Description of Fertile Age Couples with Long Term Contraception Method

The use of LTCM has many advantages and more recommended by the government than non-LTCM because it is more efficient, safer and more effective. However, the facts on the ground are that women with FA prefer non-LTCM. Data from the Pasar Merah Village were LTCM acceptors (34.42%), while non-LTCM acceptors (65.57%). This study was to analyze the descriptions of long-term contraceptive users (EFA). This research was an analytic survey with a Cross-Sectional design. The research was conducted in Pasar Merah Village. The populations were 610 women with a sample of 86 people. Data analysis was univariate, bivariate using chi-square and multivariate using multiple logistic regression with 95% confidence (α=.05). The results showed that variables associated with long-term contraceptive method users by women of FA in East Pasar Merah Village were knowledge (p=.001) and husband's support (p=.012). Unrelated variables were age (p=.118), parity (p=.019), education (p=.122), income (p=.375), health worker support (p=.128). The most dominant factor, namely the knowledge variable, had a value of Exp (B)/OR = 5.938, meaning that the respondent had good knowledge, the opportunity to use LTCM was 5.9 times higher than respondent with less knowledge. The conclusion of this research is that the husband's knowledge and support are related to the use of LTCM. It is suggested that PKB and PLKB increase counseling for women with FA and husbands so that the knowledge of women with FA increases, husbands can provide positive support. Counseling can be done individually or in groups online during the Covid-19 pandemic.


Introduction
The use of contraception in the world according to the World Health Organization (WHO) is increasing in various countries, especially in Asia, Latin America, and Africa. Regionally, the proportion of women using long-term contraceptive methods (MKJP) or modern contraception continues to increase. Although there is an increase in the use of contraceptives, population growth with high birth rates is still a major population problem such as in Indonesia (WHO, 2018).
In terms of population, Indonesia is in the fourth position in the world, after China (1.37 billion people or 18.6%), India (1.28 billion people or 17.3%), and the United States (326 million people or 4 , 4%), and Indonesia (260 million people or 3.5%) (Dickson, 2018). The number of women of childbearing age (WUS) in Indonesia is the largest in the Southeast Asia region, namely 65%, followed by Vietnam with 25.3%, the Philippines 23%, Thailand 17.9% and Myanmar 14.1%. The highest data on contraceptive use in ASEAN countries, namely Thailand, namely 80%, followed by Cambodia 79%, Vietnam 78%, Indonesia 61% and the Philippines 49%. Based on these data, it shows that Indonesia has the highest To reduce the number of births, the government recommends the use of long-term contraceptive methods (MKJP). The use of MKJP has many advantages over non-MKJP, both from a program perspective and from a client (user) perspective. Besides accelerating the reduction of the Total Fatality Rate (TFR) and preventing pregnancy, the use of MKJP contraception is also more efficient because it can be used for a long time and is safer and more effective (Irianto, 2015). The MKJP family planning method is very appropriate to use in crisis conditions experienced by some Indonesians (Anggraini, 2017). The MKJP failure rate is reported to be 0.2 per 1000 users, while the non-MKJP method is reported to be more than 10 per 1000 users (Manuaba, 2015).
The achievement of the National Population and Family Planning Board (BKKBN) in 2018 shows that out of 5 (five) strategic targets, only 2 (two) have successfully met the target. Namely a reduction in the drop-out rate (DO) with an achievement of 25 percent from the target of 25 percent (percentage of achievement of 100 percent), and an increase in the use of long-term contraceptive methods (MKJP) with an achievement of 23.1 percent of the target of 22.3 percent (percentage of achievement 103.6 percent) (Santo, 2019).
Selection and use of contraceptives by couples of reproductive age (acceptors) is a form of health behavior . According to the behavioral theory of Lawrence W. Green in Notoatmodjo, individual and community health is influenced by two factors, namely behavioral factors and factors outside of behavior (non-behavior). Furthermore, these behavioral factors are determined by three groups of factors including: predisposing factors (age, occupation, education, knowledge and attitudes), enabling factors (distance to health facilities), reinforcing factors (family support and health workers). However, in this study, researchers only focuses on a few behaviors, namely: researching age, education, occupation, knowledge, support from husbands and support of health workers in using long-term contraception .
Departing from Green's behavior theory, the factors that can be used as variables in this study are age, parity, education, family income, knowledge factors, husband's support, support from health workers. PUS aged> 35 years chose to use long-term contraception because they no longer wanted to give birth. PUS who already have> 2 children choose to use long-term contraception because they want to limit the number of children. PUS with high education tend to choose efficient contraceptives than those with low education. PUS with high family income think more about family welfare. PUS who have good knowledge and get support from their husbands and support from health professionals tend to choose an efficient contraceptive, namely MKJP, rather than choosing non-MKJP contraceptives.
Medan Area District is one of 21 Districts in Medan City. Based on data from the Family Planning Extension (PKB) until December 2019, there were 7,552 active family planning participants (70.87%) of the 10,655 reproductive age couples. The acceptors who used shortterm contraception were 4,962 acceptors (65.70%) MKJP were 2,590 acceptors (34.30%) (PKB Kec. Medan Area, 2020).
A preliminary survey conducted by researchers in Pasar Merah Timur Village, Medan Area District by interviewing 20 mothers of fertile age couples by asking about the use of KB MKJP, most of them (12 people) used Non-MKJP KB, and only 8 people used Non-MKJP KB such as IUD / IUD, and Implants. The reason 12 people used non-MKJP was because they used to use non-MKJP contraceptives. When researchers asked about MKJP contraceptives, they could not answer correctly which indicated that they lacked knowledge due to lack of information from health workers, they also lacked support from their husbands to use MKJP contraceptives because their husbands still want more children, because if they use contraceptives MKJP waited a long time.

