The Influence of Doctors Therapeutic Communication and Nurses Communication Style on the Quality Services for Pregnant Women in Hospitals Deli Serdang

The maternal mortality rate is the number of women who die during pregnancy (the 42 day period after giving birth). The higher maternal mortality rate, the lowest welfare of a country. The highest MMR in North Sumatra province 2021 was in Deli Serdang district with 23 cases. Therefore, health professional are required to have communication skills with therapeutic meaning. This study aims to analyze the influence of doctors' therapeutic communication and nurses' communication styles on the quality of services for pregnant women in hospitals deli serdang district. This quantitative research uses analytical observational methods with a cross sectional approach. Data collection was conducted on 97 pregnant women who consulted at the polyclinic gynecology and obstetrics at Drs. H. Amri Tambunan Hospital, Grandmed Hospital and Haji Hospital. The data collection technique was carried out by distributing a questionnaire. The results of this study indicate that that doctors' therapeutic communication influences the quality of service at the Deli Serdang district hospital. The nurse's communication style influences the quality of service at the Deli Serdang district hospital. There is an influence of doctors' therapeutic communication and nurses' communication styles on the quality service of hospital at the Deli Serdang district. Has a very strong relationship with a adjusted R square of 73.2%. The remaining 26.8% was influenced by other factors outside this research

The maternal mortality rate is the number of women who die during pregnancy (the 42 day period after giving birth).The higher maternal mortality rate, the lowest welfare of a country.The highest MMR in North Sumatra province 2021 was in Deli Serdang district with 23 cases.Therefore, health professional are required to have communication skills with therapeutic meaning.This study aims to analyze the influence of doctors' therapeutic communication and nurses' communication styles on the quality of services for pregnant women in hospitals deli serdang district.This quantitative research uses analytical observational methods with a cross sectional approach.Data collection was conducted on 97 pregnant women who consulted at the polyclinic gynecology and obstetrics at Drs. H. Amri Tambunan Hospital, Grandmed Hospital and Haji Hospital.The data collection technique was carried out by distributing a questionnaire.The results of this study indicate that that doctors' therapeutic communication influences the quality of service at the Deli Serdang district hospital.The nurse's communication style influences the quality of service at the Deli Serdang district hospital.There is an influence of doctors' therapeutic communication and nurses' communication styles on the quality service of hospital at the Deli Serdang district.Has a very strong relationship with a adjusted R square of 73.2%.The remaining 26.8% was influenced by other factors outside this research

INTRODUCTION
MMR is an indicator that reflects the well-being of a country's society.In addition to assessing the success of maternal health programs, MMR can also be used to assess the overall health status of the community.The sensitivity of MMR to improvements in health services, both in terms of accessibility and quality, makes it an important parameter in health system evaluation.
MMR is defined as the number of women who die during pregnancy (the period 42 days after delivery), caused by or aggravated by pregnancy or its management, but not caused by accidents, disasters, injuries, or suicide.According to Sitorus (2020), MMR is still far from the SDGs target, which sets 70 per 100,000 live births as a sustainable development goal.
Every day, around 830 women die from pregnancy and childbirth, with almost 99% of these deaths occurring in developing countries, as reported by the World Health Organization (WHO).Data from the Indonesian Ministry of Health recorded an increase in the number of maternal deaths from year to year.In 2021, there were 7,389 maternal deaths in Indonesia, showing an increase from the previous year which reached 4,627 deaths, as seen in the 2021 Indonesia Health Profile chart.
A key issue at present is the increase in the number of maternal deaths collected from the Ministry of Health's family health program records.An indepth analysis is needed to understand the causes of this increase, including the accessibility and quality of maternal health services.
The high maternal and infant mortality rate in North Sumatra, especially in Deli Serdang Regency, is a sign of problems with the health status and health services in the area.The phenomenon shows that the highest maternal mortality cases occurred in Deli Serdang Regency, with 23 cases in 2021.The increase in maternal mortality in the area is a major concern.
In the world of health, communication skills are very important because it is the main tool or method in establishing a trusting relationship between health workers and pregnant women.between health workers and pregnant women.Kurniawati (2021: 183) says this is needed so that sick patients get motivation to return.this is needed so that sick patients get the motivation to get back to health as before.healthy as before.
Deaths due to childbirth should not happen, but malpractice often occurs that can result in fatalities.Ineffective communication between doctors and pregnant women can be the cause of malpractice.Communication skills in the health world are considered very important, especially between health workers and pregnant women.Therapeutic communication is expected to enhance trusting relationships and motivate patients to actively participate in health care.
Barriers in doctor-pregnant mother communication can arise due to the lack of clear disclosure of complaints by pregnant women.Doctors who are less experienced or less skilled in history taking may draw wrong conclusions.Therapeutic communication skills are considered important, especially for doctors and nurses, to establish a trusting relationship with patients.This is expected to increase the effectiveness of health services and provide satisfaction to patients.
From the phenomena that occur, researchers will carry out research in a type B hospital located in the Regency area.Deli Serdang.There are 3 (three) hospitals, namely Drs.H. Amri Tambunan Hospital, Grandmed Lubuk Pakam Hospital and Haji Hospital.Type B hospitals were chosen as the focus of the study because they are considered the right choice with appropriate service standards and facilities, but it is necessary to understand whether these facilities are adequate to provide quality services.
The phenomenon of increasing maternal mortality in Deli Serdang Regency motivated the researcher to investigate the influence of doctor's therapeutic communication and nurse's communication style on the quality of care for pregnant women in the regional hospital.

