Analysis Factors of the Intention of Postpartum Women using Long-Acting Reversible Contraceptive Based on the Theory of Planned Behavior

Introduction: The use of Long-Acting Reversible Contraceptive (LARC) in postpartum women is still low even though the government recommends an effective method to decrease population growth. Attitude, subjective norm, and perceived behavioral control are background factors that shape people's intentions in displaying behavior. This study aimed to analyze the correlation between attitude, subjective norm, and perceived behavioral control with postpartum women's intentions using LARC.


INTRODUCTION
The increase in Indonesia's high population from one year to another year with the percentage of population growth reaches 1.33%. The target of the National Family Planning Population in Strategic Planning of National Family Planning Population (RENSTRA BKKBN) from 2015 to 2020, the percentage of population growth is 1.1.9 % in a year (BPS, 2016). The government has a Family Planning program to keep the rate of population growth. Government has the policy to increase the use of long-term contraceptive methods in the National Medium-Term Development Planning (RPJMN) and National Family Planning Population in Strategic Planning of National Family Planning Population (RENSTRA BKKBN) from 2015 to 2019. The method is more effective. To succeed in the Family Planning Program, the effort to increase the mother's health, the primary respondent of the Family Planning Program, is unmet need ground and postpartum mother. Family Program in postpartum mothers is rated very important to do. Because the reversion in the postpartum mother cannot be predicted and can happen before coming to the next menstrual cycle, even the fertility to postpartum mother can reverse in the breastfeeding time (Kemenkes RI, 2013). Based on the preliminary data study, it was found that 6 of 10 informants did not have the intention to use LARC. Most of the postpartum women still think that the insertion procedure of LARC is complicated and scary.
The total of Family Planning acceptors in Indonesia is 64% of a total couple of childbearing age (SDKI, 2017). The target user of Long-Acting Reversible Contraceptive (LARC) in Indonesia is, according to RENSTRA BKKBN, from 2020 to 2024 is 23.5%. Nowadays, Indonesia has reached the target of using LARC to be 24.6% (BKKBN, 2019). The percentage of Family Planning acceptors using LARC in postpartum women is 28.72%, from 28.72% in Indonesia (BKKBN, 2014). Surabaya is the largest city in East Java, with the largest population, such as 2.8 million people in 2017. The average population rate growth in Surabaya from 2013 to 2017 is 0.49% every year. The total of Family Planning acceptors to a couple of childbearing age in Surabaya City is 392,206. Tambaksari Sub-District dominates Family Planning acceptors with 11.5% from all of the Family Planning totals in Surabaya City. Although Family Planning Acceptors in Tambaksari Surabaya are the highest, so is the birth rate in Surabaya City, such as 2,492 birth rates in a year. In 2017, the percentage of Family Planning acceptors in the Tambaksari Sub-District was 25% of childbearing age couples. This percentage is the total of LARC as 22.9 % (BPS, 2018).
Postpartum women's participation in the Family Planning Program is still being dominated by Non-Long Acting Reversible Contraceptive (Non-LARC). This condition opens the Family Planning Program's potency to be less effective because of the high failure rate of Non-LARC with a percentage of 1.8% (SKDI, 2017). The government, especially BKKBN, has given understandable socialization to the communities about Family Planning. It is not the exception to the important figure in the communities. Although not all of the communities do not get the socialization (BKKBN, 2014). The decision to use contraception will determine Family Program in Indonesia. The choosing method of using contraception must be based on many objective considerations. It is suitable for the need and believes in the Family Planning acceptors to appear the intention, decision, and behavior in doing Family Program using LARC.
The participation of postpartum women in doing the Family Planning Program and choosing contraception devices is very important. Public Health Centers in Tambaksari have endeavored to increase the use of LARC. Through education and counseling postpartum Family Program Planning since the pregnancy. The attitude can be formed slowly from knowledge, attitude, and action. According to the Theory of Planned Behavior, people's attitudes with used LARC are influenced by three factors: attitude toward the behavior, subjective norm, and perceived behavioral control. All of those factors will appear the intention to use LARC (Fishbein and Ajzen (Nursalam, 2017). This study aimed to analyze factors that correlated with postpartum women's intention using LARC based on the Theory of Planned Behavior.

Design
This research's design is descriptive correlational uses a cross-sectional approach to finding out the correlation between the independent and dependent variables. This research is done in Tambaksari, Surabaya, from March 2020 to April 2020.

Population, Samples, and Sampling
The population in this research is all of the postpartum women < 42 days in Tambaksari Sub-Regent (Work Area of Puskesmas Gading and Puskesmas Pacarkeling) 139 people. The sample of 84 respondents is based on the purposive sampling technique. The inclusion criteria were postpartum women < 42 days in Tambaksari Sub-Regent (Work Area of Puskesmas Gading and Puskesmas Pacarkeling) who had not become KB acceptors the exclusion criteria for postpartum women with widow status.

