FACTORS RELATED TO BURNOUT INCIDENCE IN MIDWIVES DURING THE COVID-19 PANDEMIC

Background : The COVID-19 pandemic has caused an increase in the burden of health services which can also increase the incidence of burnout. During the COVID-19 pandemic, the percentage of midwives who experienced burnout was 83%. Burnout in midwives can have an impact on reducing the quality of health services. The purpose of this study was to analyse the factors associated with the incidence of burnout among midwives during the COVID-19 pandemic at Dr. Soetomo City of Surabaya. Method : The design of theis research is using an analytic observational method with a cross-sectional approach which aims to correlate the burnout variable in midwives with the variables age, length of work, marital status, relationship with husband/family, number of children, and personality. The population in this study was 94 people and the sampling was taken using the total sampling method. The instrument used is a questionnaire. The collected data were analysed using chi-square test. Results: out of 94 midwives, 53 midwives were included in the inclusion. A total of 36 midwives (68%) experienced moderate burnout. The result of the chi-square test for age, p-value = 0.000; length of working, p-value = 0.000; marital status, p-value = 0,138; relationship with husband, p-value = 0.800; the number of children p value = 0,936; and personality p value = 0,984. Conclusion: The data shows that most of the midwives who participated in the study experienced burnout in the moderate category related to the age and length of work of the midwives.

143 from 20-59% in several countries such as Sweden, Norway, United Kingdom (UK), and Australia. The data collected varies from 2013 to 2016 (Creedy et al., 2017).
In recent years, the symptoms of burnout in healthcare workers have become a concern for several reasons. The impact of burnout does not only affect the health of health workers but is also related to lower service quality and increases the risk of errors. Burnout also has an impact on health organizations as a result of increased absenteeism and intention to leave health workers which can then lead to staff shortages and additional workload for the remaining staff (Dijxhoorn et al., 2021).
Health system services experienced an increased burden as a result of the  pandemic which then also increased the workload of health workers (Santoso, 2021). The disease outbreak was declared by WHO to be a high risk level with 5,104,899 cases of death worldwide recorded on November 17, 2021 (Octara et al., 2022). As the World Health Organization (WHO) stated in 2020, COVID-19 is a highly contagious disease that has caused a global pandemic . Health workers are included in the high risk group for infection with SARS-CoV-2 (Galanis et al., 2021). This is because health workers are at the forefront of dealing with the COVID-19 pandemic. Many health workers have died as a result of being exposed to SARS-CoV-2 while carrying out their duties. The risks from exposure to COVID-19 can affect the quality of life, health services, and productivity of health workers (Santoso, 2021).
Health workers have the potential to experience mental fatigue or burnout syndrome. Based on data from research, the COVID-19 pandemic has led to an increase in the incidence of burnout in Indonesia. Burnout is experienced by 83% of medical professionals and other health workers with moderate to severe degrees with details of as many as 82% experiencing moderate burnout, 17% experiencing mild burnout, and the other 1% experiencing severe burnout. The percentage of midwives who experienced burnout during the COVID-19 pandemic in Indonesia was 83% (Santoso, 2021).
Research has found that there is a relationship between burnout, anxiety, and stress disorders during the COVID-19 pandemic which caused health workers to experience high levels of mental health problems, including burnout (Yıldırım & Solmaz, 2020). Various ways such as physical distancing, health protocols, and travel restrictions were made to overcome the COVID-19 pandemic (Dewayani et al., 2021). Controlling COVID-19 with social restrictions, lockdowns, restrictions on economic and educational activities, and loss of livelihoods can affect mental health (Witarto et al., 2022). Poor working environmental conditions during the Covid-19 pandemic can be one of the causes of poor mental health conditions for health workers (Syamlan et al., 2022). A decrease in the quality of health services and risks in the process of treatment or therapy can be an impact if health workers experience burnout (Lipin et al., 2021).
Surveys from several hospitals and midwife independent practices that have been conducted on midwives, almost all of them have experienced burnout. The increased workload due to the increase in COVID-19 patients, the lack of human resources (HR), and the negative stigma that society has towards health workers who deal directly with COVID-19 are the causes of burnout. The results of interviews with midwives who work at RSUD Dr. Soetomo stated that anxiety and worry can arise when providing services amid the COVID-19 pandemic. The increased workload due to changes in procedures and policies due to COVID-19, as well as feelings of fear of contracting COVID-19 are among the causes of this concern. Based on the background above, the researcher is interested in conducting researching on "Factors Associated with Burnout Incidence in Midwives Working in RSUD Dr. Soetomo City of Surabaya During the COVID-19 Pandemic.

