Analysis of Factors Affecting the Performance of Midwifery Workers in the Work Area of the Siborong Borong Health Center , , North Tapanuli Regency

One of the programs to reduce MMR in Indonesia is to improve the quality of health services, especially health services for pregnant women by professionals in accordance with Antenatal Care (ANC) service standards. One of the causes of the high maternal mortality rate in Indonesia is pregnant women who are at risk of not being detected early. The purpose of the study was to analyze the performance determinants of midwifery workers in the working area of the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency.The research design used in this study was an analytic survey with a cross sectional design. The population in this study were all midwifery workers who worked at the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency, as many as 62 midwifery workers, from July to September 2021. The number of samples to be studied was 62 people. Data analysis was carried out by univariate, bivariate and multivariate analysis. The statistical test used is the chi square test and logistic regression.  The results of the chi square test show that the variables of leadership, motivation, discipline, incentives and work environment have a p-value of 0.001 < 0.05, meaning that leadership, motivation, discipline, incentives and work environment affect the performance of midwives at the Siborong Borong Health Center. The conclusion of the multiple logistic regression test shows that the leadership variable with an odds ratio (OR) of 47.802 is more dominant in influencing the performance of midwifery workers.


Introduction
Health is certainly not a new word in the daily dictionary of citizens, especially the virtue or importance of the phrase taken from the word healthy. Health is anyone's dream to avoid various diseases so that daily activities run smoothly without any disturbance. However, what is still unfortunate is that the general public does not care about their own health until they get really sick, in other words, people tend to want to be healthy when they are sick while they are in good health or fit, so health will be forgotten by not paying attention to diet, rest and excessive activity (Verplanken & Faes, 1999;McMurray et al., 2014;Osibogun et al., 2020).
The concept of "healthy", the World Health Organization (WHO) formulates in a very broad scope, namely "a perfect state of being physically, mentally and socially, not only free from disease or weakness/disability". In this definition, healthy is not just free from disease or disability. People who are not diseased are not necessarily said to be healthy. He should be in Health services are products that provide services to patients, services are activities, benefits or satisfactions offered for sale, thus services can only be consumed but cannot be owned (Wang et al., 2005;Abuse, 2013). Health services that provide curative and preventive services in an integrated, comprehensive and easily accessible manner, within the working area of a sub-district or part of a sub-district in a city or district.Midwives as professionals in maternal and child health services are required to comply with midwifery service standards. Midwives' compliance with obstetric service standards has an impact and leverage on the quality of antenatal care, which in turn contributes to a reduction in maternal and infant morbidity and mortality. According to WHO, a midwife is someone who has been regularly recognized in the midwifery education program as legally recognized, where she is placed and has completed midwifery education and has obtained qualifications and is registered, legalized and licensed to practice midwifery. The main tasks of midwives include: carrying out midwifery care for pregnant women (antenatal), carrying out physiological delivery care for mothers in labor (postnatal care), providing services for newborns (neonatal care visits), seeking partnerships with traditional birth attendants in Indonesia. working area of the puskesmas, providing education through reproductive health and midwifery counseling, implementing family planning (KB) for women of childbearing age, tracking family planning (KB) for women of childbearing age, seeking Maternal Perinatal Audit (AMP) discussions if there are maternal and infant deaths.
According to Permenkes Number 4 concerning the Year 2019 Technical Standards for Fulfilling Basic Service Quality in Minimum Service Standards in the Health Sector, it is stated in article 2 point 3 regarding the types of basic services in Regency/City Regional Health MSS relating to the main tasks of midwives, including: health services for pregnant women , maternal health services, newborn health services, under-five health services and health services for productive age. According to Perkins, long before Paune expressed his opinion on health, Perkins, a medical expert had revealed in 1938 that health is a dynamic balance between function and body shape in relation to the surrounding environment that influences these two elements. In defining health, White who is a doctor has a way of interpreting health in a simple way. According to White, health is a normal condition for a person who has no complaints or absence of symptoms of a medically identified disease during the examination process.
Geographically, North Tapanuli Regency is located at coordinates 1º20'00" -2º41'00" North Latitude (LU) and 98º05'-99º16' East Longitude (BT). It has an area of ± 3,800.31 Km², with a land area distribution of 3,793.71 Km² and the waters of Lake Toba is 6.60 Km². Of the 15 subdistricts in North Tapanuli Regency, Garoga District is the sub-district that has the largest area of about 567.58 Km² and the sub-district that has the smallest area is Muara District of about 79.75 Km².
