Community-Based Model: Pondok Dalam as a Solution to Increase Neonatal Visit in Serdang Bedagai District, North Sumatra, Indonesia

Abstract

Background:

Neonatal mortality is a significant public health problem in Indonesia, particularly in rural areas where healthcare access is limited. Therefore, this study aimed to develop Pondok Dalam, a community-based model, using traditional communal spaces in Serdang Bedagai, North Sumatra. By integrating local wisdom, the model functions as a neonatal health education center to enhance maternal knowledge, foster community support, and increase neonatal visit coverage.

Materials and Methods:

A mixed-method design was used, combining qualitative and quantitative data. Qualitative data were collected through in-depth interviews, focus group discussions (FGDs), participatory observations, and structured questionnaires. This study was conducted from February 2023 to July 2024 in five sub-districts of Serdang Bedagai: Dolok Merawan, Tebing Syahbandar, Kotarih, Naga Kesiangan, and Pon Village. Respondents included neonatal mothers, midwives, husbands, and community leaders selected through purposive sampling. Quantitative data were analyzed using the Wilcoxon test, while qualitative data were thematically analyzed.

Results:

The results showed that before the intervention, neonatal visit coverage averaged 63.30%, constrained by limited access, economic barriers, and low awareness. After implementing the Pondok Dalam model, maternal knowledge scores rose significantly from 6.23 (pre-test) to 8.63 (post-test) with a P-value of < 0.001. Neonatal visit coverage improved to 85% for the first visit and 93.30% for the third visit.

Conclusions:

Pondok Dalam model effectively enhanced maternal knowledge and access to neonatal health services. It offers a replicable, culturally sensitive solution to reduce neonatal mortality in underserved rural settings.

Introduction

Neonatal mortality is a significant public health problem in Indonesia, particularly in rural areas where healthcare access is limited. According to World Health Organization (WHO) data, approximately 75% of infant deaths occur in the first 28 days of life, making it a very crucial period in determining survival. The Indonesian government has been working to reduce the mortality rate through various health models, one of which is the neonatal visit. This comprises health checks of infants in the first 28 days after birth, aimed to detect and prevent complications that could jeopardize the health status.[1] However, neonatal visit coverage in Serdang Bedagai District, North Sumatra, Indonesia, is still below the national target.[2,3] This district faces significant challenges in improving coverage, specifically in five sub-districts, namely, Dolok Merawan, Tebing Syahbandar, Kotarih, Naga Kesiangan, and Desa Pon. Geographical barriers, economic limitations, and low awareness of the importance of neonatal screening are the main factors influencing the low visit rates.

Many mothers in these areas do not understand the importance of health checks for newborns, and often only bring infants to health facilities when signs of illness appear.[4] This increases the risk of complications that could have been prevented earlier.[5] To address this problem, a community-based model is considered an effective solution. The model requires active community participation in health improvement efforts, making it more easily accepted by local communities.[6] One form of local wisdom applicable is Pondok Dalam, which has been used as a community gathering place for social and religious activities.[7] By using Pondok Dalam as a neonatal health education and service center, the community is expected to more easily access the information and services needed without having to travel far to Puskesmas (Community Health Center) or a hospital.[8]

Pondok Dalam offers a participatory method, where mothers, midwives, health cadres, and community leaders actively engage in the process of educating and monitoring infant health. In this model, local midwives provide regular education on the importance of neonatal visits, newborn care, and danger signs. This activity not only increases mothers’ knowledge but also engages the family, specifically the husband, in supporting neonatal visits. Pondok Dalam serves as a bridge between the community and health services while overcoming access barriers that have been an obstacle. It also strengthens collaboration between formal health workers and local community leaders. In many cases, community trust in local figures, such as religious leaders or traditional leaders, is stronger than in formal health workers. Therefore, engaging these figures in health education models helps to increase the effectiveness of message delivery and promote active participation from the community[9]. Through the support of community leaders, mothers feel more comfortable asking questions and seeking information related to infant health. Therefore, this study aimed to develop a model for improving neonatal visit coverage rates based on the local wisdom of the community, namely, Pondok Dalam. By using Pondok Dalam as a health education center, it is expected that the community will have easier access to information and neonatal health services.

