Abstract

One effort made by the government for implementing the strategy to reduce maternal mortality was by pushing society to have a willingness to live healthy through the alert village. This study aimed to analyze the establishment village in lowering the number of maternal mortalities in Jember Regency. The research was qualitative research, with study studies case design. The research was viewed from the stages of approach and preparation for the alert village in Jember Regency. At approach stage, alert village budget at Jember Regency Health Department as well as in Glagahwero village still was not yet realized well. However, at this stage, the preparation for each activity ran well. Attempts made by the alert village in lowering number of maternal deaths in Glagahwero village, including Tabulin (pregnant mother savings) program and blood donors, until this time still runs well.

Introduction

An advanced, independent, and just Indonesia is the vision of the "National Long Term Development Plan 2005-2025"(National Development Planning Agency, 2020). One of the efforts made by the government to realize this strategy is to encourage the community to have a will for and live a healthy life, namely through the alert village (Maharani, SI, LE Martanti, Bahiyatun, and R. Nisa, 2018).

The development of an active alert village is carried out through community empowerment, that is, an effort to facilitate the learning process of rural and urban communities in solving their health problems. The development of the active alert village consists of 4 stages, namely the approach (mandatory affairs of the district and city governments, policy support at the village and sub-district level, integration with community empowerment programs), preparation (facilitator training, training of health workers, situation analysis of the development of active alert villages), determination of community empowerment cadres, training of Human Development Cadres (KPM) and community institutions, implementation (introduction of village conditions, identification of health problems and PHBS, village deliberation, participatory planning, implementation of activities), and phasing (primary, middle, independent, perfect) (Ministry of Health, 2010).

Material And Method

This research was qualitative research with a case study research design. Qualitative research was research that does not use calculations, or, in scientific term, it is a research that emphasizes the nature of the data resource (Moleong. J. Lexy 2013). In addition, all collected information was likely to be the key to what was to be researched. This study was located at Glagahwero allert village, Kalisat. This village was an active vigilant village that had a low maternal mortality rate in 2019, with only one case of maternal death found in 2015. That research location was chosen based on the problems raised in this research. The targets to gain data in this research include 1 public health officer, 1 head of the workgroup at the vigilant village, 1 headman, 1 village midwife, 1 health promotion at the public health center, the vigilant village cadres, and pregnant women and their family members. The key informant in this study was the head of the health promotion who is in charge of the vigilant village program at the Jember public health office. The main informants in this study were the head of the vigilant village workgroup, the headman, the health promotion at the public health center, midwife and cadres, and also the additional informants involved in this study are the pregnant women and their families.

Results And Discussion

1. Alert Village Approaches in Reducing Maternal Mortality Rate
   • Country/City Approach
   • Head Village A pproach
   • Integration With Community Empowerment Program

Based on the analysis of alert village program in lowering maternal mortality rate, it was found that the operational alert village team (pokjanal) in Jember Regency has been formed since the beginning of alert village establishment in Jember Regency.

“Alert village team in Jember Regency has existed but its name is “pokjanal kabupaten” (Regency Operational Team), which is promoted by Village Empowerment Service by the issuance of decree” (IK, 43 Years) The above statement is in line with the theory that the development of active alert village is actually part of the government affairs that become the regency’s and city’s obligations and authorities to set villages and become the village government’s responsibilities (Ministry of Health, 2010).

Based on the analysis of alert village in lowering maternal mortality rate, budget specially related to alert village from Jember Regency was not available.

"There is no special budget for alert village for the last 4 years because the local government indeed does not allocate special budget for it, so the activity of pokjanal team gets stuck” (IK, 43 Years)

Thus, budget or fund allocation for alert village development was lacking. The budget support itself was originated from the community self-funding, which was used for developing the alert village activities.