From the data from the Indonesian Ministry of Health (Kemenkes) in the 2019 Indonesian Health Profile, it was recorded that in 2015 there were 305 mothers died per 100,000 live births. Based on data obtained from the North Sumatra Provincial Health Office, there are 175 deaths per 100,000 live births. From data from the North Tapanuli Health Office in 2018, there were 4 maternal deaths. In 2019 there were 4 maternal deaths and in 2020 there were 8 maternal deaths. Data obtained from the Siborongborong Health Center in 2019 the number of maternal deaths was 1 person.
One of the programs to reduce MMR in Indonesia is to improve the quality of health services, especially health services for pregnant women by professionals in accordance with Antenatal Care (ANC) service standards. One of the causes of the high maternal mortality rate in Indonesia is that it occurs in pregnant women who are at risk of not being detected early. Until June 2021, the number of K1 and K4 visits at the Siborongborong Health Center was still low at 38%, this is because there are still many targets for pregnant women who have not been reached by midwives at the Sibrorongborong Health Center, North Tapanuli Regency where the distance to go to the location where pregnant women are far enough to cause health workers to experience obstacles in health services for pregnant women in the village.
Based on data from the Siborongborong Health Center, North Tapanuli  Geography and demography UPTD (Service Technical Implementing Unit) Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency is located in the northern part of North Tapanuli City and is located in Siborong Borong District, North Tapanuli Regency. , which has a village consisting of 9 villages with 1 kelurahan, the total population is 24,791 people, with a gender division of 12,743 men and 12,048 women. The number of families is 24,791 families and 4,132 units of houses. The UPTD of the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency has health facilities located in the village, namely 1 unit puskesmas, 2 units of pustu (sub-health center), 14 units of poskesdes (village health post), and posyandu (integrated family planning health service post). unit, with a total of 62 midwifery staff, including 15 (24.19%) ASN midwives with Category II 30 (48.39%) ASN midwives with Category III and 17 (27.42%) ASN midwives with Group II IV who works at the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency.
Based on the initial survey conducted by researchers in the working area of the UPT Puskesmas Siborong Borong, Siborong Borong District, North Tapanuli Regency, there were 62 midwifery workers working at the Siborongborong Health Center, Siborongborong District, North Tapanuli Regency. The determinants of the performance of midwifery staff were 10 midwives. Of these 10 midwives who did not carry out the work determinants interviewed by researchers at the Siborong Borong Health Center, they found factors that influenced the performance system of the UPT Puskesmas Siborongborong, North Tapanuli Regency.
In interviews conducted by researchers, it was found that there are factors that affect the performance of midwives at the Siborongborong Health Center, North Tapanuli Regency, including: Education is a learning of knowledge or skills and habits of a group of people passed down from one generation to the next through teaching, training or research. Leadership is an ability or strength within a person to influence others in work where the goal is to achieve the target (Liechty, 2011;Trastek et al., 2014).
Motivation is someone who gives encouragement to others so that their goals can be achieved so that performance can be completed. Discipline is a condition that is created and formed through a process with a series of attitudes that indicate a performance system. Wage incentives are given to encourage morale in both a company and a government system (Agell & Bennmarker, 2007;Murray, 2014). Work environment is an attitude that interacts with each other in a work organization and the ability to work is able to complete the tasks and responsibilities that have been given by superiors (Jaskyte et al., 2020;Lysova et al., 2019). Of the seven factors mentioned above, there is still a lack of implementation or carried out on officers/employees at the Puskesmas and there are many more that are complained of in health services, namely the lack of assertiveness in leadership to monitor the work team and to create a pleasant work environment in supporting the actions that are needed to be done in team work.

Methods
The type of research used is an analytical survey with a cross sectional study approach which aims to analyze the performance of midwifery personnel in the work area of the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency in 2021 which was observed in the same time period. The population in this study were all midwifery workers who worked at the Siborong Borong Health Center, Siborong Borong District, North Tapanuli Regency as many as 62 midwifery workers as many as 62 people, the sample size using a total sampling of 62 people.
The tool for data collection is a questionnaire. The data that has been collected was processed by univariate and bivariate and multivariate analysis. Univariate analysis is to see the description of the frequency distribution of all the variables studied, both dependent and independent variables. Bivariate analysis aims to see the relationship between the dependent variable and the independent variable and multivariate analysis to see the effect of the independent variable on the dependent variable with the type of multiple logistic regression analysis in order to obtain the most dominant independent variable influencing the dependent variable.