Materials and Methods

This study was conducted from February 2023 to July 2024 in five sub-districts of Serdang Bedagai, North Sumatra, Indonesia, namely, Dolok Merawan, Tebing Syahbandar, Kotarih, Naga Kesiangan, and Pon Village. A mixed-method design was used, combining quantitative and qualitative data. More specifically, qualitative data were obtained through in-depth interviews, focus group discussions (FGDs), participatory observations, and a questionnaire survey. In-depth interviews were conducted to determine the perceptions, constraints, and experiences of mothers and midwives related to the neonatal visit. FGD was conducted with coordinating midwives, practicing midwives, and husbands to explore the role of families in supporting neonatal visits. Participatory observations were carried out following activities at Pondok Dalam to observe interactions between mothers, midwives, husbands/families, and community leaders. The sample size was calculated using power analysis with the parameters Z1 = 1.98 (95% confidence level), Z2 = 1.28 (80% power), P1 = 0.50 (proportion of the baseline group), P2 = 0.70 (proportion of the intervention group), and a significance level of 0.05. Based on these values, the required sample size was determined to be 60 respondents.

The questionnaire consisted of two main sections; the first section focused on maternal knowledge about neonatal health, including newborn care, danger signs, and the importance of neonatal visits. The second section measured neonatal visit coverage based on the number of first, second, and third visits in the first 28 days of life. Each question in the maternal knowledge section was scored “1” for correct answers and “0” for incorrect answers. The total score was calculated by summing all correct answers, with a maximum score of 10. The questionnaire was developed based on neonatal health guidelines from the Indonesian Ministry of Health. It was adapted to the local context and the study objectives through consultations with maternal and child health experts. Validity and reliability tests were conducted on 30 respondents before the main study. Based on the results, all questionnaire items had a correlation coefficient higher than the table value (0.361), indicating validity. Cronbach’s Alpha test also yielded a value above 0.60, indicating good reliability. These results confirm that the questionnaire is suitable for consistently and accurately measuring the study variables. Data processing and statistical analysis were conducted using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) and IBM SPSS Statistics version 21.0 (IBM Corp., Armonk, NY, USA).

The Pondok Dalam model was implemented as community-based intervention, and data were analyzed using thematic analysis for qualitative data and quantitative statistical tests. The Wilcoxon test was used to assess changes in maternal knowledge scores and neonatal visit coverage. Through the model developed, mothers and families were educated about neonatal health, including topics such as danger signs, the importance of visiting healthcare facilities, and newborn care. The education was delivered through interactive group sessions facilitated by midwives using materials based on local wisdom. The intervention also engaged families, particularly husbands, to enhance support for mothers in ensuring the neonatal visit was completed.

Ethical considerations

The Ethics Committee of the Faculty of Medicine, Andalas University, approved this study with Approval Letter No. 44/UN.16.2/KEP-FK/2023, dated February 1, 2023, for implementation. Verbal and written consent were obtained from all respondents before distributing the questionnaires. The collected data were carefully managed to maintain confidentiality and accuracy, and all procedures were conducted in accordance with applicable ethical guidelines.

Results

Low neonatal visit coverage before the intervention

Before the intervention, neonatal visit coverage in the five health centers studied averaged only 63.3%. Many mothers admitted not participating in neonatal visits due to various reasons, including long distances to health facilities, economic limitations, and a lack of understanding about the importance of neonatal check-ups. The interview results are presented in Table 1.

Table 1.