Methods
This research is a quantitative study with the type of analytic survey research using a cross sectional design. This research was conducted in Pasar Merah Timur Village, Medan Area District. The population in this study were 610 women with reproductive age couples (PUS) who were family planning acceptors. The sample was 86 people.
The research instrument uses a questionnaire that has been tested for validity and reliability. The data used are primary, secondary, and tertiary data. Data analysis was performed univariate, bivariate with Chi-Square test, and multivariate using multiple logistic regression tests with a confidence level of 95% ( = 0.05).
Based on knowledge, most of them had less knowledge as many as 47 people (54.7%), received support from their husbands as many as 45 people (52.3%), stated that 46 people (53.5%) had the support of health workers. Based on the use of MKJP, most of the women with PUS used non-MKJP as many as 53 people (61.6%), as many as 33 people (38.4%).

Bivariate Analysis
Based on the research shows that the results of statistical tests using the chi-square test obtained p-value for age (p = 0.002), parity (p = 0.001), education (p = 0.001), income (p = 0.375), knowledge (p = 0,000), support from husbands (p = 0,000) and support from health workers (p = 0.007). This shows that there is a relationship between age, parity, education, knowledge, support from husbands, and support from health workers with the use of longterm contraceptive methods in women with fertility. Meanwhile, the insignificant variable was income.