Instruments
The instrument used in this research was a questionnaire consisting of demographic data, attitude, subjective norm, perceived behavioral control, and intention. The demographic data questionnaire consisted of ages, education, the family's salary, the total of children, and the knowledge about contraceptive methods. The attitude questionnaire consisted of 8 questions with three parameters: the security of LARC, benefits, and the effect of using LARC. The attitude is classified into a positive attitude if T≥ median data and a negative attitude if T< median data. The subjective norm questionnaire consists of 10 questions with two parameters: the government, public figure, health worker, husband, and close friend. The subjective norm is classified into five categories: very good, good, enough, less, and less. The perceived behavioral control questionnaire consisted of 10 questions with five parameters, namely knowledge, cost, availability of facilities, time, and reward. The perceived behavioral control is classified into five categories, namely, very strong, strong, enough, weak, and very weak. The intention questionnaire of 5 questions has five parameters: the benefits, security, effectiveness, comfort, and desire to have children. The perceived behavioral control is classified into five categories: high, medium, low, and very low. The instrument of attitude, subjective norm, perceived behavioral control, and intention is modified (Satria, 2015).

Procedure
The researcher looks for the workers of Maternal and Child Health in the Community Health Center to get the data about the candidate of respondents and cadre contact of postpartum women. The researcher determines total samples based on the purposive sampling technique. The researcher coordinates with the caders to share the questionnaires. Then, the caders explain to the candidate of respondents. It will participate in the research. The respondents agree, and the researcher contacts the respondents to send informed consent and questionnaires to a google form. Respondents fill google form, and the researcher ensures the right data.

Analysis
The collected data is analyzed by using analysis descriptive and bivariate analysis. Descriptive data analysis is used to find out the percentage and frequency distribution. Bivariate analysis is used to find out the relationship between the variables. Bivariate analysis in this research uses a statistic test of the spearmen rho test with α = 0.05. If the value of p < 0.05, H1 will be accepted. If the value of p > α =0.05, H1 will be rejected.

Ethical Clearance
The Health Commission Ethics agrees with the procedure of this research at the Faculty of Nursing, Universitas Airlangga with number 1964-KEPK. The ethical aspects which are considered in this research such as informed consent, anonymity, and confidentiality.

RESULT
Based on table 1, the respondent's characteristics are based on the most of mothers aged 26-35 years old such as 47 respondents (56%). The husbands' most aged 26-35 years old, such as 81 respondents (96.4%) with the marriage less than ten years old. It can be reviewed from the education side that Academic/University dominates mothers' last education with respondents (51.2%). The previous education of husbands is dominated by Academic/University, with 50 respondents (59.5%). There are 58 respondents (69%) have a family income of more than IDR 4,200,479. According to the total children from 50 respondents (59.5%), have a child. It is reviewed from the knowledge of contraception methods that respondents know from non long-term conceptive method and the long-term conceptive method with 66 respondents (78.6%). Most of the respondents do not use contraception methods with a total of 63 respondents (75%). The most information source about the respondents of Family Planning comes from the nearest people (family, neighborhood, parents, and husband) with a total 33 respondents. Table 2 shows that the most of postpartum women have a positive attitude are 62 respondents (73.8%), have good support of subjective norm with the total 45 respondents (53.6%), have strong perceived behavioral control with the total of 40 respondents (47.6%). There are 39 respondents (46.4%) have high intention in using LARC.
According to table 3, it is known that there are 62 respondents (73.8%) from the total of 84 respondents who have positive attitudes in the intention to use LARC. The analysis result of the Spearmen Rank Test Correlation statistic shows that there are many strong significant and related to the attitude and similar to use the intention with using LARC (p= 0.000) and (r=0.604).
According to table 4, it is known that 25 respondents (29.8%) from 84 respondents have support from good subjective norms with the intention of using LARC. The result of the statistic test of the Spearmen Rank Test Correlation shows that there are many strong significant and similar to the subjective norm to the intention in using LARC (p=0.000) and (r=0.610).
Based on table 5, many 25 respondents (29.8%) from 84 respondents have a high intention and strong perceived behavioral control to use LARC. The result of the statistic test of the Spearmen Rank Test Correlation shows that there are many strong significant and similar to the perceived behavioral control to the intention in using LARC (p= 0.000) and (r= 0.628).