Summary of qualitative data collected through interviews

Theme	Sub-theme	Supporting quotes
Limited access to health facilities	Long distance to facilities	“The health facility is far, and it is hard to go there with a newborn.” (Mother, 25 years old, Dolok Merawan)
Economic constraints	Unable to afford transportation costs	“We do not have extra money for transport to Puskesmas.” (Mother, 30 years old, Tebing Syahbandar)
Lack of awareness	Perception of check-ups as unnecessary	“I do not feel the need to bring my infant to Puskesmas if he is not sick. I did not take my first child either, and thank God he is healthy.” (Mother, 29 years old, Pon Village)

Implementation of the Pondok Dalam-based model

After the model development, Pondok Dalam was used as a place to hold regular meetings between mothers, midwives, and health cadres. Education on the importance of neonatal visits was delivered directly in easy-to-understand language, and mothers were motivated to actively ask questions, as shown in Table 2.

Table 2.

Insights from the implementation of the Pondok Dalam-based model

Theme	Sub-theme	Supporting quotes
Community-based education	Mothers’ improved understanding	“By holding meetings at Pondok Dalam, mothers are more open to ask questions and understand more about what to do after the infant is born.” (Community leader, 45 years old, Kotarih)
Supportive environment	Active participation of mothers	“I now understand the importance of bringing my infant for a check-up, and I feel supported by midwives.” (Mother, 32 years old, Desa Pon)
Accessibility	Proximity of the meetings	“It is easier to attend since Pondok Dalam is close to our homes.” (Mother, 28 years old, Naga Kesiangan)

Improved knowledge and neonatal visit coverage

Knowledge variable before and after the intervention

Knowledge plays a key role in promoting health behaviors, particularly among mothers in the neonatal period. This study assessed the impact of educational interventions on maternal knowledge by comparing pre- and post-intervention scores. Given the non-normal distribution of data, the Wilcoxon Signed Ranks test was used to analyze statistical significance. The results are presented in two tables, including descriptive statistics to illustrate changes in knowledge scores and the Wilcoxon test outcomes to evaluate the significance of these changes. This provides a detailed overview of the effectiveness of the intervention in improving maternal knowledge. Tables 3 and 4 summarize the analysis of the variable knowledge.

Table 3.

Descriptive statistics for knowledge variables before and after intervention

Knowledge	Results
	Pre-test	Post-test
Mean (SD)	6.23 (2.07)	8.63 (1.06)
95% CI (Lower-Upper)	5.70-6.77	8.36-8.91
Median	6.00	9.00
Minimum-Maximum	2-10	7-10
Skewness	–0.063	–0.275
Kurtosis	–0.203	–1.107

CI=Confidence Interval; SD=Standard Deviation

Table 4.

The Wilcoxon Signed Ranks test results for knowledge variable

Statistic	Value
Z-score	–6.254
p (2-tailed)	<0.001
Positive ranks (n)	51
Negative ranks (n)	0
Ties (n)	9

Z-score refers to the Wilcoxon Signed Ranks test statistic

The data in Table 3 shows that there is a significant increase in knowledge scores after the intervention. Before the intervention, the mean knowledge score was 6.23 (2.07), with a range of 2 to 10. After the intervention, the mean score increased to 8.63 (1.06), with a range of 7 to 10. The median score increased from 6.00 to 9.00, reflecting a significant improvement in respondents’ knowledge.

Table 4 shows that 51 respondents (Positive Ranks) showed an increase in scores, 9 respondents (Ties) had no change, and no respondents experienced a decrease in scores (Negative Ranks = 0). Z-score = –6.254 with P-value < 0.001 indicates a statistically significant difference in knowledge scores before and after the intervention.

Neonatal visit coverage in Serdang Bedagai district

Neonatal visit is an essential component of postnatal care, aimed at ensuring the health and well-being of both mothers and infants. This study examined neonatal visit coverage across three stages, namely, first, second, and third, by categorizing respondents as “Obedient” or “Not Obey.” Understanding these trends is critical for identifying areas of improvement in neonatal care delivery. “Neonatal visit coverage in Serdang Bedagai District is shown in Figure 1.”

