This study had a quasi-experimental pretest–posttest design with a control group. The study was conducted in Jeneponto Regency, Indonesia. The sample of this study was 66 midwives in Jeneponto Regency; 33 midwives comprised the control group, and 33 comprised the treatment group.

Data from this study were collected using questionnaires. The respondents were surveyed before (pretest) and after (posttest) the implementation of the Ammuntuli Bija intervention model.

The main parameters measured in this study were the knowledge, attitude, motivation of the midwives in pregnancy care as well as the accessibility and capacity of midwives providing health services to pregnant women.

SPSS was used for the statistical analysis. The Mann–Whitney statistical analysis was conducted to test the hypothesis.

The results of the Mann–Whitney test are shown in Table 2. The value was ρ=0.024; the value (p<0.05) with a mean difference of 1.264 indicates that there was difference between the treatment group and the control group after the implementation of the Ammuntuli Bija model. This intervention model uses local sentences, which is expected to better facilitate local implementation. It is appropriate to conclude that health problems can be resolved more effectively by taking into account the local context than by using medical treatments.20

Knowledge refers to what is known and remembered after experiencing, watching, observing or being taught from birth to adulthood, especially after receiving formal or informal education. Knowledge is the result of knowing, and this happens after people have sensed an object.

Knowledge can be interpreted as a result of knowing, which occurs after sensing. Sensing occurs through the human senses, namely, the senses of sight, hearing, smell and touch. Most human knowledge is obtained through the eyes and ears through both formal and informal education.

Efforts to improve maternal health services can take various forms. One strategy is training activities. In some cases, the training and development of health services have not been fully implemented despite the knowledge that education (counselling) has an influence on knowledge and attitudes.21,22 Knowledge, skills and motivation correlate with the performance of midwives; in contrast, work time does not.23

Training to be one of the meninges efforts ka VING knowledge and skills of midwives in maternal health services, the results of research that an increase in the average knowledge and skills of midwives in maternal health services in the district Jeneponto.24 Therefore, a midwife must have broad knowledge of services, especially midwifery, obtained through both formal education and informal education. In addition, a midwife must be highly motivated to provide good midwifery services to patients.15

The results of the Mann–Whitney test are shown in Table 2. The value ρ=0.046 reflects a value of p<0.05 with a mean difference of 2.671, which indicates that there was a difference in the midwives’ motivation regarding health care for pregnant women between treatment group and the control group after the implementation of the Ammuntuli Bija model.

Motivation is an internal and external impulse to make a change in behaviour. It has the following indicators: (1) the desire to perform an activity, (2) the presence of encouragement and the need to perform activities, (3) the existence of hopes and dreams, (4) the presence of respect for others and respect for oneself, (5) the existence of a good environment, and (6) the existence of interesting activities.25

According to Berelson and Steiner in Makruf and Siswanto, motivation is an inner state that gives strength, which activates or moves; hence, it is called “mobilization” or “motivation”. This state directs or channels behaviour towards goals. From the definition above, it can be said that among village midwives, motivation is a condition that can give the midwives strength, enthusiasm, courage to be honest and enjoyment of what they do, which leads them to achieve a high level of performance.

Motivational factors are related to what is done (job content), namely, the content of the work that encourages achievement. Motivational factors are intrinsic, originating in the individual; they are also called the content factor of the work.26

The results of the Mann–Whitney test are shown in Table 2. The value ρ=0.704 reflects a value (p>0.05) with a mean difference of 4.000, which indicates the presence of a difference in attitudes between the treatment group and the control group after the implementation of the Ammuntuli Bija model. Attitude is an evaluation statement describing a relatively consistent feeling or tendency regarding an object or idea; attitude is also a feeling that arises within a person after seeing, feeling and enjoying an object. Attitudes can be considered a willingness to react to an object, including people, events, institutions, values and so on.27

According to Notoadmojo, an attitude does not necessarily translate into an action; for an attitude to transform into a real action, supporting factors or conditions that allow for supportive facilities or infrastructure are needed.

