The correlation between midwives’ support and accessed to Voluntary Counseling and Testing (VCT) on pregnant women

In 2014, globally the number of people with HIV were 36.9 million people. The 2 million of them were new people living with HIV. Furthermore, it caused 1.2 million people deaths in worldwide including children (United Nations Programme oh HIV and AIDS, 2015). UNAIDS (2009) estimated that there were 22,000 children in the Asia-Pacific region were potentially could be infected by HIV / AIDS, in which can be transmitted through pregnancy, delivery, and breastfeeding from HIV-infected mothers to children (Indonesia’s Ministry of Health, 2012b). In fact, transmission of HIV / AIDS to children can be prevented by comprehensive and effective prevention-mother-tochild-transmission (PMTCT) at health-care facilities. The availability of optimal PMTCT interventions in the developed countries proved that the program can reduce the rate of HIV / AIDS transmission from mother to child until less than 2%. However, in developing countries or poor countries, the risk of transmission was still between 20% -50% due to lack of access to interventions (Indonesia’s Ministry of Health, 2012a). A R T I C L E I N FO A BS T RA CT


Introduction
In 2014, globally the number of people with HIV were 36.9 million people.The 2 million of them were new people living with HIV.Furthermore, it caused 1.2 million people deaths in worldwide including children (United Nations Programme oh HIV and AIDS, 2015).UNAIDS (2009) estimated that there were 22,000 children in the Asia-Pacific region were potentially could be infected by HIV / AIDS, in which can be transmitted through pregnancy, delivery, and breastfeeding from HIV-infected mothers to children (Indonesia's Ministry of Health, 2012b).In fact, transmission of HIV / AIDS to children can be prevented by comprehensive and effective prevention-mother-tochild-transmission (PMTCT) at health-care facilities.The availability of optimal PMTCT interventions in the developed countries proved that the program can reduce the rate of HIV / AIDS transmission from mother to child until less than 2%.However, in developing countries or poor countries, the risk of transmission was still between 20% -50% due to lack of access to interventions (Indonesia's Ministry of Health, 2012a).HIV/AIDS cases in Indonesia are still high including the infection fro m mothers to the babies.The data of VCT in Sleman Regency working area revealed that the coverage of VCT check was still low.The research was aimed to investigate the correlation between midwives' support and access to VCT on pregnant women.The study employed observational analytic with a cross-sectional approach.The population of the study was all mothers who did pregnancy examination and received counseling VCT service.The samples used accidental sampling technique.Data analysis used chi-square with the trustworthy rate 95%.The result of the study showed that there was no correlation between midwives' support and access to VCT on pregnant women due to several reasons such as midwives' absence, lack of trained midwives on promoting VCT, stigmatisation and cultural barriers.It is suggested that midwives should identify the problem in VCT on pregnant women by giving emotio nal and respect support to the patients as well as the families.Specific training of promoting VCT for midwives is required to improve ANC service especially in promoting VCT.Involvement of community leader could be one of alternative strategies to reduce cultural barriers on accessing VCT.
The cumulative number of HIV / AIDS cases in Indonesia from 1987 until September 2014 were 150,296 cases.Such cases can be transmitted through heterosexual risk behaviors 61.5%, injecting drug use 15.2%, perinatal (mother to child transmission) 2.7%, homosexual 2.4%, bisexual 0.6%, blood transfusion 0.2%, unknown 17.1%, and others 0.3% (Indonesia's Ministry of Health, 2014).Based on the evidence, there were 28,314 pregnant women who received HIV test in January-September 2012.The 812 pregnant women (2.9%) of them were infected with HIV.While, infants living with HIV were 70 (Indonesia's Ministry of Health, 2012b).The data from the Health Service of Yogyakarta Special Province (2015) showed that Yogyakarta Special Region is the 9th largest province of people with HIV/AIDS in Indonesia.The number of people living with HIV and AIDS in Yogyakarta Special Region was 2,288 people in 2013.The incidence of HIV and AIDS in Yogyakarta Province increased until 2,667 cases in 2014.Cases of HIV / AIDS in Yogyakarta Special Region are also still found in infants aged less than 1 year.This shows that mother-to-child transmission of HIV / AIDS still occurs in this province with the incidence rate were 3% (Health Department of Yogyakarta Province, 2015).
