Journal of Health Policy and Management (2018), 3(1): 26-33

https://doi.org/10.26911/thejhpm.2018.03.01.04

Determinants of Midwife Performance in Lactation

Management in Surakarta and Karanganyar, Central Java

Nurul Wahidah1), Endang Sutisna Sulaeman1), Uki Retno Setia Budihastuti2)

1)Masters Program in Public Health, Universitas Sebelas Maret
2)Department of Obstetrics and Gynecology, Dr. Moewardi Hospital, Surakarta

ABSTRACT

Background: Exclusive breastfeeding has been recommended by World Health Organization

for reduction of infant illness and death. Midwives have an important role in lactation
management, which includes: (1) Teaching all lactating mothers on how to successfully
breastfeed and sustain it up to 2 years or more; (2) Coming in contact with mothers and infants
to promote, protect, and support breastfeeding. However, exclusive breastfeeding coverage was
still low at 80% nationally, 76.7% in Surakarta, and 61.1% in Karanganyar in 2016, suggesting
low midwife performance in lactation management. This study aimed to determine factors
associated with midwife performance in lactating management in Surakarta and Karanganyar,
Central Java.
Subjects and Method: This was an analytic observational study with a cross-sectional design.
The study was conducted in community health center in Surakarta and Karanganyar, Central
Java, from April to June 2018. A sample of 200 midwives was selected by simple random
sampling. The dependent variable was performance in lactation management. The independent
variables were skill, motivation, experience, health facility, and work load. The data were
collected by questionnaire and analyzed by a multilevel logistic regression.
Results: Midwife performance in lactation management increased with better skill (b= 2.06;
95% CI= 0.48 to 3.65; p= 0.011), strong motivation (b= 1.15; 95% CI= -0.09 to 2.41; p= 0.070),
work experience (b= 2.06, 95% CI= 0.69 to 3.44, p= 0.003), and available facility (b= 2.29, 95%
CI= 0.89 to 3.68, p= 0.001). Performance decreased with higher workload (b= -1.47; 95% CI= -
2.76 to -0.18, p=0.025). Community health center had a contextual effect on midwives
performance with ICC= 34.8%.
Conclusion: Midwife performance in lactation management increases with better skill, strong
motivation, work experience, and available facility. Performance decreases with higher
workload. Community health center has a contextual effect on midwives performance.

Keywords: performance, lactation management, determinant, midwife

Correspondence:
Nurul Wahidah. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami
No. 36 A, 57126, Surakarta, Central Java. Email: wahidahnurul246@gmail.com.

BACKGROUND months of life to reduce morbidity and

Lactation management is an attempt to mortality rates. Exclusive breastfeeding is
support the exclusive breastfeeding of highly recommended because it is not
infants. The implementation of lactation contaminated and nutritious and suitable
management should begin during preg- for infant ages, supplementary feeding at
nancy, immediately after the delivery and an early age may increase the risk of
during breastfeeding (Gay et al, 2013). The infants getting unhygienic food and may be
United Nations International Children's malnourished and contaminated with
Emergency Fund (UNICEF) and the World infection, thus having a poor immune
Health Organization (WHO) recommended system (Ministry of Health, 2014).
exclusive breastfeeding during the first six

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The presence of appropriate protect- The implementation of lactation