LITERATURE REVIEW
In this case the researcher feels that the positivism paradigm is suitable to be applied in this research because the researcher acts as an observer.applied in this study because the researcher acts as an observer by not influencing the object under study.not affecting the object under study.Furthermore, for the application of the positivism paradigm positivism paradigm in this study, the object under study is assessed by giving a score to each respondent's answer to the research instrument used.on each respondent's answer to the research instrument used by the researcher.

Communication and Interpersonal Communication
According to Soyomukti (2012: 55-56) states that the word communication comes from the Latin communis, which means "making together" or "building togetherness between two or more people".The root of the word communis is communico, which means "to share".In this case, what is shared is shared understanding through the exchange of messages.

Social Penetration Theory
Social penetration theory was developed in 1973 by Irwin Altman and Dalmas Taylor.Social penetration theory has a major role in the field of communication, that this theory proposes self-disclosure as an initial a necessity at the beginning and an important component in relationships between individuals.Therefore, social penetration theory explains self-disclosure by varying levels of information from superficial to intimate and communication in the development of interpersonal relationships.communication in the development of interpersonal relationships.The different levels of social penetration is conceptualized in two dimensions namely breadth and depth.depth.In this case, depth relates to the level of intimacy in the social penetration process which will determine the extent to which a person feels comfortable to open up about certain aspects of his or her personal because personal life is not openly disclosed (Ernala., et al, 2018: 63).Health Communication Kurniawati (2021: 183) Health communication is limited to messages that are sent or received.sent or received, namely a variety of messages related to the world of health and the factors that influence it.influencing factors.Health communication is a process of communication process involves health, elements or communication participants.In health communication the various participants involved in the health process include doctors, patients, nurses, health professionals or other people.

Therapeutic Communication
according to Adriyana (2018: 23) therapeutic communication is communication that is carried out or designed for therapeutic purposes and becomes the basic modality of therapy.communication is communication that is carried out or designed for therapeutic purposes and becomes the basic modality of therapy.the main intervention consisting of verbal and non-verbal techniques used to form a relationship between the therapist and the therapist.to form a relationship between the therapist.Doctor's Therapeutic Communication Lalongkoe (2014: 100)

Nurse
According to Nursing Law No. 38 of 2014, a nurse is a person who has graduated from nursing education both at home and abroad in accordance in accordance with applicable laws and regulations.Nursing services in hospital is an integral part of hospital services as a whole, which is also a measure of the success of achieving hospital goals.hospital services as a whole, which is also a measure of the success of achieving the goals of the hospital.hospital, and is often a determining factor in the image of the hospital in the eyes of the community.community.The organization of health services in hospitals has characteristics and a very complex organization, various types of health workers with their respective scientific devices interact with each other such as medical personnel, nurses, midwives, non-nurse paramedics and non-medical personnel.(Law No. 44 of 2009).Nurses are the largest segment of the profession in the health sector.Liliweri (2017: 261) Indicators:

Nurse Communication Style
1. Assertive communication style 2. Aggressive communication style 3. Passive communication style Service Quality Kotler and Keller (2016: 156) define quality as the totality of features and characteristics of a product or service that bear on its ability to meet the needs of its customers.and characteristics of a product or service that bear on its ability to satisfy needs in order to meet or exceed expectations.satisfy needs in order to meet or exceed expectations.It needs to be emphasized that Quality always focuses on the customer (society).Thus, products, both goods and services, are designed, produced, and services are provided to meet customer desires.are designed, produced, and services are provided to fulfill customer desires.

