Health Workers Support, Culture and Status of Exclusive Breastfeeding in Sungai Ulin Community Health Center

Exclusive breastfeeding is the most important nutrition for baby until 6 months old without any food or drinks addition. Based on Basic Health Research (Riskesdas) 2013, in Indonesia mother who exclusively breastfeeding her baby was still low only 38% while the government policy is targeting 80% in 2010. Furthermore, there was only 13,46% breastfeeding coverage in Sungai Ulin community health center in August 2015. The main factors that cause low exclusive breastfeeding coverage such as health worker support and culture of breastfeeding provision. The objective of this research is to determine correlation between health workers support and culture of breastfeeding with status of exclusive breastfeeding in the area of Sungai Ulin Community Health Center. This research used observational analytic method with case-control design, conducted in 2016. The sample in this study were mothers who have baby aged 6-12 months with 23 as cases (non-exclusive breastfeeding) and 46 as controls (exclusive breastfeeding) or the ratio of 1:2 was determined using the hypothesis test 2 proportion formula. The research used simple random samping technique using univariate and bivariate analysis with Chi-square test with 95% confidence level. The results showed there was correlation between health workers support (p-value = 0,013, OR = 6,271) and culture of exclusive breastfeeding provision (p-value = 0,0001, OR = 8,906) with status of exclusive breastfeeding.


Abstrct
Exclusive breastfeeding is the most important nutrition for baby until 6 months old without any food or drinks addition. Based on Basic Health Research (Riskesdas) 2013, in Indonesia mother who exclusively breastfeeding her baby was still low only 38% while the government policy is targeting 80% in 2010. Furthermore, there was only 13,46% breastfeeding coverage in Sungai Ulin community health center in August 2015. The main factors that cause low exclusive breastfeeding coverage such as health worker support and culture of breastfeeding provision. The objective of this research is to determine correlation between health workers support and culture of breastfeeding with status of exclusive breastfeeding in the area of Sungai Ulin Community Health Center. This research used observational analytic method with case-control design, conducted in 2016. The sample in this study were mothers who have baby aged 6-12 months with 23 as cases (non-exclusive breastfeeding) and 46 as controls (exclusive breastfeeding) or the ratio of 1:2 was determined using the hypothesis test 2 proportion formula. The research used simple random samping technique using univariate and bivariate analysis with Chisquare test with 95% confidence level. The results showed there was correlation between health workers support (p-value = 0,013, OR = 6,271) and culture of exclusive breastfeeding provision (p-value = 0,0001, OR = 8,906) with status of exclusive breastfeeding.

Introduction
United Nations International Children Education Found (UNICEF) in 2005 claimed that 30.000 infants that died in Indonesia and 10 million deaths of children under five years in the world each year could be prevented through exclusive breastfeeding (ASI). Exclusive breastfeeding is the most important source of nutrients needed by every infant and ideally should be provided exclusively for 6 months and continued with complementary foods up to the health of mothers and babies (Wilar, 2010).
Based on these descriptions, then we conducted a research to analyze the "relationship between health workers support and cultures with exclusive breastfeeding status in Sungai Ulin Community Health Center".