The analysis results of the alert village program in lessening maternal mortalilty rate showed that advocacy at the regency level already ran well, but a number of cross-sectoral parties still considered that the alert village belonged to health workers. “So far cross-sectoral parties still consider that the alert village is not owned by the village but belongs to a health worker” (IK, 43 years old)

This fact is in accordance with theorythat advocacy can be done not only by health workers but also by the community target to the policy stakeholders from various levels or sectors related with health (Nurmala, I., F. Rahman, A. Nugroho, N. Erlyani, N. Laily, and VY Anhar., 2018).

1. Alert Village Team
2. Regency budget related to alert village
3. Advocacy
4. Monitoring and evaluation

Based on the results of analysis of the alert village program in lessening maternal mortality rate, there was no monitoring from health department related to alert village.

“During this time monitoring is still not yet done, but evaluation is usually related only to alert village strata” (IK, 43 Years) Health department did not do monitoring on the alert village in 2020 because it got not budget for the alert village monitoring.

The results of analysis of the alert village program in reducing maternal mortality rate showed that there was village regulation concerning the development of alert village in Glagahwero village, District of Kalisat but not yet ever updated since alert village was formed .

“Actually, the alert village was started around 2008, in the era of President Susilo Bambang Yudhoyono, bu now the alert village is already melted into the village government whose formation is complete” (IU2, 57 years).

This is in accordance with the previous study that in the development of the alert village, the policy support at the level of village is given at least by the village head regulation (Mubarokah, E., 2018).

Based on the results of analysis of the alert village in lowering maternal mortality rate, the authority of the head of Glagahwero village related to the alert village development was undetaking advocacy and planning the alert village timetable. His tasks are, for example, procurement of facilities and infrastructure, then meeting with the 3 pillars of babinsa (village military service) and babinkabtimmas (village police service), coordinating with village midwife and Public health center” (IU 2, 57 years old).

This is in accordance with the theoryabout implementation guidelines for development of alert village where the core activity of the alert village is empowering the community, so that they are willing and able for healthy life (Ministry of Health, 2010).

1. Alert village r egulation at village level
2. Authority
3. Alert village b udget

Based on the results of analysis of the alert village program in minimizing maternal mortality rate, there was no special budget for the alert village in Glagahwero village.

"Last year the budget was allocated from the village budget, but now it is taken from the budget of Public Health Center” (IU 2.57 Years).

The budget or fund allocation for the alert village development in Glahgahwero village was exactly very low.

Based on the results of analysis of the alert village program in lessening maternal mortaility rate, there was no integration with community empowerment program.

"Community empowerment program at that time is directly implemented, including that with the village empowerment service” (IU 2, 57 Years).

This is supported by the theorythat the integration among various program planning processes occurs in the regular planning processes in the village (Syukri, M., Hastuti. Ahmadi. Kartawijaya. and A. Kurniawan, 2014).

1. Type s of community empowerment integration
2. B udget given for cross-sector s

Based on the analysis results of the alert village program in reducing maternal mortality rate, there was no budget given for crosssectors related to the alert village in Glagahwero village.

"Sometimes the budget is available, but now it is handed directly, so this year the budget for the alert village program is directly included in Public Health Center or health department” (IU 2.57 Years).

Budget or fund allocation for development of the alert village in Glahgahwero village was still very low. The support budget itself until now was originated from self-help funding for the development of alert village .

1. Preparation Of Alert Village In Reducing Maternal Mortality Rate
   • Facilitator s

Based on the results of analysis of alert village program in lowering maternal mortality rate, alert village team or Pokjanal team in Galagahwero village had been formed since the beginning of alert village establishment in Jember Regency.

“Organization structure has already been established, comprising chairman, treasurer, secretary, 2 people-in-charge for Polindes (village polyclinic” (IU 3, 47 years old).

The formed organizational structure for alert village cadres prompted the formation of active alert village cadres by the information from Jember Regency Health Department to Public Health Center (Puskesmas) of Kalisat and Glagahwero village administrators as well as health cadres about the active alert village program.

Based on the anlysis of alert village program in decreasing maternal mortality rate, absence of meetings led to failure of the activity planning in Galagahwero village.