Based on 6th page Kedaulatan Rakyat Yogyakarta in Monday's edition on May 9th, 2016 stated that the number of people living with HIV / AIDS in Sleman Regency had reached 737 people.Sleman Regency had the highest number of cases in Yogyakarta Province.It is caused by 405 heterosexuals, 124 homosexuals, 93 unknown causes, 84 injecting drugs people, 16 bisexuals, 13 transmission in perinatal, and 2 transfusions people (Kedaulatan Rakyat Yogyakarta, 2016).
HIV has the impact for the sufferer.Social stigma is generally an impact on the infected person.In addition, the increase in mortality rate is also the biggest impact.Not only in groups of adult patients but also the age group of children.It can also lead to disruption of child growth and development, increased risk of child mortality, lifelong illness, lifelong obedience compliance issues, and orphaned due to the increased mortality rate of parents (Syafei, 2009).Based on the preliminary study, it was found out that the Sleman District Health Office has 25 Public Health Centers and olny 5 public health centre provide VCT services.In 2015, pregnant women offered HIV testing were 15,870 and there 20.06% of them were willing to do the testing.In Yogyakarta, all pregnant women were offered and had been recommended to do testing at the first ANC visit but mostly they do not access that service.The research was aimed at investigating the correlation between midwives' support and access to VCT on pregnant women in a Public Health Center within Yogyakarta province.

Methods
This research is an observational analytic research with cross sectional survey design.The confounding variabels in this research were not controlled.They were VCT facility, social stigma, and the level of knowledge.The population in this study were all pregnant women who performed antenatal care and received VCT (Voluntary Counseling and Testing) service at a public health centre within Sleman District.The sample in this study were pregnant women who did antenatal care and received VCT service at public health centre by using accidental sampling technique.The sample in this study was 37. The pregnant women who received counseling pre test, lived in the area of Sleman district, and willing to be a respondent.Pregnant women who received counseling pre test more than 3 months before the study conducted were excluded to minimize bias.Data analysis used Chi-Square analysis with 95% trustworthy rate and significance level (α) 5%.It used computerized technique and presented in contingency table form.

Result
Most respondents who visited antenatal care were aged 20-35 (89.2%).The lowest group accessed antenatal care was the group of women aged < 20.The characteristic of respondents' gravida is more on multigravida with the number of respondents 54.1% and the lowest is grande multi with no inspection visits.The other characteristic is the gestational age.The highest respondent who visited is on the 3rd trimester of pregnancy with the number of respondents 54.1% and the 1sttrimester pregnancy as the lowest visit on the respondent was 5.4%.
Midwife support is one of the characteristics and variables in the study.The respondents responded good was 51.4%.It shows that the midwives have a good response to their duties.It was proven by providing good support to the client during the counseling and testing.This study also analyzed the answers points of respondents' statements that were collected through questionnaires.Based on the results of the analysis, 78.4% agreed that midwives gave good performed during the counseling process and HIV testing so that the respondents feel comfort when they seek helps.Furthermore, there were 59.5% of respondents stated that midwives enjoyed in providing HIV counseling and testing.This suggests that most respondents feel having good time for the explanation.It means the midwives giving the good support during the counseling process.There were 56.8% respondents did not feel reluctant to inquire about the intention of the midwife's unintelligible statement during the counseling process.This shows respondents feeling comfortable with the midwives and increasing their knowledge as effect.In addition, 59.5% of respondents understood the meaning of HIV negative that can be infected.This suggests that the information provided about HIV transmission is well understood by the respondents.So, it is expected that there will be a change of behavior pattern better.
The answers had involved respondents in making plans during counseling and HIV testing were 51.4%.It means that the midwife has been fair by asking the client's opinion for the client's own health interests.It also shows that there was no stigma given in health services.During the process, after analyzing the data, it was interpreted the respondent receiving good support on the informative and instrumental aspects of support.Furthermore, the emotional support and appreciation of respondents got less support.