The Correlation between Attitude and Intention of Postpartum Women using LARC
Attitude has a strong significant relationship and similar to postpartum mothers' intention in using long-term contraceptive methods. The majority of respondents have a positive attitude to high intention in using the Long-Term Contraceptive Method. The result analysis states that many respondents who have a positive attitude do not always appear high intention. It happens in the vice versa, respondents with a negative attitude do not always have a low intention to use long-term contraceptive methods. This research is, according to Lestari (2018) that there are many relationships with the intention to use contraception postpartum. This research proves that the respondents who have a negative attitude do not always appear low in using the postpartum contraceptive. Another study from Huda et al. (2016) shows that there are many significant relations between the attitude and behavior of using a contraceptive device. This research is done on 37 respondents, and the result of the positive effect will appear the significance between attitude support to use the contraceptive device. (Joeliatin, 2016) that there are many significant direct relationships between attitude and the intention of women of childbearing age to become the participants of the long-term conceptive method. According to (Anggraeni, 2015) that women of the childbearing age with positive attitudes have a chance three times higher to become the participants of a long-term conceptive method than women of childbearing have a negative attitude. Other research from (Nasrulloh, 2015) that there are many relationships between attitude and participation of couple of childbearing age in doing Family Planning program. Attitude is an important basic in the availability of participating Family Planning program.
The positive attitude of respondents with high intention happens from 26 to 35 years old. The last education dominates to Academy/University. More of them have a salary of more than IDR 4 million, and most have a child. Most of them know the nonlong-term conceptive method and long-term conceptive method. Most of them get the information from the nearest people (family, neighborhood, parents, and husband). According to result analysis in the questions of attitude questioner, on the question nomor one can be seen that respondents trust with using long-term conceptive method. They can prevent pregnancy effectively and safely.
Although respondents with negative attitudes have high intensity in using longterm conceptive methods, they are influenced by the respondents' perspective to the longterm conceptive method. Because of the afraid feeling, it will influence sexual function. Although, respondents have understood the benefits of long-term conceptive methods, it is more useful to prevent pregnancy than the non-long-term conceptive method. Most of the respondents do not want to use long-term conceptive method because they will assume to cause infertility.
Health workers should be able to encourage the Postpartum Family Planning Program since 2007. It is important to do because there are many respondents get the information's about the contraceptive method from the nearest people (family, neighborhood, parents, and husband). This condition shows that health workers' role in giving related education about the contraceptive method, especially long-term conceptive method, is less. Besides encouraging of Postpartum Family Planning Program, it can be expected that health workers also provide the education to press the using of long-term conceptive method does not disturb sexual function and longterm conceptive method except the sterilization doe not influence the infertility. The increasing of awareness about the importance in doing long-term conceptive program to the postpartum needs doing. Because it remembers the return of women fertility approximatey 45 days afterbirth as the effort to increase the degree of mothers and children.

The Correlation between Subjective Norm and Intention of Postpartum Women using LARC
Subjective norm has strong significant relation and similar to the intention of postpartum mothers uses long-term contraceptive method. Most respondents of postpartum mothers get good subjective form and have high intention by using longterm contraceptive method. More better support from good subjective form and have high intention uses the long-term contraceptive method. It is also gotten high intention. This research is similar to research from Joeliatin et al. (2016). There are indirect relationships and the significance between subjective norm and the intention of women of childbearing age (WUS) to become longterm conceptive methods through the attitude. It means that a better subjective norm, women of childbearing age attitude becomes subjective norm. Thus, women of childbearing age attitute becomes positive. Thus, women of childbearing age attitude are more positive that can be strong intention to the women of childbearing age to be longterm conceptive method participants. According to Lestari (2018) that subjective norm has a significant relationship between subjective norm to the intention of using the contraceptive device. The other research from (Putri, 2018)that subjective norm has the strongest effect in generating the intention to participate in Family Planning program. In this research, the couple's support can give influence the awareness in participating Family Program. It is the awareness of the role of health workers in suggesting the couple of childbearing age to join in the Family Planning Program.
The influence of the highest subjective norm is gotten from the respondents to the health workers. This fact is proven to most of the respondents agree in the questioner item of subjective norm number 3 such as there are many suggestions from health workers in using long-term conceptive method. It is similar to (Ruwayda, 2014) that there is a significant relationship between health workers' role with using contraceptive devices in the postpartum. The suggestion from health workers is rated to connect the attitude of using contraceptive device. According to the research from Huda et al. (2016) that there are many significant relationship between the role of health workers with the action of using contraceptive method. The other research from Setiasih et al. (2016) that there are many support relationship between the Health Worker Service of Family Planning with the choosing of non hormonal long time contraceptive method.
The suggestion from husband in this research also determines the respondents subjective norm to the health worker. It is proven that most of the respondents answer agree in the items of quesionnaire question about subjective norm number 4 to the support from husband in using long-term conceptive method. According to that there are many significants relationship between the support from husband and the action of using contraceptive device to the wife. The research from Susanto (2015) that husbands' support also has the relationship in deciding to use contraceptive devices. The support from the husband can use the long-term conceptive method because without supporting the husband, the comfortable feeling does not get used. It is proven to the research from (Mahmudah & Fitri Indarwati, 2016)said that there are many relationship between husband and the choosing of LARC.
According to the analysis result, the lowest indicator is on the public figure's subjective norm variable. Most of the respondents answer disagree in the item of questionnaire question on the number 2 to the suggestion from public figure to use ling tern conceptive methode. According to this research, the researcher believes that it is important to health workers to provide the information and education about long-term conceptive method with the participation of the public figure. Beside that, it is important to extend the education target in determining the intention. Thus, husband also provides the information and full education from the health worker about the importance of using the LARC to the postpartum women.