" It's been vacuum for 1.5 years, no meeting, so no activity plans during one year” (IU 3, 47 years old).

This is in line with statementthat planning is a guideline for reaching goals efficiently and effectively (Fidora, S., PN Prabamurti, and BT Husodo, 2018).

1. Alert village team
2. Alert village activity plans
3. Advocacy

Based on the results of analysis of the alert village program in lowering maternal mortality rate, coordination with community and cross-sectors in Glagahwero village already ran smoothly.

“Advocacy runs well; the problem is only from the village, I am sometimes not included in the team” (IU 3, 47 Years).

One important factor that can upgrade alert village performance was the support from the local government apparatus either from RT (lowest neighborhood group), RW (upper neighborhood group), up to village level.

d. A lert village cadre t raining

Based on the results analysis of alert village program in reducing maternal mortality rate, alert village cadre training had already been conducted at the beginning of formation of the alert village in Glagahwero village.

“The training was first given at the village hall, provided by health promotors and local midwives” (IU 3, 47 years old).

This is in line with theory that there is lack of training and coaching to equip cadres with adequate skills (Ministry of Health, 2010).

2.2. Health workers

a. Monitoring and Evaluation

Based on the results of analysis of the alert village program in minimizing maternal mortality rate, monitoring of the alert village was held every month in the form of alert village monthly reporting.

"Monitoring is conducted every month which provides reports like disaster report or regular report, but sometimes blood donors are available without targets” (IU 4, 40 Years).

This is in line with the theorythat monitoring is a process of collecting and presenting related information with achievement of specific purposes systematically (Kamil, M., 2010).

2.3. Community Empowerment Cadres

a. Cadre s’ Role s

Based on the results of analysis of the alert village program in lowering maternal mortality rate, there were various types cadre’s roles in the alert village organization structure in Galagawero village.

"My role is a Tabulin holder, inviting public to join. I usually do it at religious gatherings or at the Posyandu ” (IU 5, 48 years old).

The research results showed that the alert village cadres’ roles of Glagahwero were in accordance with Permendesa PDTT (Minister’s Regulation) in 2019 concerning General Guidelines of the Village Community Assistance, that village cadre empowerment (abbreviated KPMD) is the village element chosen by the village and determined by the village head for growing and developing as well as moving initiatives, participation, and mutual self-help.

b. Obstacles

Based on the results of analysis of the alert village program in lowering maternal mortality rate, the obstacles experienced by the alert village cadres of Glagahwero in doing their jobs were non-technical problems in society where they were less open in facing changes.

"Obstacle in Tabulin program is that many people don't want to join Tabulin because many of them want to pay for the service directly” (IU 5, 48 Years).

This is in line with the theorythat the community’s high mobility and solid activity are of the frequent challenges faced by health providers or facilitators (Reskiaddin, LA, VY Anhar, Sholikah, and Wartono., 2020).

2.4. Human Development Cadres (KPM) and Community Institution Training

a. C adre s’ k nowledge about a lert village

Based on the results of the alert village program in reducing maternal mortality rate, before doing their duties, the alert village cadres needed orientation or training.

“Training for the alert village cadres first invited village officers, chief of hamlet, cadres. Materials discussed were about pregnant mother, et” (IU 5, 48 Years).

This is in accordance with the theorywhich states that training is a series of individual activities in upgrading his expertise and knowledge systematically, so that he is capable of possessing professional performance in his field (Suparno, W. E, 2015).

3. A lert Village Administration

3.1. Identification of Health Problems and Clean and Healthy Lifestyle

a. H ealth p roblem s

Based on the results of the alert village program in lessening maternal mortality rate, the identification of health problems started from distribution of questionnaire to community and suggestions from Public related to problems in Glagahwero village.

"So, we plan first our needs. We recap all suggestions from the community, and then we bring them in the village deliberation forum”( IU 2 , 57 Years).