Respondents who accessed VCT testing were 67.6%.It means pregnant women who knew the importance of VCT will also had a good knowledge of HIV disease and good attention to her fetus.In the 3rd trimester of pregnancy, respondents would be more compliant to do HIV testing that were 43,24%.In the 1st trimester had not found any respondents who did testing.It means gestational age affecting to take a more positive decision.An analysis in this study used Chi-Square test that showed the result of calculation of P value = 0,414 is higher than 0,05.It is also supported by the value of r count = 0.667 is more than r table value = 0.325 which means there is no correlation between midwives assistance and VCT in pregnant women.

Discussion
The result of this study is in accordance with research Nguyen (2009) which stated there is no relationship between the presence of counselors on VCT in pregnant women with 85% of pregnant women perform testing HIV during pregnancy.The 65% of them did not accessed HIV test because they had experience of having previous counseling.This may be because the trained counselor is not fully present in health care as a counselor for all pregnant women.This is not in the line with the research of Syahrir dan Amiruddin (2014) which has result there is a relationship between healthcare support and the use of VCT clinics.Health workers are an important component in the implementation of a health service.Therefore, the health provider's skill is an enabling factor that influences the utilization of a health service such as VCT service.
Health workers, midwives, have an influence on the community in utilizing a health service.This influence can be health officer support which becomes the driving factor in VCT clinic utilization.Information support form how HIV transmission and prevention information, and motivate the community to conduct voluntary HIV testing (Syahrir, W. Amiruddin, 2014).
The results of this study are also inconsistent with research conducted by (Ardhiyanti, 2015) which stated that the role of midwives in advocating pregnant women to conduct HIV testing is to provide support in the form of providing information on HIV / AIDS which is fully provided to clients until the client understands and give her permission to conduct HIV testing.Support for this study form of information has been well done by the midwife but did not cause any behavior change on HIV testing in pregnant women.Knowledge of information forms is also important in influencing a person to make decisions.Knowledge is a knowing result, and the results of sensing of a particular object that is done using the five senses of human which are the sense of sight, hearing, smell, taste, and touch (Notoatmodjo, 2007).Knowledge is one of the predisposing factors that influence the utilization of VCT services by the community.Knowledge is in the form of information that is known by the respondent during the counseling process (Syahrir dan Amiruddin, 2014).
Therefore, the importance of a midwife as a counselor has good knowledge in accordance with research conducted by O' Connell and Downe (2009) shows that midwife knowledge about strategy for prevention of vertical HIV transmission is one of effort in order to reach the target to reduce MTCT (Mother to Child Transmission).This study shows that knowledge upgrading can change the behavior of a midwife.High knowledge will affect the quality of care provided to pregnant women with HIV / AIDS.In addition, extensive knowledge about HIV / AIDS will allow midwives or carers to be aware of the transmission of the virus and will encourage to meet the availability of resources used to apply the principle of infection prevention.But there are other things that affect it.It is the importance of support in the form of emotional and appreciation.In research conducted by Rahmandani et al (2010) stated that there is a strategy that can be done with a behavioral approach.It can affect a person in doing the examination which is one of them by providing emotional support or appreciation.It can be done by asking the client to complain or tell about their problems.A good coping strategy will greatly assist the success of the adjustment whereas failure of the mitigation will result in poor adjustment (Bishop, 1995in Rahmandani, 2010).
One form of emotional support and appreciation can be proven by the process of interpersonal communication between patient and counselor or midwife.This is in the same line with Arumsari et al (2013) which stated that interpersonal communication strategy is absolutely necessary for a wellestablished relationship to be conducted by instilling confidence in HIV patient to the counselor until openness in communication process in VCT implementation.Further interpersonal communication is expected to generate feelings of empathy, intimacy, and openness between counselor and client.So, HIV patients can be independent in meeting their own needs and have a strong motivation and spirit to fight for life.
