Factors Assosiated to Midwives' Knowledge Related to Complementary Therapies as an Effort to Provide Holistic Care in Reproductive Health Services in the Cirebon Region

The paradigm shift in midwifery services and the global situation towards the increasing demand for complementary practice requires midwives to have comprehensive knowledge of complementary therapies to integrate complementary and conventional midwifery services. The purpose of this study was to determine the factors related to midwives' knowledge of complementary therapies as an effort to provide holistic care for reproductive health services in the Cirebon Region. This research is a correlative analytical research, cross sectional approach. The respondents were midwives in the Cirebon Region. The sample size was 216 respondents. Sampling using purposive sampling. The data was analyzed with a chi-square test. The research instrument uses questionnaires that have been tested for validity and reliability. The results showed that there was significant assosiation between education, complementary training history, and information sources with complementary related knowledge, each with a p value of 0.000. There was no significant assosiation between the age of midwives, and the periode of working of midwives with complementary related knowledge with p values of 0.75 and 0.50 respectively. Midwives are expected to improve knowledge and skills based on evidence-based practice related to complementary therapies actively through available information sources, in an effort to provide excellent service to reproductive health holistically.


INTRODUCTION
Currently the view of midwifery services continues to grow and shift, the demand for midwifery services is not only on physical recovery but the highest hope of clients is to get comfort, and minimize the side effects of chemical drug administration (Kostania, 2015).There is significant demand for complementary service practices (World Health Organization (WHO), 2013).Complementary service practices not only address health problems related to physical elements, but also psychological, spiritual, socio-cultural based on loc al wisdom (Hall, Griffiths, & McKenna, 2015).Efforts to integrate complementary and conventional midwifery services have been carried out in various countries (Khadijah, 2022).
The World Health Organization (WHO) states that 80% of health practitioners in developing countries prefer complementary medicine over pharmacology.WHO's seriousness to focus on developing complementary therapies that are part of traditional medicine is outlined in the WHO Traditional Medicine Strategy 2014-2023(World Health Organization (WHO), 2013).Member States have established or developed national and regional policies and regulations to promote the use of complementary therapies as part of safe and effective traditional medicine.
In Australia, visits to complementary health professionals increased by more than 30% and found 52.0% of women were using at least one complementary therapy.Americans 68.5%,British 57.1% and Germans 50.7% use complementary therapies (Hall et al., 2015).In New Zealand, about 25% of doctors provide complementary services, 82.3% refer patients to complementary practitioners, and 37.3% of midwives recommend complementary therapies (Liu, Tang, Baxter, Yin, & Tumilty, 2021).In China, traditional medicine visits account for 18% of all medical visits, In Korea 74% of people use complementary therapy with their own judgment or decision-making (Lee et al., 2018).In the Lao People's Democratic Republic traditional health practitioners provide most health care services for 80% of population health (World Health Organization (WHO), 2013).
In Indonesia, the use of complementary practices is regulated through Permenkes RI No. 15 of 2018.Midwives as a profession that continues to grow, and are at the forefront, always maintain their professionalism by providing holistic midwifery care that pays attention to local cultural wisdom, humanistic, and based on evidence-based.This is done with the aim that every woman gets holistic services and every reproductive health problem can be overcome properly (Menteri Kesehatan RI, 2020).
The results showed that complementary therapies are effective in helping to overcome problems related to reproductive health in the obstetric sphere, including aromatherapy as a complementary modality can help relieve maternal anxiety and pain during labor (Tabatabaeichehr & Mortazavi, 2020).Research on the use of acupuncture and acupressure therapy has been shown to increase patient satisfaction in overcoming labor pain and reduce the use of pharmacological analgesics (Smith et al., 2020).The use of music therapy during labor decreases postpartum anxiety and pain, increases labor satisfaction and lowers rates of early postpartum depression (Simavli et al., 2014).Other studies show that the Lactation Hypnosis Method is influential in helping to facilitate the release of breast milk (ASI) and can produce more milk production (Widayanti, Sari, Aliah, & Tonasih, 2022).
The strategic position of midwives greatly supports the integration of complementary and conventional therapies.However, the application of complementary therapy has not been fully carried out by midwives in supporting holistic care.This can be caused due to several factors.The results stated that the knowledge and education of midwives had a significant correlation with complementary practices (Mollart, Stulz, & Foureur, 2021).Other research states that age, education, length of practice, training are factors that can relate to complementary knowledge and practice (Kostania, 2015).
Based on the paradigm shift and demands of midwifery services and the global situation towards the increasing demand for complementary practice, plus global and national policies and professional demands, it is very important for midwives to have a thorough knowledge of complementary therapies so that these complementary practices can be immediately integrated with conventional therapies in providing solutions to client problems in the health cycle reproduction.So, it is necessary to conduct research continuously starting with research related to midwife knowledge.What are the factors related to midwives' knowledge of complementary therapies as an effort to provide holistic care in reproductive health services.