METODE
This study is observational with a cross-sectional quantitative research design to explain the relationship between midwife burnout and age, marital status, and number of children.
personality, relationship with husband/family, and length of working. The total population in this study amounted to 94 people. Total sampling was used to determine the sample size to be used because in this study the total population is less than 100 people. This research was conducted at RSUD Dr. Sutomo Surabaya. The instrument used is the CBI (Copenhagen Burnout Inventory) questionnaire which is divided into three categories, namely, personal burnout, work-related burnout, and pandemic-related burnout. The questionnaire used has been tested for validity and reliability. The collected data were analysed using univariate and bivariate analysis methods and using chi-square analysis to look for relationships between variables.

RESULT AND DISSCUTION
Before data collection, the validity and reliability tests of the questionnaire were first carried out, with the results of the validity test 0.691-0.915 and the reliability test 0.971. The sample in this study was 94 midwives, including the inclusion of 53 midwives. Based on the analysis, the following results were obtained. The data above shows that of the 53 midwives, the majority experienced moderate burnout, namely 36 midwives (68%). Midwives who experienced burnout in the severe category ranked second most, namely as many as 9 midwives (17%), and at least 8 midwives (15%) experienced burnout in the mild category. The data above shows that of the 53 midwives, the majority experienced moderate burnout, namely 36 midwives (68%). Midwives who experienced burnout in the severe category ranked second most, namely as many as 9 midwives (17%), and at least 8 midwives (15%) experienced burnout in the mild category. The table above shows that out of 53 midwives, 36 midwives (68%) experienced moderate burnout with the majority of 20 midwives (56%) working as midwives for 11-20 years, and at least 1 midwife (3%) worked as a midwife for > 31 years. The bivariate test shows a sig. value of 0.00, which means sig. <0.05 so that it can be interpreted that there is a relationship between burnout and the length of time a midwife has worked. Based on the table above, it is known that out of 53 midwives, 36 midwives (68%) experienced moderate burnout with at most 33 midwives (92%) married and at least 1 midwife (3%) single. The sig. value is > 0.05 so that it can be interpreted that there is no relationship between burnout and the marital status of midwives. The  Based on the table above, it is known that, as many as 36 midwives (68%) experienced burnout in the moderate category, with a maximum of 17 midwives (47%) having 2 people and at least 1 midwife (3%) having >3 children. The sig. value is > 0.05 so that it can be interpreted that there is no relationship between burnout and the number of children. Based on the table above, it is known that, of the 36 midwives (68%) who experienced moderate burnout, at most 18 midwives (50%) had cheerful personalities and at least 1 midwife Islamiyah et al. : Factor Related to Burnout… Indonesian Midwifery and Health Sciences Journal, 2023, 7 (2), 142-152 147 (3%) had an introverted personality. The sig. value is > 0.05 so that it can be interpreted that there is no relationship between burnout and personality. From the above analysis it is known that there are factors related to burnout and factors that are not related to burnout in midwives.

Factors Associated with Burnout Events
Age Maslach et.al (1976) stated that burnout is more prone to occur in younger workers than older workers. Younger workers will have expectations that seem unrealistic which can then lead to burnout (Santoso, 2021). Younger workers usually don't have a lot of experience, so shock can occur when they face the reality of their work. A person will have a more mature and realistic view and become more stable with age (Yanti et al., 2021).
In this study, it was found that older midwives still experienced high burnout. This might be due to boredom or boredom that can arise from monotonous routines that have been going on for a long time (Yanti et al., 2021). Older midwives are also more prone to suffer from certain diseases which can interfere with productivity and increase stressors at work.
Midwives are one of the front lines in dealing with the COVID-19 pandemic, therefore older midwives will be more susceptible to being infected by the COVID-19 virus. This can cause anxiety or worry for midwives when they work. Excessive anxiety can then cause burnout in midwives.

Length of Working
The results of this study are in line with the research of Surya and Adiputra (2017) which states that workers whose working period is in the range of 11-20 years are more prone to burnout. Maslach (1976) states that there is no specific length of work that can cause burnout in workers, but the longer a person works, the more at risk of experiencing burnout due to boredom and fatigue. Work patterns that do not vary or are monotonous, have a lot of experience and are service-oriented can pose a risk of burnout (Widodo et al., 2023). Other research states that burnout is more prone to occur in workers with a long working period of 1-5 years as a result of the saturation that arises from monotonous work every day and due to demands to masterwork that can put a burden on someone (Santoso, 2021).
In this study, midwives with a working period of 11-20 years were more experienced in the moderate category of burnout. During the COVID-19 period, midwives were required to take precautions and protect themselves so they would not be infected with COVID-19.
Midwives also experience difficulties when working during a pandemic because there are many changes related to providing services during a pandemic, such as the use of complete PPE when assisting deliveries with COVID-19 which can add to the psychological burden and increase stressors. For midwives whose working period is 11-20 years of course their age is also no longer young. Therefore, midwives are more susceptible to certain diseases and are susceptible to infection with COVID-19. This can raise concerns for midwives and if this continues it can cause stress and burnout.