Univariate Analysis
Based on table 1 about the distribution of respondents' characteristics of gender, age, and education. The independent variables include leadership, motivation, discipline, incentives and work environment. Univariate analysis was conducted to see the frequency distribution of the respondent's characteristics and the frequency distribution of the independent variables (leadership, motivation, discipline, incentives and work environment) and the dependent variable (performance of midwives). Based on the research, the results showed that the majority of women were 62 respondents (100%). The majority of respondents were aged 36-50, as many as 39 respondents (57.1%). Then, from the results of the study, it was found that the majority with D4 Midwifery education were 42 respondents (67.8%).
Based on the variables the majority of respondents were Leadership, the majority of respondents 43 respondents (69.4%) gave a bad opinion based on the motivation variable 46 respondents (74.2%) gave a bad opinion, based on the Discipline variable as many as 41 respondents (66.2%) gave a bad opinion) , based on the Incentive variable as many as 45 respondents (72.9%) gave a not supportive opinion., Based on the work environment as many as 37 respondents (59.7%) gave a bad opinion.

Bivariate Analysis
Based on table 2 regarding the relationship of leadership, motivation, discipline, incentives and work environment with the performance of midwives at UPT Puskesmas Siborongborong, North Tapanuli Regency, it shows that of the 19 respondents who gave a good opinion on the importance of leadership, as many as 13 respondents (68.4%) had good performance. good and 6 respondents (31.6%) have poor performance. Then, of the 43 respondents who gave a bad opinion on the importance of leadership as many as 6 respondents (9.2%) had a good performance and 43 respondents (90.8%) had a bad performance. Then from 19 respondents who gave a good opinion the importance of motivation, as many as 14 respondents (53.8%) had good performance and 5 respondents (8.6%) had poor performance. Then, of the 36 respondents who gave a bad opinion on the importance of motivation, 31 respondents (91.4%) had good performance and 5 respondents (8.6%) had poor performance.
And from 19 respondents who gave a good opinion on the importance of discipline, as many as 11 respondents (57.9%) had good performance and 8 respondents (42.1%) had poor performance. Then, from 43 respondents who gave a bad opinion on the importance of discipline as many as 35 respondents (87.7%) had a good performance and 8 respondents (12.3%) had a bad performance. And of 31 respondents who gave opinions supported the importance of incentives , as many as 12 respondents (38.7%) had good performance and 19 respondents (61.3%) had poor performance. Then, of the 31 respondents who gave opinions that did not support the importance of discipline, 7 respondents (13.2%) had good performance and 24 respondents (86.8%) had poor performance.
Then of the 31 respondents who gave a good opinion on the importance of the work environment, as many as 12 respondents (38.7%) had good performance and 19 respondents (61.3%) had poor performance. Then, of the 31 respondents who gave a bad opinion on the importance of the work environment, 7 respondents (13.2%) had good performance and 24 respondents (86.8%) had poor performance.

Influence of Leadership with Midwifery Personnel Performance in Siborong Borong North Tapanuli Regency Health Center
Leadership is an activity to influence the behavior of others so that they will be directed to achieve certain goals. Leadership is defined as the ability to move or motivate a number of people to simultaneously carry out the same activities and be directed at achieving their goals. Leadership is also a process of moving a group or groups in the same direction without coercion.
Based on the results of the study, it was explained that of the 19 respondents who gave a good opinion on the importance of leadership, as many as 13 respondents (68.4%) had good performance and 6 respondents (31.6%) had poor performance. Then, of the 43 respondents who gave a bad opinion on the importance of leadership, 6 respondents (9.2%) had good performance and 43 respondents (90.8%) had poor performance.
Based on the Chi Square Test statistical test, the p-value is 0.001 < 0.05 so that there is an influence of leadership on the performance of midwives at the Siborong Borong Health Center.
This is in line with Maghda Nisah's research (2019). The results showed that the variables that had a significant effect on nurse performance were leadership (p=0.01) intrinsic motivation (p=0.30<p=0.005) and extrinsic motivation (p=0.028 <p=0.005). It is recommended for the leadership of the Porsea Regional General Hospital to improve the leadership function as an effort to improve the performance of nurses by implementing it in the form of guidelines and assignment schedules in leading nurses by re-examining nursing care documents and making sure they are completely filled.

