The roles of Tuha Peut Gampong in Healthcare Services for Pregnant Women

This research was aimed to identify the roles of Tuha Peut in healthcare service for pregnant women. This study was also examined the obstacles of Tuha Peut in implementing the roles and identified the efforts taken to strengthen the roles. This research employed quantitative and qualitative approaches. The quantitative approach using a questionnaire to collect data was used to provide indicators for maternal healthcare and the knowledge of Tuha Peut towards maternal health care. Meanwhile, the qualitative approach using open-ended interview guide and focus group discussion (FGD) was employed to explore the constraints and efforts in improving maternal healthcare. The research location was in Nagan Raya, Aceh Province. A total of 48 respondents was recruited in this study. The result shows there is a relevance between the health care achievement and TuhaPeut knowledge as the legislative assembly in decision making regarding the village fund (p< 0.001). Concerning the decision-making, most Tuha Peut were not involved in decision-making related to the health sector. Some of them were only passively involved, and some could not provide considerations for maternal healthcare. Unfortunately, efforts to maximize their roles in improving maternal healthcare had not been carried out. It is recommended that TuhaPeut can be more involved in every planning process of maternal healthcare service, such as arranging Qanun as the jurisdictional basis. Tuha Peut’s roles can be maximized to increase the health care for pregnant mothers.


Introduction
Pregnant women's health has been the focus and one of the performance indicators of the Ministry of Health program, which has the aim to give birth to a healthy and highquality generation (Vermeiden et al., 2018).This is stated in the regulation of the Minister of Health of the Republic of Indonesia Number 97 of 2014 concerning health services during the period before pregnancy, during pregnancy, childbirth, and the period after giving birth; the implementation of contraceptive services; and sexual health services (Lori et al., 2021).Village funds are used to accelerate the achievement of Village Actions, one of which is the prevention of stunting (Chakrabarti et al., 2019).Stunting occurs before 1000 days of life and prevention can be started as early as during pregnancy curative, and rehabilitative approaches that are carried out in an integrated and sustainable manner.Preliminary studies indicate that health services for pregnant women in Nagan Raya Regency have not been implemented effectively.In 2021, research on the profile of the Nagan Raya Health Office found that the coverage of K1-K4 pregnant women visits was only 59%.This coverage is a long way from meeting the specified target, which is 90% (Lawrence et al., 2020).
Solving this problem will require the commitment of village officials as outlined in the standard rules.Based on Aceh Province Qanun No. 5/2003, Keucik and Tuha Peut are positioned as executive and legislature.Tuha Peut provides an opportunity and is tasked with resolving customary issues.It plays an important role in joint decision-making with the village head (Keucik).The Tuha Peut Gampongas legislature plays an important role in making joint decisions with the village head (Keucik) regarding health services for pregnant women (Zhang et al., 2019).The increase in chronic energy deficiency in pregnant women, which contributes to stunting, indicates the urgent need for this study.Hence, this research seeks to empower Tuha Peut as an agent of change in decision making, as well as to reduce the prevalence of chronic energy deficiency in pregnant women and stunting/loss generation.This research is conducted in synergy with the Nagan Raya Regency Strategic Plan 2020-2024 and the Teuku Umar University Research Strategic Plan 2020-2024, which focuses on poverty alleviation, independence, improving community health, and rural area development.The objectives of this study are, first, to identify the roles of Tuha Peut Gampong as a village consultative body related to health services for pregnant women; second, to find out the obstacles causing Tuha Peut Gampong to not play an effective role in promoting health services for pregnant women; and third, to find out the efforts made to strengthen the role of Tuha Peut Gampong in improving maternal health services.

Method
This was a mixed-method study utilizing quantitative and qualitative approaches.Initially, the quantitative approach using a crosssectional design was performed to describe the indicators of pregnant women's health services, including 90 Fe tablet consumption, attending nutrition counselling and pregnant women class at least 4 times, getting nutritional status monitoring, having access to clean water and latrine, and having health insurance.Tuha Peut's knowledge variable depicts the description of Tuha Peut's knowledge related to health services for pregnant women.This research was located in Nagan Raya regency, district of Suka Makmu with six villages: Macah, Suak Bilie, Lueng Baroe, Cot Peuradi, Cot Kuta, and Blang Sapek.The population in this study was 180 pregnant women in the second and third trimesters of pregnancy.This study employed total sampling, so that the total population represents the total sample.The data was collected in the form of secondary data from January to August 2021 using an observation sheet instrument.Data analysis using univariate and bivariate.
After conducting the quantitative study, the qualitative approach analysing the obstacles and efforts of Tuha Peut in pregnancy health care was performed.The main informants in this study were 48 Tuha Peut consisting of six chairpersons, six secretaries, and 36 members.Before being interviewed, the informants were handed the informed consent that they were voluntarily become the subjects in this study.Besides, they also gave truthful information during the interview.The data collection technique was carried out using an openended question in in-depth interview and focus group discussion.Then, the data analysis used Content Analysis.

