Implementasi pelayanan maternal pada ibu remaja: “a scoping review” Implementation of maternal services for young mothers: a scoping review

Services for adolescents with pregnancy are the same interventions in antenatal care, intranatal care and postnatal care with other pregnant women. This scoping review (ScR) aims to identify mapping themes from the literature related to the implementation of motherhood for young mothers. The inclusion criteria were the original full text research articles published in 2010-2020, in English, and discussed the implementation of services for young mothers. There were 10 articles that were reviewed and obtained 3 service themes, namely factors that influence maternal care for young mothers, barriers to maternal care from the perspective of health providers and barriers to maternal services from the perspective of young mothers.


INTRODUCTION
Maternal care refers to the health of pregnant women during pregnancy, childbirth and childbirth (WHO 2021). According to World Health Organization (WHO) data (Kemenkes RI, 2015), adolescents are the population in the age range of 10-19 years. Of the 21 million adolescents aged 15-19 years who are pregnant and giving birth globally, 95% come from developing countries (WHO, 2011). The problem of adolescents in developing countries has now become a global concern, namely teenage pregnancy, this is because around 12 million girls aged 15-19 years and at least 777,000 girls under 15 give birth every year and at least 10 million cases of adolescent KTD occur annually in among adolescent girls aged 15-19 years (WHO, 2020). Of the estimated 5.6 million abortions that occur annually to girls aged 15-19 years, 3.9 million are perpetrators of unsafe abortion cases that contribute to maternal mortality, morbidity and other health problems (Darroch, J. E., Woog, V. and Bankole, 2016).
Maternal mortality rate (MMR) refers to maternal mortality caused by complications of pregnancy or childbirth. From 2000-2017, the global maternal mortality ratio decreased by 38% from 342 to 211 deaths per 100,000 live births, although the Sustainable Development Goals (SDGs) target is still far from being 70 deaths per 100,000 live births by 2035. UNICEF data shows that MMR in developing countries (Low Development Countries) decreased from 2010 by 520 to 415 deaths per 100,000 live births in 2017 (UNICEF., 2019). In Indonesia, the maternal mortality rate in 2015 was 305 deaths per 100,000 live births (Badan Pusat Statistik, 2018). Globally (WHO) the infant mortality rate (IMR) has decreased from 2010 by 65 to 39 deaths per 1,000 live births in 2018 (WHO, 2019). IMR in Indonesia in 2012 was 34 and decreased to 24 deaths per 1,000 live births in 2017 (Central Statistics Agency, 2019).
The indirect causes of maternal mortality in Indonesia are 4 too, namely too young, too old, too close and too many. In pregnancies and childbirth that are too young, previous research states that the risk of experiencing negative outcomes in physical and psychosocial aspects is higher for both mother, baby and husband (Dadi, 2020). However, the programs that have been implemented mostly focus on preventive efforts so that teenage pregnancy does not occur, while services for adolescents who are pregnant have not been specifically provided.
Adolescents with pregnancy receive the same intervention in antenatal care, intranatal care and postnatal care with other pregnant women. Research evidence shows that adolescent pregnancy has a higher risk of complications of pregnancy and childbirth such as anemia, postpartum hemorrhage, narrow pelvis, obstructed labor, premature birth and low birth weight (LBW). Other negative impacts are related to psychosocial, such as unpreparedness to become parents both mentally and financially which has an impact on depression and poverty (Endah Nur Wakhidah, Kusyogo Cahyo, 2017). In addition, the transition period to become a young mother is one of the most challenging changes in social, biological and psychological aspects (Anisa, 2020). Previous research suggests that the experiences of adolescents and young parents have cultural and religious influences on social policies and (Astuti, A. W., Hirst, J. and Bharj, 2019) The ScR question guides the development of inclusion criteria for ScR by including the PEO (Population, Exposure, and Outcome) (Peters et al., 2020). For the population, it does not have to include certain groups or conditions. For the population, certain groups or conditions do not have to be included, so that the population is young mothers. Exposure is a maternal service. Outcome also includes certain arrangements, in this case Implementation. Therefore, the question of ScR is "How is the implementation of maternal services for young mothers"? ISSN 2549-3353 Vol 5, No. 2, September 2021 Yayuk Puji Lestari et.al (Implementasi pelayanan maternal pada ibu remaja….)

