Prevalence and Characteristics of Tubectomy Contraceptive Users in Bali from 2019-2020

Indonesia is the country with the largest population in Southeast Asia. The total population in Indonesia was recorded at 255.18 million, with a population growth rate of 3.33 million every year. This population growth has an impact on the economic development and welfare of the country. One of the efforts to suppress the increasing population is to use tubectomy contraception. This study aims to determine the characteristics of tubectomy contraceptive users in Bali in 2019-2020. The design of this research was descriptive crosssectional. The inclusion criteria in this study were tubectomy contraceptive acceptors recorded in the medical records of the Sanjiwani Hospital in the range of 2019 to 2020. The exclusion criteria were incomplete medical record data. The results of this study found that the prevalence of tubectomy users at the Sanjiwani Hospital from January 2019 to September 2020 was 6.71%. Characteristics of the most users are 36-45 years old, as many as 32 people (65.3%), the highest number of children are 3 children, namely 22 people (44.8%), the highest education level was high school level, which is 24 people (49%), the most occupations are housewives as many as 32 people (65.3%), the most common type of tubectomy was postpartum tubectomy as many as 40 people (81.6%), and for insurance, the most is a Surat Keterangan Tidak Mampu (SKTM) which is as many as 27 people (55,1%). This study concludes that the characteristics of the most contraceptive users are 36-45 years old, the highest number of children are 3 children, the highest education is senior high school, the majority are IRT, the most type of tubectomy contraception is postpartum, and the majority of insurance used is SKTM.


METHOD
This research has ethical approval from the Health Research Ethics Commission (KEPK) of Warmadewa University, 134/Unwar/FKIK/KEPK/VIII/2020. This research is a descriptive study. Samples were from the medical record of RSUD Sanjiwani Gianyar from January 2019 to September 2020, and forty-nine samples were selected. The inclusion criteria were acceptors who were certain to do tubectomy, recorded in the medical records, and the exclusion criteria were patients with incomplete medical record data. In addition, this study's variables were: age, the number of children, education, occupation, type of tubectomy contraception, and insurance used. The results will be presented in the form of tables and narratives.
These results indicate that the percentage of new and previous tubectomy acceptors at the Sanjiwani Hospital is still below 7%. The prevalence of tubectomy users at the Sanjiwani Hospital in 2019-2020 was 6.71% (49 people) out of 730 new family planning acceptors.

BACKGROUND
In the last 15 years, increasing Indonesia's population has reached 3.33 million people per year. Indonesia was recorded to have had a total population of 255.18 million people in 2015. 1 This condition directly affects the country's economic, education, and social welfare sectors. 2 Therefore, the National Population and Family Planning Agency (BKKBN) was formed, which its main task is to reduce Indonesia's population growth rate below 1% and cut down the female fertility rate by 0.4, from an initial value of 2.6 to 2.2. Total 7.1 million new acceptors were targeted to join the family planning (KB) program. However, this target is not being reached yet. Data from the BKKBN Strategic Plan in 2018 shows that the female fertility rate in Indonesia is still at 2.38, which is certainly still above the target set. 3 Couples of childbearing age (PUS) in Indonesia were reported to have reached more than 38 million people in 2018, with the number of active family planning users (acceptors) being 63.27%. These acceptors include 7.35% using an intrauterine device (IUD), 2.76% tubectomy, 0.5% using the male operative method (MOP), 7.2% using implants, 63.71% injections, and 17.24% utilizing pills, and 1.24% with condoms. 4 The unmet need is also reported as still high. It reached 8.2% in 2012. It only decreased by 0.1% compared to the results achieved ten years ago. The unmet need community does not receive any services related to the family planning program, which need to be solved immediately. 5 Data on users of long-term contraceptive methods (MKJP) in 2018 was reported to be around 17.8% and increased to 24.6% in 2019. However, tubectomy contraception is the lowest of the various available MKJP options. 4 Based on this issue, further research is needed to determine the prevalence and characteristics of tubectomy contraceptive users in Bali, especially in the Sanjiwani Hospital, Gianyar. ple) as a housewife, and 14,3% (7 people) as a daily worker. None of them work as a civil servant ( Table 4).