ive and nutrient factors in breast milk management in exclusive breastfeeding is
ensures good baby's nutritional status as inseparable from the role of midwife
well as decreases the morbidity and mor- performance in Community Health Center
tality of the children. Some epidemiological as an effort of health service which has
studies suggest that breast milk protects positive influence to the achievement of the
infants and children from infectious exclusive breastfeeding. Lactation manage-
diseases, such as diarrhea, otitis media (ear ment aims to improve the exclusive breast-
infections), cough, colds, acute respiratory feeding effort of six months in infants such
infections (ISPA) and allergies (Lok et al., as through information and communica-
2017). The nutritional content contained in tion and education (IEC) to the wider
colostrum has 10-17 times greater than community, especially pregnant women
mature milk. According to study conducted and breastfeeding mothers so that mothers
by Bhutta and Kumar (2013); Lamberti et are willing and able to breastfeed their
al., (2013); Hanieh et al. (2015), in a babies exclusively. Lactation management
number of developing countries, it is during the antenatal period is a strategic
concluded that exclusive breastfeeding can way for pregnant women who need health
reduce morbidity and mortality because of services to know their pregnancy and
diarrhea and pneumonia. Breastfeeding in delivery preparation. Pregnant women
the first hours of infant life or Early should have at least four antenatal visits
Breastfeeding (EBF) has been shown to during pregnancy, and it is hoped that the
decrease neonatal mortality (Bacolinia et visit will strengthen and empower the
al., 2013); (Victoria et al., 2017). mother to be willing and able to exclusively
Exclusive breastfeeding coverage in breastfeed her baby, to motivate the
Indonesia in Infants 0-6 Months fluctuated mother to be confident that her breast milk
within 3 years ie in 2013: 48.6%, s 2014: is enough to give to her baby (Suryantini,
54.3% and 2015: 41.9% (Ministry of health, 2008).
2016). The coverage of exclusive ASI in The achievement of exclusive breast-
Central Java is 41,3%, Surakarta City 2014 feeding in CHS in Surakarta has increased
is 67.7%, 2015 is 72.9% and in 2016 during the last three years, but it is unlike
exclusive ASI Surakarta is 76.7%, and an Karanganyar District which is still far from
increase in exclusive breastfeeding in the national target that is 80%. The achieve-
Surakarta City Region, and on average the ment of exclusive breastfeeding program
achievement of Surakarta City Region targets in relation to midwife performance
exclusivity is almost close to the national can be identified based on determinants of
target of 80% (Health office of Surakarta, causes such as factors: skills and abilities.
2016). Karanganyar District Health Office Sahito (2013) states that a person's ability
data shows that in 2013 exclusive breast- and skill can have a good impact on the
feeding coverage of 14.93% and then success and smoothness of an organization
increased to 25.12% in 2014 and declined in order to achieve a particular goal.
to 18.2% in 2015. On average the achieve- Research conducted by Tecla et al. (2017)
ments of exclusive breastfeeding in reveal that facilities and infrastructure
Karanganyar District is still far of the affect health service delivery and health
national target of 80% (DHO Karanganyar personnel performance. Workload: work-
District, 2016). load affects a person's performance, work
that demands too much The effectiveness

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of a person's performance (Nurul, 2014), 2. Population and samples

Motivation, Research (Weldegebriel et al., The target population was midwives in
2016) revealed that the motivation of puskesmas (community health centers) in
health personnel reflects the interaction Surakarta and Karanganyar, Central Java.
between health professionals and their A total of 200 midwives from 28 puskes-
work environment, potentially affecting the mas was selected by simple random
provision of health services, experience. sampling. As many as 28 puskesmas was
Gibson (2010) describes that work expe- selected by stratified random sampling.
rience can affect from one's performance, 3. Study variables
with experience then someone will be able The dependent variable was midwife
to work better. performance in lactation management. The
The success of exclusive breast- independent variables were skill, health
feeding is closely related to the presence of facility, workload, motivation, and
lactation management provided by health experience.
personnel. The role of health personnel is 4. Operational definition of variables
essential for training on lactation mana- The midwife performance in the imple-
gement. The performance of midwives who mentation of lactation management was
support the application of lactation mana- defined as an effort to support the imple-
gement to the client or pregnant and lacta- mentation of infant breastfeeding exclu-
ting mothers will be able to increase the sively for six months. The implementation
coverage of exclusive breastfeeding so that of lactation management should start
the baby will get the best nutrition of breast during pregnancy, immediately after the
milk. Mother's Milk is the first vaccine and delivery and breastfeeding. The measure-
the best source of nutrition for infants, ment scale was continuous, but for the
strengthens brain development, increases purpose of data analysis, it was transform-
the lives of 520,000 children in the next 10 ed into dichotomous.
years (UNICEF, 2017); (World Alliance for Skill was defined as midwife skill in
Breastfeeding Action) (WABA, 2017), and giving and conducting lactation manage-
is a unique source of nutrition that plays an ment service. The measurement scale was
important role in the growth, development continuous, but for the purpose of data
and survival of infants (Erkul et al., 2010). analysis, it was transformed into dichoto-
Good nutritional status of children is given mous.
as early as possible since pregnancy Facility was defined as the availability
because the condition and physical mother of tools and places as the media in which
during pregnancy is very influential on midwife provide services. The measure-
milk production (Suryantini, 2008). ment scale was continuous, but for the
purpose of data analysis, it was transform-
SUBJECTS AND METHOD ed into dichotomous.
1. Study Design Workload was defined as the weight
This was an analytic observational study of midwife task. The measurement scale
with a cross sectional design. The study was continuous, but for the purpose of data
was conducted in community health analysis, it was transformed into dichoto-
centers in Surakarta and Karanganyar, mous.
Central Java, from April to June 2018. Motivation was defined as midwife
willingness of someone to their task.
Experience was defined as the length of