Protocol
ScR consists of various types of literature that are reviewed further with a scope, namely the technique of mapping relevant literature in a particular field with a broad topic (Arksey and O'Malley, 2005). The use of the ScR results is highly relevant and provides a broad overview concerning the evidence for treatment problems before clinical practice guidelines are available (Peterson et al., 2017). The drafting and reporting of this ScR use the framework referred Reporting Items for Systematic Reviews and Meta-Analyzes Protocols for Scoping Reviews (PRISMA-ScR) with 22 checklist items as the guideline for authors in preparing good ScR research that will be published (Tricco et al., 2018). The PRISMA-ScR framework will improve the quality of research results that are presented in a more concise manner so that they are easy to read and improve the access to the articles identified in this ScR (Lockwood, dos Santos and Pap, 2019).

Eligibility Criteria
Articles reviewed must meet the inclusion criteria, namely articles that discuss maternal care for young mothers, meaning that articles that do not contain content on maternal services will be removed. The population included in this article is young mothers and health workers. The article is in English and is included in the review because it makes it easier for researchers to understand and analyze the content of the article. Articles to be published are articles written from 2010 to 2020. Only full text articles and original research are included. Irrelevant articles containing commentary articles, reviews, recommendations or policies will be excluded.

Information Sources
Literature search uses a database because it is more reliable in searching for literature and is faster than manual library search (Fry dan Attawet, 2018). These databases used were EBSCO, PubMed, ScienceDirect, and Wiley Online Library in order to provide more comprehensive insights than citation data derived from other databases (Cózar, 2018)

Search Strategies
The literature search was conducted by identifying relevant keywords and their use may differ from each database (Arksey and O'Malley, 2005) from published articles from tahun 2010 to 2020. The use of boolean operators namely AND, OR, and NOT aims to optimize the search for relevant articles (Bramer et al., 2018) by using keywords as follows: Implementation OR Use* OR Barrier* OR Attitude* OR Factors* OR Evaluating* OR Experience* OR Perception* AND Maternal care* OR maternal* health care* OR maternal health service* AND Young mother* OR Female adolescent* OR adolescent mother* OR early motherhood* OR Teenage mother* OR Youth mother*.

Selecting of Sources of Evidence
The selection process of articles was conducted by including the collected articles into reference management named Mendeley. Mendeley is free software that eases the researchers to organize, sort references by certain criteria, and allows direct import features from the database and to be used online (Da Silva and Pedrosa, 2017). Furthermore, the data were included into covidence, namely a web-based software that helps researchers in the process of ISSN 2549-3353 Vol 5, No. 2, September 2021 Yayuk Puji Lestari et.al (Implementasi pelayanan maternal pada ibu remaja….) filtering references and reflecting the multiphase review process (Kellermeyer, Harnke and Knight, 2018;University of South Australia, 2018). The selection process of articles begins with the screening of titles and abstracts conducted by the first researcher independently. Furthermore, complete text selection was carried out by the first and second researchers to see the suitability of the articles one by one. The third researcher rechecked the suitability of the article with the eligibility criteria.

Data Charting Process
The identification of specific and general information about the author, research location, year of publication, research methodology, population, type of intervention, and research results were carried out in the data charting process (Arksey and O'Malley, 2005). All researchers reviewed and identified each article simultaneously by determining the data below: a. Article identity: author's name, title, year published, country, the purpose of the article b. Research methods: type of research, research design, research tools, number and characteristics of respondents (young mothers and healthcare giver) c. Result: the findings from the research conducted.

Data Items
Data charting in ScR is the process of providing information about a logical and descriptive summary of the results of an research article that is in accordance with the objectives and questions of ScR to readers (Ghalibaf et al., 2017;Peters et al., 2020). Data charting was conducted by identifying general and specific information relating to the author, year of publication, location of the research, population, type of intervention, research objectives, and methodology, and important results of each article (Arksey and O'Malley, 2005).

Critical Appraisal Tools
The critical appraisal tool used MMAT (Mixed Methods Appraisal Tool), which is an efficient appraisal tool functions to assess the quality of research methodologies with various designs including mixed methods (Pluye, 2015). The latest version of MMAT (2018) focuses more on the quality of research methods rather than the article reports. Appraisal tools for mixed methods articles were not widely found in other critical appraisal tools. However, in the appraisal, there was no provision for value limits yet, so it was the authority of researchers to determine the limits of their appraisal (Hong et al., 2019).
The assessment was adjusted to the research method and design, then identified according to the assessment criteria according to the MMAT. The assessment criteria are divided into 3, namely No (score 1), Unclear (score 2), and Yes (score 3). Then the results of the assessment use the PAP (Benchmark Reference Assessment) method which is known as the absolute standard and is usually used in formative assessments (Nurbayi, 2012). Because each MMAT Critical Appraisal checklist has 7 question items and the assessment points are represented by numbers 1-3 where 1 is the minimum point and 3 is the maximum point, so the score range set by the author is 21 as the highest value and 7 as the lowest value with 14 as the mean. . The results were then categorized as follows: Good (15-21), good enough (8-14), and bad (<7).

