Class Service for Pregnant Women: Lesson learnt from the Covid-19 Pandemic

The maternity class service is a class for pregnant women aimed at educating expecting parents so that they can undergo a healthy pregnancy and delivery process. This study examines the role of midwives in implementing class services for pregnant women during the Covid-19 pandemic. This study uses a qualitative phenomenological approach. Based on the theme, it can be figured out that there are 5 midwives as human resources. All midwives have followed training for pregnant women and have worked with nutritionists, psychiatrists


INTRODUCTION
The spread of Corona Virus Disease first entered Wuhan in 2019 and then entered Indonesia in 2020 [1].Based on data from the World Health Organization for 2020, there were 86,973 Covid-19 sufferers, an increase in 2021, as many as 250,715,502 confirmed positive cases of Covid-19.The death rate for Covid-19 sufferers was 5,062,106 [1].The rise in Covid-19 cases indicates that the disease is transmitted swiftly and easily [1].The Covid-19 virus attacks all ages, including vulnerable groups, one of which is pregnant women [2].Cases of positive COVID-19 in pregnant women in Indonesia in 2020 were 9.7% of the 3,833 available data, 0.2% of cases of mothers were treated and isolated independently, 9.3% of mothers were declared cured, and 0.2% were declared dead [3].
The Covid-19 virus is increasingly spreading and experiencing an increase in deaths in pregnant women infected with Covid-19 [4].Based on data from the DIY Health Office, there were 1,498 cases of pregnant women who tested positive for Covid-19, and 67 of them died [5].During the Covid-19 pandemic, health services must be optimized continuously.If pregnant women want to check in at health facilities, they should follow the Covid-19 handling instructions, which include wearing masks, keeping their distance, and washing their hands [6].To keep the service running and safe for patients and midwives, various adjustments relevant to the prevention of Covid-19 using information technology-based health services as innovative solutions for telemedicine, online consultations,  425 and media applications for IEC (Education Intervention Consultation) are applied [7].The midwife or health worker is responsible for identifying participants in the class for pregnant women who will participate in the antenatal class, including in the preparation stage for implementation [10].The role and duties of midwives during the performance of the class for pregnant women are as presenters, motivators, and advocates.The midwife's role as a speaker is to provide material about pregnancy, childbirth, postpartum, and newborn care class activities while implementing the class for pregnant women [9].Additionally, the midwife serves as a motivator to motivate pregnant women and their husbands to attend classes for pregnant women's husbands at least 1 time during pregnancy so that husbands know about pregnancy and newborn care.The next role of midwives is to advocate for support from community leaders and local governments in administering antenatal classes [8].
There are some difficulties in matching the timing of the class for pregnant women, especially for them to attend classes on the working day of Public health services [11].During the Covid-19 pandemic, the inhibiting factor was the reason for reluctance and absence from classes for pregnant women for fear of being exposed to the Covid-19 virus.Implementing virtual models in pregnant women's classes is necessary because the internet has become necessary in the last decade.Advances in communication and information technology can be utilized for the better service implementation, including in the health sector.Training with virtual classes has proven effective in increasing knowledge and skills in maternal and child health management [12].The weakness of internal factors is that they often do not follow the technical instructions, which include the incompetent facilitator side, consistency of implementation, method of delivering material, incomplete tools, and problems of pregnant women who do not come during the class for pregnant women [12].In 2021, the government has designed a class for pregnant women to reduce maternal mortality in terms of the Minister of Health Regulation No. 21 of 2021 concerning health services for the pre-pregnancy, delivery, and post-natal period, implementation of contraceptive services, and sexual health services.The midwife's role as a health worker is explained in the Minister of Health Regulation No. 853 of 2021 Articles 3 and 4 that midwives are authorized to provide individual and public health services, especially maternal and child health [13].

METHOD
This study uses a qualitative method with a phenomenological approach.Participants in this study were midwives in charge of implementing the class for pregnant women.Participants are determined based on the total sampling technique.This study uses an in-depth interview technique along with observations in the interview process using field notes, and the interview process was recorded using an audio recorder.Researchers conducted direct interviews with 4 participants at the Public Health Center, and 1 participant was interviewed online; the study was conducted from June-July 2022.Researchers analyzed the data using the thematic analysis method.Thematic analysis is one way to analyze data to identify patterns or find themes through researchers' data [9].

