Midwifery Continuity of Care in Indonesia: Initiation of Mobile Health Development Integrating Midwives’ Competency and Service Needs

Midwives’ competence in providing continuity of care using mobile health (mHealth) applications is limited in developing countries. This study identified and explored midwives’ competency and service needs to develop mHealth in Midwifery Continuity of Care (MCOC) education and training. It used an explanatory sequential mixed method, and was conducted from August to December 2021. A cross-sectional approach was used to find the characteristics and competency scope of 373 midwives in West Java, and continued with a qualitative design through a Focus Group Discussion (FGD) of 13 midwives. Descriptive data analysis (frequency, mean, deviation standard) and qualitative data analysis (coding, sub-themes, and theme) were conducted. In terms of the midwives who participated in this study, more than half were aged ≤ 35 years (58.98%), with a working period > 10 years (56.30%), had diploma degrees (71.12%), and used smartphones on average 1–12 h/day (78.28%). Most midwives needed to develop competency in the MCOC scope, including its early detection of the risk factor of complications and treatment management. They were concerned about the purposes, benefits, and design of mHealth. In summary, midwives’ competency indicators for early detection are more needed in MCOC using mHealth. Further research is required to evaluate midwives’ competence in MCOC using mHealth.


Introduction
The World Health Organization (WHO) 2017 reported that around 810 women die every day due to complications of pregnancy or childbirth in the world [1]. In Indonesia, decreasing the Maternal Mortality Rate (MMR) is still an unfinished agenda, with 305 deaths per 100,000 live births. Meanwhile, Sustainable Development Goals (SDGs) target a reduction in MMR by 70 per 100,000 live birth in 2030 [2]. In this case, the WHO recommends that all developing countries provide midwifery services with continuity of care at the primary care level to accelerate the reduction in MMR [3]. Midwifery continuity of care (MCOC) starts from pregnancy, childbirth, and postpartum to provide satisfaction for mothers to receive midwifery care [4,5]. Maternal satisfaction with maternity care is an essential indicator of the quality of delivery services [6]. This is because the quality of maternal and infant health services is determined by the management of MCOC through a and contraception services while supervising CHWs in Posyandu. To facilitate data quality verification in Posyandu and MCH data monitoring, Rinawan et al. built Posyandu mHealth, called iPosyandu, in 2017, starting for CHWs, currently extended to midwives/bidan, named the iPosyandu Bidan app [16,38,43]. This app development is conducted as it is essential for fulfilling the need to increase midwives' competencies integrated with their services based on mobile health that can facilitate midwives to develop themselves according to their profession [18]. The application menu should refer to the midwives' competencies and service needs to ensure the quality of mHealth [44], as midwives need to be well prepared to have the capacity to change client health outcomes through the adoption of evidence-based practice. In this case, education and training that are appropriate to the context and meet the different needs of midwives must be available to support the professional growth of midwives [45]. A needs assessment was conducted to understand midwives' education and training needs, including addressing gaps in the availability and access to quality education in general and training in particular [46]. A recent systematic literature review stated an urgent need for midwives' competency because of existing gaps in quality competency involving education, training, and services' provision [34]. In the last decade, the gaps solved in simulated learning can potentially benefit midwives' skills because it impacts educational and clinical skills [47]. Nowadays, solving the gaps with technological advances is challenging [33]. Competency in using mHealth to solve those gaps is limited [48]. The development process should identify and address the competency needs of midwives in education and training [49]. This study aimed to identify and explore midwives' competency and service needs to develop mHealth in MCOC education and training.

Study Design
This study used an explanatory sequential mixed method, consisting of quantitative research using a cross-sectional design and qualitative research using Focus Group Discussion (FGD) ( Table 1). Quantitative research was conducted from August to November 2021, and then qualitative research was performed in December 2021. First, the quantitative analysis aimed to identify the needs of midwives for the characteristics and competency scope of MCOC using mHealth. After that, mHealth was developed according to the needs of midwives in providing MCOC using qualitative research.