Synthesis of Result
The synthesis of the results was presented with tables, pictures, diagrams displaying the characteristics of the article in the form of the year of publication, intervention area, country of origin, and research method, or in a description format explaining the objectives and scope of the review (Tricco et al., 2018).

Selecting of Evidence
PRISMA flowchart was used as a guide in ScR reporting consisting of 4 stages, namely identification, screening, eligibility, and included articles (inclusion) (Selçuk, 2019). Based on searching articles from 4 databases, namely Pubmed, Wiley, EBSCO, Sciendirect, 899 articles were found. Based on 899 articles identified by title and abstract, 159 duplicate articles were removed, bringing it to only 740 articles. A total of 379 irrelevant articles were removed and 361 articles were read in full text. After reading in full text, 351 articles had to be excluded because the population was not suitable (180), reviewed articles (11) and did not focus on discussing maternal services (Picture 1) (160).

Critical Appraisal
Critical assessment with MMAT obtained articles that have good quality with a score of A, namely articles 1, 3, 4, 6, 7, 8 and 9, while articles that get a score of B are articles 2 and 5. (see Table 1).

Results of Evidence
Analysis of the 10 articles reviewed found important information that was displayed through charting data (Peters et al., 2020) (see Table 2).

Synthesis of Results
From the 10 articles included in this ScR, it was found that 3 themes and 13 sub-themes as shown in Figure 3.

DISCUSSION
Based on the ScR theme mapping, three themes have been determined as follows: Theme 1: Factors affecting maternal care for young mothers 1. Knowledge A study suggests that adolescents have poor knowledge about pregnancy, sexual and reproductive health (Govender, Naidoo and Taylor, 2019 and their parents (Singh et al., 2019). The level of knowledge of young mothers affects mothers' attitudes towards maternal services. The results showed that adolescent mothers who had heard messages about antenatal care from the mass media or had had interpersonal communication with health workers were 2 times more likely to do ANC in full than adolescents who were never exposed (Singh, Kumar and Pranjali, 2014).

Educational Status
One way to enhance youth knowledge is through the education and health sectors. The role of the education sector is very important because schools can offer skills-based reproductive and sexual education (Govender, Naidoo, and Taylor, 2019). Educational status greatly affects the use of health services for adolescent mothers, when the study was conducted there was an increase in the use of maternal health services. Educated adolescents have the ability to access health care information and understand more about the importance of the negative effects of not taking care (Singh, Singh, and Singh, 2021). The higher the level of education the higher the level of ANC utilization (Banke-Thomas, Banke-Thomas, and Ameh, 2016).
Pregnant women who have tertiary education will have their pregnancies checked regularly to find out how the fetus is developing. A highly educated person has a strong desire to know her health. This encourages mothers to find out information about their pregnancy, the higher one's education will affect one's behavior (Inaya, 2019).

Economic Status
Economic status is a very important factor in the use of quality health services. Mothers with low economic status and mothers with higher economic status tend to use more maternal health services. This can result in low coverage of young mothers' medical care by mothers of high or low economic status  The low economic status is caused by the lack of public attention to health and their inability to fulfill their basic daily needs. In addition, families with low economic status do not have the resources to pay for medical expenses, while families with high economic status can spend most of their income on medical care. It is often found that young mothers with low economic status are uneducated, unemployed, separated from social networks or excluded, therefore, programs that rely on the mass media for information dissemination to use highquality health services have fewer visits to them (Singh, Kumar and Pranjali, 2014).

Parity
Parity is a very important factor in the use of quality health services. With regard to the utilization of health services, several studies have emphasized the care of delivery before and during the delivery of a second or more child, compared to the delivery of a first child . The results of other studies indicate that the use of maternal health services and social development shows the number of births has a more significant impact on the use of maternal health services. Other studies have also suggested that mothers with first children are more careful with their pregnancies than mothers with second or more children, and that generally the first child is more likely to have difficulties during childbirth (Fulpagare et al., 2019).
In addition, with the increasing number of pregnant women, mothers rely more on experience and knowledge in previous pregnancies. The reason for the lack of use of maternal medical care during the second pregnancy is because the mothers have built up self-confidence. Beside that, the mothers do not consider modern medical care necessary because they have gained experience and knowledge from previous pregnancies and deliveries (Maharjan, Rishal and Svanemyr, 2019).

