PREGNANT WOMEN’S EXPERIENCE DURING ANTENATAL CARE IN PRIVATE CLINIC MATERNITY NURSING

Maternity nurses are authorized health workers that provide antenatal care, but their roles and function in antenatal care services are not recognized by the public. This research aims to reveal the experience of pregnant women during antenatal visits in private clinic maternity nursing. Six pregnant women selected using purposive sampling underwent an in-depth interview in this descriptive phenomenological study. Data were analyzed through thematic content analysis with Moustakas approach. Three themes were identified in this study: 1) women experience good communication with maternity nurses; 2) women receive family-centered nursing care; 3) the schedule, cost, facility, and types of service meet the participants’ needs. This study suggests for nurses to improve their competencies in delivering antenatal care according to clients’ needs.


Introduction
Many pregnant women in Indonesia do not make antenatal care (ANC) visits. According to the World Health Organization, the minimum number of ANC visits during pregnancy is four times. Routine ANC visits can prevent maternal complications. The Indonesia Health Profile (Riskesdas) in 2013 showed that 81.6% (among 49,603 people) pregnant women do the ANC visit at least once during the first trimester, whereas only 70.4% pregnant women do the ANC visit routinely, which is at least four times during pregnancy. Moreover, almost 30% of pregnant women in Indonesia do not routinely check their pregnancy in accordance with standardized regulation, which is at least four times of medical pregnancy check-up (Ministry of Health Republic of Indonesia, 2013). Pell et al. (2013) found that the ANC visits of pregnant women are influenced by several factors, including interactions and communication of health workers with pregnant women, as well as the costs incurred for visiting pregnant women. This study depicted that the health workers delivering ANC can affect an expectant mother's willingness to do ANC visits. This issue can be avoided through the involvement of competent health workers, such as Obstetrician-Gynecologist (OB-GYN), general practitioner, midwives, and nurses (Ministry of Health Republic of Indonesia, 2010). ANC can be delivered by nurses, especially maternity nurses. However, the number of ANC visits on maternity nurses is still low.
This phenomenon can be attributed to the unrecognized competencies of maternity nurses, as evidenced by the low number of ANCs carried out by nurses. Constitution number 38 year 2014 article 28 about independent nursing practice states that every maternity nurse has a wide chance to start independent medical practice, specifically in ANC. The independent medical practice is expected to raise antenatal visit rates.
An independent medical practitioner that delivers ANC is private clinic maternity nursing ran by maternity nurses. This clinic has numerous clients from various districts or cities around the nation. Initial study showed that the clinic has around 15-20 visits per week. Most of the clients check their pregnancy from prenatal to postnatal.
In consideration of the phenomenon above, the experience and perception of expectant mothers in doing ANC visits on private clinic maternity nursing need further study.

Methods
This study used a qualitative phenomenological approach to understand the experience of expectant mothers in private maternity nursing practice. The participants of this study involved six pregnant women who regularly did ANC visits on independent maternity nursing practice. The participants were selected through purposive sampling. Data were collected by an in-depth interview subjected to thematic content analysis with Moustakas approach (1994). Data collected by conducting in-depth interviews were recorded, transcribed, and analyzed.
In this study, credibility of the data was maintained by confirming and clarifying the information submitted by participants regarding their experience in conducting ANC visits in private clinic maternity nursing. The results of the transcript should agree with the intent submitted by the participant. Researchers spent time with the participants before the interview to establish rapport and make the participants feel relaxed during the interview.