Figure 1.

Neonatal visit coverage in Serdang Bedagai District

Figure 1 shows that coverage increased from the first neonatal visit at 63.30%, to 85%, and 93.30% in the second and third visits, respectively. This was supported by increased maternal awareness regarding the importance of neonatal check-ups. Many mothers who previously did not know that infants should be examined in the first 28 days developed a better understanding of the importance of these examinations.

One mother from Dolok Merawan stated, “I just found out that infants should be checked quickly, now I bring my infant to be checked immediately after birth.” (Mother, 30 years old, Dolok Merawan)

Discussion

In this study, ethical considerations were given special emphasis due to the participation of vulnerable populations, including infants and families. Approval was obtained from the Ethics Committee of the Faculty of Medicine, Andalas University (Approval Letter No. 44/UN.16.2/KEP-FK/2023, dated February 1, 2023). Verbal and written informed consent was obtained from all respondents before data collection, ensuring a full understanding of the objectives and procedures. The collected data were managed with strict confidentiality and accuracy, in compliance with applicable ethical guidelines in the study process. These ethical measures reaffirm the commitment to protecting the rights and welfare of respondents while underscoring the importance of ethical rigor in community-based interventions aimed at improving neonatal care and family health outcomes.

The results showed that before the intervention, neonatal visit coverage was low, with an average of only 63.30%. One of the main contributing factors was the low awareness of mothers regarding the importance of neonatal health checks. Many mothers believe that infants do not need to be brought to the health center in the absence of symptoms. Long distances to health facilities and economic limitations are also significant barriers for mothers in rural areas. One respondent felt there was no need to bring the infant to the health center due to the absence of visible illness signs. This lack of understanding illustrates a major challenge in educating the community on the importance of newborn health monitoring, specifically during the crucial period of the first 28 days after birth. This view is quite common among mothers in rural areas, where access to information and health facilities is limited.[6,10,11]

The main challenge in Serdang Bedagai District is the long distance between health facilities and where people live, as well as the lack of health professionals. With the Pondok Dalam method, the community will no longer have to travel a long distance to get basic health services. This is expected to reduce morbidity and infant mortality rates in the region, as well as provide convenience for mothers in accessing health services.

To address the issue of low coverage in neonatal visits, the Pondok Dalam community-based model was implemented. The model was designed as a platform to organize regular meetings between mothers, midwives, and health cadres in the local environment. The meetings are held in easily accessible locations, thereby reducing access barriers usually experienced by mothers. During these meetings, education on the importance of neonatal visits is delivered in understandable language, and mothers are motivated to ask questions.[6,12]

Aside from providing education, local community leaders play an active role in helping to disseminate information about the importance of neonatal screening.[13] With the support of local leaders, mothers feel more comfortable and open to asking questions, which improves understanding of neonatal screening. As stated by the community leader at Puskesmas Kotarih, Pondok Dalam model succeeded in motivating mothers’ participation in health discussions, which was previously difficult in formal meetings.

After 1 month of implementing Pondok Dalam, there was a significant increase in mothers’ knowledge about the importance of neonatal visits. Based on the data in Table 1, the mean knowledge increased from 6.23 before the intervention (pre-test) to 8.63 after the intervention (post-test), with a difference of 2.40 points. The increase was statistically significant with a P-value < 0.001, meaning that the intervention was effective in improving maternal knowledge. This suggests that the community-based model focused on intensive education was successful in increasing mothers’ awareness regarding the importance of health checks for newborns.[14]

The results are in line with a study conducted by,[6] stating that good knowledge can increase neonatal mothers’ compliance in caring for infants to strengthen the immune system and cognitive growth of infants by providing breast milk and immunizations. Another study[7] reported that neonatal mothers who have good knowledge about neonatal visits tend to be more proactive in seeking medical assistance to treat their infants when facing serious symptoms of illness.