Tradition and Culture
Tradition and culture are important factors in the use of quality health services. A mother goes to her parents' place to give birth, especially her first pregnancy. In this case, the location of delivery and delivery assistance is very dependent on the characteristics of the parents, parents must provide the best care for their daughters during pregnancy and delivery. Therefore, as the number of births increases, the likelihood of using maternal health services may decrease. However, this study recommends that family problems with high rates of adolescent mothers are addressed through visits of local health officials to provide appropriate consultation on the use of maternal health services (Mekwunyei and Odetola, 2020). Other researches also indicates that the marriage culture and pregnancy of girls are normal, and marriage after the age of 20 is considered undesirable. Indeed, many people worry about not getting married by the age of 20 (Sychareun et al., 2018).

Healthcare Service (Access to health services) (distance and costs)
Location and cost are the barriers to accessing health services that are felt by young mothers. The remote location of health service facilities is an obstacle for adolescent mothers. In some remote areas ox carts and motorbikes are used as transportation to health facilities. During the rainy season, bad roads prevent teenage mothers from going to health care facilities. The opening hours of health service facilities are not flexible so teenage mothers have to wait to be able to have themselves checked (Sarker et al., 2019). Most young mothers are worried about financial problems so they decide not to visit health services. Service, medicine and transportation costs are barriers for many youth to access health services (Sychareun et al., 2018).
Although there are maternal health service facilities for adolescents, which are public facilities where services and commodities are supposed to be free, there is often a shortage of ISSN 2549-3353 Vol 5, No. 2, September 2021 Yayuk Puji Lestari et.al (Implementasi pelayanan maternal pada ibu remaja….) medicine stocks so that teenagers are expected to buy some medicines and birth supplies. For adolescent mothers, most of whom do not get the support of their husbands or parents, buying medicine and supplies for birth can be expensive and burdensome (Apolot et al., 2020). In Nepal, each pregnant woman receives 500 rupees (5 $) to give birth in a public health facility but this amount is not enough to cover the cost of an ambulance (Sarker et al., 2019).

Quality of Health Service
The quality of health services for young mothers is assessed by the availability of service facilities and the skills of health workers in providing maternal services to young mothers. Limited visual and voice privacy during services, long waiting times, unreachable maternal health services, limited family planning services, and the lack of post-abortion care services make maternal health services uncomfortable, especially for unmarried adolescents and lead to exclusion health services (Apolot et al., 2020).

Support for the young mothers
Young mothers who are going to become parents really need the support of their families and partners, this is an important factor to help young mothers care for and nurture and look after themselves and their babies. In addition to family and social support, young mothers need good antenatal care so that they must be given counseling on how to care for babies and breastfeeding as well as postpartum care must be strengthened in child care and contraception (Sarker et al., 2019).
Being a young mother is not easy. Young mothers have financial problems and need financial support, emotional support, psychological support. Pregnant teens need help. They need to know where to go, what to do and what kind of help they can get .

Availability of Human Resources
Health care providers have difficulty with the clinical structure. Health workers stated that they also experience difficulties in providing systemic care due to limited human resources. This limitation is associated with poor quality aspects of care. This is also exacerbated by the difficulty of working with adolescents . Providing care for pregnant adolescents is somewhat limited by matters related to labor, time and network environment .

Service Standards
Health workers expressed concern over the lack of guidance they received, especially the availability of standard procedures regarding teenage pregnancy. Health workers also do not know exactly where they are in the network of institutions dealing with teenage pregnancy issues. This limits the ability of health workers in terms of extending their support to include matters relating to financial, emotional and psychological domains .

Skills
Health service providers admit that there is no special training on how to provide services to young mothers. Many health service providers do not have the skills related to the needs and ways of providing maternal services to adolescents. This deficiency causes health care providers to have a negative attitude towards adolescent mothers so that they cannot understand and apply good communication and counseling according to the developmental stages of adolescent mothers. Knowledge, attitudes, ways of communication and counseling ISSN 2549-3353 Vol 5, No. 2, September 2021 Yayuk Puji Lestari et.al (Implementasi pelayanan maternal pada ibu remaja….) skills of health service providers can build a trusting relationship between adolescents and care practitioners so that maternal care can be provided optimally (Singh, Kumar and Pranjali, 2014). The importance of counseling and educational delivery in maternal health programs is given in an empathetic and nonjudgmental way. Health service providers state the importance of reproductive health education in the school environment to help prevent health-threatening behavior during adolescence (Maharjan, Rishal and Svanemyr, 2019).