Results
Participants' Characteristics. The participants included in this study were pregnant women who stay in the same city as the clinic and those from other cities. The first, fourth, fifth, and sixth participants live in the city the same as the clinic, whereas the second and third live outside the city where the clinic is. Half of the participants were employed (first, second, and fifth), whereas the other half were unemployed. All participants were multigravida because the primigravida variation was not achieved.
In terms of educational background, one participant has level three associate degree, four participants have a bachelor degree, and one participant has a master's degree. The participants were also from various ethnicities: three participants are Javanese, one is Batak, one is Sundanese, and one is Betawi. The youngest participant was 28 years old, whereas the eldest was 34 years old. The gestational age of each participant during the interview varied from 25 weeks to 36 weeks. Meanwhile, the number of ANC visits of each participant ranged from three to five on average.
Theme One: Women Experience Good Communication with Nurses. This theme is supported by two categories. Category one shows the women describe the nurses as friendly, pa-tient, communicative, and informative. This experience was stated by all participants. The statement below is an example of two statements, "…the nurses here are really friendly, communicative, and informative. I feel welcomed." (P4) The other participant said, " … Alhamdulillah, all health workers (nurses) are friendly" (P2) Category two demonstrates the nurses use eyes contact, gestures, and good expression. The statement below is an example of two statements: The first participant says that the health workers show nice gesture toward clients during their visit.
"…what I like from here (the clinic), the nurses give good eye contact and gesture, and also their (facial) expression which can make feel assured. Well… mm... to me, those things can make me feel more comfortable psychologically." (P1) The other participant said, "…when talking to nurses, they have expressions, they pay attention to me, they don't do other work." (P5) Theme Two: Participants Receive Family-Centered Nursing Care. This theme is supported by three categories. Category one shows that the women associate the atmosphere in the clinic with that at home. This experience was stated by all participants. The statement below is an example of two statements: Category two exhibits that the women feel the clinic services involve husband, children, and other family members. Almost all participants said they felt free to bring children during pregnancy control. During the examination, the presence of children was also accepted by the health workers. The statement below is an example of two statements:

"… So, what I like from here (the clinic), err.. they (health workers) want us to feel… mmm … like being accepted (the newborn) by the family, so mm… the service here involves the family members… their service is not given to not just me, but also to my husband… like the information about my medical check-up is being told to my husband as well" (P4)
The other participants said, "... if I check (for pregnancy), they (the children) also like to be involved, listen to the sound of their sister's/brother's heart ..." (P4) Category three shows that the women are placed in a family-centered birthing room. This experience was stated by all participants. The statement below is an example of two statements: In addition, the delivery room in the clinic allows the client to be accompanied by her family during delivery.
"... giving birth is also there, we and the family remain in that room ... besides the mattress for me, there is a sofa for the family who are waiting" (P2) Theme Three: Schedule, Cost, Facility, and Types of Service Meet the Participants' Needs. This theme is supported by three categories. Category one shows the women have a flexible control schedule. This experience was stated by all participants. The statement below is an example of two statements.
One participant conveyed about the flexible visitation schedule.

"…the schedule (of antenatal visit) can fit in to my time, the class is on Wednesday and Saturday. Well I usually choose the Wednesday (class). And others who have jobs usually take the Saturday class" (P2)
The participants stated that the schedule for consultation is flexible; they can ask questions without time limitation.
"… in here (the clinic) I can freely consult (to the health workers)… it can be done anytime, by sms (short message service), so it's not being limited at all." (P4) Category two depicts the many types of ANC services experienced by the women. Almost all participants stated that the ANC activities in the clinic are not limited to physical examinations and that other forms of activity support ANC. The ANC activity package in the independent practice of maternity nurses includes the assessment of complaints and medical history, physical examinations, health education, prenatal classes, yoga, hypnobirthing, and pregnancy massages. This statement is illustrated as follows: Category three shows that the women feel the costs incurred correspond to the services obtained. All participants were satisfied with the services provided. Thus, the fees charged are not a problem for the participants. Some participants stated that the services in the private clinic are expensive but justifiable by the knowledge, quality of services, and facilities available. The statement can be seen as follows:

