Analysis of Description of Nurse Breastfeeding Behavior who Work at Puskesmas

This research is a qualitative research with case study method to examine the nurse breastfeeding behavior who work at puskesmas pademawu pamekasan. The focus of this study was to explain the behavior of nurses in exclusive breastfeeding to their infants while working in Puskesmas. The purpose of this research is to give a conclusion about nurse motivation factor in exclusive breastfeeding to the baby, to know the husband support and health center policy and nurse strategy in giving exclusive breastfeeding while working in Puskesmas. The data analyzed were interviews with nurses who had successfully provided exclusive breastfeeding, husband and head of Puskesmas. Population in this research is Nurses who succeed to give exclusive ASI as much as 37 people at Pademaku Pamekasan Health Center while the sample taken is 15 people taken by purposive sampling. The results showed that several factors that influence the exclusive breastfeeding of working nurses is the desire and commitment to continue breastfeeding. In addition, the results showed that family support in providing exclusive breastfeeding is needed by nurses who work. Workplace policy in providing freedom of exchange shift is also a supporting factor. Today many factors that make it easier for mothers to give exclusive breastfeeding even while working. Many techniques and ways to keep the baby breastfeeded even though the mother works, one of them using a package of electric pumps complete with breast milk box for breastfeeding storage. Breast pump can be done in place of working mother then delivery to their home so that a baby can drink milk according to time. In addition, the information about exclusive breastfeeding problems while working can be accessed through social media or the media breastfeeding mothers group by What Apps Group. This makes it easier for mothers to get a solution of the problems at hand.


INTRODUCTION
Exclusive breastfeeding is breastfeeding for 6 months without any additional fluids, such as formula, orange, honey, tea and water, and without additional foods such as bananas, milk porridge, biscuits, rice porridge, and team rice, except vitamins, minerals, and drugs (Prasetyono, 2009).
Exclusive breastfeeding is a series of activities performed by mothers with family support in breastfeeding only during infants aged 0-6 months, but in the fact, some factors such as work cause the mother's time for breastfeeding to be reduced.
Facing the challenges of the MDGs, it is necessary to have a child health program that can reduce morbidity and mortality in infants and children. One of the programs in the process of decreasing infant mortality and under-five mortality rate is exclusive breastfeeding program, and provision of exclusive ASI consultant at Public Health Center or Hospital (Badan Pusat Statistik, 2007).
This study aims to analysis of description of nurse breastfeeding behavior who work at Puskesmas Pademawu Pamekasan.

METHODS
This study is a qualitative research to check the behavior of exclusive breastfeeding on nurses who work at Pademawu Pamekasan Puskesmas. The focus of this study was to explain the behavior of nurses in exclusive breastfeeding to their infants while working in Puskesmas. The purpose of this research is to give a conclusion about nurse motivation factor in exclusive breastfeeding to the baby, to know the support of husband and health center policy and nurse strategy in giving exclusive breastfeeding while working in Puskesmas. The data analyzed were interviews with nurses who had successfully provided exclusive breastfeeding, husband, and head of Puskesmas. Population in this research is Nurses who succeed to give exclusive ASI as much as 37 people at Health Center Pademawu Pamekasan while sample taken is 15 people taken by purposive sampling.

RESULT
This study produced five major themes from the thematic analysis. the five themes produced are:

1.
Mother's want to exclusive breastfeeding, an important factor in exclusive breastfeeding is a commitment to keep breastfeeding babies alone, this is related to relatively long delivery times, as well as the circumstances in the workplace.

2.
Family Support in Giving Exclusive Breast Milk. At the time the mother is working the other party who must have commitment in exclusive breastfeeding is family. The family, in this case, is the person who cares for a baby other than the mother, can be a husband or mother's parents.

3.
Workplace Policy (Puskesmas Pademawu Kabupaten Pamekasan) Some workplaces give a corner of breast milk for their employees but not all of these workplaces. 4.
The strategy of exclusive breastfeeding is primarily related to workplace policies. A nurse with different shift schedules must have a strategy in managing time-related work, time for husband, and intensive time for infants. 5.
Facilities owned by Mother are related to the fulfillment of exclusive breastfeeding needs.

