Determinants of Exclusive Breastfeeding in Babies 0-6 Months in Medan Sunggal District

Exclusive breastfeeding for 6 months is very important for both mother and baby. The number of mothers who exclusively breastfeed their babies is still low (<80%). Medan Sunggal Puskesmas, Medan Sunggal Subdistrict, has a low achievement of exclusive breastfeeding in 2018 at 49.3% and decreased in 2019, namely 45.6%. Many factors influence exclusive breastfeeding, namely predisposing factors, enabling factors and reinforing factors. The purpose of this study was to find the determinants of exclusive breastfeeding in infants aged 0-6 months in Medan Sunggal District. Population of 256 people. Samples using the Slovin formula obtained 156 people. Data collection using a questionnaire. Data were analyzed by univariate, bivariate and multivariate using multiple logistic regression tests at the 95% significance level. The results showed that statistically knowledge (0.016), attitude (0.016), maternal ability (<0.001), breastfeeding facilities (0.001), husband's support (0.004), and parental support (0.010) had a significant effect on exclusive breastfeeding. Trust, ability of health workers, support from friends and the role of cadres have no effect. The dominant factor influencing is the ability of mothers with the value of Exp (B) 30,233, meaning that mothers have good abilities tend to be 30,233 times the mother gives exclusive breastfeeding to babies than the ability is not good. The conclusion is that the determinants of exclusive breastfeeding are knowledge, attitudes, abilities of mothers, breastfeeding facilities, husband's support and parental support. It is recommended that the Medan Sunggal government to increase regular counseling and form a companion group to make exclusive breastfeeding successful through peer groups or groups of mothers who love babies.


Introduction
The nutrition recommended for newborn babies is breast milk (ASI). Breast milk is the most ideal food for babies in early life. In addition to containing high nutritional value, breast milk also contains immune substances that can protect babies from various types of diseases that One of the government programs in increasing the scope of exclusive breastfeeding is through health promotion or counseling to mothers / families to succeed in giving Early Initiation, followed by exclusive breastfeeding until breastfeeding for 2 years. Decree of the Minister of Health of the Republic of Indonesia Number: 585 / MENKES / SK / V / 2007 concerning Guidelines for Implementation of Health Promotion in Puskesmas, emphasized that the role of health education is very much needed in improving community behavior so that it is free from health problems.
To increase the coverage of exclusive breastfeeding, health workers and health service providers are required to provide information and education on exclusive breastfeeding to mothers and / or family members of the baby from the time of pregnancy check-up until the end of the exclusive breastfeeding period. If not implemented, administrative sanctions can be given in the form of oral or written warnings and revocation of licenses for health facilities (Indonesian Government Regulation No.33 of 2014).
Health education or promotion activities on Exclusive Breastfeeding have become a promotional program for health workers to improve maternal behavior regarding Maternal and Child Health (KIA) in various health facilities. Although the results are not optimal, it may be due to various factors. According to (Green et al., 1980) health behavior is influenced by 3 main factors, namely 1) Predisposing factors consisting of knowledge, beliefs, values, attitudes, beliefs, abilities, 2) Enabling factors in the form of availability of information sources, breastfeeding facilities and the ability of health workers. And 2) Reinforing factors namely husband support, friend support, family support, role of cadres and role of community leaders (Green et al., 1980). Medan Sunggal Puskesmas, Medan Sunggal Subdistrict, has a work area of 4 sub-districts consisting of Sunggal Village, Tanjung Rejo Village, Babura Village and Simpang Tanjung Village. It is known that the coverage of exclusive breastfeeding for infants 0-6 months in 2019 is 387 babies (49.3%) of 785 babies, decreased to 450 babies (45.6%) from 987 babies in 2019. This coverage is very far from the target of 80%. The concept of exclusive breastfeeding seems difficult for breastfeeding mothers to apply. Although health workers in Medan Sunggal Subdistrict have conducted counseling on exclusive breastfeeding for pregnant women, counseling for women of reproductive age (WUS), and coaching cadres in each posyandu, the coverage of exclusive breastfeeding is not yet optimal. Infants aged 0-6 months who received treatment for diarrhea cases because they had been given additional food were 15 people in the work area of Medan Sunggal Subdistrict.
Based on the results of the initial survey in January 2020 in Medan Sunggal Subdistrict, by interviewing 20 mothers who had babies aged 0-6 months, it was found that 8 people (40%) gave breast milk only to babies when they were 0-6 months old and 12 people (60%) had provide foods such as water, sweet tea, coffee, bread, honey and formula milk.
The mother also said that from the experience of caring for babies, she believes that babies who are given food do not experience disease, instead babies experience faster growth and can cause the breasts to become sagging so that they interfere with their appearance. . Another reason, mothers also do not receive proper training and practice on how to provide breast milk and how to care for breasts. Mothers are only given information in the form of booklets, posters and counseling without any practice and reassessment of maternal abilities by cadres and health workers.
The mother stated that her husband does not support exclusive breastfeeding because the baby's business is the mother's business, the husband rarely motivates the mother to give exclusive breastfeeding, he does not pay attention to the healthy diet for the mother to produce nutritious breast milk There are also mothers who get support from parents, friends and cadres, but they feel that it is not deep enough so that the mother's motivation is not strong enough to provide exclusive breastfeeding.
Based on the description above, the researchers are interested in studying the determinants of exclusive breastfeeding for infants aged 0-6 months in Medan Sunggal sub-district.