Health Insurance
The distribution of health insurance used by the samples in this study was 10,2% (5 people) without insurance (general), 30,6% (15 people) using national health insurance -BPJS, 55,1% (22 people) owned certificate of incapacity (SKTM), and 4,1% (2 people) using Jampersal (Table 6). The level of education plays an important role in the decision making, including the use of contraception. Women with a higher level of education will tend to have broader knowledge, and understand new thoughts/perspective/information better, more independent, and can think more rationally. 11 Education also affects the mindset and decision-making related to the period of reproduction or fertility. Education can be the cause of a woman delaying her pregnancy, especially when she wants to continue her education to a higher level. Therefore, it is not uncommon for a woman to delay marriage, so that her reproductive period becomes shorter. 12

Employment Status
The study found that the acceptors who worked were less than those who did not. This is in accordance with the results of research conducted at Pukesmas Jombang, South Tangerang, where the percentage of acceptors who do not work is 76.8%. 13 Employment status has an impact on a person's economic level. People who have jobs will be able to earn income that can be used to provide their daily needs. (14) However, it seems that employment status have no effect in choosing tubectomy contraception. The role of other factors such as age and number of children are more likely to be dominant.
However, employment status is closely related to a person's level of education and knowledge. Employment status may affect a person's risk of experiencing a sexually transmitted disease (HIV/AIDS). (15) In this condition, tubectomy is not a contraceptive method that can prevent the disease, but other types of contraception such as condoms. Therefore, efforts to increase knowledge and empower the community are a solution to overcome this problem. 16

Type of Tubectomy
A study in the United States states that the postpartum is the most common tubectomy performed, based on the length

Age
This study found that mostly the acceptors were in the age range of 36-45 years (65.3%). This result is similar to a study conducted in Surabaya where the age of most of the acceptors was 35-39 years old (41%). 6 This finding is also in line with the goals of contraception according to the World Health Organization (WHO). WHO states that women have 3 reproductive phases, namely: the phase of delaying pregnancy (age under 20 years), the phase of spacing out pregnancies (age 20-30 years), and the phase of ending fertility with (age over 30 years, especially in women over 35 years old). In the termination phase of fertility, the woman is assumed to have had enough children, so it is not recommended to have another child due to medical or other non-medical reasons. Thus, in this phase, the best contraceptive method is tubectomy as a steady and permanent contraception. 7

Number of Children
The study found that the acceptors were mostly women who had 3 children (44.8%). This is similar to a previous study which also found that the most tubectomy family planning acceptors were those who had 3-4 children (57%). 6 The number of children affects the type of contraception to be used. PUS tends to choose contraception with lower effectiveness when they have a few children, while PUS who have more children tend to use contraception with a higher level of effectiveness, such as using MKJP, including this tubectomy. 8,9

Educational Background
The highest use of tubectomy contraception in this study was in women with a high school education background (49%). This result is also similar to a study in 2012 conducted at the dr Pirngadi Regional General Hospital in Medan. The results of the study stated that the most acceptors were mothers with a high school education level of 60.3%. 10 8. Fitrianingsih

Healthcare Insurace
Based on the types of health insurance in this study, it showed that insurance is not a single factor in the selection of tubectomy contraception. Medical reasons, age and number of children should also be considered in making decisions in the choice of contraception. In addition, this study was only conducted at the Sanjiwani Hospital which is a government hospital, so it is likely that most of the patients were referral patients from first-level health services.

CONCLUSION
The prevalence of tubectomy contraceptive users at the Sanjiwani Hospital in 2019-2020 is 6.71%. The characteristics of the most contraceptive users are 36-45 years old with high school background working as housewife. Most of them have 3 children and chose to have postpartum tubectomy with majority used SKTM to get healthcare insurace.

ACKNOWLEDGMENT
The authors would like to thank the Sanjiwani Hospital Gianyar and the Faculty of Medicine and Health Sciences, Warmadewa University, who have supported and facilitated this research. The author declares that there is no conflict of interest in this research.