Mother's knowledge and psychology
Breast milk (ASI) is a single food source for babies until the first 6 months of life. The Government of Indonesia has issued a regulation on exclusive breastfeeding contained in Government Regulation (PP) no. 33 of 2012 on exclusive breastfeeding.1 Breast milk (ASI) plays an important role to keep up the health and survival of babies because breast milk is the best meal for babies because infants who are given breast milk will make infants rarely suffer from disease and avoid the less nutrition compared to other milk-fed infants.3 The lack of breast milk intake resulting in infant nutritional needs is not met. Lack of nutrition will have an impact on the decline in the quality of human resources which can further result in the failure of physical growth, mental development and intelligence, lower productivity, increase morbidity and mortality. Breast milk provides benefits for both mother and for breastfed fetus also seems to cut the chances of getting leukemia, lymphoma, diabetes, and asthma as the child grows up. 4 Breastfeeding by breastfeeding mothers requires support from the nearest person, such as family members, friends, relatives, and co-workers.
Breastfeeding mothers are affected by maternal emotions and affection towards the baby will increase the production of hormones especially oxytocin which will eventually increase milk production. Bond of mother and baby affection occurs because of various stimuli such as skin touch (skin to skin contact). The baby will feel safe and satisfied because the baby feels the warmth of the mother's body and hear the mother's heartbeat that has been known since the baby is still in the womb. This intense bonding of feelings ultimately makes the mother's relationship with the baby naturally entwined. Afifah (2007) in his research wrote the success factors of the mother in giving exclusive breastfeeding one of them is because they have to work. Women always work, especially of childbearing age, so it is always a problem to find ways to care for the baby. A supportive work environment will help mothers to breastfeed their babies exclusively.
Various studies have shown that working mothers are at higher risk of exclusive breastfeeding than unemployed mothers, where unemployed mothers are more likely to be able to exclusively breastfeed 16.4 times compared to working mothers (Yuliandarin, 2009). Similarly, Kurniawan's research (2013) has a significant relationship between maternal work and exclusive breastfeeding, ie the mothers who work the percentage of exclusive breastfeeding are smaller compared to the unemployed mothers. A Singapore study of 2149 hospitalized mothers found a significant association that working mothers were more likely to stop breastfeeding than non-working mothers (Ong, G et al., 2005).
The result of the research shows that the informant knows if the bad psychological condition can affect the quality of breastfeeding in breastfeeding mothers, as stated by the informant as follows "Good psychology can influence the attitude of the pregnant mother in breastfeeding". Besides the influence of knowledge about breastfeeding, education and mother motivation, another cause that can influence his mother's attitude toward breast milk. According to Notoatmodjo (2008), attitude is a reaction or a person's response is still closed to a stimulus or object. Attitudinal manifestations cannot be directly seen, but can only be interpreted in advance of closed behavior.

Mother's motivation and commitment
From the results of the study also found that all informants said that they have a great want to give exclusive breastfeeding but with varying reasons. Some say that child health is the main reason mothers commit to exclusive breastfeeding.
In addition, some informants said breast milk is an affordable and inexpensive nutrient in terms of cost.
Providing exclusive breastfeeding requires a strong commitment because for working nurses requires patience and discipline in terms of dividing the time for work and for baby to be given ASI Eksulsif. The role of the family is also indispensable both when the maternity leave is more so when it begins to work again. The motivation for exclusive breastfeeding for working moms may decrease with the workload. This makes the family as the main actor in maintaining motivation and mother's patience during giving exclusive breastfeeding.
Families in this case husbands or parents are considered as the most capable parties to give influence to the mother to maximize exclusive breastfeeding. Support or support from others or people closest is very instrumental in the success or failure of breastfeeding. The greater the support gained to continue breastfeeding the greater the ability to survive for breastfeeding.

Support husband and family
The award support in this study shows most of the good. The award support in this research is the praise, encouragement, positive reinforcement given by the family for the mother's actions in exclusive breastfeeding. Good family support cannot be separated from good family attitudes. Families who provide support or support is a reflection of a good family function. Family support also cannot be separated from family health care function, where this function plays an important role because of how the family can maintain and maintain the health of family members so as not to be sick, and family becomes the main supporting factor.
The results of the study show that the majority of respondents get support from families, especially husbands in exclusive breastfeeding programs.