Multivariate Analysis
The result of multiple logistic regression test shows that there are 2 variables that influence the choice of place of delivery, namely knowledge and support from husbands. The most dominant variable related to long-term contraceptive use in women with PUS is that the knowledge variable has a value of Exp (B) / OR = 5.938, which means that the respondent has good knowledge of MKJP, the opportunity to use MKJP is 5.9 times higher than the respondent with poor knowledge.
The husband support variable has a value of Exp (B) / OR = 4.079, meaning that respondents whose husbands support the opportunity to use long-term contraception is 4 times higher than respondents whose husbands are not supportive. Based on the results of the multiple logistic regression test, it also shows that variables that are not related to long-term contraceptive use because they have a significant value> 0.05 are age (p = 0.118), parity (p = 0.119), education (p = 0.122), and support from health workers (p = 0.128). Details can be seen in the following table. The results of this study are in line with previous research conducted by Sari at the Kutalimbaru Community Health Center in 2018 showing that one of the factors related to the use of contraceptives is knowledge (Sari, 2017). Salviana's research at the Kassi-Kassi Public Health Center in Makassar found that there was a significant relationship between knowledge and the low use of hormonal contraceptive methods (implants) (Salviana, 2013). Koba's research in the Camplong Community Health Center work area shows that the level of knowledge possessed by PUS has a relationship with PUS interest in using MKJP contraceptives (Koba, 2019).
Risnawati's research in Lompo Riaja Village found that there was a relationship between knowledge and interest in using intrauterine devices (IUDs) (Risnawati, 2013). Likewise, Wibowo's research in Kedungwuni Village found that there was a relationship between knowledge and the choice of IUD contraception (Wibowo, 2013). Lating's research at Puskesmas Mlati II Sleman found that the lack of knowledge of prospective acceptors greatly influenced the use of contraception. If knowledge is lacking, contraceptive use also decreases (Lating & Wijhati, 2019).
Knowledge is the result of knowing and this happens after people sense a certain object. Sensing occurs through the five human senses, namely the senses of sight, hearing, smell, taste and touch . Knowledge affects the level of public interest in the choice of contraceptives, especially the choice of MKJP contraceptives. People who have sufficient knowledge about side effects, how to correct MKJP are likely to choose MKJP as their contraceptive tool. On the other hand, people who are less knowledgeable about side effects, how to install MKJP are definitely less likely to choose MKJP as their contraceptive tool (Everett, 2017).
This study proves that the use of MKJP is influenced by the knowledge of women with fertility in the East Pasar Merah Village. Knowledge is the most dominant factor influencing the use of MKJP contraceptives. (Wardani, 2019;Sariyati, 2018) The knowledge possessed by women with PUS is one of the factors that plays an important role and is related to a person's behavior to use or not use contraceptives. A mother who is well-informed will try to find out information related to the contraceptive device she will use. As with the choice of MKJP contraceptives, mothers should have a good understanding of the contraceptives they will use, such as the IUD / IUD, implant / AKBK, or the female surgery method (MOW), what is the purpose of the contraceptive, its effectiveness, advantages or disadvantages, side effects, indications and contraceptives, how to install the contraceptive device, and others.
Mothers with good knowledge will feel comfortable using this contraceptive because they already know the advantages and disadvantages of the contraceptives used. Conversely, with a lack of knowledge, the mother will always raise questions that disturb her mind, feel uncomfortable or feel anxious about the contraceptive used. Mother's knowledge can be obtained from reading lots of books, health information about MKJP contraceptives, as well as counseling or education for health professionals so that mothers understand MKJP contraceptives. Mothers with less knowledge tend not to use MKJP contraceptives because mothers do not know and do not understand the benefits and advantages of using MKJP contraceptives.
Increasing the knowledge of women with EFA in the Pasar Merah Timur Kelurahan through counseling or health education, either individually or in groups. But during the Covid-19 Pandemic, individual and group meeting activities can be anticipated using online communication tools such as WhatsApp and zoom, especially now that everyone is connected online, especially the people of Medan. The use of electronic media, especially online media, is currently very helpful in disseminating correct and positive information about MKJP so that it can reach more acceptors. FUS women who use non-MKJP contraceptives can switch to MKJP and women of childbearing age who have not used contraceptives can be invited to participate in using MKJP contraceptives.
For the time being, outreach activities during the Covid-19 and new normal can be done through online or online methods. After the end of the Covid-19 pandemic, outreach activities can be carried out using offline or face-to-face methods, either individually or in groups.