Result and Discussion
The characteristics of the respondents (Tuha Peut) in the 6 villages can be seen in Table 1.The average age of the Tuha Peut is 25-35 years old (52%).Concerning the educational level, the majority of the Tuha Peut educational level is high school (61%).Additionally, most of their profession is as farmers (77%) and their length of service as the Tuha Peut is 0-2 years (85%) in average.An overview of the attainments of the pregnant health service indicators from the 6 villages was shown in Table 2.The indicators attainment for pregnant women health services in 6 villages in the Suka Makmu sub-district, Nagan Raya Regency, can be stated as follows.The lowest achievement is Pregnant women having classes on nutrition or pregnancy in specific (45% out of 85% targeted) of the Cot Kuta Community Health Centre.The description of the availability of classes for pregnant women in the village is also still low (45%).
The following illustrates Tuha Peut's knowledge regarding health services for pregnant women that must be facilitated by the village in accordance with Minister of Health Regulation Number 4 of 2019 concerning Technical Standards for Fulfilling Basic Service Quality in Minimum Service Standards in the Health Sector (Table 3).The Tuha Peut's knowledge of pregnant women health care is still low, with an average of 43.2%.The results of in-depth interviews with six chairpersons and six secretaries of Tuha Peut's show that they were not informed about the health services for pregnant women that must be fulfilled.They did not know the mechanism for the service implementation either.
Table 4 shows that there is a significant correlation between the Tuha Peut knowledge and maternal health service attainments as a cultural council responsible for the maternal health service attainments (p-value < 0.05).The results of the qualitative study based on the document review in 6 villages found that there were no specific rules in governing health services for pregnant women.The village officials did not play a direct or indirect role in health service activities for pregnant women.Health service activities for pregnant women focus on the responsibility of the village midwives who are assisted by health cadres under the responsibility of the Public Health Centre.nTheinformants provided information concerning the fact that since 2017, they had shed village funds for Integrated Healthcare Centre operational activities.However, Tuha Peut emphasized that these funds were focused on purchasing food ingredients (PMT) and cadres' salaries, while other activities that were directly related to health services for pregnant women were the responsibility of the Health Centre.
To obtain the accurate information from the main informants, triangulation data was performed by interviewing 36 members of Tuha Peut and conducting focus group discussion.The result of FGDs revealed general information that some supporting informants did not know the implementation of health services for pregnant women.They assumed that as long as the delivery process is assisted by midwives, health services are safe.Meanwhile, other groups mentioned that the services for pregnant women had been wellattained because there is a specific schedule for the provision of iron tablets at the healthcare centre, and there was also health and nutrition counselling for pregnant women.All informants provided information that they were involved in the use of village funds for healthcare centre activities, but the details of the proper use of the budget for these activities were not within their authority.It was absolutely decided by the village head and approved by the chairperson of Tuha Peut.
The relevant health service indicators are in accordance with Minister of Health Regulation Number 4 of 2019 concerning Technical Standards for Fulfilling Basic Service Quality in Minimum Service Standards in the Health Sector.These include antenatal care; consumption of a minimum of 90 Fe pills; attendance at nutrition counseling or a pregnant mother's class at least four times; nutritional control; access to safe drinking water; household access to family latrine, and health insurance (Goossens et al., 2016).Based on the results of the study, it was found that the level of these indicators of health services for pregnant women in six villages (Macah, Suak Bilie, Lueng Baroe, Cot Peuradi, Cot Kuta, and Blang Sapek) was low, 60% on average, well below the specified target of 90%.This is due to Tuha Peut's low involvement in health services for pregnant women.The role of Tuha Peut, as stated in the Aceh Qanun, is not able to perform optimally due to various obstacles in the village.These obstacles and constraints include the involvement of all Tuha Peut members in village deliberations related to fund allocation in the village, as well as the lack of knowledge of Tuha Peut on the importance of health services for pregnant women in reducing stunting rates.
Based on Aceh Province Qanun No. 5/2003, Keucik and Tuha Peut are positioned as executive and legislature.Tuha Peut is tasked with resolving issues, playing an important role in joint decision-making with the village head (Keucik).The Tuha Peut Gampong legislature makes joint decisions with the village head (Keucik) regarding health services for pregnant women.It should be noted, however, that the low attainment of health services for pregnant women may also be caused issues related to a geographical location far from central health services, the condition of health services with limited resources, the nature of health infrastructure facilities, and the obstacles in obtaining health insurance faced by pregnant women (Akbarzadeh et al., 2015).Field observations revealed that midwives are mostly not accessible in the village, the public health centre is too far away and the pregnant women are not able to travel to urban areas (Kimberly et al., 2010).In addition to this, the midwives available in the village are still relatively young in age, graduated only a few years ago, have not been in service for a long time, and do not have much experience.According to the informant (head of the public health centre), these midwives mostly come from outside the area (immigrants) and reside in the sub-district areas because their family live in urban areas.The health workers, in performing their duties to provide services to the community, do not appear to follow the appropriate rules.