Recruitment and Participants
Quantitative research subjects included midwife participants in West Java Province, Indonesia, using a convenience sampling technique. It resulted in 373 midwives who participated in this research. The research used a questionnaire containing the competence of midwives based on the scope of early detection and treatment of risk complications during (1) pregnancy, (2) childbirth, and (3) newborns, as well as (4) the puerperium contained in the Decree of the Minister of Health of the Republic of Indonesia No. 320 of 2020 concerning the professional standards of midwives. The risk of complications refers to risk factors that are found before complications. For example, when performing anamne-sis, a midwife can assess determinants, such as at-risk behaviors and history (the "4 toos": too young; too old; too close in labor time; and too many children); additionally, on performing a physical examination, e.g., vital signs, head to toe, including abdomen examinations (Leopold I-IV), and then laboratory tests [50].

Research Ethics
Quantitative research data were collected using a Google form questionnaire (online), which was provided via WhatsApp. Detailed information was explained on the initial page of the Google form regarding the researcher's identity, research title, objectives, content, confidentiality, ethics, questionnaire, length of time to fill out, functions, and benefits of the survey. After the participants read and understood the information, we asked them to voluntarily and independently answer the truth based on their perception towards the questionnaire items. Then, informed consent was filled in (yes or no) upon their agreement. Once agreed, they could go directly to the next page, containing more detailed procedures for answering the questionnaire. Participants received incentives (internet quota) after completing the questionnaire. The research was conducted after obtaining approval from the Health Research Ethics Committee of the Faculty of Medicine, Universitas Padjadjaran, with the number: 640/UN6.KEP/EC/2021.

Quantitative Research
The results of this study consisted of the characteristics and indicators of competency MCOC on 373 midwife participants in West Java Province, Indonesia. Then, the survey results were explored through qualitative research with a Focus Group Discussion (FGD). Table 2 shows that midwives who need mobile health-based MCOC competencies have characteristics that mean they were: mostly 35 years old (58.98%); with a working period > 10 years (56.30%); possess a diploma as final education level (72.12%); and the scope of competencies needed by midwives in the early detection and treatment of risk complications in MCOC (84.99%). Most midwives use smartphones 1-12 h/day (78.28%), for social media (28.15%). * age cut-off on adaptation in using mHealth [51]. Table 3 shows midwives assessed the importance of all indicators of competence in midwifery care, namely three indicators of competence in childbirth, nine for newborns, and one for postpartum care (mean ≥ 3.60). Nevertheless, midwives assessed that the competency indicators for caring for newborns were less critical in mothers with human immunodeficiency virus (HIV), hepatitis, and syphilis (mean < 3.60).