This is in line with the theory about Alert Village Development by facilitating the community to undergo the empowerment process through the organized problem-solving cycles (community organization) (Margono, 2010).

b. Causes of health problem s

Based on the results of the alert village program in lowering number maternal mortality rate, the analysis of causes of health problems in Glagahwero village was held through meetings in public village discussion where they themselves analyzed the causes of the problems.

"Causes of the helath problems vary. The latest maternal mortality was because the patient’s family needed to make negotiation related to the patient’s refrerral. We finally should be waiting for the patient family’s decision, and then the patient could be referred” (IU 3, 47 Years).

This is in accordance with the theory about alert village development by facilitating community to undergo the empowerment process through the organized problem-solving cycle (Margono, 2010).

c. P roblem s olution

Based on the results of the analysis of the alert village program in lowering maternal mortality rate, health problem solution was usually made at the meeting of village deliberation froum.

"Problem solving depends on the problems discussed. It usually proposes activities such as communication, information, and education to the pregnant mother’s family and home visit” (IU 3, 47 Years).

This is in line with the theorythat the alert village development is conducted by facilitating the community with the learning process through the organized problem solving cycle (Margono 2010).

d. UKBM (Community-Resourced Health Efforts)

Based on the results of analysis of the alert village program in lowering maternal mortality rate, UKBM in Glagahwero village included Ponkesdes and Posyandu.

"At first tt was Poskesdes; because there was a nurse, it became Ponkesdes. Besides, there is Integrated Healthcare Center, but it was not yet active last year due to pandemic. Instead, this year it already starts its operation again” (IU 3, 47 Years).

This is suppported by the theory that the implementation of active alert village and family development should meet one of the criteria of alert village, that is, the easy access to public health service and community-based health effort development (UKBM) (Margono, 2010).

3.2 Village Community Meeting

a. Socializing health problem s

Based on the results of analysis of the alert village program in lowering maternal mortality rate, health problems were identified by questionnaire distribution to community and suggestions from the community related to problems in Glagahwero village; after that, the problems were socialized in the village community forum.

"Village community forum discusses the available data from questionnaire. In addition, there are similar data proposed by public because sometimes some problems do not appear in the questionnaires” ( IU 3, 47 Years).

This is supported by the study that the data and other findings presented at the village community forum are a list of health problems, potential data, and community’s expectations (Austin, A., AS Rehana, SL Zohra, KD Jai, and AB Zulfiqar, 2014).

b. P roblem a greement

Based on results of the analysis of the alert village program in reducing maternal mortaility rate, agreement on health problems is obtained from distribution of questionnaire to community and suggestions from the community related to problems in Glagahwero village; after that, the problems are socialized in the village community forum for agreement on which problems should be solved first.

"Problems are later agreed and then followed up together among cross-sectors” (IU 3, 47 Years).

This is in line with the study that the data and other findings are obtained in village community forum which presents a list of problems health, potential data, and the community’s expectation (Austin, A., AS Rehana, SL Zohra, KD Jai, and AB Zulfiqar, 2014,).

c. UKBM Agreement

Based on the results of analysis of the alert village program in lowering maternal mortality rate, UKBM agreement was obtained from distribution of questionnaire to the community and suggestions from the public related to problems in Glagahwero village; after that, the problems were socialized in the village community forum for agreement on which UKBM problems should be solved first.

"UKBM problems are also proposed through working group, then later agreed and followed up together among cross-sectors” (IU 3, 47 Years).

This is in line with the study stating that data and other findings are obtained in village community forum which presents a list of problems health, potential data, and the community’s expectation (Austin, A., AS Rehana, SL Zohra, KD Jai, and AB Zulfiqar, 2014,).

d. Setting the village activities

Based on the results of analysis of the alert village program in lessening maternal mortality rate, village activity planning was started from distribution of questionnaire to community and suggestions from Public related problems in Glagahwero village; after that, the problems were socialized in the village community forum for agreement on which UKBM problems should be solved first and then followed in the village activities.

"Problems are later agreed and then followed up together among cross-sectors but I don't know if that has been included in the budget or not” (IU 3, 47 years old).