Method
This research was conducted from March to May 2016 in Sungai Ulin Community Health Center. This study design was observational analytic with case control design. This study aimed to analyze the relationship between health workers support and culture to the status of exclusive breastfeeding in Sungai Ulin Community Health Center. The population was all mothers with children aged 6-12 months who were in Sungai Ulin Community Health Center working area, as many as 132 people.
The sample was taken by simple random sampling technique. The inclusion criteria for cases group in this study were mothers with infants aged 6-12 months and mothers who did not breastfeed exclusively, these based on data of Sungai Ulin Community Health Center in 2015. While the inclusion criteria for the control group were mothers with infants aged 6 -12 months and mothers who breastfeed exclusively, these based on data of Sungai Ulin Community Health Center in 2015. The exclusive criteria for case and control groups were mothers who had infants with birth defects/disorders of the oral cavity/medical indications and mother whose husband had died/divorced when the infants is 0-6 months old. The sample size was determined by estimation formula of difference of two population proportions, as many as 69 people, whereas 23 people in case group (not exclusively breastfeeding) and 46 people in control group (exclusive breastfeeding). The instrument used in this study was a questionnaire.
The dependent variable in this study was the status of exclusive breastfeeding. There were two independent variables including health workers support and culture of exclusive breastfeeding provision. We used univariate analysis to describe the frequency distribution of each variable and bivariate analysis to determine the relationship of each independent variable with dependent variable using Chisquare with 95% confidence level and measured the Odd Ratio (OR). of population (Kemenkes, 2013). While the coverage of exclusive breastfeeding in infants 0-6 months by province in 2013 according to Center for Data and Information Ministry of Health about 58.7% in South Kalimantan. Data attainment of exclusive breastfeeding in the working area of the Public Health Office Banjarbaru city in 2014-August 2015 showed a decrease as much as 1.07% (2014 to 53.17% and in August 2015 to 52.12%) . The lowest coverage of exclusive breastfeeding in Banjarbaru in February to August 2015 is Sungai Ulin community health center, namely 20.67% and 13.46% whereas the target set in 2015 is 80%. If we look at the coverage of exclusive breastfeeding in Banjarbaru, Sungai Ulin Community Health Center is a region which increasing rates of exclusive breastfeeding coverage are relatively low compared to other regions (Dinas Kesehatan, 2015). Factors that lead to the low coverage of exclusive breastfeeding are health workers support and culture of giving exclusive breastfeeding (William, 2011).
There are habits of mother who do not support exclusive breastfeeding such as give formulation milk instead of breast milk if they find any obstacles in breast-feeding and the habit of giving extra food to infants before the age of 6 months (Media, 2005). Cultural factors that exist in community such the myths associated with breastfeeding in Sungai Ulin is still quite strong, such as the belief that giving honey is very beneficial for the health of infants because it contains nutrients that are good for health and belief of smearing baby's lips with honey will make the baby lips turn red.
Successful exclusive breastfeeding is influenced by support of health workers by encourage the mother to breastfeeding her baby exclusively. Encouragement of health workers is also very important to protect and improve the behavior of mother to exclusively breastfeed her baby. Health workers can help mothers solve the problems associated with breastfeeding practices and improve their knowledge by providing information on the importance of exclusive breastfeeding and correct the things that are not right or myths associated with breastfeeding. Therefore, the mother would know which culture is harmful or beneficial to

