive health and the preparation of family life and prevention of MMR and IMR.The data is taken with interview technique with structured questionnaires that have been tested the validity and reliability.Data analysis was conducted by Wilcoxon match paired test.

Result and Discussion
Research with bride and groom candidates respondents registered in KUA Kabupaten Brebes in July and August of 2016 has the following characteristics: most of the respondents were women (61.0t%), bride and groom candidates age were mostly between 21-35 years (75.0%), with the youngest was 17 years old and the oldes was 38 years old.Education of bride and groom candidates, majority of the respondents have graduated from junior high school or equal (32.0%), all bride and groom work mostly as employee in private sector (67%), whether the bride or the groom.
The implementation of pre-marital courses provided by KUA officers for 3-4 hours includes knowledge related to maintaining reproductive health, free sex before marriage Furthermore, the cause of maternal decease is also inseparable from the mother's condition itself and is one of the 4 "too" criteria, too old at delivery (over 35 years), too young at delivery (less than 20 years), too many children (more than 4 children), too close birth/parity interval (less than 2 years).Sixty-five per cent of maternal decease occurrs at the time of childbirth, at the time of pregnancy of 26.33 per cent, and at the time of delivery of 12.76 per cent.Causes of death are such as bleeding, hypertension, infections and disorders of the circulatory system.Based on the age group, the highest incidence of maternal deaths was in the age of 20-34 years 68.50 percent, then in the age group over 35 years 26.17 percent and in the age group less than 20 years 5.33 percent (Kementerian Kesehatan RI, 2017).
High MMR and all the problem can be caused by the lack of reproductive health education.Reproductive health education has existed in various programs such as youth care service program (PKPR) contributing to adolescents related to knowledge, attitude and activities in maintaining reproductive health in Buleleng sub-district (Wijaya, 2014).The MMR decrease effort needs a great innovation that is supported by many parties.The chain of maternal decease is very possible to be disconnected or prevented from the beginning by taking into account the life cycle of expectant mothers with regard to sexual behavior.The interaction between the expectant mother and the surrounding individual has a major influence to prevent inappropriate sexual behavior (Azinar, 2013).One effective effort is to empower the Office of the Ministry of Religious Affairs in this case the Extension Officers in the religious affairs office (KUA) as individuals who deal directly with the prospective bride.The innovative pre-marital course is one of the strategic actions that have significant leverage for problem solving that improve mother's knowledge to minimize the cause of decease during pregnancy, labor and immediately after childbirth.This is also in line with one of the goals of sustainable development until the year 2030 is about the reduction of MMR, considering that the next generation is determined by the quality of maternal and child health, among others, by improving the prohibition, tetanus immunization, reproductive organs, SEZ handling, ideal pregnancy, contraception, contraception use plan, fetal development process, late menstruation , pregnancy test, blood pressure measurement, added blood tablet, pregnant women avoid cigarette smoke, and risky pregnancy, performed for one day.
The result of Wilcoxon test shows that there is difference of knowledge of bride and groom candidate before and after intervention in the form of pre-marital course by KUA officer with p value = 0,001 (p <0.05), increase of average value equal to 2.58 points.
There is an increasing knowledge of the bride and groom especially about premarital preparation, nutrition preparation and reproductive organs.This is aligned with research which states that pre-marital education can improve knowledge about reproductive health and couples' readiness significantly for bride and groom candidate (Keshavarz et al., 2013).Respondent knowledge regarding the ideal pregnancy and unwanted pregnancy are also improved.This is in accordance with the recommendation of The International Federation of Gynecology and Obstetrics (FIGO) that adolescents, preconception partners, women preparing for pregnancy, require knowledge preparation on health, particularly about optimum nutrition.Adequate nutrition before preconception is the key to achieve healthy pregnancy, delivery and postpartum.Thus a healthy pregnancy, exclusive breastfeeding success, embryonic growth, fetus and healthy baby can be achieved (Hanson, 2015).
Respondents' knowledge of pregnancy tests, pregnant women should not be exhausted and risky pregnancy are increased after pre-marital courses.Studies by Greenaway also stated that pre-marital education in Sub-Saharan Africa can improve readiness, women's knowledge of the first marriage, and pregnancy preparation.Women who have had reproductive health education are safer than women who have not been exposed to reproductive health education in preparing for their pregnancies (Smith, 2016).The bride and groom have problems at the beginning of the marriage due to the limited knowledge about having own family and reproductive health, so this period is appropriate to provide education as an effort to improve health status (Giarratano et al., 2010).