METHODOLOGY
The approach in this study is a quantitative approach, in Raihan (2017: 35) the quantitative approach emphasizes its analysis on numerical data which will be processed with statistical methods to determine the results.data which will be processed with statistical methods for data interpretation.interpretation of the data.Basically, the quantitative approach is implemented in research using inference statistical measurement tools for hypothesis testing.In hypothesis testing, we will see the effect, relationship, and difference obtained.

Obtained
This research is an analytic observational research with using a cross sectional approach.Analytic observational research or analytic survey is research that examines the relationship between two or more variables.or more.In this case the researcher only observes without giving treatment or intervention on the research subject.Provide clear and concise versions of your methods of conducting research, population and samples, and data analysis tools (Harlan dan Johan, 2018).

Measurement scale
In quantitative research, a measurement scale is needed.Raihan (2017: 116) in his book explains that the measurement scale in research is a reference in the use of measuring instruments used to measure variables through established indicators, by producing data in through the indicators set, by producing data in numbers.numbers.This study uses a measurement scale with a Likert scale.This study uses a Likert scale with intervals of 1-3.
Modification of Likert scale is intended to adjust to the needs of the research, namely eliminating the Strongly Agree (SS) and Strongly Disagree (STS) options.Modification Likert scale in this study is to eliminate the undecided category.The category has a double meaning, of course not expected in a research instrument.research instrument, in Eko Hertanto (2017).

Population and Sample
Population is a collection (total number) of individuals who have characteristics to be studied (quality and predetermined criteria).have characteristics to be studied (quality and criteria that have been determined) in advance by the researcher who will be used as the object of research in the study.Raihan (2017: 85).The population in this study were pregnant women who consultedat the obstetrics and gynecology polyclinic of the Deli Serdang Regency hospital from January -September 2023.January -September 2023.The sample is part of the population or in other words the sample being a representative of the population or part of the population studied.Researchers must do sampling in such a way that the sample obtained obtained can truly serve as a representation of the population so that it can describe the true state of the population.can describe the actual state of the population.In this study, determination of the number of samples from the population needed in the study using the Slovin formula as follows.

Sampling technique
In this study, the population to be studied has homogeneous properties so that there are no significant differences in the samples that will be used during the research, therefore, researchers use probability sampling with the cluster random sampling method so that the population has the same opportunity.
Cluster random sampling method so that the population has the same opportunity to become a sample.to become a sample.In determining the number of research samples from each hospital can be seen as follows.

Primary data
To obtain the primary data needed in this study, the researcher used a questionnaire.using data collection techniques using a questionnaire.The questionnaire is used to collect data using a list of questions or a list of entries against the object under study.
Secondary data This research uses secondary data obtained from books, journals, statistical data and data that has been validated and recognized by several government and nongovernment institutions.government and non-government institutions.

Validity test and reliability test Validity test
The test technique used is a correlation technique through product moment correlation coefficient.The score of each question item tested The validity is correlated with the overall item score.If the correlation coefficient is positive, then the item is declared valid, while if it is negative then the item is invalid and will be removed from the questionnaire or replaced with an improved statement.statement of improvement Where: r = correlation coefficient N = number of samples ∑X = Number of item scores ∑Y = Total number of answer scores ∑X2 = Sum of squares of item scores ∑Y2 = Sum of the squares of the total answer score ∑XY = The sum of the multiplication of the answer score of an item with the total score

Reliability test
It is said to be reliable if there is consistency in a person's answer to a statement or stable over time.statementor stable over time.This needs to be done to maintain stability in research.The reliability test in this study was calculated using the cronbach alpha formula (a) on SPSS version 25.According to Ghozali, (2018: 46) "It is said to be reliable if a variable provides a cronbach alpha value (a) > 0.60.alpha (a) > 0.60 ".