Qualitative Research
Based on the survey results in Tables 2 and 3, midwives assessed the importance of competence to provide MCOC using an android smartphone, especially for communication, information, and education to patients. Then, qualitative research was conducted through a Focus Group Discussion (FGD) to explore the survey results.
Midwives as informants in qualitative research have the characteristics stated in Table 4, including gender, age, employment status, years of service, last education, and job placement. The results of the qualitative analysis were explored under three themes including the midwife's characteristics, MCOC competencies, and health services as the basis for designing mHealth applications ( Table 5). The themes involved were: (1) the first theme was the midwife's characteristics, consisting of three sub-themes: education level, experiences, and professional standards. The increase in the competence of midwives is influenced by their educational background and length of service experiences. Midwives who often handle midwifery cases, means that they gain experience and are motivated to obtain up-to-date information through education and training; (2) the second theme is the MCOC competencies starting from pregnancy, childbirth, newborns, and the puerperium. Midwives need competence in the early detection and treatment of risk complications while providing MCOC based on professional standards and midwife's authority; (3) the third theme is mHealth. Midwives already use smartphones with various learning applications and health services. In providing MCOC, they need a mobile health application to help record and report the results of continuous maternal and infant health checks. Therefore, the application required a complete MCH services menu such as pregnancy, childbirth, postpartum, infants, and children, telemidwifery containing a combination of digital communication using robots (chatbots) and semi-automatic chatbots (communication with clients using a variety of chatbots and midwives), and inter-professional collaboration (IPC) referral communication with other professions such as a doctor, nutritionist, and health promotion officer. Along with the services menus, education, and training for midwives are essential supports. The image and color of the app's icon correspond to the MCH book owned by the client for recording the results of MCH checks from when the mother becomes pregnant, gives birth, postpartum, and infant health checks, including immunization. The themes and sub-themes of competency and service needs in MCOC as the basis for designing mHealth for midwives were developed as learning media for MCH education, training, and health services. The application design includes dashboards, menus, the content of each menu, features, and icon images for menus in mHealth. Figure 1 shows that midwives providing continuity care need a mHealth application for learning and providing health services including counseling or health education to patients using telemidwifery. By these features, midwives can detect complications early in pregnancy and provide treatment during pregnancy. Thus, it prevents complications in childbirth, newborns, and the puerperium. After providing the services, the midwife's duties are recording and reporting the results of MCH examinations. The statement was obtained from informants that midwives needed mobile applications because they made it easier to record and report MCH data anytime and anywhere by using a smartphone. The mHealth contains a menu based on a cohort form containing data on the health of pregnant women, mothers in labor, infants and toddlers, postpartum, and family planning. Cohort reports have standardized formats from the Ministry of Health. In addition, there is an education menu purposed for midwives and a training menu different from other mHealth applications (details in Figure 2b). The mHealth application also has a telemidwifery menu containing a semi-automatic communication feature between the midwife and the client and chatbot features.
The education menu for midwives guides midwives regarding interventions given to mothers during pregnancy, childbirth, newborns, and postpartum. The mHealth application has a front page shown in Figure 2a,b for users (midwives) who aim to enter and read data. At the same time, the back end (the "kitchen" of the app) shown in Figures 3  and 4 is for the application developers to see a recapitulation of data that the midwife has input. The mHealth contains a menu based on a cohort form containing data on the health of pregnant women, mothers in labor, infants and toddlers, postpartum, and family planning. Cohort reports have standardized formats from the Ministry of Health. In addition, there is an education menu purposed for midwives and a training menu different from other mHealth applications (details in Figure 2b). The mHealth application also has a telemidwifery menu containing a semi-automatic communication feature between the midwife and the client and chatbot features.  The education menu for midwives guides midwives regarding interventions given to mothers during pregnancy, childbirth, newborns, and postpartum. The mHealth application has a front page shown in Figure 2a,b for users (midwives) who aim to enter and read data. At the same time, the back end (the "kitchen" of the app) shown in Figures 3 and 4 is for the application developers to see a recapitulation of data that the midwife has input.    In Figure 3, midwives can register pregnant, labor, and postpartum mothers' including toddlers' identities through the Posyandu Reporting Information System for Midwives (PRISM) in the app. Those data will be used with pregnancy, labor, postpartum, and toddler checkup data. Moreover, midwives can make cohort reports, such as pregnancy, baby, toddler, labor, postpartum, and family plan, from stored checkup data. The PRISM also accepts consultations from pregnant women to be submitted to midwives who can provide consulting solutions to pregnant women's problems. To improve competence, midwives can request educational and training content through PRISM. The content comes from the Posyandu Health Content Information System (PHCIS In Figure 3, midwives can register pregnant, labor, and postpartum mothers' including toddlers' identities through the Posyandu Reporting Information System for Midwives (PRISM) in the app. Those data will be used with pregnancy, labor, postpartum, and toddler checkup data. Moreover, midwives can make cohort reports, such as pregnancy, baby, toddler, labor, postpartum, and family plan, from stored checkup data. The PRISM also accepts consultations from pregnant women to be submitted to midwives who can provide consulting solutions to pregnant women's problems. To improve competence, midwives can request educational and training content through PRISM. The content comes from the Posyandu Health Content Information System (PHCIS).
The actor of the system is the midwife, who can interact with the eight system services (Figure 4). Midwives can record the results of a toddler, pregnancy, labor, and postpartum checkup. The data obtained from recording these checkups can be processed into a cohort report following the format determined by the government. The telemidwifery service receives consultations from pregnant, labor, and postpartum mothers. Then, to improve their competence, midwives can take advantage of training and education services. Figure 2a explains that the MCH menu on the mHealth dashboard consists of data on pregnant women, mothers giving birth, infants and toddlers, postpartum, and family planning. Figure 2b shows that the other menus include midwife education about the development of information and health program updates from the government. Moreover, there are standard operating procedures for MCH services, the training menu (which contains an e-module, learning video, and online test), maternal and child health reports called cohorts, telemidwifery, accounts, and log-out features. In addition, the mHealth application can be downloaded on Google Play named the iPosyandu Bidan application (version 1.0.9).