A study conducted by[6] reported that despite the lack of knowledge about the importance of routine neonatal visits, neonatal mothers can recognize signs of danger and obtain the medical assistance needed to care for and treat infants. In addition to improving knowledge, this intervention also had a direct impact on increasing neonatal visit coverage. Table 2 shows that coverage of the first neonatal visit (days 1 to 7) increased from 63.30% to 85% at the second (days 8 to 14), and reached 93.30% at the third (days 15 to 28). This increase in coverage can be attributed to better knowledge among mothers about the importance of neonatal health checks.

One informant admitted not being previously aware that infants should be examined immediately after birth, but after receiving education through the Pondok Dalam model, the infant was brought immediately for examination. This statement shows how community-based education interventions can change people’s health behaviors, specifically related to the crucial monitoring of infant health.

Increased neonatal visit coverage is expected to reduce the risk of health complications in newborns that are not detected early.[15] With regular check-ups, various health problems such as infections, respiratory problems, or malnutrition can be identified early for timely treatment. The success of this model is not only evident from the increase in the number of neonatal visits but also from changes in the behavior of mothers who are more proactive in maintaining the health of their infants.[10,16]

A previous study showed that a community-based model can improve access and use of health services in rural areas. Husband and family participation also played an important role in motivating mothers to make neonatal visits, reinforcing the results of studies showing that family support is an important factor in maternal and child health.[17]

Neonatal health services are crucial for reducing infant mortality, specifically in rural areas with limited health facilities and access. Serdang Bedagai District, North Sumatra, is one of the areas with challenges in terms of health services, specifically for mothers and infants. Given this condition, a community-based model, such as the Pondok Dalam model, is one of the potential innovations to improve neonatal visits in the area. This model actively engages the community in monitoring and providing health services for postpartum mothers and infants.[18]

In general, the results show that the implementation of the Pondok Dalam-based model is effective in improving mothers’ awareness and knowledge about the importance of neonatal visit while increasing neonatal visit coverage in Serdang Bedagai District. It offers a solution that can be adapted to other regions in Indonesia with similar challenges in terms of neonatal health access and education. The model of increasing neonatal visit coverage based on Pondok Dalam is proven to be effective in increasing maternal awareness and accessibility to neonatal services. This local wisdom provides a more comfortable and familiar platform for mothers to learn and discuss infant health, in contrast to the formal atmosphere at Puskesmas or other healthcare facilities.

In this model, an important role is played by health professionals such as village midwives, assisted by health cadres and traditional birth attendants trained by midwives. These cadres and traditional birth attendants are tasked with monitoring infant condition, providing education on newborn care, and assisting in the early identification of health problems that require referral to a more complete health facility. The role of these cadres and traditional birth attendants strengthens community trust in health models, thereby increasing neonatal visits and maternal engagement in health models.

The model is integrated with health promotion efforts that focus on improving mothers’ knowledge of the importance of neonatal visits. Activities such as health counseling and group discussions are routinely held by cadres and village midwives. This aims to increase awareness about the importance of newborn healthcare, as well as prevent complications that can lead to infant mortality, including infections or respiratory problems.

One of the advantages of the Pondok Dalam model is the participatory and inclusive method. Community is not only the beneficiary but also actively engaged in the planning and implementation of the model. This helps to create a strong sense of ownership, making the community more committed to ensuring success. In addition, this method also emphasizes the importance of cross-sector collaboration, including with community leaders and religious leaders who have a strong influence on the community.