Data analysis technique Descriptive analysis
Descriptive statistical analysis using SPSS analysis using SPSS is carried out to provide an overview or description of the data seen from the average value (mean) in Molli (2020: 96).

Classical assumption test
Before doing regression analysis, it is necessary to test classical assumptions first so that the processed sample data truly represents the population as a whole overall.

Normality test
According to Sugiyono (2017) the normality test is a test to see if the residuals obtained have a normal distribution.residuals obtained have a normal distribution.This statistical test uses the kolmogorov-smirnov test.If the significant value> 0.05, it can be said that the residuals are normally distributed and vice versa.normal distribution and vice versa.A good regression model is one that residuals are normally distributed.This normality test was carried out using SPSS software version 25.

Multicollinearity test
According to Ghozali (2018: 105) multicollinearity testing aims to test whether the regression model found a correlation between independent variables.(independent) variables.A good regression model should not have a correlation between the independent variables.independent variables.The basis for making this test decision is seen from the value of.Tolerance and VIF (Variance Inflantion Factor) as well as the amount of correlation between independent variables.independent variables.

Multiple linear regression analysis
This analysis technique is used as a researcher's step to measure how far the influence of variables X1 (Therapeutic Communication), X2 (Communication Style), on Y (Service Quality).Communication Style), on Y (Service Quality).(Sugiyono, 2017).

Hypothesis testing
Before testing the hypothesis, a correlation analysis was conducted between independent variable with the dependent variable.Correlation coefficient analysis, then continued with the t-test and f-test to prove the significance of the influence between the independent variable with the dependent variable in this study.

Overview of the Research Location
Drs. H. Amri Tambunan Hospital is a public hospital owned by the government of Deli Serdang Regency, which is a service referral center with type b status, Drs.H. Amri Tambunan has achieved Five-Star Plenary Pass status in the 2019 Hospital Accreditation Survey.Hospital Accreditation Survey in 2019.On November 2, 4 and 5, 2022.
Drs. H. Amri Tambunan Hospital is led by a Director.by a Director.It has 4 (four) types of sub-specialists, gastroenterology, Nephrology, Mental and Orthopedics and 16 types of specialists (internal medicine, pediatrics, surgery, obstetrics and gynecology, eye, ENT, skin and sex, lung, neurology, orthodentia, orthopedics, anaesthesia, radiology, clinical pathology, and anatomy).Deli Serdang Regional General Hospital has an effective working area of effective in 14 sub-districts out of 22 sub-districts in Deli Serdang Regency, with a population of approximately 1.85 million people.
Grandmed Hospital is a privately owned hospital on Jalan Medan Lubuk Pakam, Deli Serdang Regency.The hospital is located in the capital Regency, within the working area of the regional government center of Deli Serdang Regency.Serdang Regency stands on 3.4 hectares of land with a building area of 17,513.512m2 with a type b service capability.This type b service capability was established in 2009.Gradmed Hospital is a private hospital that is a referral for health services for doctors and the community in need.and the community in need.Gradmed Hospital has advantages including commitment to quality, ease of access, quality of service, completeness of specialties and medical support equipment.Achievements that have been achieved by Grandmed Hospital since its establishment until now is the realization of Grandmed Hospital's commitment to quality health services.Grandmed Hospital's commitment to quality health services.This will continue to be carried out to achieve the vision and mission of the hospital through the service values that are embraced which are care, service, integrity, cooperation and quality.
haji hospital was established on the basis of creating superior health care facilities and referral centers with services with Islamic nuances, environmentally friendly competitiveness according to national and international standards.international standards.Location of Haji General Hospital Medan, North Sumatra Province is located on Jalan Haji Medan Estate Medan, Deli Serdang Regency and is located at the border crossing of Medan city.The land area haji hospital of is 60.002 M2 and the building area is 13,837 M2 .Based on geographical position haji hospital has boundaries on the west bordering the Office of Baznas, Kec/Desa Deli Serdang, on the east bordering the Academy of haji.Baznas Office, Deli Serdang Sub-District/Village, to the east is bordered by the State Tourism Academy, Deli Serdang Sub-District, to the north is bordered by the State Tourism Academy.State Tourism Academy, Deli Serdang Sub-District/Village, to the north is bordered by Jl haji hospital Medan, Kec/Desa Deli Serdang and to the south bordered by with the State Administrative Court, Kec/Desa Deli Serdang.
This research requires respondent data collected from characteristics, namely data on age, latest education and occupation.Each These characteristics are considered to influence respondents in providing answers in the research questionnaire. in the research questionnaire.Respondents in this study were pregnant women who visited the obstetrics and gynecology polyclinic at Drs. H. Amri Tambunan Hospital, Grandmed Hospital and haji hospital.Researchers focused on the therapeutic communication process carried out by the doctor and the communication style communication style of nurses in obstetrics and gynecology polyclinics whether it has provided the best quality of health services to pregnant women.health services to pregnant women.
Characteristics of respondents based on the age of pregnant women are in the range age range of 26-35 years, namely 58 people.This means that the majority of respondents 26-35 years old are in the productive age range.According to the ministry of health ministry which states that the ideal gestational age for women is 20-35 years because in that age range, women have reached the peak of growth so that they can be said to be physically ready.growth so that it can be said that they are ready physically, mentally, and emotionally.emotionally.However, pregnancy and childbirth at the age of under 20 and over 30 years turns out to have a greater risk to the health of the mother and baby.Due to maternal unpreparedness and obstetric complications that will result in death.To avoid this, pregnant women should routinely check up with the gynecologist of her choice.
The basic level of education is the minimum education of completing junior high school, intermediate level for senior high school and higher level indicates college level in the form of diploma, strata-1.This shows that the majority of respondents have knowledge of formal education at the secondary and tertiary education levels, as many as 83 people.If the level of education is associated with the average age of pregnant women, the increasing age will increase the absorption of information and understanding about pregnancy.information absorption and understanding of pregnancy.Characteristics of respondents based on work who are housewives 40 people and 57 people who work.In this case high level of education apparently affects the number of pregnant women who work.working.Whereas the pregnancy period in working pregnant women is not easy because of the unstable physical and psychological conditions.because of the unstable physical and psychological conditions.