"... Yes, that is pretty good (the cost). It can't be said to be cheap, it's quite high, but ... but that's it ... If in my opinion, it is in accordance with the services provided." (P4)
The other participant said, "... yeah ... pretty high (the cost). But ... I don't think it is so high when compared to the knowledge and facilities provided. So, we have to sacrifice more to get something more... " (P2)

Discussion
Participants Experience Good Service and Good Communication from Nurses. The participants prefer independent nursing practice for ANC visits because the services delivered meet their needs and expectation. One service component experienced by the participants is the communication by the health workers in the clinic. All participants feel the workers are friendly, communicative, and informative. This type of gesture can make clients feel comforttable during their visit or consultations. By contrast, some participants shared their previous experience on another clinic where the nurses do not give eye contact. This theme is in line with the report of Ekott et al. (2013) that expectant mothers prefer competent and friendly health workers in a reliable clinic for their ANC routine. This finding is supported by the report of Shabila, Ahmed, and Yasin (2014) that pregnant women show a good perception toward nurses who communicate well, are friendly, and are polite in delivering care.
Health workers should be nice and friendly to expectant mothers during ANC visits. They also need to understand the needs and respect the privacy of clients. This gesture creates a comfortable atmosphere to clients during ANC visits. According to Rani, Bonu, and Harvey (2008), how nurses provide their time adequately to clients, how polite and how much care nurses can give to clients, and how respectful the nurses are to client privacy can be observed.

Participants Receive Family-Centered Nursing Care. Health workers or nurses in ANC
give their attention not only to expectant mothers but also to their families by involving them in deciding things or making choices. The workers must follow the process of communication, participation, and partnership with the clients' family before making a decision (Khatun, 2010).
In the context of ANC services, nurses not only provide nursing care to expectant mothers but also involve and collaborate with the clients' respective families by adapting the Family-Centered Maternity Care (FCMC) concept. This finding is in line with the finding of Katz (2012) that FCMC can increase the feeling of security and satisfaction of clients. Nurses can provide health education and nursing intervention to the clients' family for supporting expectant mothers during the prenatal period, thereby improving the health of the mother and the fetus.
The second participant says she pleasantly involves her child in doing antenatal class activities. Children can be involved in many activities, such as checking the baby's heartbeat and learning to accept and recognize the newborn child as their family member. Moreover, the husband can learn about pregnancy, childbirth preparation, and his role during those periods. This activity is in line with the report of Engel (2008) that FCMC is an approach in delivering obstetric care to encourage information exchange and collaboration among clients, families, and nurses by assuming that the clients' family and relatives care about and fully support them.
Participants also stated that the ambience of the clinic feels homey to them as unlike most clinics or hospitals. According to them, the independent maternity nursing practice does not have the aseptic smell, thereby providing comfort to the client. This finding is in accordance with Novick's statement (2009) that physical and ambience adjustment to antenatal clinics can be considered by expectant mothers when choosing their facility.