Economy
The perspective of health workers from an economic point of view on young mothers greatly affects maternal services. Most of the young mothers get pregnant and give birth only to get support from the government. Teenagers who become pregnant and become parents are described as unemployed and have low socio-economic backgrounds, because they do not have financial reserves to care for their babies (Govender, Taylor and Naidoo, 2020).
Theme 3: Barriers to Maternal Care from a Teenage Mother's Perspective 1. Psychological a. Stigma from health service providers and the public Some health care providers have a negative stigma against young mothers which has the potential to reduce adolescent perinatal care. Untrained clinical staff often label, denigrate and stereotype adolescent mothers thereby undermining the primary objective of providing high quality patient-centered healthcare by healthcare professionals. The social stigma of adolescent pregnancy is rooted in cultural values and negative stereotypes that translate teenage pregnancy into a stigmatized identity .
Lack of empathy and ignorance of midwives and doctors in maternal services often make young mothers feel uncomfortable and do not want to come back to health facilities (Sarker et al., 2019). Harsh treatment of health workers such as scolding young mothers during examination (Sychareun et al., 2018). Sometimes doctors and midwives say harsh words that make young mothers traumatized to come again to health facilities (Sarker et al., 2019).
The social impact experienced by young mothers must face stigma. They are treated badly in their home and living environment. Young mothers are often forced to look after themselves and their babies because their families don't want to be responsible for looking after young mothers and their babies. In the community, young mothers are looked down upon so that it is difficult for them to communicate and interact with the surrounding community (Sarker et al., 2019).
Teenage pregnancy is generally understood to be a pregnancy that is always negate. Research shows that the younger the pregnant teenager, the greater the negative stigma attached to it. Younger adolescents, especially those aged 17, experience greater feelings of fear and shame than older adolescents (Olivia et al., 2020).
b. Ashamed The delay in ANC examinations is usually caused by a lack of openness between young mothers and their families, young mothers are afraid to reveal their pregnancy because they are afraid to embarrass their family and are afraid to accept the consequences of their parents if they reveal pregnancy (Olivia et al., 2020). Young mothers, especially mothers who are single or unmarried, are afraid of losing their reputation and being gossiped about when visiting health services. Feelings of shame discourage unmarried young mothers from visiting health services. Young mothers usually do self-medication if they have reproductive problems and buy contraceptives at pharmacies. Shame, lack of self-confidence and limited understanding of the potential and benefits of giving birth in health care facilities make hospitals the last choice for young mothers (Sychareun et al., 2018).
c. Afraid ISSN 2549-3353 Vol 5, No. 2, September 2021 Yayuk Puji Lestari et.al (Implementasi pelayanan maternal pada ibu remaja….) The presence of male nurses in providing maternal services to young mothers is one of the problems that causes young mothers to choose to give birth at home. Young mothers feel embarrassed when served by male nurses (Sarker et al., 2019). Lack of privacy in local hospitals and health facilities is often raised as a matter of concern, leading to fear for young mothers if their visits to health services are seen by friends, relatives or community members (Sychareun et al., 2018) 2. Economy Young mothers who live in remote areas with low economic conditions are worried about the costs involved in visiting health care facilities. The cost of concern is not only about treatment costs but also transportation costs to health service facilities. Most of the teens also think that if they don't have the money then the doctors won't want to provide treatment and just leave them alone (Sychareun et al., 2018) Limitations The limitations of this study are the first, although a thorough literature search has been carried out, it is possible that the article was missed. Only articles in English are included, which may result in data loss. However, there are advantages, namely that this study was prepared based on a clear and detailed PRISMA-ScR protocol so that it is expected to provide useful information.

CONCLUSION
Many factors influence maternal care for young mothers. Services for pregnant young mothers have not been provided specifically. This ScR has identified mapping themes from various literatures related to maternal care for young mothers. However, the results of the study still indicate a limited theme of findings in this study. Further research is needed on maternal services specifically for young mothers, such as effective maternal care practices or measurement of the quality of maternal services in various countries so that an overview of maternal services specifically for young mothers can be found. This is useful in providing information in developing strategies or programs to improve the quality of maternal services especially for young mothers.