The Effect of Doctor's Therapeutic Communication on Service Quality
Based on the results of descriptive analysis of doctor therapeutic communication variables which consists of four indicators, namely the preparation stage, opening stage, exploration stage and termination stage with 18 question items.exploration and termination stages with 18 question items.The results of this study The results showed that there was an effect of doctor's therapeutic communication on the quality of service at the Deli Sergio quality of service at the Deli Serdang Regency hospital, this is evidenced by the value of the Significance (Sig) 0.05.
Significance (Sig) 0.02 <0.05.t-table at the 95% confidence level (5% significance or 0.05) and free degree (df) = N-k-1 = 97 -2-1 = 95 where N = number of samples, and k = number of independent variables, the t-table value is 1.661.This means that with the value of t count 3.122> t table 1.661 that the therapeutic communication variable of doctor.
significant effect in improving service quality in hospitals Deli Serdang Regency, so that the hypothesis proposed can be accepted the truth.The doctor's therapeutic communication at the preparation stage is an initial assessment of the doctor.pregnant women against doctors.Based on the results of the study, the doctor has doctor has prepared himself in advance and already knows information in the form of identity of pregnant women.This is evidenced by the doctor greeting pregnant women by name.mentioning her name, as many as 56 pregnant women agreed.The doctor also introduced themselves and said greetings at the beginning of the meeting.Approach taken by the doctor at the beginning of the meeting will affect the next stage of the next stage of therapeutic communication.In this case the doctor has successfully passed this preparatory stage well according to the responses given by pregnant women.
So if it is associated with the theory of social penetration, the activity of approaching the pregnant woman is included in the orientation stage.at the beginning is included in the orientation stage that in the process of social penetration and process of social penetration and therapeutic communication where the information provided or obtained is only the surface.the surface only The doctor maintains a therapeutic climate and builds trust, becoming a trust binder for pregnant women.The doctor asks about the pregnant woman's complaints, followed by an explanation of the examination action plan.Pregnant women feel comfortable to convey complaints in detail, showing the opening of the relationship.Pregnant women are more open and trusting of the nursing actions taken by the doctor.Therapeutic communication in the exploration stage is an important phase, in line with previous research.This section allows you to describe your research findings academically.You may not enter figures related to your statistical tests here; instead, you should explain those numbers here.You should structure your discussion with academic support for your studies and a good explanation according to the specific area you are investigating.Doctors and pregnant women work together to address the complaints that pregnant women feel.The doctor asked the pregnant woman how she felt after the examination, and the results showed a positive response.The therapeutic communication between doctors and pregnant women was interpreted through social penetration theory.Stages such as affective exchange and stable exchange reflect the development of a good relationship and understanding between doctors and pregnant women.