METHODS
This type of research is correlative analytics with the aim of assessing factors related to midwives' knowledge related to complementary therapies.The research design used a cross sectional approach, namely the measurement of independent variables and dependent variables at one time.The research time is from March -September 2023.The variables in this study consist of independent variables, namely factors (age, education, length of service, complementary training history, sources of information), while the dependent variables are complementary related knowledge.The study population was midwives in the Cirebon area, the research sample used purposive sampling techniques, the sample size was calculated using the slovin formula plus drop out, a sample of 216 respondents was obtained with an e value (error) of 5% and drop out of 10%.The inclusion criteria in this study are 1) Midwives who provide services in midwives' independent practices (TPMB) and other health services; 2) TPMB and / or health service places domiciled in the Cirebon Area.While the exclusion criteria are 1) Midwives who are not willing to be respondents; 2) Incomplete when filling out questions.Instruments to measure independent and dependent variables in this study using questionnaires.A knowledge-related questionnaire containing 24 questions was then tested for validity and reliability resulting in 20 valid questions, with a Cronbach's Alpha value of 0.922.Data analysis using chi square.Each respondent fills out informed consent.

RESULTS
The results of the study of respondent characteristics in table 1 showed that most respondents were in the beginer age category (21 -34 years) as many as 85 people (39.4%),Midwifery Diploma III Education as many as 130 people (60.2%), working period of > 5 years as many as 165 people (76.3%), had never attended complementary training as many as 175 people (81%), did not know about complementary therapies as many as 87 people (40.3%) and low knowledge related to complementary therapies as many as 89 people (41.2%).The results of the correlation study showed that most respondents with low knowledge were in the beginer age category (21-34 years) by 44.7%, sufficient knowledge in the retirement category (55-64 years) by 58.3% and good knowledge in the pre-retirement category by 40.5%.The p value is 0.75 > α (alpha) 0.05, meaning that there is no significant assosiation between the age of the midwife and complementary related knowledge.This is shown in table 1. Table 3 shows that the majority of respondents with low and sufficient knowledge existed in the working period of ≤ 5 years , respectively namely 49% and 39%, while high knowledge in the working period of > 5 years was 28.7%.The p value is 0.50 > α (alpha) 0.05, meaning that there is no significant assosiation between the periode of working and complementary related knowledge.In Table 4, it can be seen that most respondents with less and less knowledge, have never attended complementary related training, namely 50.9% and 40.6% respectively.While respondents with good knowledge, have attended complementary related training, which is 92.7%.The p value of 0.000 > α (alpha) 0.05 means that there is a very significant assosiation between complementary training history and complementary related knowledge.Table 5 shows that respondents with low knowledge are mostly unaware of complementary therapies, which is 75.9%.Sufficient knowledge mostly knows complementary therapies through electronic media by 51.8%, while respondents with high knowledge mostly know about complementary therapies through educational institutions by 56.7% apart from professional organizations and electronic media.The p value of 0.000 > α (alpha) 0.05, means that there is a very significant assosiation between the source of information and complementary related knowledge.