A. RESULTS
Researchers gather information from subjects they think can contribute data; in this case, the researchers used 5 informants, the midwife who provided class services for pregnant women and up to 3 pregnant women, to provide supporting information on the role of midwives in putting such services into place.The following table contains the characteristics of the primary informants: Researchers analyzed the results of the analysis model research (Miles and Huberman, 1984) in (Sugiyono, 2016).The analysis model consists of 3 stages of data, namely data reduction, data presentation, and verification (drawing conclusions).Determining the theme starts by compiling the interview results in text form (verb transcripts and general findings).The researchers read the transcripts repeatedly to find interesting quotes according to the research objectives, then coded the meanings, grouping them into embryos and sub-themes.Then in the final stage, formulating the theme.

a. HR (Human Resources)
The theme of human resources is divided into 3 sub-themes: collaboration of health workers, number of midwives involved, and training of midwives.

1) Health Worker Collaboration
Based on the interviews with informants, information was obtained that the collaboration of health workers in implementing classes for pregnant women at the Mantrijeron Public Health Center was with nutrition officers and psychologists.This is supported by the results of the interviews submitted (B1 and B3)."…..there are nutritionists, psychologists……."B1 "….eee the class for pregnant women usually collaborates, not only midwives, at least those who follow are midwives, there are nutritionists, psychologists, sometimes doctors too.So there are 5 midwives, so it takes turns for implementation.So the first class of mothers may be supplemented by nutrition.The second is not one midwife, so they take turns.….." B3

2) Number of Midwives Involved
Int Jou of PHE  426 Based on the interviews with informants, information was obtained that the number of midwives involved in implementing the pregnant women class was 5 people.This is supported by the results of the interviews submitted (B3)."…….Yes, the class for pregnant women usually collaborates, not only midwives.There are midwives, nutritionists, psychologists, and sometimes doctors too.So there are 5 midwives, so it takes turns for the implementation……."B3 (executive midwife)

3) Midwife Training
Based on in-depth interviews with the leading informant group, efforts were made to meet the requirements for implementing classes for pregnant women with training or guidance for classes for pregnant women.This is supported by the results of the interviews submitted (B1, B2).

b. Roles and Duties of Midwives
The theme of the midwives' role and duties in the implementation of the class for pregnant women has a sub-theme: midwives' role and responsibilities as a speaker.

1) Presenter
The sub-theme of the role and duties of midwives describes the midwife in charge of implementing the class for pregnant women as a speaker, as obtained by 3 informants who revealed that the midwife's role in the implementation of the class for pregnant women was the speaker.This is supported by the results of interviews delivered by key informants (B4, B5)."…the division of tasks is different, so for each class the first class is like me, then in the second class there will be Mrs. *** (implementing midwife), later in the third class there will be Mrs. ***** (executive midwife), fifth there is Mrs. **** (coordinating midwife) later for the next class, it will be rolled back.So it's not just me in the first meeting mother class.So there is a change of role so that we too have experience giving other materials.……" B4 "…When the class was divided, there were those who delivered the material.The meeting was divided into one, two, three, and four.Each of them are providing material.Some supervised pregnancy exercises as well.If the material is given later, only one midwife……."B5

c. Implementation of Maternity Class Services
The theme of the implementation of the class for pregnant women describes the performance of the class for pregnant women.The theme of the implementation of the class for pregnant women is divided into 3 sub-themes, namely the online implementation system and the provision of materials, and the schedule for the implementation of the class for pregnant women.

1) By online class
The online sub-theme describes the implementation of online classes for pregnant women as obtained by 2 informants who revealed that the implementation of classes for pregnant women was carried out online.This is supported by the results of the interviews submitted (B1 and B2).

"…during the pandemic, we have online class, we can use WhatsApp or later via Private Message if someone doesn't understand. The schedule is once in a week……." B1
"…During pandemics, we are not as active as usual.Usually we have 4 classes, right, 4 classes in a week before the pandemic.The class is also not focused like online, so sometimes e... pregnant women online……."B2 2) Material Giving Based on the interviews with informants, it can be concluded that the material was given through WhatsApp groups and applications in implementing classes for pregnant women.This is supported by the results of the interviews submitted (B1, B2, B3, and B4)."…face-to-face class is available, online class in the group is also available……."B1 (executive midwife) "…If during the pandemic period it is given through the WhatsApp group, for face-to-face meetings it will only be held in 2022.……."B2 (executive midwife) "…The material is given face-to-face and online.During the face-to-face meeting, the mother will be gathered in one room, and then the midwife will start giving the material online via WhatsApp group……."B3 (executive midwife) "…Through face-to-face then through WhatsApp group during the pandemic……."B4 (executive midwife)  427

3) Schedule of Classes for Pregnant Women
Based on the interviews with informants, information about the class schedule for pregnant women is supported by the results of the interviews submitted (B1 and B3).