The Influence of Motivation with the Performance of Midwives
Motivation is a change in energy within a person which is characterized by an impulse that comes from a person to achieve goals. The drives and reactions of effort caused by the need for achievement in life. This makes individuals have the effort, desire and drive to achieve high learning outcomes. So, motivation is defined as the power contained within the organism that encourages to act or is a driving force.
Based on the results of the study, it was explained that of the 19 respondents who gave a good opinion on the importance of motivation, as many as 14 respondents (53.8%) had good performance and 5 respondents (8.6%) had poor performance. Then, of the 36 respondents who gave a bad opinion on the importance of motivation, 31 respondents (91.4%) had good performance and 5 respondents (8.6%) had poor performance.
Based on the Chi Square Test statistical test, the p-value is 0.001 < 0.05 so that there is an influence of motivation on the performance of midwives at the Siborong Borong Health Center.
This study is in line with (2018) the results of the study showing that the majority of midwives have cooperation with primary health services. Midwives have high motivation and positive attitude. Midwives performance to non-insured and insurance patients is very high. There is a moderate correlation (r=0.446) between cooperation (midwife with primary health care) and performance towards non-insured patients. There, there is a very weak correlation (r=0.111) between cooperation (midwife and doctor) and performance on patient insurance, and a weak correlation (r=0.311) for non-insured patients.

Influence of Discipline with Midwifery Energy Performance
Discipline is an attitude, behavior and actions that are in accordance with the regulations of the company, both written and unwritten. According to Prajudi Atmosudirjo in I.G. Wursanto: "Work discipline is obedience to an institution or organization and all that is a provision without using feelings, only based on awareness and awareness that without such obedience all the provisions in the organization's goals cannot be achieved.
Based on the results of the study, it was explained that of the 19 respondents who gave good opinions on the importance of discipline, 11 respondents (57.9%) had good performance and 8 respondents ( (2019). The results show that there is a relationship between time discipline and health service performance with the category on time (good) = 10 (83.8%), on time (not good) = 2 (16.7%). While the time discipline with the category of slow (good) = 8 (40%), slow (not good) = 12 (60%).

The Influence of Incentives on the Performance of Midwives
Incentives as a means of motivation that encourage employees to work with optimal abilities, which are intended as extra income outside the salary or wages that have been determined. The provision of incentives is intended to be able to meet the living needs of employees or workers and their families. The term incentive system is generally used to describe wage payment plans that are linked directly or indirectly to various employee performance standards. Based on the results of the study, it was explained that of the 31 respondents who gave opinions supporting the importance of incentives, as many as 12 respondents (38.7%) had good performance and 19 respondents (61.3%) had poor performance. Then, of the 31 respondents who gave opinions that did not support the importance of discipline, 7 respondents (13.2%) had good performance and 24 respondents (86.8%) had poor performance.
Based on the Chi Square Test statistical test, the p-value is 0.001 < 0.05 so that there is an influence of discipline on the performance of midwives at the Siborong Borong Health Center. This study is in accordance with research by Emy Hariani (2019). The results of this study conclude that there is a significant and positive relationship between incentives and workload and there is a significant and positive relationship between incentives and workload on performance and the effect of workload on performance. directly obtained by 0.104 is smaller than the indirect effect obtained by 0.134. This means that incentives will be better at improving performance if they are supported or without going through the workload first.

Influence of Work Environment with Midwifery Performance
The work environment is a place where employees carry out daily activities. A conducive work environment provides a sense of security and allows employees to work optimally. The work environment can affect employees' emotions. If the employee enjoys the work environment, the employee will feel at home in his workplace, carrying out his activities so that work time is used effectively. Productivity will be high and employee performance will also be high.
Based on the results of the study, it was explained that of the 31 respondents who gave a good opinion on the importance of the work environment, as many as 12 respondents (38.7%) had good performance and 19 respondents (61.3%) had poor performance. Then, of the 31 respondents who gave a bad opinion on the importance of the work environment, 7 respondents (13.2%) had good performance and 24 respondents (86.8%) had poor performance.
Based on the Chi Square Test statistical test, the p-value is 0.001 < 0.05 so that there is an influence of the work environment on the performance of midwives at the Siborong Borong Health Center.