Analysis of Factors Affecting the Increase in the Number of Sesarea Sections at the H. Sahudin Kutacane Regional Hospital, Southeast Aceh

Caesarean section delivery is a method of delivery in which an incision or incision is made in the abdominal wall and uterine wall to remove the product of conception. This study aims to analyze the factors that influence the increase in the number of Sesarea sections in the H. Sahudin Kutacane Regional Hospital, Southeast Aceh, Aceh Province, Indonesia. This research method is a mixed method with a crosssectional or explanatory sequential approach. The number of samples used for the quantitative study were 40 women giving birth by cesarean section, and for qualitative research using 4 informants consisting of 2 maternal, 1 obstetrician, and 1 clinic midwife. Data collection techniques in this study used primary, secondary, and tertiary data. The data analysis techniques used in this study were univariate, bivariate, and multivariate. The results of this study indicate that the factors of age (p = 0.221), education (p = 0.000), work (p = 0.733), parity (p = 0.000), medical indications (p = 0.140), JKN KIS (p = 0.000), knowledge (p = 0.007), and attitude (p = 0.000). Of the 5 related variables, there were no variables that directly affected the increase in cesarean section (p value => 0.05). There is a significant relationship between education, parity, national health insurance, knowledge and attitudes towards increasing cesarean section delivery in RSUD. H. Sahudin Kutacane, but of the five variables, none of the variables had an effect on the increase in the cesarean section rate in RSUD.H. Sahudin Kutacane.


Introduction
Normal delivery is the process of delivering a baby by the mother's own power, without the aid of tools, and does not injure the mother and baby which generally lasts less than 24 hours. However, not all deliveries go smoothly, it is not uncommon to find complications in the delivery process. This complication can be caused by the mother or the fetus, so the medical personnel must find other ways to save the mother and the fetus, such as cesarean section surgery. As for complications in labor that are often found, such as large fetuses (macrosomia), shoulder dystocia, narrow pelvis, placenta previa, breech location, and congenital abnormalities such as hydrocephalus (Mochtar, 1998).
The World Health Organization (WHO) has set a standard average caesarean section rate of 5 -15% per hundred thousand live births. It is considered effective in saving complicated labor. A study showed with an ecological study in several countries that showed that maternal and JOURNAL LA MEDIHEALTICO VOL. 01, ISSUE 06 (017-027), 2020 DOI: 10.37899/journallamedihealtico.v1i6.164 infant mortality rates decreased with the alternative of cesarean section surgery. However, if cesarean section deliveries are above 16% of total deliveries, then cesarean section surgery is considered bad because it can increase morbidity such as severe pain after the effects of anesthesia wear off, risk of puerperal infection and bleeding and risk of pain due to scarring for the long term (WHO, 2016 ).
Based on WHO data, the cesarean section of the delivery rate continues to increase, the following data is the latest data published by WHO. We start from China in 2014 it was 34.9%, Thailand in 2016 was 32.7%, Vietnam in 2014 was 27.5%, Cambodia in 2014 was 6.3%, India in 2016 was 17.2%, Malaysia in 2006 it was recorded at 15.7%, and Indonesia in 2012 at 12.3%. Of the 7 countries above, we can see that none of them comply with the WHO mandate, the country averages a cesarean section rate above 10% of a thousand births (WHO, 2018).
In Indonesia, the incidence of cesarean section has increased in 2000 the number of mothers giving birth with cesarean section 47. 22%, in 2001 it was 45.19%, in 2002 it was 47.13%, 2003 was 46.87%, in 2004 it was 53 , 2%, in 2005 amounted to 51.59%, in 2006 53.68%. The National Survey in 2009, 921,000 deliveries with a sectio of 4,039,000 deliveries or about 22.8% of all deliveries (Sumelung et al., 2014). Based on the results of the 2017 Indonesian Demographic and Health Survey, the number of deliveries by post-section surgery was 17% of the total deliveries in the last 5 years. An increase of 7% from the 2012 survey, which was 10% of total deliveries (Promkes, 2018).
In Aceh, at the Zainal Abidin General Hospital, Banda Aceh, in 2007 the incidence of cesarean section was 23.6% of total deliveries. In 2011 this figure has decreased to 13, 90%. The indications for cesarean section delivery were history of CS by 41.30%, shoulder dystocia of 6.52%, placenta previa 4.5%, PROM 30.43% and PEB of 23.91%. It can be concluded that the delivery was by cesarean section in RSUZA. Banda Aceh is below the standard limit set by WHO, namely 5-15% of total deliveries (Sumelung et al., 2014).