Discussion
Midwives need competency in the MCOC health service, including the early detection of the risk factor of complications and treatment management. They are concerned about the purposes, benefits, and design of mHealth to support their needs. In providing services, the midwife's duties in MCOC are identifying, providing appropriate and safe midwifery care, monitoring, and supporting women during preconception, pregnancy, childbirth, newborn, and postpartum [52]. By strengthening this continuously [1], including in emergencies [53,54], health service quality can be improved [16], preventing complications [4,55]. Midwives should have more quality time when providing MCOC to build relationships with clients, have a sense of community, and respect cultural diversity [56]. In Indonesia, midwives must have competence in MCOC based on the Indonesian Midwifery Constitution No. 4 of 2019, so that midwives carry out the early detection of risk complication cases during pregnancy, childbirth, post-delivery, postpartum, including post-miscarriage care and follow-up with referrals [57]. All women should receive continuous midwifery care as the gold standard for improving maternal and infant health [58]. However, women giving birth who live in a village may have limited access to obtain MCOC due to the characteristics of their population (such as economic, psychological, and social burden on women and their families), the limited number of midwives in the workforce, geography (difficult access to healthcare facilities), and technology (mHealth access) that may affect midwifery care [59]. To support this, the government can support physical and digital infrastructure through which MCOC services can be accessed, including using mHealth [60,61].
Both developed and developing countries should be supported by the competence of midwives to reduce their MCH problems [62]. It is because midwives need the skills, knowledge, and attitudes to provide quality care [63]. A recent review stated that factors influencing the MCH competencies of the midwifery workforce were their educational level (diploma, bachelor, and master degrees), working years, and more education and training experiences [64]. Nonetheless, the midwives' MCH competencies supporting the MCOC (e.g., cases in detecting the risk of complication and its treatment management in pregnancy, childbirth-related complications, neonatal resuscitation, and management of postpartum hemorrhage) are still inadequate [27,65] because not all midwives meet the cases in their experience in the field [66]. The experience of midwives who work in the field with many cases, including complications, is higher than those with lower numbers of cases [65]. The International Confederation of Midwives (ICM) believes that midwives carrying out competencies must be based on the philosophy of midwifery care because the midwives view the normal birth process in women's lives from the biological, psychological, and social sides [67]. Midwives also obtain knowledge through critical thinking and experiences that can improve competence after providing MCOC [52]. This competency is needed by midwives to be able to carry out early detection to prevent complications in pregnancy, childbirth, newborns, and the puerperium, as stated in the Decree of the Minister of Health of the Republic Indonesia Number 320 of 2020 [50], and also found in our research (Tables 2-4). The assessment of midwives' training needs is the first step in establishing a training curriculum based on mHealth, that can be used as a national curriculum standard [68]. The assessment is a fundamental aim of professional development in effectively increasing the competence of midwives [69] and for future education and training interventions [25,70]. Education and training programs should be organized according to the needs of midwives based on their service work [71]. Recent reviews stated that practicing midwives lack knowledge of diagnosis and care aspects in the early detection of pre-eclampsia [72], which was also found in our research (Table 3). This early detection is part of midwifery emergency training [73,74]. Education and training for midwives can improve their knowledge and skills to provide better health services [75,76], then reduce maternal and newborn mortality [77].