DISCUSSION
Based on the results of the study, it shows that midwives' education, history of complementary training, and sources of information are significant assosiation with midwives' knowledge related to complementary therapies.The level of education a midwife has has an effect on how she absorbs information and implements it in life.Formal education owned by midwives can provide more value for midwives, especially in accepting new things including complementary therapies.The results of this study show that 100% of midwives who have high knowledge are at the Post Graduate of Health level.This is in line with research conducted by (Damayanti & Sofyan, 2022) with the results that there is a relationship between the level of education and the level of knowledge with a sig value of 0.000 (< 0.05) where the higher the level of education, the higher the level of knowledge possessed, and vice versa.Although there is a relationship between education level and knowledge related to complementary therapies, data shows 60.2% of midwives are at the level of Midwifery Diploma III.When midwives increase the level of education, there is a great opportunity for midwives to be exposed to information related to complementary therapy, this is because some educational institutions make complementary therapy as an advantage or characteristic of the study program so that midwives are equipped with complementary related knowledge and even included in complementary and certified training.
Training is a planned process to modify the attitude or behavior of knowledge, skills of midwives through experiential learning.Midwives who attend complementary related training can develop individual abilities to meet current and future client needs.This is in line with research conducted (Mollart et al., 2021) entitled Midwives knowledge and education/training in complementary and alternative medicine (CAM): A national survey found that there was a significant relationship between midwives who attended CAM workshops with competency assessments (p value < 0.000) and confidence to discuss CAM options compared to participants who had not.Another study conducted (Suliyanti Otto, Masni, 2013) stated that there was a meaningful relationship between midwife training and knowledge with a p value of 0.025.Although there is a relationship between training and knowledge, data shows that of 216 midwife respondents, only 41 people (19%) have attended training and 175 people (81%) answered that they have not optimally learned about complementary therapies and some even do not know.
The source of information is an important thing that can be related to the midwife's knowledge related to complementary therapies.Midwives will easily remember exposure to information obtained through these information sources.This is in line with research conducted by (Apriliani, 2022) which shows that there is a relationship between information sources and knowledge (P value = 0.04).Another study conducted by (Di, Jakarta, & Tahun, 2015) showed the same results that information sources related to knowledge with X² hits 9.06 > X² tables 5.99 db=2 α=0.05.Although there is a relationship between sources of information and knowledge, this study shows that most midwives do not know about complementary therapies, which is 40.3%, and midwives who are exposed to complementary therapies get information sources through electronic media 25.9%, professional organizations 19.9%, and educational institutions 13.9%.Now a days in the digital era all forms of information are very easy to obtain, including complementary therapies.The impact of the COVID-19 pandemic has become a momentum that can be interpreted positively in the dissemination of information sources.This is evidenced by the many webinars held online or online by educational institutions and training institutions related to complementary therapies and this can be used by midwives to increase knowledge.
The age and periode of working of midwives are variables that show no significant assosiation with midwives' knowledge related to complementary therapies with a p value of 0.75 and a p value of 0.50.This result is in line with research conducted by (Febriati, Rahayu, Factors Assosiated to Midwives' Knowledge Related to Complementary Therapies as an Effort to Provide Holistic Care in Reproductive Health Services in the Cirebon Region & Zakiyah, 2020) which shows that age is not related to complementary practices with a p value of 0.290.In this study, most of the midwives' ages were in the category of beginer (21-34 years) and most of the working period was > 5 years.Based on the researchers' assumptions, the age and periode of working of midwives are not related to knowledge based on knowledge in this study is knowledge related to complementary therapies.Complementary therapy is a method that can be integrated with conventional methods with an increasing trend in demand at this time.To get exposure to information related to complementary therapies there must be media or sources of information sought or obtained by midwives.So even though the midwife is included in the age category and working period which is considered full of experience, it is not necessarily directly proportional to knowledge related to complementary therapies.Other data in this study showed that 40.3% of midwives did not know about complementary therapies and 81% had never attended complementary training.For this reason, it is necessary to increase efforts so that midwives are motivated to increase knowledge with the aim of providing excellent service based on evidence-based practice in an effort to provide holistic care for reproductive health through the integration of complementary therapies.

CONCLUSION
There is a very significant assosiation between midwife education, history of complementary training, and sources of information with midwives' knowledge of complementary therapies.There was no significant assosiation between the age and periode of working of midwives and midwives' knowledge of complementary therapies.It is necessary to increase efforts made by various parties including professional organizations, educational institutions and midwives themselves so that midwives are motivated to increase knowledge with the aim of providing excellent service based on evidence-based practice in an effort to provide holistic care for the improvement of reproductive health through the integration of complementary therapies.
Factors Assosiated to Midwives' Knowledge Related to Complementary Therapies as an Effort to Provide Holistic Care in Reproductive Health Services in the Cirebon Region

Table 1
Frequency Distribution of Respondent Characteristics

Table 1
Distribution of Age Relationship with Respondents' Knowledge Related to Complementary Methods In table 2 it can be seen that less knowledge related to complementary therapies is mostly in the Midwifery Diploma III category by 58.5%, sufficient knowledge in Bachelor Degree of Health/Midwifery by 60% and high knowledge in Post Graduate of Health by 100%.The p value of 0.000 > α (alpha) 0.05, means that there is a very meaningful relationship between midwife education and complementary related knowledge.Table 2 Distribution of Educational Relationship with Respondents' Knowledge Related to Complementary Methods

Table 3
Distribution of Periode Of Working Relationship with Respondents' Knowledge Related to Complementary Methods

Table 4
Distribution of Training History Relationship with Respondents' Knowledge Related to Complementary Methods

Table 5
Distribution of Information Source Relationship with Respondent's Knowledge Related to Complementary Methods Factors Assosiated to Midwives' Knowledge Related to Complementary Therapies as an Effort to Provide Holistic Care in Reproductive Health Services in the Cirebon Region