From the results of observations and indepth interviews, midwives are considered to be less able to approach the local community, and the level of interaction between the midwife and the local population is relatively low.This is clearly related to the presence of midwives in the local area, which is considered by the community to be lacking.This limitedservice condition causes pregnant women who want to have their pregnancy monitored and who would like delivery assistance to prefer traditional health services (traditional birth attendants) (Kachi et al., 2021).According to informants (health workers), the behaviour of health workers and their lack of performance and attendance at work is caused by several reasons.These include that the environmental conditions where they live are not comfortable; the condition of the facilities and infrastructure in the official residence where they live is relatively limited; the electricity and water for bathing and cooking is often unavailable and requires them to bathe in the river.In addition, they are sometimes affected by others disturbing their peace, such as thieves stealing their electronic devices.These issues make them less likely to want to stay in the village for any great length of time.
On the other hand, the low level of health services for pregnant women is also related to community participation and utilisation of these health services.This can be seen from the low level of antenatal care participation (60%, on average).This low community participation is due to public ignorance regarding the importance of health services for pregnant women (Bunch et al., 2018).Moreover, all health program activities in the village, including services for pregnant women, are routinely carried out through the Integrated Healthcare Center.Every month, midwives report on Integrated Healthcare Center activities and other health programs to the Public Health Center.Tuha Peut only obtains this information through the Keuchik.The data on health problems, including the ones of pregnant women, are handed over to the Public Health Center by the village midwives and cadres.Meanwhile, Tuha Peut remains unaware of the problems faced by pregnant women in the village.
Pregnant women are one of the groups who are prone to malnutrition due to the increase in nutrition that is required to meet the needs of both the mother and the fetus.Fetuses who are not getting enough nutrients will be at risk of stunting.Readily available and acceptable food ingredients, such as tempeh and tofu, can help to support the health of the mother and the fetus (Yarmaliza & Syahputri, 2019).Pregnant women require nutritional monitoring during pregnancy.Nutritional monitoring evaluates whether a pregnant woman is consuming the food and nutrients that are required by a pregnant woman in her first, second and third trimester; and whether this is sufficient in quantity and quality and fulfilled on a daily basis, so that the fetus can grow properly and does not experience growth disturbances or problems (Montalban, 2017).
Other monitoring that may be required includes the measurement of the upper arm circumference of women of childbearing/fertile age (Nurhalimah et al., 2012).This can be carried out easily by the women themselves, or laymen, to find out whether there is any risk of chronic energy deficiency (Reihana & Duarsa, 2012).Chronic energy deficiency is a condition where the woman suffers from chronic food shortages, which may result in health problems during pregnancy.Upper arm circumference is a measurement of nutritional status that is easy and practical as it only uses one measuring instrument, an upper arm circumference measuring tape (Reihana & Duarsa, 2012).
Besides nutritional needs, it is also necessary to pay attention to the examinations received by pregnant women as part of their antenatal care.Antenatal care is a service that women receive during pregnancy.It is very important in helping to ensure that the mother and fetus are safe during pregnancy and childbirth (Anindita, 2018).For normal pregnant women, it is recommended to receive antenatal care at least four times during pregnancy (Rayment-Jones et al., 2019).The midwife conducts home visits and interacts with the community on a regular basis to provide counseling and motivation for mothers, husbands, and family members to encourage pregnant women to receive regular checkups from early in their pregnancy (Tessari et al., 2016).Pregnant women having a good household environment is another important factor that deserves attention.Pregnant women are a group that is often vulnerable to risk, so they need a family/household environment that maintains a clean and healthy lifestyle (Badriyah & Syafiq, 2017).The results of this study showed that 75% of households with pregnant women have healthy latrines, 67% of households with pregnant women have access to safe drinking water, and 74% of households with pregnant women have health insurance (Li et al., 1996).
The provision of clean water to meet the needs of pregnant women is one of the fundamental factors in ensuring the needs and health of pregnant women (Badriyah & Syafiq, 2017).Clean water is used by humans for daily needs such as drinking, bathing, cooking and washing; thus, it is very important to the health of pregnant women.Due to the importance of access to clean water for the community, especially for pregnant women, the government needs to pay special attention to water management issues.Clean water management is an effort to get access to clean and healthy water in accordance with the water quality standards for health.The purpose of the clean water supply system is to provide an adequate amount of water to meet the needs of the community, especially pregnant women, which is also suitable with the level of progress and development of the service area (Torlesse et al., 2016).
Increasing access to health insurance is one of the ways to maintain the health of pregnant women that aims to increase equality in access to health services.Through Presidential Regulation number 12 of 2013, the government issued a regulation regarding health insurance.Health insurance is a guarantee, in the form of health protection, which means that participants, including pregnant women, can obtain health care benefits and protection to meet the basic health needs of everyone who has paid dues or whose contributions are paid by the government.The implementation of health insurance is regulated by national law (Wang et al., 2017).
One of the causes of low maternal health service levels is that the Tuha Peut's involvement in village deliberations is not yet optimal.In overcoming this problem, Tuha Peut need to formulate village regulations/qanuns that determine that village midwives must live in the village and be obliged to carry out their duties and responsibilities in the village, providing health services for pregnant women.Tuha Peut are also responsible for the security and safety of the village midwives.Tuha Peut allocate funds for the health of pregnant women such as funds for antenatal classes, nutritional counseling and PMT.They are also responsible for regulating health cadres and their incentives, and regulating the duties and responsibilities of health cadres in monitoring pregnant women's access to healthy latrines, safe drinking water, and health insurance (Brooks et al., 2017).