"...the online class schedule for pregnant women can use WhatsApp or via Private Message if anyone doesn't understand.
The schedule is once in a week.The first and second meetings are material giving.The third meeting is pregnancy exercise…."B1 "…..If you go online, usually once a week, we asked them to review again.They are invited to ask something.If someone asks a question, it is answered by a midwife; it is in accordance with the midwife's operational standards; face-to-face meetings are held 4 times a month on Mondays and Wednesdays, so on the first and second Mondays it was given the material, then the 3rd day of pregnancy exercise.It is in accordance with the operational standards of the Public health center.…." B3 a. Barriers to the Implementation of Maternity Classes The theme of obstacles in the class of pregnant women describes the barriers to implementing the class of mothers, which has 1 sub-theme, namely maternal factors.Data was collected through in-depth interviews.

1) Mother Factor
Based on the interviews with informants, it can be seen that the mother's factor was an obstacle to the implementation of the class for pregnant women.This is supported by the results of the interviews submitted (B2 and B5)."…Well, yes, that's the problem, sometimes in the class of pregnant women, some of them should go to work.5x, 4x, if the pregnant woman doesn't come, she's called again, but it's not possible right now, so we'll be notified by phone via WhatsApp.You didn't come, then the lesson was told and the discussion earlier…..." B2 (executive midwife) "... some pregnant women respond, some don't..." B5 (executive midwife) The research's findings on how midwives implemented class services for pregnant women during the Covid-19 epidemic were divided into 4 main themes and 9 sub-themes, which will be explored in greater detail by elaborating on the study's findings with the use of findings from earlier studies.

Human Resources a) Collaboration of Health Workers
Based on the interviews with informants, it was found that there was a collaboration with other health workers, namely Nutrition Health Workers/Nutritionists, Psychologists, and Doctors.This is in accordance with government regulations (Minister of Health Regulation of Republic of Indonesia, 2019) according to the Midwifery Law No. 4 of 2019 concerning midwifery services.Midwifery services are a form of professional service that is an integral part of the health care system provided by midwives independently, in collaboration, and/or through referrals.Midwives carry out their duties and responsibilities in collaboration with other health workers [13].
According to research by [14] Interprofessional Collaboration (IPC) comes from different professional backgrounds, including doctors, midwives, nutritionists, environmental sanitation experts, and community leaders, working together with patients, families, and communities.In providing quality services, it is hoped that it will accelerate the goals of the class achievement of pregnant women, namely increasing knowledge and changing maternal behavior towards a more positive direction in maintaining their health [14].The duties and roles of each health worker are to provide health services in accordance with their respective fields.Interprofessional education (IPE) will bridge effective collaboration between health workers to achieve better health outcomes.One of the health outcomes can be seen in patient satisfaction [15].

a) Number of Midwives Involved
Based on the interviews, it was found that the number of midwives involved in the implementation of the pregnant women class was quite fulfilled, and all midwives had performed their roles and duties in the implementation of the pregnant women class.This research is in line with [16] research, which conveyed that the availability of human resources was very influential in developing a class program for pregnant women.Procurement of health human resources aims to determine the number and type of personnel following the needs.The need for human resources is not appropriately planned.There will be a shortage of personnel which affects the servise and patient comfort and results in an increased workload [16].
The results of [17] research which states that the class for pregnant women is enough for 1 midwife, are in libe with the researchers' statement that all midwives on duty at the Mantrijeron Public Health Center had attended all training classes for pregnant women as a condition for implementing classes for pregnant women [17].Based on the results of interviews with informants, it was found that the involvement of midwives in implementing classes for pregnant women was significant.This study is in line with the results of [18] research, which stated that the midwife is one of the health workers on the front line of maternal and child health services, family planning, and reproductive health in the new normal.According to Government Regulation Number 61 of 2014, maternal health Int Jou of PHE  428 services include health services before pregnancy, childbirth and after delivery, pregnancy management contraceptive and sexual health services, and reproductive system health services.

b) Midwife Training
The requirements for carrying out the class for pregnant women are by participating in training.The results of interviews conducted by researchers found that midwives at the Mantrijeron Public Health Center had conducted training for pregnant women.This research is in line with the study of [19].Which states that the midwife's authority in carrying out government programs is authority in carrying out government programs is authorized to Provide health services, one of which is integrated antenatal care, fostering community participation, implementing community midwifery services, and carrying out other health services which are government programs.This is stated in the Minister of Health Regulation Number 1464 of 2010 article 13 and 18 which added that in carrying out practice, midwives are obliged to from government programs to improve the health status of the community.In the Regulation of the Minister of Health of 2010 itself, the duties and authorities of midwives in carrying out all types of government programs, including KIH, have been regulated in the Minister of Health Regulation by participating in class training for pregnant women [19].
Based on the interview results, the conditions for the implementation of the class for pregnant women must attend class training.This is in line with the Minister of Health Regulation of the Republic of Indonesia, 2014 that the requirements for conducting classes for pregnant women are by participating in training organized by the Health Office where midwives must attend training for trainers (TOT), training for facilitators, socialization of pregnant women classes to religious and community leaders, preparation for the implementation of classes for pregnant women, monitoring, evaluation, and reporting.The midwives in this study had attended classes for pregnant women from the Health Office [19].