Methods
An analytic survey research with a cross sectional approach was conducted in Medan Sunggal Subdistrict from July to September 2020. The population of all mothers who had babies aged 0-6 months from January 2020 was 256 people. Samples were taken. Distributing questionnaires to respondents, searching documents / reports and literature study. Data analysis was univariate, bivariate using chi square test and multivariate binary logistic regression.
The results of the measurement of the independent variable of exclusive breastfeeding were greater the tendency of mothers not to exclusively breastfeed 92 babies (59%) than exclusively breastfeeding 64 people (41%).

Bivariate Analysis
The results of the chi square statistical test showed that from the predisposing factors, there was a significant relationship between the knowledge, attitudes, beliefs and abilities of mothers with exclusive breastfeeding for babies, each probability value was 0.001; 0.001; 0.001; and 0.024 is less than 0.05. Enabling factors have a significant relationship between breastfeeding facilities and the ability of health workers to provide exclusive breastfeeding for babies, with probability values being 0.001 and 0.001 respectively. Reinforcing factor there is a significant relationship between the support of husbands, friends, parents, and the role of cadres with exclusive breastfeeding for babies, each probability value is 0.001; 0.001; 0.001; and 0.001.

Multivariate Analysis
Multivariate analysis using multiple logistic regression (binary). The results of the multivariate test using multiple logistic regression (binary) showed that of the three independent variables, the p value was less than 0.05, namely knowledge (0.016), attitude 0.016, maternal ability <0.001, ASI facilities 0.001, husband support 0.004 and parental support. 0.010 means that there is an effect of knowledge, attitude, belief, maternal ability, breastfeeding facilities, husband's support and parental support for exclusive breastfeeding for babies.
The interpretation of the value of Exp (B) on the knowledge variable is 1.630; it means that mothers have good knowledge, tend to be 1,630 times more likely to give exclusive breastfeeding to babies than poor knowledge. Likewise, the variables of attitudes, beliefs, maternal abilities, breastfeeding facilities, husband support and parental support which were categorized as good and supportive tended to provide exclusive breastfeeding to babies with the value of Exp (B) respectively compared to those categorized as less good and less supportive.

The Effect of Knowledge on Exclusive Breastfeeding
Based on the research results, it shows that knowledge has an effect on exclusive breastfeeding for babies. In line with Handayani & Anggorowati (2016), there is a relationship between knowledge and exclusive breastfeeding in the working area of Puskesmas Pengasih II Kulon Progo According to Sari et al. (2018) there are differences in the level of knowledge of mothers before and after being given counseling about exclusive breastfeeding. Rizqiea (2018) stated relevant research concludes that there are significant differences in knowledge between before being given a booklet and after giving a booklet.

The Effect of Attitudes on Exclusive Breastfeeding
Based on the results of the study, it shows that attitudes have an effect on exclusive breastfeeding for babies. In line with Permatasari et al. (2018) research, the factors related to the intention to provide exclusive breastfeeding are the attitudes and work of the mother. Perceptions of high behavioral control are three times more likely to have 'high intention' to provide exclusive breastfeeding than mothers with low control perceptions.
Attitude is a reaction or response that arises from an individual to an object which then raises the individual's behavior towards that object in certain ways. The next process is expected that the mother will implement or practice what she knows or responds to (considered good), so that after someone knows what exclusive breastfeeding is, the composition, and the benefits that can be generated, especially in infants, are expected to be better at giving exclusive breastfeeding which can avoid infectious diseases such as diarrhea (Yanuarini et al., 2017).

The Effect of Trust on Exclusive Breastfeeding
The results showed that trust had no effect on exclusive breastfeeding for babies. In contrast to the research, Setyaningsih (2018) states that the relationship between trust and family traditions in breastfeeding mothers with exclusive breastfeeding in Sidotopo Village, Semampir, East Java.
The results of this study are in accordance with several opinions of experts that a strong selfconfidence and a sense of confidence in the adequacy of breastfeeding can provide a positive attitude in exclusive breastfeeding. On the other hand, mothers who lack self-confidence tend to have difficulty facing challenges and difficulties in breastfeeding their babies (Fahriani et 59 ISSN 2721-1215, ISSN 2721-1231(Online) Copyright © 2021, Journal La Medihealtico, Under the license CC BY-SA 4.0 al., 2016. Mothers believe babies given exclusive breastfeeding are healthier and have a higher level of intelligence than babies fed formula milk. Mothers believe that other food additives can cause allergies due to hygiene factors (Manullang, 2020).