Conclusion
Tuha Peut is a legislative institution that plays a role in drafting Village Qanuns related to the health of pregnant women.Unluckily, Tuha Peut's knowledge of health services for pregnant women is still low, such as not knowing the form of health services for pregnant women since they assume that health services for pregnant women are the responsibility of health workers; whereas village involvement is very important in the use of village funds for Posyandu activities which can be regulated in a policy made by Tuha Peut, namely the Village Qanun.The importance of Tuha Peut's involvement in achieving health services for pregnant women can regulate and formulate a regulation related to health service problems, including limited resources and health services, health infrastructure facilities, obstacles in the implementation of health insurance faced by pregnant women, and village midwives who are most of them are absent from the village.In overcoming this problem, the role of Tuha Peut plays an important role in formulating village rules/qanuns in determining that village midwives must live in the village.Village midwives are obliged to carry out their duties and responsibilities in the village related to health services for pregnant women; are responsible for the security and safety of village midwives; allocate funds for the health of pregnant women such as funds for classes for pregnant women; give nutritional counseling for pregnant women and PMT for pregnant women; regulate health cadres and their incentives; and regulate the duties and responsibilities of health cadres in monitoring households that have pregnant women must have healthy latrines, resources safe drinking water, and health insurance.Regarding the contribution to literature, this research tries to solve the problems of pregnant women's health through village policies.The implication of this research is that Tuha Peut has an important role in decision making with the village head (or Keucik) by compiling a village regulation/ qanun to regulate health services for pregnant women in the village as an effort to improve indicators of health services for pregnant women that can be regulated in the Qanun.

Table 2
Distribution Table of Attainment Indicators for Maternal Health Services Source: Primary Data, 2022

Table 3
Frequency Distribution of Tuha Peut's Knowledge of Maternal Health Services

Table 4
Correlation between the Tuha Peut's Knowledge and Maternal Health Service Attainments Source: Primary Data, 2022