Roles and Duties of Midwives a) presenter
Based on the results of interviews with informants, it was found that the midwife's role in implementing this class for pregnant women is to provide material during the implementation of the class for pregnant women.This study's results align with research [20] on the role of midwives in implementing classes for pregnanr women, namely midwives providing material about pregnancy, childbirth, postpartum, and newborn care class activities for pregnant women.Midwives alco act as motivators to motivate pregnant women and their husbands to attend classes for pregnant women's husbands at leats 1 time at birth.The role of the motivator is to make pregnant women aware and encourage pregnant women to recognize problems or complaints thar occur during pregnancy.
According to [20], The midwife's task in conducting classes for pregnant women is critical to providing counseling, information about pregnancy to newborn nursing, and patient education.Midwives can provide all information during pregnancy to pregnant women.Midwives can motivate pregnant women to take classes during pregnancy which is useful for accessing all information related to the development of the fetus and can reduce discomfort and anxiety during pregnancy [20].
Midwives are one of the primary health workers in health development to accelerate the decline in MMR and IMR.Skilled midwives perform clinical procedures with analytical, critical, and precise skills in the management of care for women.The involvement of midwives in regular and physiological care is very decisive for saving the lives of mothers and babies because their professional powers and responsibilities are very different from other health workers.Midwifery care for a woman during the critical phase (pregnancy, delivery, and postpartum) greatly determines the quality of women's health.Health workers, especially midwives, should monitor a woman's condition during pregnancy, childbirth and the postpartum period [20].
Midwives are vital in preventing and encouraging a person to behave healthily, especially during ANC visits.Midwives are pregnant women's most trusted health professionals.Midwives must also update information about pregnancy by participating in training held by the Health Office to improve nutritional care for pregnant women [21].Midwives provide maternal nutrition education to pregnant women during pregnancy checks, such as nutrition and diet for pregnant women.Nutrition counseling is only given once to pregnant women on the first visit to ANC [21].The high motivation or encouragement given by midwives in class services for pregnant women, even though there are service restrictions, does not become an obstacle in providing class services for pregnant women.The midwife's job is to provide education through social media.The use of electronic IEC through social media is currently considered the most effective and efficient way to increase the knowledge and behavior of pregnant women to maintain and improve their health during a pandemic [21].

Implementation of Maternity Class a)
By online Based on research on informants, it was found that the implementation of classes for pregnant women during the pandemic was carried out online, according to Supraoti's study (2021), which states that the application of  429 virtual models in the implementation of classes for pregnant women requires the internet to access information provided by midwives.Advances in communication and information technology can be used to improve the standard of human life, including in the health sector.The training model with virtual classes has proven to effectively increase knowledge and skills of maternal and child health management in India while increasing satisfaction [22].
Based on the results of research on informants, it was found that the implementation of classes for pregnant women during the pandemic was carried out online, then during the new normal era, the class was held face-toface [22].explained that in the Covid-19 pandemic situation, there are many restrictions on almost all services, including class services for pregnant women and maternal and neonatal health.Pregnant women are reluctant to go to public health centers or other health care facilities as they are fear of infection.There are recommendations for postponing pregnancy check-ups and classes for pregnant women, as well as the unpreparedness of services in terms of personnel and infrastructure, including Personal Protective Equipment.Pregnancy monitoring must continue, which can be done by communication between health workers and mothers individually or by holding Mother Classes online.Health workers must strengthen the ability of mothers and families to understand the MCH Handbook to recognize danger signs and apply care during pregnancy and postpartum [22].
The research of [23] in Iran proves that the virtual model (e-learning) in learning effectively increases the satisfaction and awareness of primigravida pregnant women in prenatal care.The use of the virtual class model for pregnant women can support social distancing (physical distancing) policies through the delivery of health education and counseling materials to every pregnant woman in the formed group (WhatsApp or Line group) because pregnant women do not have to gather in one room as the mother class model conventional pregnancy [23].Advances in technology are the solution to this situation during the Covid-19 pandemic.The provision of counseling, information, and education from midwives to pregnant women can still be made by utilizing modern technology on social media [23].