The initial evaluation of Pondok Dalam implementation in Serdang Bedagai District showed positive results. Neonatal visits increased significantly, and the community became more aware of the importance of newborn healthcare. The model also created a good domino effect, where mothers started sharing knowledge and experience with neighbors and relatives, thereby expanding the reach at the community level.[19]

There are still challenges that need to be overcome, such as limited funding and support from the local government. In addition, continuous training for cadres and traditional birth attendants is also an important aspect to keep up to date with the latest medical knowledge. With maintained commitment, Pondok Dalam has great potential to be adapted and developed more widely, not only in Serdang Bedagai District but also in other regions in Indonesia that have similar characteristics. The model demonstrates that community empowerment and strengthening cooperation between local health actors can be an effective solution to improve access and quality of neonatal health services. In addition, it offers new hope for improving maternal and infant health in remote areas. The model is also an innovative method that should be emulated by other regions facing similar challenges.[17]

The significant increase in maternal knowledge and neonatal visit coverage observed in this study can be explained through community-based mechanisms implemented in the Pondok Dalam model. One of the primary factors is the strong role of social support networks in the community. Active participation of community leaders, midwives, and health cadres fostered trust and a sense of connection between participating mothers and healthcare providers. These networks not only provide emotional support but also facilitate access to relevant information and motivate positive behavioral changes regarding neonatal care. Support from family members, particularly husbands, played a crucial role in motivating mothers to adhere to neonatal visit schedules.

Personalized and targeted counseling was another key mechanism for the success of the intervention. In the Pondok Dalam model, mothers received education tailored to specific needs, including the benefits of neonatal check-ups, potential risks of non-adherence, and the importance of early detection of complications. The educational content was culturally relevant and delivered through interactive methods, enhancing understanding and acceptance. Furthermore, the inclusion of real-life examples and case studies from the community reinforced the health messages being conveyed. These mechanisms collectively supported increased awareness and more proactive actions toward neonatal care. This study provides valuable insights into the effectiveness of the Pondok Dalam model in improving neonatal visit coverage and maternal knowledge. However, some limitations must be recognized. Firstly, this study was conducted in five sub-districts in Serdang Bedagai, which may limit generalizability to other rural areas with different socio-cultural characteristics. Future studies should consider broader geographic coverage to assess the model’s adaptability in different settings. Secondly, as the study relied on self-reported data, there is a possibility of recall or social desirability bias, particularly in maternal knowledge assessment. Combining self-reported data with objective health indicators in future studies may improve accuracy. Thirdly, although the mixed-method approach strengthens the study’s findings, the relatively small sample size in the quantitative analysis could limit statistical power. Larger-scale studies with more extensive sampling would provide stronger evidence of the model’s impact. Lastly, due to the study’s limited follow-up period, its long-term effects on neonatal health outcomes remain uncertain. Extending the follow-up duration in future research could provide deeper insights into the sustainability of the intervention. Despite these limitations, the findings suggest that the Pondok Dalam model is a promising, community-based approach to improving neonatal health services in underserved areas. Addressing these limitations in future research will further refine and optimize this model for broader implementation.

Conclusion

In conclusion, the community-based model Pondok Dalam was found to be effective in improving maternal knowledge and neonatal visit coverage in Serdang Bedagai District. Before the intervention, neonatal visit coverage was low, averaging 63.30%, due to limited access to health facilities, a lack of understanding regarding the importance of neonatal check-ups, and economic factors. However, after the implementation, which comprised intensive education and active participation from mothers, midwives, community leaders, and health cadres, there was a significant increase. The mean knowledge of mothers increased from 6.23 (pre-test) to 8.63 (post-test), with a P-value < 0.001, indicating that the intervention was statistically effective. In addition, neonatal visit coverage increased to 85% by the second visit and 93.30% by the third visit, reflecting increased maternal awareness of the importance of newborn checks in the first 28 days.

The development of the Pondok Dalam model was successful in increasing the neonatal visit coverage rate. The model was also effective in increasing the knowledge of mothers and husbands/families about the importance of neonatal health. This local wisdom-based method can be replicated in other areas with similar accessibility and public health awareness challenges. Future studies should explore the long-term impact of this intervention on maternal and neonatal health behaviors and outcomes. These results contribute to the growing body of evidence supporting the integration of educational strategies into health models, particularly those focused on neonatal care.

Conflicts of interest

Nothing to declare.

Funding Statement

Yayasan Medistra Lubuk Pakam, Indonesia.