The Effect of Nurse Communication Style on Service Quality
The nurse's communication style consists of three indicators: assertive, aggressive, and passive.The results of descriptive analysis showed that nurses' communication style was in the good category, with an average value of 2.33.There is a significant influence between nurses' communication style and service quality in Deli Serdang Regency hospitals.The significance result (Sig) 0.00 <0.05 indicates that the proposed hypothesis is acceptable.
Nurses' communication style has a greater influence on service quality than doctors' therapeutic communication.Nurses are considered an integral part of hospital services and have a significant role in providing care to patients.Nurses' assertive communication style is the most preferred by pregnant women.Nurse assertiveness increases patient satisfaction, provides appropriate care, and contributes to improving the quality of care in the hospital.
The nurse's communication style only reached the orientation stage in social penetration theory.The short frequency of meetings in outpatient services makes the relationship between nurses and pregnant women at a limited level of openness.The nurse's communication style only reaches the orientation stage in social penetration theory.The results of the study are in line with the findings of previous studies regarding patient satisfaction related to the assertive communication style of nurses.The implications of the research results can be used to improve nurse communication training and service quality in hospitals.Recommendations to pay more attention to nurses' assertive communication style in an effort to improve satisfaction and service quality.

The Influence of Physician Therapeutic Communication and Communication Style Nurses on Service Quality
Consists of five indicators: reliability, responsiveness, assurance, empathy, and tangibles.The results of descriptive analysis show that service quality variables in Deli Serdang Regency hospitals are at a good level.There is a significant influence between doctors' therapeutic communication and nurses' communication style on service quality in hospitals.The correlation coefficient (R) of 0.859 indicates a very strong relationship between the two independent variables and service quality.
Reliability: Medical personnel carry out careful checks on the progress of the pregnancy.Responsiveness (responsiveness), Assurance (guarantee), Empathy (empathy), and Tangibles (direct evidence) are factors for assessing service quality.Doctors' therapeutic communication and nurses communication styles have an important role in improving the quality of service in hospitals.Its influence is greater than other factors such as service facilities and infrastructure.
The findings are in line with previous research which emphasizes the importance of staff attitudes and behavior in providing health services.The assertive attitude of nurses, as recognized by WHO, supports patient rights and can increase patient trust and satisfaction.Assertive attitude, therapeutic communication and service quality are factors that influence the satisfaction of pregnant women, in line with other research findings.The quality of service in hospitals plays a very important role in determining the satisfaction of pregnant women, showing that good service will have a positive impact on the image of the hospital.

CONCLUSION AND RECOMENDATIONS
Doctors' therapeutic communication variables influence quality services at the Deli Serdang district hospital.This is proven bt it was found that the calculated t value of the doctor's therapeutic communication variable was greater from t table (3.122 > 1.661).This means every stage of therapeutic communication.Doctors for pregnant women greatly determine the quality of services in the hospital.
Nurse communication style variables influence service quality at the Deli Serdang district hospital.This is proven by it was found that the calculated t value of the nurse communication style variable was greater than t table (16.343 > 1.661).This means the communication style of nurses towards pregnant women greatly determines the quality of service in the hospital.Doctors' therapeutic communication and nurses' communication styles are influential 73.2% of the quality of service at the Deli Serdang Regency hospital.The remaining 26.8% is influenced by other factors outside the research model these include information media, hospital costs and location affordability hospital.

FURTHER STUDY
This research still has related limitations so further research needs to be carried out on the topic The Influence of Doctors Therapeutic Communication and Nurses Communication Style on the Quality Services for Pregnant Women in order to perfect this research and increase insight for readers.

Table 1 .
Operational Definition of Variables