Schedule, Cost, Facility, and Types of Service Meet Participant Needs.
Aside from family-centered care, the participants also stated that the schedule, cost, facility, and types of service meet their needs. This response is supported by Eryando (2008), who explained that expectant mothers choose flexible antenatal clinics. Similarly, Shabila et al. (2014) found that expectant mothers rely on antenatal clinics that provide long consultation sessions and complete health education.
Moreover, Novick (2009) stated that expectant mothers choose a clinic with a short waiting time. In the present study, the participants conveyed that the clinic informs them about the schedule via phone. The participants also confirmed the good punctuality of the clinic.
Participants also commented on the clinic's attempt to provide complete ANC activities that are suitable to their needs. Expectant mothers need various activities aside from physical examination during their ANC visit.
According to participants, the ANC visit in the clinic begins with a medical check-up, which includes consultation on pregnancy and medical history. This procedure is necessary because nurses must understand their clients' conditions. This finding is in line with Khatun's research (2010), which explained that health workers must observe comprehensively the medical history of their clients to prevent prenatal complication. Cicolini et al. (2015) stated that a health assessment helps in making an appropriate clinical judgment and provides important information that can lead to the right diagnosis.
The participants reported that the medical checkups include physical examination, body weight measurement, tension check, eyes examination, Mid-Upper Arm Circumference, abdominal examination, fetal heartbeat examination, and ankle and foot examination for swelling. Baid, Bartlett, Gilhooly, Illingworth, and Winder (2009) reported that holistic nursing care requires patient assessment based on information obtained from interviews, physical examinations, and assessments of patient history. In addition, nurses must examine their client's head, hair, eyes, nose, ears, teeth, mouth, neck, breasts, respiratory system, cardiac system, and abdomen (measuring symphysis-fundus height, leopold, fetal pulse rate, and hyperpigmentation), extremity reflexes, pelvis, and rectum.
After medical check-ups, the clinic also provides various prenatal class activities. The class provides health education and complete materials about pregnancy, childbirth preparation, childbirth process, and newborn care. Fawole, Okunlola, and Adekunle (2008) stated that expectant mothers have a positive perception on antenatal clinics that provide health education about gestational age, breastfeeding, obstetric danger signs, nutritional needs during pregnancy, sexuality needs during pregnancy, activities during pregnancy, self-care, and positive affirmation to prepare normal childbirth.
ANC care includes yoga session, hypnobirthing, and massage. These activities are suitable for participants who desire for gentle birth and Vaginal Birth After Cesarean (VBAC). According to the participants, this type of class, activities, and materials cannot be acquired in other clinics.
Health services that provide satisfying information about client conditions are the choice of pregnant women. Novick (2009) reported that pregnant women seek information about certain topics, including pregnancy condition, self-care, signs of high-risk pregnancy, childbirth, baby care, family planning, psychosocial problems, and the role of partners. Pregnant women also want services to provide antenatal classes or groups where they can share their stories with fellow pregnant women.
All participants conveyed that they feel satisfied with the services provided in the private clinic maternity nursing. Thus, the service costs incurred are not a problem for the participants. The results of this study are different from those obtained by Eryando (2008), who reported that the cost is the main factor for pregnant women to choose antenatal clinics. However, the participants of the present study disagree with this statement and explained that they prefer considering the quality of the services provided than the cost.
The participants said the costs incurred justify the facilities and services provided. The private clinic maternity nursing has facilities that are sufficiently complete and comfortable so that participants feel satisfied. In line with the-se results, the study of Shabila et al. (2014) reported that pregnant women in Iraq have poor perceptions of ANC services because of uncomfortable waiting room facilities and the unavailability of laboratory and ultrasound utilities.
Pregnant women involved in this study stated that the independent practice of maternity nurses provides complete and comfortable facilities, including a safe, comfortable and comfortable bed. Other facilities such as waiting rooms, service rooms, delivery rooms, and facilities for children are also comfortable and complete in inspection equipment, which make the independent practice of maternity nurses attractive for expecting mothers who wish to pay ANC visits. The results of the present study are in line with Novick's research (2009), which stated that expectant mothers prefer antenatal clinics with play areas for children, a relaxing and informal environment that maintains client privacy, and a consultation place that allows clients and families to attend examinations.

Conclusion
The study involved six participants. Three themes describe the experiences of pregnant women in choosing the antenatal clinic. The first theme shows the participants' experience of good service and good communication from nurses. The second theme depicts the familycentered nursing care received by the participants. The third theme exhibits that the schedule, cost, facility, and types of service meet the participants' needs.
Maternity nurses should provide ANC in accordance with the needs and expectations of clients. Nurses should pay attention not only to the physical aspects but also to the biopsychosocio-culture in providing ANC.
Independent nursing practice is an attractive venue for antenatal visit routine. Thus, nurses should always deliver ANC services in accordance with the preference of clients. Provision of ANC services that meet the needs and expectations of clients can increase the number of ANC visits to the clinic.