Husband's Support Associated with Long-Term Use of Contraceptive Methods
The results of the study are in line with Rizqyawati's research in Anggalomelai, that the reasons for the interest of PUS in choosing the MKJP method are because of the effectiveness in delaying and terminating pregnancy, feeling comfortable and suitable for contraception / family planning, the perceived benefits and support of family / husbands (Rezqyawati, 2019). Uprianti's research at the Hakatutobu Polindes found that there was a relationship between husband's support and the low interest of mothers in choosing an IUD (Uprianti, 2018). Pinamangun's research at the Makalehi Public Health Center, West Siau District, found that the husband's support for WUS provided good support so that there was a significant relationship between husband's support and the choice of IUD contraceptive type for WUS (Pinamangun et al., 2018).
The results of further related research, namely Sulastri's research in Bergas Semarang, showed that the respondents who received support were slightly higher than those who did not and most of the respondents had low interest. There is a significant relationship between husband's support and mother's interest in using IUD contraception (Sulastri & Nirmasari, 2014). Furthermore, Elizawarda's research at the Pancur Batu Health Center provided information that among those who support their husbands are strong who use long-term contraceptive methods (MKJP). Bivariate analysis using showed a significant relationship (Elizawarda, 2017).
The factors that influence the choice of long-term contraception are divided into 2 factors, namely internal and external. One of the external factors is husband or family support (Marmi, 2016). Husband's support is defined as assistance that can be provided by the husband in the form of material assistance, useful information, and emotionally which can lead to feelings of being valued and loved in individuals receiving support (wife) (Pinem, 2018).
The results of this study prove that the use of MKJP contraceptives by women of PUS in Pasar Merah Timur is influenced by the support of their husbands. This can be seen from the data which shows that respondents who get good support from their husbands tend to choose MKJP contraceptives such as IUD, implants, or MOW, while those who do not get support from their husbands tend to choose non-MKJP contraceptives such as pills or injections. This is also because the installation of MKJP contraceptives such as IUD, implant, and MOW requires the consent of the partner (husband), while the use of non-MKJP contraceptives such as pills and injections does not require the husband's consent.
A good husband's support is almost the same as a husband who does not provide support to his wife. The husband's lack of support for his wife to choose MKJP contraceptives because husbands usually leave the decision to use contraceptives to their wives, both regarding the type of contraception used by the wife and the place where the wife makes an examination visit to use contraceptives (Aulia et al., 2020).
For wives who do not get support from their husbands but use contraceptives, usually the husbands only give permission, so that the wives play their own role in determining which contraceptives to use and suitable for themselves with the help of health workers.
Most respondents answered no, about the husband stated that he was willing to give money if needed to use the MKJP contraception. This means that some respondents use their own money or set aside money from the remaining spending money to pay for the cost of using contraceptives. Respondents who use their own money usually have their own jobs such as employees or traders, while respondents who set aside money to pay for contraceptives usually do not work (housewives). The fees for using contraceptives that pay are usually made at private practice midwives or clinics or, for example, mothers use contraceptives at the South Medan Area Health Center, so the mother must pay because Pasar Merah Timur Village is in the working area of the Sukaramai Health Center. Meanwhile, the free ones are usually carried out by the National Population and Family Planning Board (BKKBN), during a family planning safari.

Age Does Not Relate to the Use of MKJP
Based on the research results, it shows that age is not related to long-term contraceptive use in Pasar Merah Timur Village. The results of this study are in line with Mahampang's research in Banyubiru Subdistrict, Semarang Regency, that the bivariate analysis she does shows that there is no relationship between age and the choice of long-term contraceptive method or MKJP (Mahmudah & Indrawati, 2015).
Age is one of the factors that influence a person's behavior in using contraceptives Balleisen et al., (1985). Older people have a smaller chance of using contraceptives compared to younger people. The basic pattern of rational contraceptive use between the ages of 20-35 years is contraception with high reversibility because at that age couples of childbearing age still desire to have children. Whereas at the age> 35 years the recommended contraception is one that has high effectiveness and can be used for a long time (Anggraini, 2017). Each prospective participant must meet the requirements for happiness, meaning that the prospective participant is bound in a legal and harmonious marriage, the wife is at least 25 years old with 2 living children, and the smallest child is more than 2 years old (Wiknjosastro, 2015).
According to the researcher, the results of this study indicate that the use of MKJP contraceptives in Pasar Merah Timur Village, Medan Area District is not influenced by the age of the respondents. A person's decision in determining which contraceptive device to use is not always influenced by age, but many factors influence it, such as knowledge and support from the husband. Based on the distribution of data, the number of respondents using MKJP is almost the same between respondents aged> 35 years and respondents aged 20-35 years. Respondents> 35 years old were 15 people, while respondents aged 20-35 years were 18 people. Because the numbers are not much different, so there is no difference or there is no relationship between age and the use of MKJP contraceptives.