A study conducted by the World Health Organization (WHO) in 2005 on 410 health facilities consisting of 24 districts in eight Latin American countries that were randomly selected. The results showed that mothers who underwent labor by caesarean section were proven to have significantly increased maternal morbidity compared to deliveries that occurred vaginally. The risks that threaten delivery by cesarean section are placenta accreta and emergency hysterectomy during delivery (Suryati, 2012).
The main causes are endomyometritis, bleeding, urinary tract infections, and thromboembolism. In addition, morbidity also increases in women who are obese. In a study conducted by Perlow and Morgan in 1994, the morbidity factor of patients with caesarean section also experienced an increase in recovery time which led to a twofold increase in the cost of delivery when compared to the cost of vaginal delivery (Sihombing & Andayasari, 2015). From the background presented, this study aims to analyze the factors that influence the high rate of cesarean delivery. IN RSUD (Regional General Hospital) H. Sahudin Kutacane, Southeast Aceh, Aceh Province.

Methods
This type of research uses mixed methods research methods. The strategic method that will be used is a sequential explanatory strategy. In this study, qualitative research data complements quantitative data. This research strategy begins with the collection and analysis of quantitative data that is built on quantitative results. The quantitative approach was carried out by using a questionnaire to the respondents aimed at analyzing how the factors that influence the increase in labor by cesarean section in women who gave birth. A qualitative approach was carried out The quantitative test analysis used in bivariate analysis is the chi-square test. Multivariate analysis aims to see the effect of the independent variable on the dependent variable by performing the Logistic Regression test.
Qualitative data analysis used to reduce data is to summarize, select the main things, focus on important things, make friends and patterns from the interview results. Data presentation is carried out in the form of short descriptions, narrative text, charts, relationships between categories, and the like and the conclusions of qualitative research can answer the problem formulation. The conclusions of qualitative research are new findings that haven't been there before.

Univariate Analysis
Based on the data obtained from the research results it can be seen in the frequency distribution table as follows: Based on the table above, it can be seen that of the 40 respondents with no risk age, there were 32 respondents (80%) who gave birth by emergency section 14 people and 18 respondents who gave birth by elective section with p value 0.221> 0.05, which means there is no influence of age with an increase in delivery by cesarean section in RSUD H. Sahudin Kutacane.
Based on the table above, it can be seen that of the 34 respondents with good education, there were 13 respondents (38.2%) who gave birth by elective cesarean section, more than 21 respondents (61.8%) who were emergency. The p value is 0.000 <0.05, which means that there is a significant relationship between education and an increase in labor by cesarean section in RSUD H. Sahudin Kutacane.
Based on the table above, it can be seen that of the 26 respondents with non-working mothers, 26 respondents (65.0%) gave birth by elective section, more than 18 respondents (69.2%). The p value is 0.733> 0.05, which means that there is no significant relationship between work and an increase in delivery by cesarean section at RSUD H. Sahudin Kutacane in 2019.
Based on the table above, it can be seen that of the 40 respondents with multiparous parity, 23 respondents (57.5%) who gave birth by elective cesarean section were more than 14 respondents (60.9%). The p value is 0.00 <0.05, which means that there is a significant relationship between the parity of increasing delivery by cesarean section at RSUD H. Sahudin Kutacane.
Based on the table above, it can be seen that of the 40 respondents with an indication that 38 respondents (95.0%) gave birth by elective cesarean section, it was greater than 23 respondents (60.5%). The p value is 0.140> 0.05, which means that there is no significant relationship between the increase in labor by cesarean section in RSUD H. Sahudin Kutacane.
Based on the table above, it can be seen that of the 40 respondents with the use of the JKN KIS health insurance, there are 40 respondents (100%) who all use JKN KIS to finance their delivery costs, elective section delivery is greater than emergency delivery of 25 respondents (62.5 %). The p value is 0.000 <0.05, which means that there is a significant relationship between health insurance and the increase in delivery by cesarean section in RSUD H. Sahudin Kutacane.