This is in accordance with the study that a development planning will appropriately reach the target and useful results when the planning truly meets the community needs, so it is a public obligation to get involved directly in composing development plan, which is sourced from multiplication and formulation of the problems in the community (National Development Planning Agency, 2020).

e. Set ting the source of funds

Based on the results of analysis of the alert village program analysis in lowering maternal mortality rate, the source of funds used for the alert village development was allocated from self-subsistent funding.

“I don't know if that is already included in the budget or not, but it was just already noted” (IU 3, 47 Years). This is in line with the previous study that the success of a village health forum is greatly affected by the budget size for operational activities. The bigger the operational budget, higher the level of success of the village health forum (Syukri, M., Hastuti. Ahmadi. Kartawijaya. And A. Kurniawan, 2014).

3.3 Participatory Planning

a. T imetable for formation/reactivation of UKBM

Based on the analysis results of the alert village in reducing maternal mortality rate, the timetable arrangement for UKBM reactivation was held every year by the chairman, midwife and secretary of the alert village.

"I usually remind for timetable planning, and then chairman and secretary make the schedule of activities for a year; the activities will later be submitted and then discussed in the community deliberation forum inviting cross-sectors” (IU 3, 47 Years).

This is supported by the research results that UKBM is health effort that is planned, formed, managed from and by the community for overcoming health problems in their area, including: surveillance based on public health emergency, and coping with disaster as well as environment health (Mubarokah, E., 2018).

b. Facilities and Infrastructure

The analysis results of the alert village program in reducing maternal mortality rate showed that facilities and infrastructure of the alert village had been sufficiently fulfilled.

"Facilities and infrastructure are already enough, including our asset of Ponkesdes that has long existed; indeed, facilities of Ponkesdes are complete” (IU 2.57 Years).

Supported with the the related theoryinfrastructure of health service can be defined as a collaborative process of effective and efficient utilization of health facilities and infrastructure to provide services professionally in the provision of facilities and infrastructure for the effective and efficient process of health service (Moleong., J. Lexy, 2013).

c. Budget for village activities and other funds

Based on the results of analysis of the alert village program in lessening maternal mortality rate, the source of funds used for development of the alert village activities was originated from the community self-subsistent funding.

"Last year it was included in the village budget but now it is allocated from public health center budget” (IU 2.57 Years).

This is in accordance with the theory that budget is one necessary resource in village health management forum (Feldman, R. S, 2010).

d . discussion on village development planning

Based on the results of analysis of the alert village program in reducing maternal mortality rate, development planning was started from distribution of questionnaire to the community and suggestions from public related to problems in Glagahwero village; after that, problems were socialized in the village community forum and then agreed for which problems should solved first and followed up in village activities.

"I usually remind for timetable planning, and then chairman and secretary make the schedule of activities for a year” (IU 3, 47 Years).

This is in line with the study results which state that the village community discussion is performed after an insightful self-awareness survey (Adisasmita, R., 2011).

3.4 Activity Implementation

a. UKBM E stablishment

Based on the results of the alert village program analysis in lessening maternal mortality rate, UKBM formed in the Glagahwero village consisted of Ponkesdes and Posyandu.

"The villagers come to village office, and then there are public complaints. They gather in the village and are asked for what is needed in the village and what comes first for solution” (IU 7, 52 Years).

This is in accordance with the research resultsthat UKBM is health effort that is planned, formed, managed from and by the community for overcoming health problems (Mubarokah, E., 2018).

b. Setting executing cadres

Based on the results of the alert village program analysis in lowering maternal mortality rate, in preparing for the implementation of alert village in Galagahwero village to make it run well, working groups (Pokja) were formed. "Because I am an RW chairman, I potentially can invite public for participating in blood donation” (IU 6, 41 years old). It is supported with the theory that the presence of team is wanted when organization should make an important decision (Effendy., O. Uchyana., 2011).

c. A ctivity i mplementation

Based on the results of the alert village program analysis in reducing maternal mortality rate in Jember Regency, the implementation of alert village in Glagahwero village was already started since the regency announced the start of the alert village formation.