Parity is not related to the use of MKJP
The results showed that parity was not related to long-term contraceptive use in Pasar Merah Timur Village. The results of this study are in line with Ningrum's research at the Batang Hari Community Health Center which shows that there is no relationship between the number of children and the choice of MKJP contraception (Ningrum et al., 2018). Lilestina's research in six regions of Indonesia shows that the variable number of children still alive is one of the factors affecting the use of MKJP (Lilestina, 2011). Likewise the results of Kusumaningrum's research in Semarang, which states that the number of children is one of the factors that has a significant relationship with the choice of contraceptive types in fertile age couples (Kusumaningrum, 2019). Parity is the number of children born to mothers who are still alive or dead. The number of children greatly influences the decision of couples of reproductive age to use contraception. The government expects every family to have two children. According to the BKKBN the number of children born alive is grouped into 2, namely 0-2 low parity, 3 or more high parity people. The decision to increase the number of children is left to the decision of a husband and wife with the BKKBN standard, namely the number of children is less or equal to two (BKKBN, 2018).
According to researchers, parity or the number of children is not related to the use of long-term contraceptives (MKJP) in Pasar Merah Timur Village, Medan Area District, because the number of respondents who have 1-2 children is almost the same as respondents who have children> 2 people. The number of children with 1-2 children was 41 and those with> 2 children were 45. In addition, between the two parity groups the majority used non-MKJP so there was no difference between the two groups and when statistical tests were carried out there was no relationship between parity and the use of long-term contraceptives (MKJP).

Education is not related to the use of MKJP
Based on the research results, it shows that education is not related to long-term contraceptive use in Pasar Merah Timur Village. The results of this study are in line with Lating's research at the Mlati II Public Health Center. It was found that there was no relationship between education and the use of MKJP. This is because the choice of contraceptive method to be used is not only decided by the acceptor, but there are people around the acceptor, such as husbands or close friends or figures who are considered important such as cadres and health workers (Lating & Wijhati, 2019).
The educational factor of a person is very decisive in the pattern of decision making and the receipt of information from that person. Education will also be able to influence a person's knowledge and perception of the importance of a matter, including his role in the family planning program. For family planning acceptors with a low level of education, their participation in the family planning program is only intended to regulate births. Meanwhile, family planning acceptors with a high level of education, their participation in the family planning program are not only to regulate births and the number of children but also to improve family welfare. The higher a person's level of formal education, the easier it is to absorb information including health information, the higher the awareness to behave in a healthy life (BKKBN, 2017).
According to the researcher, the results of this study indicate that the use of long-term contraceptives or MKJP by PUS in Pasar Merah Timur Village is not related to the education of the respondent. Similar to the parity variable (number of children) which is not related, this is because the number of respondents with high education is almost the same as those with low education. Based on the data distribution, the number of respondents with high education is almost the same as those who use MKJP and those who use non-MKJP, so that in the selection and use of MKJP contraceptives, there is no significant difference in respondents with high education. It can be seen that they choose to use contraceptives not based on the education they have but one of the factors because they feel they are compatible with non-MKJP contraceptives. In addition, the knowledge factor is the most important factor for women with PUS in Pasar Merah Timur Village, Medan Area District in determining the choice of using MKJP contraceptives.