The Correlation between Perceived Behavioral Control and Intention of Postpartum Women using LARC
Perception for Control Action has a significant relationship and similar to the intention of postpartum mothers use log term conceptive method. The high perception for action control, thus the result of the intention is high. The previous research is supported by Joeliation et al. (2016) that there are many indirect relationships and significances between control action and the participation from women of childbearing age in the intention of long-term conceptive method. It means that high perception in control action from women of childbearing age in long-term conceptive method. The research of Lestari (2018) said that there are many perception for control actions and the intention of using contraceptive method.
Respondents have high intention to use long-term conceptive method because they have many knowledges about long-term conceptive method such as benefit, the using effect, and know the using. It is proven to the most of respondents answer agree in the item of perception for control action perception in the number 1. It is according to the research of Ruwayda (2014) that many respondents have good knowledge will be the acceptors of postpartum Family Planning. The knowledge is one of the factor influences to the action control perception to the person. Nasrulloh (2015) to the research that there is the relationship between knowledge and the participation from the couple of childbearing age in doing Family Planning. It is reviewed from the knowledge, the research from (Megawati, Febi, & Adisty, 2015). This research is gotten the data that the using of contraceptive method is dominated by the respondents with good knowledge.
The supporting facilities also determine the respondents of action control perception. It is proven that more respondents answer agree to the questionnaire question about action control perrception nomber 3 such as the facilities to probe in using long-term contraceptive method. It is similar to Putri (2018) 's research that easy access reachers the supporting facilities in the implementation of Family Planning Program. It becomes an important thing in participating of Family Program. Bailey (2014) in the research, describes that there are many variations in the participation of couple on the childbearing age in the Family Planning program. The affordability and information exposure will support Family Program about the participation from the couple of childbearing age in the Family Planning Program. The availability of the facilities also becomes a determining factor according to Setiasih et al. (2016) said that the service of availability such as infrastructure, distance, and advice influences the interest in women of childbearing age in using Non Hormonal long-term conceptive program. It is similar to the research of (Haloho & Tety, 2011) that there is significant relationship between the completeness of the infrastructure to choose Innauterine Device contraception.
The cost factor is one of the factor to make person intention. This fact is proven with the most respondents' answer in question number 2 of action control perception questionnaire about the cheapest cost. It will make the respondents use long-term conceptive method. This research is similar to the research of (Septalia & Puspitasari, 2016)about the cost of fixing the contraceptive device with the using. The percentage of the non long-term conceptive method with cheap price is higher than longterm conceptive method. Because non leng conceptive method is cheap. It shows that the community intentions use something with cheap price higher than the desire uses thing with expensive price.
According to the analysis data, the lowest indicator is on the variable of action control perception in the gift/reward parameters. It can be shown that most of the respondents' answers disagree with the questionnaire question of action control number 5 about the reward atu gift to motivate the using of the long-term conceptive method. According to this research, researchers gets opinion that health workers can provide the information and high education to reach all of the communities to increase the knowledge of the community. Beside that, it can be expected that the government provides health facilities in may regions especially far away from the health facilities. The government also expected to give the subsidy about the contraceptive especially long-term contraceptive method. In order to all of the communities can reach that method from the cost.

CONCLUSION
The positive attitude to postpartum mother generates high intention in using Long-Term Contraceptive Method. However, negatif attitude does not always appear the low intention. More support from subjective form of postpartum mothers generates high intention in using Long-Term Contraceptive Method, supports from health workers and husband are the support to get high effect to postpartum mother. More good perception in controlling the attitude (knowledge, the availability of facility, and high cost) of postpartum women generates high intention in using LARC. The recommendations for future researchers are expected to conduct a comparative study of the behavior of choosing LARC and Non-LARC in postpartum women.

ACKNOWLEDGEMENT
We want to thank you for the respondents and all of the participants who help in the implementation of this research.