Effect of Mother's Ability on Exclusive Breastfeeding
The results showed that the mother's ability had an effect on exclusive breastfeeding for babies. In this study, the mother's ability as a dominant factor in exclusive breastfeeding in Medan Sunggal Subdistrict, Medan City. In line with Idris & Enggar (2019) research that there are differences in attitudes of mothers towards exclusive breastfeeding after being given counseling using audio visuals at the Singgani Community Health Center, Palu City.
The efforts of mothers to continue to provide exclusive breastfeeding are by increasing their understanding of the steps, techniques and correct breastfeeding positions so that the baby can get enough breast milk. Another effort is to make milk production smooth and plentiful by consuming a variety of foods while breastfeeding so that the milk content has the nutrients the baby needs (Idris & Enggar, 2019;Desmawati, 2013).

The Effect of Breastfeeding Facilities on Exclusive Breastfeeding
The results showed that breastfeeding facilities had an effect on exclusive breastfeeding for babies. In contrast to Rinata et al. (2016) states that the existence of a breastfeeding corner is not related to exclusive breastfeeding for working mothers at Sidoarjo Hospital.
The dominant enabling factor influencing exclusive breastfeeding is the availability of health facilities in the form of a breastfeeding corner which is part of a government program to make it easier for mothers to express milk that is full. If not done it can cause symptoms of pain and even fever. Each office can provide a breastfeeding corner, but some working mothers prefer to express breastmilk at home (Pratiwi, 2016).
The availability of a breastfeeding room is the availability of a room when the mother is breastfeeding or expressing breastmilk in the workplace which has special conditions and makes nursing mothers feel comfortable using the room. Basically, the breastfeeding space provided in the workplace is to make it easier for mothers to give breast milk or express breast milk. However, there are several factors that may cause the breast milk chamber to not function optimally. In this study, breastfeeding corners in public facilities recommended by the government are not yet functioning or not available so that it can prevent traveling mothers from giving exclusive breastfeeding.

Effect of the Ability of Health Workers on Exclusive Breastfeeding
The results showed that the ability of health workers had no effect on exclusive breastfeeding for babies (0.742> p 0.05). In contrast to Permatasari et al. (2018) research, the factor related to intention is the support of health workers.
Each health facility is supported by adequate facilities to create patient satisfaction with health services. Health workers carry out tasks in the form of providing promotional visits, education, socialization (counseling), and campaigns by encouraging and inviting and convincing mothers to implement exclusive breastfeeding for their babies. Health workers can ensure that mothers The family, especially the husband, is an important part of the success or failure of breastfeeding, because the husband determines the fluency of the knowledge of the mother in breastfeeding in increasing self-confidence and motivation so that she wants to breastfeed the baby. In addition, increasing knowledge about correct breastfeeding through counseling in health care (Nuzulia, 2013).

The Effect of Peer Support on Exclusive Breastfeeding
Based on the results of the study showed that peer support had no effect on exclusive breastfeeding for babies). In contrast to the research Shakya et al. (2017) said in low and middle income countries, peer support increases breastfeeding initiation within the first hour of life and reduces the risk of prelacteal feeding (RR: 0.38).
The support of good friends while at work will give mothers the opportunity to continue participating in the ASI program. Peer support that can be done, such as providing information about breastfeeding techniques, motivation or giving praise and encouragement, continues to support the mother so that she is healthier and not worried about physical changes, and sharing experiences of caring for a good baby (Fikawati & Syafiq, 2010).

The Effect of Parental Support on Exclusive Breastfeeding
The results showed that parental support had an effect on exclusive breastfeeding for infants (0.010 <p 0.05). In line with Manullang's research (2017) states that social aspects that can influence the success of exclusive breastfeeding for babies include family attachments, community views, economics, information and education as well as health workers / cadres. Cultural aspects that can influence mothers to be able to provide exclusive breastfeeding for babies are religion / philosophy of life and cultural values ( Manullang, 2020).
The smaller the parental support for the mother in providing information, helping breastfeeding and providing nutritious food, the less positive the mother's attitude in exclusive breastfeeding. If a mother gets positive support, it will strengthen her belief that the act of giving exclusive breastfeeding to the baby is right.

The Influence of Cadre's Role on Exclusive Breastfeeding
The results showed that the role of cadres had no effect on exclusive breastfeeding for babies (0.520> p 0.05). In contrast to Permatasari et al. (2018) research, the factor related to intention is the support of health workers. Jama et al. (2020) concluded that the prevalence of exclusive breastfeeding is very low, 20.47% in Burao City, Somalia. The causative factor is the low formal education of mothers. The need for education to women and encouragement of antenatal nurses and exclusive breastfeeding counseling during antenatal care to increase exclusive breastfeeding.

Conclusion
There is a significant influence between knowledge, attitudes, beliefs and abilities of mothers on exclusive breastfeeding for babies. Ability as a dominant factor. There is a significant effect of breastfeeding facilities on exclusive breastfeeding for babies. There is no significant effect between the ability of health workers to exclusive breastfeeding for babies. There is a significant effect of husband's support and parental support on exclusive breastfeeding for babies. There was no significant effect between peer support and the role of cadres on exclusive breastfeeding for babies.