Income Not Related to Use of MKJP
Based on the research results, it shows that income is not related to long-term contraceptive use in Pasar Merah Timur Village. Sejalna with Sari's research shows that there is no relationship between income and interest in using IUD contraceptives (M. N. Sari, 2018). Likewise, the results of this study are in line with Widya & Yulnefia's research at Payung Sekaki Health Center that income is not related to MKJP selection, because the need to use contraception is not a primary need and family income does not play a role in decision making in determining which contraception to use (Widya & Yulnefia, 2019).
Family income influences the choice of contraception. This is because in order to get the necessary contraceptive services, acceptors must provide the required funds. Even if it is calculated from an economic perspective, long-term contraception is cheaper than injectable or pill contraceptives, but people see how much it costs for one pair (Marmi, 2016).
The results of this study indicate that the use of long-term contraceptives or MKJP in Pasar Merah Timur Village, Medan Area District is not related to the respondent's income. This is because the number of respondents who have a high income or family income per month is above the Minimum Wage for Medan City in 2020 amounting to Rp. 3,222,556, -. And the number of respondents who have a low income or family income per month below the UMK tends to choose non-MKJP contraceptives. The two groups were almost equal in number who chose non-MKJP. In terms of the percentage of respondents who chose MKJP between high income and low income groups was also not much different. The percentage of high-income respondents who chose MKJP contraceptives was 42.9% and low-income respondents who chose MKJP contraceptives was 32.4%. There were fewer respondents who chose MKJP contraceptives in these two groups than those who chose non-MKJP contraceptives. So that there is no difference in the two groups so that when the multiple logistic regression statistical test is carried out, it is not related.

Health Officer Support Not Related to Use of MKJP
Based on the results of the study showed that the support of health workers was not related to long-term contraceptive use in Pasar Merah Timur Village. The results of this study are in line with the research of Misrina and Fidiani in Teupin Raya Village, Bireuen Regency, showing that the participation of health workers is not related to the low use of MKJP. The role of medical personnel is in the active category, but the use of MKJP is still small because medical officers only explain and introduce MKJP contraceptives. However, the decision to choose a family planning device is still in the hands of the acceptors themselves. However, even though health workers are active in promoting, local culture is a very background of the successful use of MKJP or not (Misrina & Fidiani, 2018). Support from health workers is one of the external factors, for example the existence of messages, advice or suggestions from health workers, friends / peer support, family members that aim to motivate someone to take action. Support from health workers, such as providing materials, emotions or information (Arum, 2017). Support from health workers as facilitators. Other support for health workers is facilitating (as the person providing the facilities), providing all the needs of the EFA when facing problems with MKJP users. Health workers must open consultation services at health facilities such as health centers or provide information facilities such as posters, brochures or leaflets that are useful for women in providing knowledge about the need for MKJP contraception. If this has been fulfilled, then the readiness of the PUS to use KB MKJP can be increased .
According to researchers, the use of long-term contraceptives or MKJP in Pasar Merah Timur Village is not related to the support of health workers. This is because the number of respondents in the supporting category is almost as large as the number who say they are not. The distribution of data shows that almost the same number of respondents who said they received support from health workers in choosing contraceptives were almost the same as those who used MKJP and non-MKJP contraceptives. Respondents who said that health workers provided support because they were more directing to use MKJP contraceptives, as well as some respondents who said health workers were supportive but respondents preferred to use non-MKJP contraceptives. So even though they both get support, the choice of contraception is different. This is when seen by respondents who stated that health workers were not supportive of making them prefer to use non-MKJP contraceptives. In providing information to PUS, health workers try to direct mothers to use the MKJP contraception, but the decision remains at the discretion of the mother and husband. Health workers are not allowed to force PUS to use the MKJP contraceptive tool because it must be adjusted to the condition and health of the PUS itself. So, even though health workers have been active in providing information about MKJP contraceptives, the family planning acceptors themselves who do not use MKJP cannot be forced. There are also many KB MKJP acceptors who choose non-MKJP contraceptives even though health workers have recommended using MKJP contraceptives.

Conclusion
This study concluded that the variables associated with long-term contraceptive method users (MKJP) by women of PUS in Pasar Merah Timur Medan were knowledge and support from their husbands. Variables that are not related are age, parity, education, income, health worker support. The most dominant factor associated with long-term use of contraceptive methods by women with PUS, namely knowledge has a value of Exp (B) / OR = 5.938, meaning that respondents have good knowledge, the opportunity to use MKJP is 5.9 times higher than respondents with less knowledge.