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work that has been taken by someone so km (121, 60.5%), and tenure ≥10 years
that they will be able to understand the (121, 60.5%).
task or job well. 2. Bivariate Analysis
5. Study instruments The results of bivariate analysis with Chi
The data were collected using question- Square test in Table 2 showed that
naires. The validity test in this study was performance of midwives was affected by
conducted on 30 midwives who work in skill (r= 0.95; p= 0.030), health facility (r=
Surakarta and Karanganyar. The reliability 1.06; p= 0.008), workload (r= -1.01; p=
test was measured by Cronbach alpha. 0.015), motivation (r= 0.98; p= 0.014), and
6. Data Analysis experience (r= 0.87; p= 0.025).
The characteristics of study subjects were Table 2. Results of bivariate analysis
indicated by the frequency and percentage. of factors associated with midwives
Bivariate analysis was conducted using Chi performance
Square test. The relationship of variables Independent
r p
studied was analyzed using multilevel variable
analysis model. Variables at level one that Skill 0.95 0.030
directly affect the individual including skill, Facility 1.06 0.008
Workload -1.01 0.015
health facility, workload, motivation, and
Motivation 0.98 0.014
experience. The study variable at level two Experience 0.87 0.025
was puskesmas accreditation.
7. Research ethics 3. Multilevel Analysis
The research ethical licenses were obtained Based on the results of multilevel analysis,
from the Research Committee at Dr. Moe- it showed that the variables in the fixed
wardi hospital, Surakarta, Central Java. effects group, skill was positively affected
The research ethics include informed modwife performance. Higher skill
consent, anonymity, and confidentiality. increased performance (b= 2.06, 95% CI=
0.48 to 3.65, p = 0.011).
RESULTS Facility was positively affected
1. Characteristics of Subjects performance. Better facility increased
Table 1. Study subjects characteristic performance (b= 2.29, 95% CI= 0.89 to
Characteristics n % 3.68, p= 0.001).
Age
Workload was negatively affected
≤ 40 years old 129 64.5
> 40 years old 71 35.5 performance. Higher workload decreased
Education performance (b= -1.47; 95% CI= -2.76 to -
<Diploma III 11 5.5 0.18; p=0.025).
≥Diploma III 189 94.5
Residence Motivation was positively affected
< 10 Km 121 60.5 performance. Strong motivation increased
≥ 10 Km 79 39.5 performance (b= 1.15; 95% CI= -0.09 to
Tenure
≤ 10 years 79 39,5 2.41; p= 0.070).
>10 years 121 60,5 Experience was positively affected
performance. Had experience increased
Table 1 showed that most of the study performance (b= 2.06; 95% CI= 0.69 to
subjects were at the age of <40 years (129, 3.44; p= 0.003).
64.5%). Most of study subjects were
≥Diploma III (189, 94.5%), residence <10

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Puskesmas accreditation status had performance with ICC= 34.8%.

strong contextual effect on midwife
Table 3. The result of multilevel analysis of factors that influence the
performance of midwives in the implementation of lactation management
95% CI
Midwives Performance b p
Lower Limit Upper Limit
Fix Effect
Ability 2.06 0.48 3.65 0.011
Facilities and Infrastructure 2.29 0.89 3.68 0.001
Workload -1.47 -2.76 -0.18 0.025
Motivation 1.15 -0.09 2.41 0.070
Experience 2.06 0.69 3.44 0.003
Random Effect
Puskesmas accreditation
Skill
Health facility
Workload
Motivation
Var (constants) 1.76 0.47 6.46
Observation score = 200
log likelihood = -90.739
ICC =34.8%
LR Test vs. Logistic Regresion
p<0.001

Community health center with a good performance in providing health

plenary accreditation status has a main service.
purpose to increase the likelihood of This study is consistent with
having higher midwife performance than Isfahani et al. (2015) which stated that
primary and basic health centers with no skill affected performance. Snowden et al.
accreditation. Level of ability and skill, (2015) stated that skill could give a
facilities and infrastructure of health positive emotional impact in working.
center. Good motivation and experience 2. The association between facility
increased the likelihood of having a higher and performance
midwife's performance than the lack of The results of this study showed that
ability and skill, facilities and infrastruc- facility affected midwife performance in
ture of health center, motivation, and providing health services in health center.
experience. A high level of workload Facility was positively associated with
would decrease the likelihood of having a performance.
decreased midwife's performance rather This study is consistent with Putri-
than low level of workload. ningrum et al. (2016) which stated that if
activities were facilitated by complete
DISCUSSIONS facilities and infrastructure, it would
1. The association between skill and affect the success of a program. In
performance addition, Sari (2016) also stated that work
Based on the result of the study, skill had facility was a tool or infrastructure that
a positive effect on midwife performance. was used to provide convenience in
Midwife with better skill tends to have processing an input to the expected

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output. Therefore, if the facility was in respondents who have a lot of experiences
good and complete condition, it could tend to be easier in providing health
automatically grow work’s enthusiasm of services (performance).
the employees in improving services to the This study is consistent with Fateme
community. et al., (2016), which stated that someone's
3. The association between work- experience would give a good impact in
load and performance providing services. Parker et al., (2014)
Based on the result of the study, there was stated that people who have worked for a
a negative effect of workload on midwives long time would have a good experience
performance. Midwife with heavy work- than those who have never worked.
load decreased midwife performance.
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