Determinants and Informative Antenatal Health Record Development

Gemala Hatta


Maternal death has been a prime concern globally. The maternal mortality rate (MMR) in Indonesia of 390/100,000 live births is among the highest of contributing Asian nations, revealing deep-seated problems. One way to decrease MMR in Indonesia is by performing good quality obstetric care, which would be highly effective and efficient if it is supported by an additional tool of collecting information related to the three "delays" (3 Ds) and four "too much" (4 Ts) (or 3 K and 4 T in Indonesian language) (WHO, 1998), as well as other relevant information. This simple and unique tool known as the informative antenatal health record (referred to as the RKAN) acts as an early warning, early detection, and early treatment system, abbreviated as the 3 E system.

Four main problems with the RKAN in Indonesia are its inadequacies related to its physical quality, complete itemised antenatal information, complete content, and utilisation of antenatal health information in the RKAN for decision-making purposes.


A study was conducted to obtain a representative quality of the current RKAN, to know the determinants of an informative RKAN, and to develop a new, informative antenatal health record (RKAN) as a decision-making tool to certify the quality of obstetric care based on the 3 E system.


This study had two phases--phase one, to obtain correlated determinants of an informative RKAN, and phase two, to develop a RKAN model that supported the 3 E system in antenatal care.

This cross-sectional design study used 216 antenatal clinics in Jakarta as its population and, due to the homogeneity of the clinics, took 20 antenatal clinics as the sample. Respondents of this study were 20 heads of health record units, all health workers in antenatal clinics (75), all health record practitioners in antenatal clinics (56), and the available RKAN called Kartu Ibu (255). Proportionate simple random sampling technique was used to take the antenatal clinics sample and to collect all RKAN of mothers who gave birth from February to April 1998. Due to the homogeneity of the clinics, it was decided to limit the size of the sample to 20 RKAN. The dependent variable is the informative RKAN that consists of four subvariables, while the independent variables consist of environment, input, and process, using seven observation instruments with the score of 1-5. Validity and reliability of data were checked by the Cronbach Alpha test.


The current quality of the RKAN on environment, input, and process (independent variables) based on a median cut-off point are as follows.

The environment and input variables for manpower and facility and process variables are found to be good in 50 percent of antenatal clinics. Meanwhile, 25 percent of antenatal clinics are found to be satisfactory on the input variable of its financial condition.

The quality of output (dependent variables) on physical quality of an informative RKAN and antenatal information for decision-making purposes is, respectively, 40 percent and 45 percent satisfactory on antenatal clinics. While other output variables on complete itemised antenatal health record and complete content on antenatal health record are 50 percent satisfactory on antenatal clinics.

Phase One: Determinants of an Informative RKAN

Physical quality of an informative RKAN will be achieved if the following conditions are fulfilled. These are the environment condition, especially the organisation's policy; input, that is, the type of health staff and practitioners working on the health record, form facility, budget, especially for printing and operational costs in the health record unit (UKRK); and process, consisting of the morbidity code practice and accuracy checking of the codes.

Itemised information on the RKAN will be complete if professionalism of the health record practitioners is maintained.

Content of the RKAN will be complete if the conditions below are met. These are the availability of total staff, especially the type and education of UKRK practitioners, working period of health staff, and skill of the UKRK head; hardware facilities; and the total process management in the UKRK.

The utilisation of RKAN content for decision-making purposes will be achieved if the following conditions are met. These are the availability of the manual and planning of the UKRK management, staff, especially health staff and the head of the UKRK; potential ability of staff, especially those who have been trained in recording and reporting systems; staff education on health record and on recording and taking notes; and the working period of the health staff.

Phase Two: An Informative Antenatal Health Record (RKAN) Development

Based on factor analysis, the model of an informative RKAN was constructed from 33 variables. The 33 variables are 6 physical conditions of pregnant woman--height, arm circle, birth spacing, family medical history, number of children, age, and gravida; 14 health and pregnancy conditions--obstetric history, haemoglobin level, chronic disease(s), multiple pregnancy, transver lie, fetal position, fetal weight, oedema, eclampsia, blood pressure, vaginal bleeding, ruptured membrane, premature, severe infection; antenatal visits--less (<) than 4 times, first visit > trimester 1; 4 basic care to mother--weight and height, tetanus toxoid, iron tablets, fundal height; condition of the new born baby--Apgar score, birth weight, vital signs; referral patient-- information on condition, prompt delivery, referral address; and health education.

In addition to the above variables, other information considered important for the baby is included in the model. These are folic acid, which can reduce the incidence of neural tube defects to the infants and proteinuria, which is important for the well-being of mother during antenatal period.