b)
Material Giving Based on the results of research on informants, it was found that the provision of classes for pregnant women during the pandemic was carried out through Whatsapp Groups, which was in line with the results of the study.[22].conveyed that the delivery of information and messages can also be delivered virtually and directly in the formed WhatsApp or Line group or group, which at the same time mothers can get direct feedback from health workers and other pregnant women without delay in the length of time [22].The delivery of virtual or online counseling materials is proven to make it easier for pregnant women to access various information midwives provide.Health education materials are still delivered wherever and whenever pregnant women are (not having to meet face-to-face) so that the constraints of limited time and access can be overcome.The enhancing effect and effectiveness are also proven to be better [24].The results of this study follow the research of [24], which states that there is the effectiveness of pregnant women's classes through Whatsapp on the level of knowledge of pregnant women about pregnancy, childbirth, postpartum, and newborn care.

c)
Implementation Schedule Based on the research results on informants, it was found that the schedule for carrying out classes for pregnant women before the pandemic was regular every month.Still, during the pandemic, classes for pregnant women could not be implemented routinely to reduce the spread of the Covid-19 virus.The results of this study agree with the research [24].Implementing classes for pregnant women is carried out routinely every month, but the covid pandemic has resulted in various health problems, including the health of pregnant women.The government's policy to implement social distancing, maintain physical distance and work from home to prevent the transmission of Covid-19 has caused class activities for pregnant women to be unable to be carried out.Pregnant women need monitoring of their pregnancy.Although the initial condition of pregnant women is normal, this pregnancy monitoring is vital to detect high-risk factors for pregnancy early, either by health workers, cadres, or pregnant women themselves [24].

Barriers to the Implementation of Maternity Classes a)
Mother Factor Based on the interviews with informants, it was found that the mother factor was the obstacle to implementing the class for pregnant women.The study's findings are consistent with the research limitations encountered when conducting class activities for pregnant women, including challenges matching the time of pregnant women because not all pregnant women have free time on weekdays, making it challenging for pregnant women to attend classes held on the days that public health center's services are in operation [25].Obstacles to implementing online classes for pregnant women are the lack of skills of pregnant women and facilitators to use technology; offline obstacles are the fear of pregnant women being exposed to Covid-19 and difficulties in determining meeting schedules [25].Another obstacle encountered when the maternity class is conducted online is the limited skills of the mother.Based on the results of interviews that mothers are less proficient in operating the technology used during the class for pregnant women [25].

CONCLUSION
During the pandemic, the Mantrijeron Public Health Center experienced changes in pregnancy services due to Covid-19, including regulations on the use of health protocols for pregnant women and health workers, online registration, limiting the number of visits, pregnancy services with telehealth, changes in pregnancy examination procedures, and affecting the performance of health workers.The number of human resources owned by the public health center is 5.They have met the minimum standards of midwives in the public health center guidebook.They consisted of 2 midwives with Midwifery education, 2 D4 midwives, 1 D3 midwifery education.All midwives have attended mother class training pregnant from the Department of Health.Human resources are in accordance with the Ministry of Health of the Republic of Indonesia concerning Guidelines for Implementing Classes for Pregnant Women in 2014.All key informants have attended class training for pregnant women and collaborated with other health workers, such as nutrition and psychology.Overall the role of midwives in the implementation of pregnant women's class services is appropriate to carry out their duties in the pregnant women's class program, namely as presenters, facilitators, and implementers.Implementing online classes for pregnant women during the Covid-19 pandemic has been done well through the Whatsapp Group and the Bidan Rindu application.However, there are obstacles in delivery caused by the admin of the Rindu Midwife application, so the provision of information through the application does not run optimally.Overall, the role of midwives in the implementation of pregnant women's class services is appropriate to carry out their duties in the pregnant women's class program, namely as presenters, facilitators, and implementers.Implementing online classes for pregnant women during the Covid-19 pandemic has been done well through the Whatsapp Group and Bidan Rindu application.However, there are obstacles in delivery caused by the admin of the Bidan Rindu application, so the provision of information through the application does not run optimally.Overall the role of midwives in the implementation of pregnant women's class services is appropriate to carry out their duties in the pregnant women's class program, namely as presenters, facilitators, and implementers.Implementing online classes for pregnant women during the Covid-19 pandemic has been done well through the Whatsapp Group and the Bidan Rindu application.However, there are obstacles in delivery caused by the admin of the Bidan Rindu application, so the provision of information through the application does not run optimally.