Result and Discussion
The frequency distribution of respondent characteristics of exclusive breastfeeding status in case group and control group can be seen in Table 1. Most respondents both in case and control groups were at the age of 24-29 years, 8 (34.8%) and 23 (5 0%), respectively. Based on the mother's health condition, mostly in case group and control group were in healthy condition, 11 (47.8%) and 41 (89.1%), respectively. Mostly both in case group and control group were high school graduates, 8 (34.8%) and 24 (52.2%), respectively. Most of respondents were housewife either in case group or control group, 9 (39.1%) and 26 (56.5%), respectively.
Comparison of independent variables in the case and control group was presented in Table 2. Summary results of the bivariate analysis were presented in Table 3. The results of the bivariate showed that there was a relationship between health workers support and culture of exclusive breastfeeding provision with exclusive breastfeeding status.
According to the table 2, of 23 people who were not exclusively breastfeeding, there were 7 (30.4%) mothers who received less support by health workers. Of the 46 people exclusively breastfeeding, there were 43 (93.5%) mothers who received support by health workers. It was revelead from this study, that mothers who were not exclusively breastfed more common among women who received support by health workers. This was in line with research conducted by Abdullah (2013), that the support of health workers is important not only before birth, but also after delivery in puerperal phase approximately 6 weeks after birth. The role of health workers is very important because with good information about exclusive breastfeeding, the mother will know, understand and realize that breastfeeding is beneficial for her baby. It arises after health workers perform their role well in providing health services or interacting with clients (Widdefrita, 2014).
Odd ratio of health workers support showed women who received support from health workers 6.271 times more likely to give exclusive breastfeeding than mothers who did not receive support from health workers. The results are consistent with research conducted by Zakaria (2015), indicate that there is a relationship between the supports of health workers to the status of exclusive breastfeeding.
Exclusive breastfeeding has to do with the role of health professionals related to breast feeding is needed, especially in dealing with the promotion of infant milk formula manufacturers and the provision of complementary foods such as bananas, honey, rice porridge. Support of health workers to motivate mother to give exclusive breastfeeding can be showed when perform antenatal care (ANC). Mental support for mothers can be showed by teaching them to practice the correct way of breastfeeding (Arintasari, 2016). The role of midwives in providing counseling and motivation to mother about early initiation of breastfeeding (IMD), the benefits of breastfeeding earlier, as well as  the benefits of the colostrum is necessary to give, start from the mother doing ANC until the postpartum period. Advisory assistance and support after discharge is essential given to the mother before and after childbirth (Raharjo, 2014). Intensive lactation counseling as many as four times during the prenatal and five times during postnatal may influence toward the increase of knowledge, change attitudes and increase the number of mothers who exclusively breastfeeding until the age of 3 months (Ambarwati, 2013). The results of the study conducted by Ichsan (2015), showed that there were significant differences between knowledge and attitudes about exclusive breastfeeding of mothers who are members of a mother support community and the mother who are not. Mothers who are members of mother support community have knowledge and a better attitude about exclusive breastfeeding. Thus, the role of health workers (Arts, 2011), highly influence the decision making of exclusive breastfeeding, as mother will support exclusive breastfeeding when they obtain appropriate information from the health workers (Wibowo, 2016). That is because they consider health professionals know much more about exclusive breastfeeding. Based on the   (2011), suggested the need for lactation management counseling given to mothers during antenatal, intranatal, and prenatal to successful exclusive breastfeeding. Fikawati (2009), said education when perform antenatal care is more important than after delivery, this is because the effect of such milk formula advertising is highly influence the breastfeeding practice, especially in women with low education. According to the Table 2 that of 23 people who were not exclusively breastfed, there were 15 (65.2%) of mothers who have culture of exclusive breastfeeding. Of the 46 people exclusively breastfed, there were 38 (82.6%) of mothers who did not have culture of exclusive breastfeeding. It was revealed from this study that mothers who were not exclusively breastfed were more prevalent in women who have culture of exclusive breastfeeding.
Odd ratio of breastfeed culture showed that mothers who do not have a exclusive breastfeed culture 8.906 times more likely to give exclusive breastfeeding than mothers who have a breastfeed culture. This supplementary feeding is commonly practiced to newborns since a long time ago and done for generations by the family. Mothers who have a culture of giving additional food like sweet water or sugar water, honey, and zam-zam water. This is in line with research conducted by Rokhliana (2011) that found no relationship between social and cultural status with exclusive breastfeeding. The habits of mothers who do not support breastfeeding such as provide food/drink after the baby is born like honey, coconut water, papah rice, bananas, and give formula milk earlier, and also parents, families and health workers who still encourage to give formulation milk. This greatly affects the mother to practice exclusive breastfeeding (Rokhliana, 2011).
This supplementary feeding is commonly practiced to newborns since a long time ago and done for generations by the family. Based on interviews conducted by researchers to the mother, the reasons for the selection of honey as a food supplement, which were it can treat fever and boost baby's immunity so that the baby not easily got sick if he/she eats sweets, because since childhood baby is used to eating sweet like honey, in addition to the honey treatment can redden the lips of the baby if the it applied to the baby's lips. Purnami (2008), giving prelacteal food early is a habit of families and communities for generations while waiting for the breast milk out, they assumed that give food in an early age causes the infant not fussy, not easily hungry, and infant growth will faster.
Lack of knowledge of mothers on exclusive breastfeeding, at the same time they have the knowledge of the local wisdom in the form of the ideology of food for babies. Knowledge of local wisdom is clearly an inhibiting factor for the practice of exclusive breastfeeding (Nurafifah, 2007). Public perception of giving the honey is clearly erroneous and should be corrected because it will cause more and more infants who are not exclusively breastfed, whereas breast milk is the best food for infants' health. While the reason for a mother who give supplementary food such as sugar water or sweet water and zam-zam water just following old habits of the ancestor without knowing the meaning contained therein.
It is supported by Kholifah (2008), that cultural knowledge about food is one of the factors that determine what is edible and what is not. Often they restricted socially by their own beliefs or traditions about what should and should not be eaten, what is good and not good. All of it obtained through inheritance from the older generation to the younger generation continuously (Kholifah, 2008).

Conclusion
Based on the result, it was found that there is a relationship between health workers support and culture of exclusive breastfeeding with status of exclusive breastfeeding in Sungai Ulin Community Health Center.

Acknowledgement
A great gratitude is given to the Chief of Public Health Office of Banjarbaru who has given permission to conduct research in their working area. A great gratitude also given to Sungai Ulin Community Health Center, as well as respondents who are willing to participate in this study.