“The implementation activity already runs smoothly” (IU 3, 47 years old).

It is also supported by the results of the previous study that mobilization and implementation are efforts to reach the goals of the alert village program (Nurmala, I., F. Rahman, A. Nugroho, N. Erlyani, N. Laily, and VY Anhar, 2018).

4. Alert Village in Lower ing Maternal Mortality Rate

4.1 Standby Husband

a. Knowledge

Based on the results of the alert village program analysis in lowering maternal mortality rate in Jember Regency, there was a lack of knowledge about definition of standby husband.

" I know about standby husband, ready at anytime pregnant mother needs us; husband is ready for accompnying and taking care of her” (IT, 36 Years).

It is also supported with the theory that husband’s role is the most important factor for preventing the occurrence of lateness, and the role of good husband can be said as a standby husband (Margono, 2010).

b. Attitude and belief

Based on the results of the alert village program analysis in reducing maternal mortality rate in Jember Regency, there was no special belief about pregnancy and husband’s attitude to pregnant wife where he sometimes accompanied his wife for checking pregnancy in the village local midwife.

"I never accompany my wife at Posyandu, but I accompany her when checking to midwife and sometimes to pregnant mother class; anyway, I don’t have any belief related to pregnancy” (IT, 24 Years).

It is also supported with the theory that standby husband is a form of the assistance provided to mother because he is one of her closest persons. Standby (“Siaga”) itsself is abbreviated from “siap” (ready), “antar” (deliver) and “jaga” (take care) (Margono, 2010).

4.2 Standby Midwife

a. Delivery service

Based on the results of the alert village program analysis in lowering maternal mortality rate in Jember Regency, the midwife service at home, Ponkesdes, and Posyandu had already been satisfying pregnant mothers who checked up for her pregnancy to the local midwife.

“Midwife service here is already good; she often does home visit” (IT, 26 Years).

This is in accordance with the research results that quality maternity service can impact on the decline of maternal mortality (Austin, A., AS Rehana, SL Zohra, KD Jai, and AB Zulfiqar, 2014).

b. A lert village i nnovation

Based on the results of the alert village program analysis in reducing maternal mortality rate in Jember Regency, alert village innovation needed re-socialization because there were people who had not known the concept of alert village and its innovation.

"I don’t now know about the alert village” (IT, 26 Years).

This is in line with the researchthat the existence of alert village can overcome problems in the village (Maharani, SI, LE Martanti, Bahiyatun, and R. Nisa, 2018).

c. Tabulin

Based on the results of the village program analysis in lowering maternal mortality rate in Jember Regency, additional informants stated that no there was no special fund for maternity savings, and the saving program did not run well.

"There is no special fees for pregnancy at this moment” (IT, 26 Years).

TABULIN (maternity savings) can be used by pregnant mother for the childbirth cost.

d. Blood donation

Based on the results of the alert village program analysis in lowering maternal mortality rate in Jember Regency, most of the additional informants stated that blood donation had already run smoothly in Glagahwero village.

"Blood donation here exists and runs well; sometimes it is held in the village or sub-district hall” (IT, 36 Years).

One direct cause of maternal mortality in giving birth/maternal was the effect of bleeding, so fulfillment of blood needs for lowering maternal mortality rate (AKI) is very important.

Conclusion

1. The village alert approach in reducing maternal mortality rate is performed by Jember Regency Health Department and Galagahwero village by establishing alert village team at regency level and refers to the alert village regulations from the Ministry of Health, but the Health Department does not have a special budget related to village development

2. Preparation for the alert village in reducing maternal mortality rate is performed through the facilitators’ important role in the formation of alert village, starting from planning the alert village activity schedule, advocating across sectors to training community empowerment cadres.

3. Alert village must run well in reducing maternal mortality rate, ranging from delivery services, village alert innovations, Tubulin and blood donation, so that the alert village can also run smoothly

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