Down-to-earth Approach as A Sociological Solution: Learning from Ineffectiveness of Maternity Waiting Home Implementation in Wonogiri, Indonesia

A maternity waiting home is a health facility that is considered helpful in preventing maternal deaths. The service aims to be a transit place for pregnant women to get primary health services. Due to geographic reasons, there is a waiting house for births—many cases of successful implementation of maternity waiting homes in various developing countries, especially in African countries. As a developing country, certain regions in Indonesia have implemented the service in imitation of the successful implementation of other countries. However, the implementation is not entirely effective. This study explores the root barriers in the implementation of the service from a sociological perspective. This study uses a qualitative research method with a case study approach. The data were collected through literature study, observation, in-depth interviews, and FGD. The results of this study were that various factors were found that caused the implementation of the maternity waiting home to be ineffective. Using a sociological analysis, the top-down policy of the maternity waiting for home is a significant factor in this ineffectiveness. This paper presents a concrete solution that uses an approach to emphasize the aspirations and needs of the community as a foundation in the implementation of this service.


Introduction
A maternity waiting home is a health facility considered beneficial in some locations in the world. Maternity waiting home aims to be a transit place for pregnant women to get primary health services. Maternity waiting for home is provided to get access closer and prevent the delayed treatment of pregnant, parturient, and post-partum women and neonates, particularly in areas with difficult access to health facilities. Pregnant women domiciling in the difficult-access areas should stay temporarily in Maternal Waiting Home up to her post-partum period (along with the baby she bears), in order to be close to puskesmas (public health centre), that can give maternity assistance or Regional/Central Public Hospital [1]. Due to geographic reasons, there is a waiting house for births-many cases of successful implementation of maternity waiting homes in various developing country, certain regions in Indonesia have implemented the service in imitation of the successful implementation of other countries.
Some studies have evaluated the effectiveness of Maternity Waiting Home intervention in developing countries in the world [2][3][4][5][6][7]. In Ethiopia, Maternal Mortality Rate is lower in women working in hospitals through maternity waiting for a home than in those going to the hospital straightly [8]. In Zimbabwe and Niger, the use of maternity waiting for home improves the potential parturition in hospital healthily and contributes to decreasing maternal mortality rate by ten times in hospital [9]. In Latin America, the successful experience with maternity waiting for home has been documented in such states as Nicaragua, Cuba, Brazil, and Columbia [10].
Maternity waiting home is a governmental program designed to decrease maternal mortality due to the far distance from healthcare facilities. Poor pregnant women with maternal insurance or Jampersal can utilize the maternity waiting for home facility [11]. Several regions have implemented maternity waiting homes in Indonesia with their challenges and success stories [11][12][13][14][15].
No charge is imposed on those using this facility, and Wonogiri Regency's Government assumes all costs. In Wonogiri Regency, there are five maternity waiting for homes in five different sub-districts. The maternity waiting home in Wonogiri Regency is located well, not far from the hospital. The maternity waiting for home is a fitting room or house leased by Wonogiri Regency's Government with the cost determined to support the primary healthcare facilities existing. In addition to physical facilities (building and ambulance), Maternity Waiting Home is also supported by experts in the sense of midwives and nurses. In addition, the women about to give birth and willing to transit in Maternity Waiting Home will get food facilities for two persons.
Wonogiri Regency's territorial condition consists of steep hills, slope hills, karstic hills, particularly in the south, including a thousand mountain rows and constituting water source from Bengawan Solo, despite some level land and beach. Broad area and unlevel land require the government of Wonogiri Regency to provide some public facilities like transportation, telecommunication, and the significant one, healthcare facilities.
Indeed, the presence of public health facilities will improve the health of the people surrounding. Public health degree is affected by four factors: behaviour, environment, healthcare service, and genetic factor. Therefore, the development of the health sector is closely related to and is affected by education, social-cultural, demographic and geographic, environment development, natural and living environment, and other aspects.
In Wonogiri Regency, Puskesmas and Puskesmas Pembantu are the pioneers of equal distribution of primary healthcare services. Up to the end of 2015, there have been 34 units of Puskesmas. Thus, the mean ratio of abscissa to 100,000 people is 2.71 or, on average, 2 or 3 abscissae per 100,000 people [1]. To improve the service quality, some puskesmas have been upgraded to be the one with treatment facilities. This treatment abscissa is mainly located far from the hospital, in the accident-vulnerable road and remote areas. Up to 2019, there are inpatient departments in Wonogiri Regency: Pracimantoro, Wuryantoro, Baturetno and Purwantoro [11].
This research explores Maternity Waiting Home in Wonogiri Regency, Central Java. The Maternity Waiting Home in this region can be divided into five areas: Pracimantoro, Purwantoro, Wonogiri, Wuryantoro and Baturetno. This research collected data from the caretakers of maternity waiting for a home, health workers, and informants or people surrounding. In addition, FGD (Focus Group Discussion) has been conducted, in which stakeholders were invited to discuss the implementation of maternity waiting homes.

Methods
This research was a qualitative study with interview and focus group discussion, with interview and focus group discussion being the techniques of collecting data. Informants of the research were stakeholders in the implementation of maternity waiting homes in the Wonogiri Regency. The informants consisted of health service offices, caretakers of maternity waiting for a home, including physicians or midwives existing in the facility, pregnant women, and surrounding people. The sampling method used was purposive sampling. Data analysis was conducted using an interactive qualitative data analysis (Miles and Huberman, 1994). Data analysis was conducted by exploring the result of research and making elaboration with the theory becoming the reference of research. The theory used as a reference in this study was Weber's social action theory. This study employed a source triangulation model through clarifying data based on different information sources.