POLICY AT WORK
Discuss the issue of Exclusive Breastfeeding on working mothers cannot be separated from workplace-related policies (Puskesmas Pademawu) not all nurses work in Puskesmas Outpatient Services that have morning service schedules (axcep in certain circumstances such as accreditation) some nurses who work in the Emergency Unit and Inpatient Installations have a more difficult portion in implementing exclusive breastfeeding management.
Respondents admitted that the room policy and support from colleagues really greatly affect the process of exclusive breastfeeding. The flexibility of shift schedule exchange is very important to exclusive breastfeeding process especially in certain circumstances such as when the sick child clearly needs care and more time The final requirement in exclusive breastfeeding management of nurses working at Pademawu Puskesmas Pamekasan District is a facility owned at home. Ownership of facilities and infrastructure of each person is different depending on the ability of each individual and family and socio-economic circumstances that are not only determined by the work of the mother as a nurse. The work of the husband also greatly determines the preparation and availability of facilities in the process of exclusive breastfeeding.
The results showed that the condition of the working environment when mother gave breast milk that is not the availability of lactation corner, informant usually use change place to milk milking. The place is awake enough privacy and milked milk can be done well. As disclosed "Indeed we have not provided a corner of breast milk, this is because the working time in the greatest is still in the morning, and even then we give the policy loose sengan not leave the record task without permission or no replacement when shift Mother: (Triangulation) exclusive breastfeeding is very important for the baby. Workplace and comfortable environment will support Mother to breastfeed. The composition of breast milk is not constant and different from time to time. Factors affecting breast milk composition are lactation stage, race, nutritional state, and mother's diet (Soetjiningsih, 2007). Mother's condition is good, healthy and comfortable in breastfeeding it will improve the quality of breastfeeding to the baby.
The results show that informants can breastfeed babies exclusively for 6 months although Mother works supported by the policy of where the mother works.
Exclusive breastfeeding for 6 months is important for nutrition and infant intelligence as it grows in the golden period. Mothers with exclusive breastfeeding supported by a comfortable environment are very beneficial for the mother in giving mother's milk and psychological.
A comfortable environment for breastfeeding strongly supports the quality of breast milk that comes out, as it relates to the physical and psychological responses that the mother feels. A workplace institution policy with tolerance is needed because the institution has not provided a breast milk corner. A supportive workplace environment or institutional policy in Mother's tolerance of breastfeeding is urgently needed for mothers working in such places or institutions. The comfort of the environment in milking breast milk strongly supports the comfort and privacy of the mother. Mom can change her work environment to be a corner of breast milk or milk with support from friends and local agencies. A comfortable working environment brings confidence, and the mother feels comfortable to breastfeed her baby. Institutions should be able to prepare a comfortable and privacyfriendly place to give breast milk shelter. Mothers who give exclusive breastfeeding can be very helpful if there is a place provided.

Ask for help from parents and babysitter
In addition to the ability factor in providing facilities, husband's work factors also decide the needs of facilities that must be provided at home. The husband who works almost full day is certainly different from a husband who works only half a day or husband who stand by living at home.
The results showed that when nursing mothers work required good strategies to divide the time and the role to do exclusive breastfeeding in infants. One is to ask parents or babysitters to keep the baby when the mother works.
In addition, different ways did some respondents, namely pumping milk and store it in the refrigerator. When mothers are not working, they pump breast milk for supplies during work time. This keeps the child breastfeeding even if the mother is working, although it still requires monitoring by the mother and family so that the forgiven milk is actually properly provided.
Another strategy in keeping the child when the mother works is with the help of her husband. Giving an exclusive breastmilk is certainly not a difficult thing for housewives, mothers can at any time provide breast milk to their babies without limited work or time constraints. However, for working mothers, exclusive breastfeeding is a challenge and does not rule out the mother having difficulty in providing exclusive breastmilk during working mother. Thus, this results in exclusive breastfeeding stalled at the time the mother is actively back to work.
There are several factors that guarantee the success of exclusive breastfeeding for working mothers. In addition to the commitment of mother and father to provide an exclusive breastmilk to her baby, of course, a mother must also know how to milk, store and give ASI well as long as working mother. The office where the mother works should also provide time and also provide a decent place for the mother to milk ASI.