Based on the table above, it can be seen that of the 40 respondents with good knowledge, 25 respondents (57.5%), who gave birth by elective section were greater than 25 respondents (62.5%) who gave birth by emergency section. The p value is 0.007 <0.05, which means that in labor there is a significant relationship between knowledge and an increase in labor by cesarean section in RSUD H. Sahudin Kutacane. Based on the table above, it can be seen that of the 40 respondents with a positive attitude as many as 36 respondents (90%), who gave birth by elective section was greater than 22 respondents (61.1%). The p value is 0.000 <0.05, which means that there is a significant relationship between attitudes and an increase in labor by cesarean section in RSUD H. Sahudin Kutacane. The results of this test indicate that factors (education, parity, knowledge, attitudes) do not have a significant effect on increasing cesarean section in RSUD. H. Sahudin Kutacane in 2019. The results of the OR value on the education variable are indicated by the OR value of 0.708. This means that education tends to be 0.7 times less likely to have an effect on increasing cesarean section delivery in mothers who give birth. The value of β = the natural logarithm of 0.708 = -.0 346 because β is negative, education does not have a negative effect on increasing cesarean section delivery. The result of the OR value on the parity variable is indicated by the OR value of 1.065, which means that parity tends to be 1.0-fold and has no effect on the increase in labor by cesarean section of women who give birth. The value of β = natural logarithm 1.065 = 0.063 by β is positive, so parity does not have a positive effect on the increase in labor by cesarean section. The result of the OR value on the knowledge variable is indicated by an OR value of 1.283, meaning that knowledge tends to 1.2 times have no effect on the increase in cesarean section delivery in mothers who give birth. The value of β = natural logarithm 1.283 = 0.250 by β is positive, so knowledge does not have a positive effect on cesarean section delivery. The OR results on the attitude variable are indicated by OR 0.536, which means that the attitude tends to be 0.5 times less likely to have an effect on the increase in cesarean section delivery in mothers who give birth. The value of β = natural logarithm 0.536 = -0.624 is negative, so the attitude does not have a negative value towards the increase in cesarean section delivery

Multivariate Analysis
Based on the results of the study, of the 40 respondents (100%) there were 8 respondents (20%) who were at risk, and 32 respondents (80%) were not at risk, and the majority of respondents gave birth by cesarean section in RSUD.H. Sahudin Kutacane in 2019 is included in the age category that is not at risk. The results of the chi square statistical test on the variable age with p value = 0.221> 0.05, which means that there is no significant relationship between age and delivery of cesarean section in RSUD. H. Sahudin Kutacane in 2019.
The results of this study were not in line with the research conducted by Marlina on the factors of cesarean section delivery at the hospital. Immanuel Bandar Lampung in 2014 who said there was a close relationship between age.
It is known qualitatively that informant 1 has an age that is not at risk at the time of childbirth, namely 26 years old and at the time of giving birth to her first child normally is 18 years old. and informant 2 was included in the at-risk age group, namely 19 years old when giving birth to their first child. Informant 1 said and informant 2 said "I am 19 years old, and this is my first child". The results of this study were not in line with the statement of informant 3 who said that "the increase in cesarean section delivery was due to relatively young pregnant women <20 years who could be considered as children".
According to the results of the author's analysis, age is not related to cesarean delivery due to a paradigm shift that cesarean delivery is a modern type of delivery and uses sophisticated technology that does not cause prolonged pain, so that mothers want to try and experience the labor process for themselves. without thinking of the side effects that will be caused both short and long term. Reproductive age and not at risk are usually rarely encountered problems in childbirth unless there are certain diseases. However, because mothers think that giving birth by section is not painful and fast, pregnant women who have no problems still choose to give birth by cesarean section.
There are 34 respondents (85%) highly educated and as many as 6 respondents (15%) have low education and the majority of respondents who gave birth by cesarean section at RSUD H. Sahudin Kutacane in 2019 have higher education. The results of the statistical test showed that there was a significant relationship between education and delivery by cesarean section in RSUD.H. Sahudin Kutacane in 2019 with a value of p (sig) = 0.000 <α = 0.05.
This study is in line with research conducted by Marice and Lelly in 2011 which stated that there was a relationship between mothers who had higher education and delivery by cesarean section and contributed 68.7% compared to mothers who had low education with a chance of 1.80 times higher education mothers. preferring section over the vaginal route (Sihombing & Andayasari, 2015).
Qualitatively, it is known that informant 1 has a high education category, namely SMA. And informant 2 also has a high education category, namely SMA. Informant 1 "The last education I ever completed was high school, I was going to college but a mate arrived". Informant 2 "my last education was high school sis, there was no tuition fee". Both informants have high education but they have problems with their pregnancy so they have to give birth by cesarean section.
According to the authors' analysis, there is a relationship between education and cesarean delivery because respondents who deliver by cesarean section are because educated mothers get and receive information faster. Many mothers today think that cesarean delivery is a comfortable and fast delivery so that it avoids pain caused by contractions as said by informant 2 who said "I chose to give birth by cesarean section because normal labor is painful, it takes a long time. and terrible ". A statement like this, if heard by young mothers, especially mothers with first parity, will certainly greatly influence their decisions in deciding which method of delivery to choose.