The respondents’ attitudes towards labour delivery services are not surprising; their feelings arise because they recognize that as health workers, when they arrive to help with a delivery, their appearance should be neat and clean, and they should provide opportunities for the families to accompany them during labour. This good attitude, in addition to encouraging patients to ask for the respondents’ help, can also lead to increased coverage of health workers, especially midwives, which means that the risk of death for pregnant women can be reduced as much as possible.28

The attitude of health workers in health care facilities affects the frequency of ANC visits for pregnant women. The better the attitude of health workers, the more often a pregnant woman will visit a health facility to have her pregnancy checked. The unevenness of health workers in remote areas can also reduce access to health services for pregnant women.29 In addition to attitudes and priorities, is the ability to communicate is an important characteristic among health workers.30

Health workers with better attitudes increase pregnant women's participation in antenatal care visits, while those with worse attitudes reduce participation in antenatal care visits. This is in accordance with Lawrence Green's theory that a reinforcing attitude among health workers can influence behaviour change.31

The results of the Mann–Whitney test are shown in Table 2. The value ρ=1.000 reflects a value of p>0.05, indicated that access to maternal health services did not differ between the treatment and control group after the implementation of the Ammuntuli Bija model. The concept of access to health services refers to the patient's ability to obtain a health service from a health facility. In this study, researchers limited access to ease of service coverage, distance travelled, travel time and transportation used to reach the health service.32

The results of the WHO study stated that although the awareness and knowledge of people in developing countries are already quite high, they have difficulty engaging in healthy behaviours if health facilities are not affordable. Access to health services encompasses several concepts: respondents’ perceptions of cost and transport issues based on travel time to health facilities in minutes (≤30min, 31–60min, >60min) or hours, the distance in kilometres (<1km, 2–3km, 4km), or the degree of transportation difficulty (close, sufficient, far). Gambia found that factors that inhibit access to health services and midwives include time, transport issues, distance, and economic limitations.33–36

In line with the results of research conducted by Karman in South Konawe Regency, the variables distance, travel time and mode of transportation from the respondent's residence to health services have a significant influence on the utilization of health services.37

Distance creates a disturbance because it takes time and energy (costs) to travel from one location to another. In addition, distance also creates information disturbances so that the further away from a location, the less value associated with that location. The farther the distance to be travelled, the lower a person's interest in travelling will be, assuming other factors are all the same.38

Furthermore, health care facilities increasingly support the need for regular antenatal care. Transportation difficulties or long travel times may make a pregnant women reluctant to visit a health service for regular pregnancy checks.31

The results of the Mann–Whitney test are shown in Table 2. The value ρ=0.017 reflects a value (p<0.05) with a mean difference of 5.105, which indicates a difference in ability between the treatment group and the control group after the implementation of the Ammuntuli Bija model.

The Ammuntuli Bija model was very important for improving the results of health services for patients/clients and families. Competence specifically identifies knowledge, skills, attitudes, values, and dynamic evaluations of development and evolution.

Competence is defined as the abilities needed to perform work tasks based on knowledge, skills and work attitudes. Thus, competence can be defined as a person's observable ability, including knowledge, skills and work attitudes to complete a job or task in accordance with established performance standards.

Another explanation for the importance of ability was proposed by Muchlas, who stated that the higher an employee's abilities, the more tasks or jobs he or she can complete within a certain period, which shows that ability affects the quantity of work an employee can perform.39

This study has various limitations, namely, the small sample, which could not reveal the complete picture of health care for pregnant women. Activities in daily health services in Pustu and Poskesdes allow for limited intervention and communication time when conducting research; thus only a few aspects of health care services for pregnant women could be observed, and environmental, social, economic and family support factors were not addressed. Additionally, the lack of role exchange across sectors (such as the private sector, NGOs and fields and institutions such as agriculture, education, BKKBN, social, Empowerment Women, Ministry of Religion, PKK Enforcement Teams, Posyandu Cadres and government officials such as village/district) contribute to the less-than-optimal health services for pregnant women.