Results and discussions
There are five Maternity Waiting Homes in Wonogiri Regency, distributed in five different sub-districts. The maternity waiting home in Wonogiri Regency is located well, not far from the hospital. The maternity waiting for home is a fitting room or house leased by Wonogiri Regency's Government, with the cost specified to support existing primary healthcare facilities. Some obstacles were encountered in its implementation. One of them is the less enthusiasm among the users, in this case, pregnant women.
Pregnant women said they were less interested in attending the maternity waiting room because its use would be troublesome, as they should stay there first. In 2018, many pregnant women used maternity waiting homes due to referrals in Wonogiri. The facilities existing in the maternity waiting home are guest room, kitchen, bathroom, toilet, and bedroom. The government provides the fund through the Jampersal program. The caretakers of the maternity waiting home inform that the home was intended for remote areas originally. Having arrived here, within no more than 30 minutes, pregnant women will instead prefer going home.
Considering the result of an interview with the caretakers of maternity waiting homes existing in Wonogiri, this home is less desirable to the people surrounding it. It is more appropriate to be located outside Java because healthcare facilities are more complex than in Wonogiri. The maternity waiting room is considered inefficient because the location of a primary healthcare facility is not too far. Time taken to wait and bring temporary personal equipment to Maternity Waiting Home is considered ineffective, moreover in patients with an emergency condition.
Considering the challenge and problem existing in maternity waiting homes, an appropriate solution should be formulated with a relevant approach. The author offers a sociological approach to help solve the problem existing. The author uses the terminology 'down-to-earth' to call this solution. Terminologically, the phrase down-to-earth can be defined as the characteristics of being open and honest, pragmatic, realistic, and capable of adapting to the actual reality.
In reality, the direction of maternity waiting for home policy implementation is topdown rather than bottom-up. The maternity is waiting for home policy results from the central government's perception on the urgency of it. It is followed up by the implementation of maternity waiting for homes existing in Wonogiri. Theoretically, maternity waiting for home has an essential function in preventing the maternal mortality rate. It is implemented by providing a temporary waiting place for pregnant women to bridge the far geographic distance to the primary healthcare service in an emergency condition. However, the top-down policy that is not aspirational or coming from the actual need implements maternal waiting home hindered. The obstacle is related to people and even health workers being uninterested in this program. Socialization has been conducted adequately, but people are still uninterested in using this program.
According to Max Weber [16], social action can be classified into four groups (types) to explain the meaning of action by the context of its actors' motive: instrumental rationale, value-oriented rational, traditional, and practical actions. • Instrumental Rational Action. An individual does this by considering the compatible means used to achieve the objective using the existing instrument. It is the action determined by the expectation of an object's behaviour in the environment and other human's behaviour; these expectations are used as the condition or a means of achieving the actor's objectives through reasonable effort and calculation. • Value-oriented Rational Action. Value-oriented rational action implies that the tools used are only conscious considerations or calculations, while the objectives have to exist about the absolute individual values. This action is rational and takes its benefit into account, but the objective to be achieved does not matter too much to the actor. The actor only assumes that, most importantly, the action belongs to good and right criteria according to surrounding people's measure and assessment. The action "specified by a belief aware fully of ethical, esthetical, religious behavioural values or other behaviour, independent of its prospect success". • Affective action. This action is primarily dominated by feeling or emotion, without reasoning. This action is often taken without mature planning and full consciousness. So, it can be said that it is a spontaneous reaction to an event. It is the action determined by the actor's emotional condition. Anger, love, and piety are examples of effective action. • Traditional action. This action is an irrational one as it is oriented to tradition. An individual takes this action due to the habit prevailing within society without realizing the reason or planning it first about the objective and the means used. This action is determined by the actor's behaving way done habitually and commonly. Such a mechanism of action is always based on normative laws specified firmly by society.
The sociological analysis relevant to dealing with this ineffectiveness of implementation is to see the problem from a rational social action perspective. In sociological theory, Weber uses the rationality concept in his classification of social action. According to Max Weber, rational action is human action that can influence other individuals within a society.
When an individual acts rationally, one will consider it from the need aspect of the importance of action. If the action is considered unimportant or another alternative more accessible or equally good action, the action will unlikely be taken. This principle applies to the social action of the users of maternity waiting for home service, namely people and health workers. If they do not have an incentive to use this service because they assume it is unnecessary, it will not run well.
This 'down-to-earth' approach can be applied by using the principle of communication and participating in the implementation of maternity waiting homes. Those interested in this service implementation should discuss to find the solution appropriate to the people's needs. This forum of expressing aspiration is essential to make the subsequent maternity waiting for the home implementation effective and targeted. Even if necessary, the reduction of the number of maternity waiting homes in Wonogiri can be recommended. The aspiration of those interested should be understood jointly to implement as needed.

Conclusion
From the explanation above, it can be said that the implementation of maternity waiting for home is not fully effective because this policy is top-down. This policy is not compensated with the surrounding people's needs. Therefore, this article encourages the new approach in this context, the down-to-earth approach. This approach emphasizes people's aspirations and needs as the material of consideration in formulating policies, particularly in this implementation of maternity waiting homes.