Differences of the bride and groom candidate attitude before and after intervention in the form of pre-marital course with p value = 0,001 (p <0.05) and increase of average value to 3.21 points.Based on the research, respondents have positive attitude regarding reproductive health knowledge, have sex with unauthorized spouse, contraception method usage, pregnancy plan, TT injection, cigarette smoke, pregnant woman's diet, pregnant woman's meal portion, PMS examination, pregnancy warning sign, pregnancy gymnastic, pregnancy examination, and wanted pregnancy.As the knowledge, attitudes consist of various actions, such as receiving, responding, valuing, and being responsible (Rizki, 2012).This indicates that pre-marital course can improve the knowledge, readiness and attitude of the bride and groom candidate.Pre-marital course through discussion class can improve the knowledge, readiness, attitude and behavior of the bride and groom candidate.Through counseling and media tool can minimize the incidence of mortality during pregnancy, delivery to postpartum (Brixval et al., 2016).
Premarital education regarding mother and child health promotion on pre pregnancy, morbidity preventive efforts, complications and mortality incident for the bride and groom, including contraception usage plan, are a strategic effort for social protection to create prosperous and qualified families (Al-Sulaiman et al., 2008;Alswaidi & Sarah, 2009;Ibrahim et al., 2011;Al-Azeem, 2011).Pre-marital education can prevent the occurrence of illness, and preventive efforts to improve mother and baby health (Al-Azeem, 2011).Based on Beamish's review in Ibrahim et al., (2013), free sex before marriage increases the risk of sexually transmitted disease infection.It stated that the bride and groom are in great need of reproductive health information, because it is included in the critical phase in the preparation of pregnancy, childbirth, postpartum and the health of the baby (Ibrahim et al., 2013).
The respondents showed a negative attitude to reproduction organ abnormalities  and abstinence in pregnancy.This needs special attention since there might be a misperception to the media, align with Ibrahim's (2013) study stating that the success of the counselor or premarital and genetic preparation educator in providing positive counseling to the bride and groom candidate are influenced by the basic knowledge and skills concerning the theory and practice of counseling and interview skills as well as interventions conducted in Jeddah, thus training of prior knowledge and expertise in pre-marital preparation are required (Ibrahim et al., 2013).In addition to educator, the duration of time in the pre-marital course enables the presence of negative attitudes related to reproductive health because humans need about 3 weeks to adapt to changes (Lally, 2010).
The success of the pre-marital course in Brebes District, one of them through booklet media, is aligned with the result of the study that with the use of media minimize the difference of interpretation (Mutmainah et al., 2014), besides graphics media and game stimulation method can support the premarital counseling implementation and adolescent reproductive health improvement ( Ibrahim et al., 2011;Rizki, 2012).It is necessary to follow up in the form of pre-marital education which can be presented massively through other media such as television, radio and magazine so that the purpose of saving mother and baby can be achieved equally, through interesting media that can increase the interest of respondents up to 65% (Al-Aama, 2018, Al-Aama, 2008).Comprehensive program for bride and groom candidate previously is applied by developed countries.The government requires the bride and groom canditate to receive premarital education and reproductive and genetic health examination (Ibrahim et al., 2011, Serjeant et al., 2017).

Conclusion
The intervention of pre-marital preparation education for bride and groom candidate has significant influence in improving knowledge and attitude, therefore it will improve the quality of information transfer (transfer of knowledge), public health status monitoring, particularly in the effort to save mother and baby, MMR and IMR decrease, achievement of Family Planning, improving the quality of family life, improving understanding and knowledge regarding family life in the build of sakinah, mawaddah, warrahmah family and reduce the number of dispute, divorce, and domestic violence.The results of the study can be used as a policy recommendation (public policy brief) related to the program of Premarital Course.
Advised recommendations are premarital course socialization by KUA officers is expanded and the booklet as a tool for the KUA officers to implement pre-marital course is multiplied.For the Diponegoro University Public Health Faculty and other Institutions related to mother and child health, there needs to be continuous research on counseling and media distribution in other forms related to pre-marital preparation and reproductive health of the bride and groom, as well as media content improvement.

Table 1 .
The difference of bride and groom candidate knowledge

Table 2 .
Bride and Groom Candidate Attitude Change