Provide exclusive breastfeeding support equipment
There are several things that mom and dad can do to support the success of exclusive giving during work. Mom and dad should prepare some of the supporting equipment needed to store breastmilk, such as storage bottles, cooler bags that can store for a longer period of time and a few bags of ice. It was prepared because not all offices are available refrigerators, let alone provide a container that can be used to store breastmilk.
For milking, it is advisable for the mother to flush with clean hands rather than pumping, in addition to effective and efficient, milking with hands is believed to increase the number of breast milk than the pumping with the tool. As for giving breastmilk, the best way is to use a spoon or cup feeder than a pacifier or bottle of milk that can trigger confusion problems in the baby's nipple.
The results of the study show that most informants claimed to have supporting facilities in providing exclusive breastfeeding. Facilities or supporting tools such as electric and manual breast pumps, breast milk storage refrigerators, breast milk boxes or boxes, sterile milk bottles, to ice gel. Now there are various facilities in the form of electrically pumped pumps and manuals in rent, thus saving costs.
The results of the Wattimena (2012) study in the psychological strength of mother for breastfeeding indicates that mother's awareness of spiritual excellence and strength in breast milk and support, positive affection, resilience, purpose, and welfare becomes their psychological power. The psychological state of the mother associated with awareness and supported by good knowledge will support in exclusive breastfeeding which is very beneficial for the baby. A good psychological state is beneficial for improving the quality of mother's milk produced, as well as increasing the quantity of breast milk. With complete information, and experience information from friends who have previous experience is very useful to reduce the anxiety that psychologically disturbs the mother in giving breast milk.

Role of Puskesmas and Government
Not all mothers know information about how to milk breast milk, store breast milk and give breast milk to the baby properly and correctly. Thus, the dissemination of information related to the things that a mother needs to work to meet her baby's breast milk needs is very important. Dissemination of information is not only through information media such as leaflets, booklets or flipcharts but also through online discussions or social networks that are now perceived to be more effective and efficient in disseminating information access in the community. Obviously, with enough information, the mother will be far more committed to giving an exclusive breast milk to her baby.
There are times when the mother encounters obstacles when giving exclusive breastfeeding to her children, such as obstacles the child does not want to suckle directly to the mother's breast or milk production is increasingly declining. These obstacles, if not handled properly, will affect the exclusive quality of breast milk, or even the mother fails to exclusively breastfeed, mix with formula milk or all together with formula milk.
Therefore, it needs consultation and management services that can help mothers overcome problems in breastfeeding. Access to required consultations is accessible and efficient. In addition, there are now many media information that can be used by mothers in overcoming problems in providing exclusive breastmilk for mothers who work either in the form of counseling or sharing in social media such as Group What Apps or other social media such as Instagram and Facebook.
Going forward, the Government may be able to give a place for consultation services and basic management of breastfeeding problems in Puskesmas or Posyandu. Thus, mothers who have problems in breastfeeding to their babies or who require intensive consultation especially for working mothers can easily come to the Puskesmas or Posyandu located close to where the mother lived, without having to spend a large fee.

CONCLUSION
The result of the research showed that the informant knew when the bad psychological condition could affect the quality of breast milk in the breastfeeding mother. From the results of the study also found that all informants said that they have a great desire to provide exclusive breastfeeding but with varying reasons.
The support and appreciation in this study show most of the good in the form of praise, encouragement, positive reinforcement provided by the family for the mother's actions in exclusive breastfeeding.
The results showed that the condition of the working environment when mother gave breast milk that is not yet the availability of lactation corner, but informant can use change place of clothes to milk. In addition, informants said supported by the policy of the employer where the mother works. The results showed that the strategy is to pump breastmilk and store it in the refrigerator and ask the help of parents or babysitters to give to the baby when the mother works. Now there are various facilities in the form of electrically pumped pumps and manuals in rent, thus saving costs. Other facilities are refrigerator storage ASI, box or breast milk box, sterile milk bottle, up to ice gel. In addition, there are now many information media for mothers in exclusive breastfeeding in the form of counseling and sharing in social media such as Group What Apps, Instagram, and Facebook.