The importance of the interpersonal communication strategy is supported by Priyanto (2009) also stated that midwife's ability to apply therapeutic communication techniques requires exercise, sensitivity, and sharpness of feelings.Because of the successes of communication is not influenced by one's ability but by dimensions of value, time, and space.This can be seen through the impact of its therapeutic source for the client and the satisfaction of the client itself.So it can be a supporter of the client to take a more positive decision such as HIV testing.In addition, there are other factors that can affect the behavior of pregnant women to conduct HIV testing based on the results of research conducted by Anggarini (2014) stated that there are other factors that affect the examination of VCT in pregnant women.The factors are age, education, and employment.The age factor stated that the more mature respondents's age the more obedient did HIV testing.It is caused by maturity in thinking able to face and adapt to something new.It can be useful to make their own decisions without the help of a husband or parents and even in-laws.Notoatmodjo (2007) also supports the results of Anggarini (2014) who stated that the more mature a person the more experience his knowledge becomes and the more prepared to face something.This will affect compliance with VCT visits and checks.On the other hand, the level of education also has the effect.Education is related to the knowledge of the mother.The basic concept of education is a learning process.The higher the mother's education the easier it will be to receive information, so much of knowledge possessed, otherwise less education will hinder the development of one's attitude toward newly introduced values.It is also suggested by Notoatmodjo (2007) that stated low education can lead to irrational thinking and superstitious beliefs.This mother will be hard to accept new things.In Anggarini (2014) shows that all respondents with basic education do not conduct HIV testing because of knowledge is lacking and acceptance of new things around them will be slow and may be difficult.Similarly, respondents with secondary education, although the level of education is quite good, lack of socialization given to mothers about HIV testing and stigma against HIV sufferers make mothers being afraid to conduct HIV testing.
Employment is also one of the factors studied by Anggarini that can cause pregnant women to do HIV testing.By working as a civil servant or private employee, respondents will have hours of work, work environment, association in the work environment or association outside the home that can open insight about health.These reasons will support respondents to meet the needs of improving women's health.This is what makes pregnant women who work as permanent employees can spend the time to conduct VCT examination as an effort to meet the needs of improving women's health.Widyastuti (2009) also points out that women from lower-middle strata, working in the public sector are mostly driven by economic necessity.In order to meet the economic needs, they tend to ignore the fulfillment of the needs of improving women's health, in this case, do the HIV testing of pregnant women.In addition, respondents who work as traders and workers do not have hours of work, work environment, association in the work environment that can open insights about health and support respondents to meet the needs of improving women's health.This is what makes pregnant women who work as traders and workers cannot take the time to conduct HIV testing.
The existence of perceptions of risk is also one of the factors studied by Purwaningsih et al (2011) as a factor that may influence a person's decision to utilize VCT services.Individuals who have a perception that they are at risk for HIV / AIDS will consider doing VCT.HIV / AIDS prevention behavior will arise if a person feels that he or she is at risk of developing the disease.The vulnerability is a subjective condition so that individual acceptance, especially high-risk people for susceptibility to HIV / AIDS infection may vary.A person may be expressed as having a very strong vulnerability to HIV / AIDS if he/she has a belief that he/she is at risk of HIV / AIDS, having a friend or partner infected with HIV / AIDS, or having a history of behavior at risk for contracting HIV / AIDS.
A person may otherwise be exposed to a very weak vulnerability to HIV / AIDS if he/she does not believe that he/she is at risk of HIV / AIDS, has no infected friends or partners, and has no history of risky behavior.High-risk people with very strong vulnerabilities to HIV / AIDS may be encouraged to use VCT (Purwaningsih et al, 2011).Marital status can also affect a person's perception of the vulnerable conditions experienced.Wamoyi et al (2011) stated that the low utilization of VCT generally occurs among married individuals.A person who has been married and has lived a long life with her partner will think she has no risk of being infected with HIV because she believes in her partner so that the individual will not have the initiative to do VCT.In addition, environmental factors can be one of the driving factors that make the respondent feel strong seriousness towards HIV / AIDS so that it can motivate her to utilize VCT.According to Fisbhein (2000) in Purwaningsih et al (2011), environmental conditions are among the factors that can directly affect human behavior.
Support is generally given at the first visit of the pregnancy assessment.While the mother's decision to perform pregnancy checks vary.The ability of each respondent to remember when given support by midwives is different.So as to cause the possibility of recall bias.In addition, the existence of uncontrollable disturbing factors is also likely to cause bias.The samples are not representative and the another confounding factors such as spouse and family support did not conducted as the limitations of this study.So, the further research should increase the samples and measure the another factor which can influence the VCT behaviour.This can be used as an effort to awaken the awareness of the benefits VCT in pregnant women.