Development of an informative RKAN model is based on 3 E system principles. The model has also addressed the problem of incomplete forms among the staff by designing the examination profile with tolerance criteria that should be taken into consideration--the tolerance criteria differentiating the normal and non-normal classification of risk condition of pregnant mother. In the newly developed informative RKAN, some items have been added into the design, such as columns for problem/risk, allergy, and healthcare history; additional spacing for antenatal visit notes and morbidity coding; and a pointer box for medical alertness, health education, and progress notes.


To produce an informative antenatal health record (RKAN), there should be a complementary and supportive relationship among environment, input, and process. A good quality informative RKAN should possess a set of physical quality criteria (KFF), complete itemised antenatal information, complete content of antenatal health record, and the utilisation of the antenatal health information for decision-making purposes (PIPK). The environment condition and its subvariables, especially on organisational policy, manual, and planning of UKRK, played an important role in increasing the quality of an informative RKAN, especially for the KFF and PIPK. This study showed that increasing the potential capability of staff, especially with education and training on UKRK management, played an important role in increasing the quality of an informative RKAN. Working facilities and the availability of an operational budget on the UKRK become the primary needs, which have not yet been provided by the antenatal clinics. The study confirmed that the UKRK management process, especially in analysing the documentation, is still low.

In producing the informative RKAN, it showed that KFF, complete itemised antenatal health information, complete content of antenatal health record, the utilisation of antenatal health information for decision-making purposes, had to be seen as supportive or complementary.


Scientific Development

The implications of this study for the development of scientific knowledge follow.

The new antenatal health record model, referred to as the RKAN, that uses the 3 E system, should be more effective and communicative and yet simple to use in detecting some antenatal risks that endanger the life of pregnant women and fetus.

This study recommends four new concepts for handling health records, which should be seen as a group rather than separate parts.

  1. The new concept of seeing KFF should not be fragmented, but on the contrary, should be embodied into a set of five subvariables in order to achieve better output.
  2. The new concept in developing the itemised antenatal health information should be designed by combining two aspects, namely standardised medical science (example, antenatal) and the Government policy.
  3. The new concept of having complete content on the antenatal health record should be seen differently from the traditional ways. A new, proposed analysis technique, called the itemised qualitative analysis per item, should be used in reviewing the health record content.
  4. The new concept for using antenatal information in the decision-making process, will work efficiently if another proposed analysis technique on recording, called the qualitative medical analysis, is used in reviewing the record process. The two above concepts and the two old systems will compose four progressive health record reviewing techniques. This kind of review will make the quantitative and qualitative methods on health record work in harmony to achieve better information on antenatal care. The application of these techniques is considered very important and should be used in reviewing health/medical records, especially in the health information era when higher-quality outcomes has become of a prime concern to the health world.

Utilisation of Information

Due to inadequate data for detecting antenatal risks and the habit of not completing forms, it is recommended providers begin using the newly developed model on an informative RKAN with the 3 E system approach and undertake a consistent review of the model to find its best utilisation. Health staff must keep its discipline and integrity to assure the best use of this new model of an informative RKAN.  

To achieve an informative RKAN, it is necessary that problems regarding environment, input, and process be minimised accordingly and be followed by action. This can be recommended by reorganising the management of the UKRK and antenatal clinic, and placing the emphasis on remedial actions on the weak points in environment, input, and output. In the long run, consistently reorganising these weak points will bring good results for antenatal care as a whole, hence reducing the maternal mortality rate in Indonesia.

It is recommended to the Department of Health (DOH) that a mutual cooperation between DOH and the Department of Education be initiated to increase worker ability through education and training, especially in the allied health schools and faculties of medicine. To be noted also, the antenatal clinics health staff and UKRK practitioners should also receive training on health record management.

Rekam Kesehatan Antenatal health record form


  1. 3 Ds = 3 delays (= 3 keterlambatan ): delay in the decision to seek medical care, delay in efforts to reach a medical facility with adequate care, and delay in receiving quality care at the facility; 4 Ts =   4 "too much" (= 4 terlalu ), too early or too late for giving birth, too frequent (birth spacing less than 2 years), and too many children.
  2. The dependent variable is the quality of an informative RKAN, consisting of 4 subvariables: (i) physical quality of RKAN; (ii) complete itemised antenatal information on RKAN; (iii) complete content inside RKAN; and (iv) the utilisation of antenatal health information in RKAN for decision-making purposes.
  3. Environment (total) condition is an independent variable consisting of organisation policy, organisational chart (organogram), manual, and planning.
  4. Total process of UKRK is an independent variable consisting of essential systems in health record management--patient master index card (KIUP); analysis methods in documentation--quantitative analysis; and total system on medical audit (PAM).
  5. Physical quality condition of RKAN (KFF) is a dependent variable consisting of five criteria: (i) maintaining the continuity of logistic form; (ii) availability of printed form; (iii) size of form (A4); (iv)type of paper being used for RKAN (HVS); and (v) typography format of the RKAN.
  6. Total staff is an input (independent) variable consisting of the type of staff (health staff or UKRK practitioners), number of staff, and capability of the staff.


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