Of the 40 respondents (100%) there were 26 people (65%) who did not work, and 14 people (35%) who worked. The results of statistical tests show that there is no relationship between work and delivery by cesarean section in RSUD. H. Sahudin Kutacane Southeast Aceh in 2019 with a value of p (sig) = 0.733> α = 0.05. There are several reasons that underlie the tendency to give birth via caesarean is greater, especially mothers who live in big cities who are generally working mothers. having the status of a time-bound worker also encourages mothers to choose cesarean delivery because it has been determined when they should return to work after delivery. This condition also encourages mothers to choose to give birth by cesarean section (Sihombing et al., 2017).
Qualitatively, it is known that informant 1 does not work other than doing household chores and helping her husband's work in the garden and being inaah, and informant 2 works as an entrepreneur. informant 1 "I don't work, just at home, but sometimes help my husband in the garden and in the fields". Informant 2 "self-employed sis, I open a shop at home".
According to the author's analysis, there is no relationship between work and persalina cesarean section because many of the women who live in Kutacane do not work, they only do housework and help their husbands in their own gardens or rice fields. And this is not considered a job because it is only helpful and not always done. The work that is carried out is classified into heavy work and requires a lot of energy, such as planting rice and corn, cleaning the fields, even to the harvesting process of women who participate. And this can influence the mother's decision in choosing the method of delivery to be performed. With a heavy workload, mothers will choose the normal delivery method because normal delivery does not require a long time for the healing process and can quickly return to activities. Like the statement of informant 1 who said "I chose to give birth normally because if the operation is not free movement, and I cannot lift heavy objects". Mothers who work do not always tend to choose the method of delivery by cesarean section, but rather pay attention to the type of work being done. Of the 40 respondents (100%), 23 people (57.5%) had multiparous parity, and 17 mothers (42.5%) had primiparous parity. The majority of respondents who gave birth by cesarean section had multiparous parity. The results of statistical tests showed that there was a significant relationship between parity and delivery by cesarean section with a value of p = 0.00 <α = 0.05.
According to Nicholson, women with high parity are a risk factor for diseases during pregnancy such as anemia, diabetes mellitus, hypertension, malpresence, placenta previa and can even cause death in children. This is for mothers who have high parity, the level of defense against a disease has decreased, because the recovery process after childbirth does not happen completely because they have to get pregnant again (Lindqvist et al., 1999;Ko et al., 2005).
This study is in line with research conducted by Andriani in 2012 regarding the factors that influence the action of cesarean section in Dompu Regency, which found that there was a significant relationship between parity and delivery by cesarean section (Andriani, 2012).
Qualitatively, informant 1 has multiparity parity, namely the informant has given birth to 3 children. The first child was born normally, then the second child was born by cesarean section operation, and the third child was born by cesarean section as well. and informant 2 had primiparous parity, namely the new informant had one child and was born by cesarean section. Informant 1 "this is my third child, my first child was born normally, my second child was born by cesarean section, and my third child was born by section and never had a miscarriage". informant 2 "this is my first child sis, never had a miscarriage".
According to the authors' assumptions, the higher the delivery, the higher the chance of giving birth by cesarean section, especially for mothers who give birth by cesarean section, so most of the next child will give birth by cesarean section As said informant 3, namely a gynecologist on duty at RSUD.H. In addition, mothers with first parity usually have no experience regarding childbirth so they are easier to be influenced and feared by those around them. Of the 40 respondents (100%) who gave birth by cesarean section, it was found that 38 people (95%) gave birth by cesarean section. with medical indications, and only 2 mothers gave birth not on the basis of medical indications (5%). The results of statistical tests showed that there was no relationship between medical indications and delivery by cesarean section with a value of p = 0.140 <α = 0.05.
Medical indications are signs and symptoms shown by patients to establish a diagnosis and action. The indications for cesarean section are a history of cesarean section, labor dystocia, fetal distress and location abnormalities (Yunizar et al., 2018). This research is not in line with research conducted by Andriani in 2012 concerning the factors that influence the operation of cesarean section at the Dompu District Hospital, which states that there is a significant relationship between medical indications and delivery by cesarean section with a value of p = 0.03 (Andriani , 2012).