Technological developments successfully contribute to education and training, midwifery care, and lifelong learning [78]. The effectiveness of technology integration into healthcare training can improve clinical skills professionally and enhance health workers' learning experiences [79]. Previous studies show that innovative on-traditional methods, such as mHealth, have the potential to increase midwives' knowledge [72,80]. Besides, educational and skills training that integrates techniques and practice with the mHealth application can increase midwives' self-efficacy [81] and be a learning medium for training through e-modules and learning videos with blended learning strategies [82,83]. Our research suggests the potential innovation with the combination of midwife competency and midwifery care services (Figures 3 and 4). mHealth, which involves using information and communication technology to implement MCOC [16], can support healthcare to improve the quality of MCH [80,84,85]. It has been publicly utilized and suggests an effective public health service [38]. In our research, mHealth can be used to record maternal health from pregnancy, childbirth, newborn, and postpartum. Midwives can use it for early detection of risks, such as during pregnancy checkups (Figures 2 and 4). When using the app, e.g., for pregnant women, a midwife can detect malnutrition, anemia, and hypertension before determining interventions to prevent complications.
Previous research stated that mHealth was used for competency applications in patient care, medical knowledge, practice-based learning, its improvement, systems-based practice, and professional, interpersonal, and communication skills. The curriculum with case-and problem-based teaching, supervision, and practice evaluation improves the quality of competencies [63]. mHealth is a promising solution in pregnancy care compared to the standard of maternal care. One of the benefits of mHealth is the media that can be used for digital health communication in telemidwifery [41]. Midwives need telemidwifery to provide health education services for clients (Table 4). Mobile applications can be practical learning tools and significantly transfer information and expertise to midwives [86]. In addition, skills to use mHealth in education and training have become one of the emerging needs for clinical professionals. It will contribute to curricula gaps in the learning process [87].
Education and training programs can improve healthcare professionals' decisionmaking and communication competencies [69]. A systematic approach, comprising assessment to service, supports the education and training of midwives. Therefore, it helps the recommended need to provide a standard of care following the practice of midwives [88,89]. The programs significantly affect midwives' leadership [90] and their performance. Thus, competence greatly influences performance appraisal in midwifery services [91]. It is needed to meet public health needs so midwives can provide quality healthcare [35,66]. Midwives working within an organization should be supported to develop their professional roles to become knowledgeable, competent, and confident [92]. The efforts of midwives should be supported by the interoperability between mHealth and the govern-ment's health information system (HIS) [93]. Our research in this iPosyandu for midwives version is in the initial phase and needs more development on the interoperability in the future. It has potential because, previously, the iPosyandu was created to integrate with one of the governmental HIS for Posyandu activities, including nutrition status, called ePPGBM [16,38,43].

Strengths and Limitations
The primary strength of the present study is that mHealth combines MCOC competencies and services. In future work, as we are developing chatbots between midwives and mothers, this app will have strengths in telemidwifery [16]. Communicating with a chatbot can help limited numbers of healthcare workers in performing health education services [94]. Our app is planned to be completed with communication features with interprofessional collaboration, such as a doctor and nutritionist. However, it needs more effort to advocate the integration with the governmental midwifery cohort application. Thus, both apps can be synchronized to maintain good data and quality of midwives' training and services.

Conclusions
In summary, midwives need competence in MCOC, including the early detection and treatment of risk complications, using mHealth as a learning medium. Amongst its services, mHealth has functions from recording and reporting the results of maternal health examinations to interventions during pregnancy, childbirth, postpartum, and newborn. Education and training programs can improve midwives' decision-making and communication skills in their healthcare provision. In the future, the development of mHealth will continue with efforts to integrate with the government health information system.