Factors Not Related to Burnout in Midwives
Marital Status, Relationship with Husband, Husband or Family Support Santoso's research (2021) states that burnout tends to be experienced more by someone who is not married than by someone who is married. Based on the research results obtained by researchers, burnout in the mild, moderate, and high categories was also experienced more by midwives who had a harmonious relationship with their husbands. All midwives in this study also received support from their husbands/families to become midwives, but the majority of midwives still experienced burnout. Previous research states that burnout can be experienced in someone who is married if there is disharmony in the household which then also affects the support that can be received by that individual. Support from the family should also be able to help someone solve their problems properly (Santoso, 2021). Other research states that workers who are not married or are still single are more at risk of experiencing burnout. This is caused by the presence or absence of social support from a spouse, but someone unmarried can still get support from the family because the Indonesian population has nuclear family characteristics where an unmarried child will still live with the family (Swasti et al., 2018). This study shows that marital status, relationship with husband, and family support do not affect the occurrence of burnout, because all respondents in this study still experience burnout in different categories regardless of their marital status, relationship with family and social support received.
Midwives are one of the front lines in handling the COVID-19 pandemic. This can make midwives vulnerable to contracting COVID-19 infection. Working during the COVID-19 pandemic requires midwives to be careful and increase their self-protection to avoid infection with COVID-19. Midwives are often hesitant to work during a pandemic for fear of infection and then transmitting it to their families.

Number of children
The results of this study are in line with research by Swasti et al. (2018) that a person is at risk of experiencing burnout no matter how many children they have. Santoso's research (2021) revealed that someone who already has children will tend to experience burnout in a lower category than someone who doesn't have children. This can be caused by the involvement of the family, including children, which can help provide emotional support to someone to deal with problems or conflicts.
In this study, it is known that all midwives have the potential to experience burnout in several categories regardless of the number of children they have. Midwives who have children tend to experience burnout in a higher category than midwives who do not have children. A woman who works and who is married (married and has children) will have increased responsibilities due to demands from the culture in society that still thinks that taking care of her husband and children is a woman's duty and responsibility (Santoso, 2021). The COVID-19 pandemic can certainly add to the burden of a mother and midwife. As a mother, of course midwives have instincts to protect children and their families from all dangers including COVID-19 infection. During the COVID-19 pandemic, midwives will sometimes experience anxiety about being infected with COVID-19 and passing it on to their families. Therefore midwives are required to be extra careful and protect themselves with PPE in the work environment. This can cause stress which can then lead to burnout in midwives.

Personality
The personality of a person can affect how a person responds to pressure. If a person fails to deal with pressure, then they can experience stress which then causes burnout. In this study, it was found that the majority of midwives with cheerful personalities experienced mild, moderate, and severe categories of burnout. Based on the results of this study it is also known that there is no relationship between burnout and personality. Research by Santi (2020) states that burnout is prone to occur in someone who has an anxious personality and unstable emotions (mood swings). Someone with this personality tends to have negative emotions when faced with a stressful situation.
Someone who has a cheerful personality, calm, friendly, and quiet has a lower potential to experience burnout. Individuals with this personality, they will be more able to provide positive emotions when facing pressure. The positive attitude of this personality can prevent them from burnout. In addition, based on research from Atia and Soetjiningsih (2020) someone with an introverted personality type is also prone to experiencing burnout. This is because introverted personalities tend to keep their problems to themselves and tend to find it difficult to find the right solution to the problem. An introverted personality is also more prone to developing negative emotions such as frustration, sadness, and depression. Someone with an introverted personality also tends to be pessimistic and anxious when faced with pressure. If this continues to happen, it can cause emotional exhaustion which then causes burnout.
During the COVID-19 pandemic, midwives experienced difficulties doing their jobs.
Working during the COVID-19 pandemic can add to the burden on midwives. Changes related to services and demands for self-protection can increase stressors or pressure on midwives.
Apart from that, working during the COVID-19 pandemic can also drain the energy of midwives. In this study, midwives with cheerful personalities experienced moderate burnout.
Stressors during the COVID-19 pandemic can cause emotional changes where previously a person had positive emotions, then turned into negative emotions. Midwives with cheerful personalities can still experience burnout, possibly due to a mental disorder that was not detected beforehand as well as other factors, such as anxiety due to feelings of fear of contracting Covid-19. This then can cause burnout in midwives.

Conclusion
The results of this study indicate that the majority of midwives who participated in the study experienced moderate burnout. Burnout can be caused by several factors. Based on the results of this study, it is known that there are factors related to burnout in midwives, there are factors that are not related. Factors related to burnout in midwives were age and length of service, while factors not related to burnout in midwives were marital status, relationship with husband/family, husband or family support, number of children, and personality.

Suggestion
The researcher suggests that future researchers who are interested in conducting research related to burnout in midwives use more samples so that the research results are optimal. In addition, there is a need for a more in-depth study regarding the symptoms of burnout in each midwife and their impact on performance in providing services and the midwife's daily life.