Qualitatively, it is known that informant 1 gave birth by elective cesarean section with indications of a cesarean section. And informant 2 gave birth by elective cesarean section with an indication of the location of the breech. Informant 1 "yes, I know because I have had surgery before". Informant 2 "yes I know because my baby is breech". This shows that the two informants gave birth by elective cesarean section and for informant 1 they still had the opportunity to give birth normally because the previous child's age was 5 years old and his age was still productive, namely 26 year.
According to the investigators' analysis, the absence of a relationship between medical indications and cesarean section delivery was because the medical indications found were not urgent indications, but relative indications, namely most elective sections. Although the majority of deliveries by cesarean section were indicated, the indications that were found were the majority of elective indications were 25 people (62.5%), and only 15 people gave birth by emergency section (37.9%). This suggests that these indications are not absolute indications but relative indications that can still be considered such as indications for mothers. or even a social indication said by the doctor in charge of the hospital. That the patient has the right to request (request) action to be taken against him and this is supported by Law No.44 of 2009 concerning the rights and obligations of patients in the hospital.
The results of statistical tests show that there is a relationship between national health insurance and delivery by cesarean section with a value of p (sig) = 0.000. The Indonesian Health Card (KIS) is a card that has the function of providing health insurance to the public to get free health services. The use of KIS can be used in all first-level and advanced health care facilities according to the condition suffered by the patient. This card is a program to expand health coverage (Promkes, 2018).
Qualitatively, it is known that informant 1 uses JKN KIS to finance childbirth. And informant 2 also used the JKN KIS to pay for the costs of her delivery. Informant 1 "yes, I only use KIS to pay for operating costs". Informant 2 "yes I use KIS to cover my delivery costs".
According to the author's analysis, JKN KIS has a relationship with cesarean delivery because all respondents use KIS to finance their delivery costs. Ownership of health insurance has a relationship to the incidence of cesarean section. Based on the results of the research carried out at the hospital. H. Sahudin Kutacane In 2019 it was found that out of 40 mothers who gave birth by cesarean section, the majority of mothers gave good knowledge as many as 23 people (57%), and mothers who had less knowledge were 17 people (43%). The results of statistical tests showed that there was a significant relationship between maternal knowledge and delivery by cesarean section with a value of p (sig) = 0.07 <α = 0.05. This study is in line with the research conducted by Duma which stated that there was a significant relationship between maternal knowledge and cesarean section. The results of this study found that the majority of mothers who gave birth by cesarean section had less knowledge as much as 33 mothers or about 67.3% and 16 mothers had knowledge. good 32.7% of the total 49 births (Lubis, 2018).
According to the assumptions of researchers referring to the above research, it is known that there is a relationship between knowledge and delivery by cesarean section. Mothers who have good knowledge are usually accompanied by good education as well, and we know that from the results of this study that the majority of mothers who gave birth by cesarean section in RSUD. Sahudin Kutacane has a good education (34%), but good education and knowledge do not make women giving birth realize that delivery by cesarean section has a greater risk than normal delivery.
Based on the results of research conducted at RSUD H. Sahudin Kutacane on 40 mothers who gave birth by cesarean section, it was found that the majority of respondents had a positive attitude towards delivery by cesarean section as many as 46 people (90%), and only 4 people (10%) had a negative attitude. Based on the results of statistical tests it is known that there is a significant relationship between attitudes and delivery by cesarean section with a value of p (sig) = 0.000 <α = 0.05.
The results of this study are in accordance with Notoamodjo's theory of attitude, namely the tendency of research in a person to certain groups, objects, or situations in positive or negative forms, this opinion will affect the mother's decision on something such as choosing methods and birth attendants (Notoatmodjo, 2010). According to the researchers' assumptions Referring to the results of the above research, it is known that there is a relationship between attitude and delivery by cesarean section. That is, the majority of women who give birth have a positive attitude towards cesarean delivery and it means that the mother agrees with the statement made by the researcher. One of the contents of the attached statement is that "vaginal delivery is a labor that is sick and scary". And the majority of respondents agreed with the statement. In fact, according to the results of interviews with informants, normal delivery is more comfortable than delivery by section. Although informant no 4 said that a cesarean delivery is a terrible and painful delivery. But the respondent has never given birth normally, so the expressions they say are not very accurate. It is different from respondent number 3 who has had a vaginal delivery and has also given birth normally. So that what was said by informant No.3 is more acceptable.

Conclusion
There is a significant relationship between education, parity, national health insurance, knowledge and attitudes towards increasing cesarean section delivery in RSUD. H. Sahudin Kutacane, but of the five variables, none of the variables had an effect on the increase in the number of cesarean sections in RSUD.H. Sahudin Kutacane.