Bagaimana dan Dimana Proses Persalinan Berlangsung Berpengaruh Penting terhadap Keberhasilan Pemberian ASI Eksklusif How and Where the Birth Delivery Taking Place Matter towards the Success of Exclusive Breastfeeding

Background: Breast milk is the best nutrition for babies. The coverage of exclusive breastfeeding in Indonesia in 2017 was still low. However, there are many factors that contribute to low rates of exclusive breastfeeding including socio-cultural factors, factors related to the health system, market, environment, and knowledge. Recent studies have shown that there was a relationship between the place and type of delivery with exclusive breastfeeding. Objectives: This study aimed to analyze the correlation between the place and type of delivery with the success of exclusive breastfeeding practice in Indonesia among mothers of infants 0-6 months. Methods: This study was a secondary data analysis using data from the results of the 2017 Indonesia Demographic and Health Survey (IDHS), conducted in 34 provinces in Indonesia with a total sample of 1810


INTRODUCTION
Exclusive breastfeeding is the best nutrition for babies in the first six months of life. Exclusive breastfeeding means that babies only get breast milk from birth until they are six months old, no other food or drinks are given except medicines, vitamins, and minerals (Kementrian Kesehatan RI, 2020b). After six months of age, infant must consume nutritionally supplementary foods and continue breastfeeding for two or more years to meet their nutritional needs (WHO, 2019).
The results of the Indonesia Demographic and Health Survey (IDHS) in 2017 showed the percentage of children under 6 months who were exclusively breastfed in 2017 was 52%. The data shows an increase in the percentage of exclusive breastfeeding in the last 5 years, from 42% in the 2012 IDHS to 52% in the 2017 IDHS (Badan Pusat Statistik, 2018). However, the increase in exclusive breastfeeding coverage is still quite low when compared to the Strategic Plan Target of the Ministry of Health for 2020-2024, which is 60% (Kementrian Kesehatan RI, 2020a).
There are many factors contribute to low rates of exclusive breastfeeding including social culture, factors related to the health system, market, environment, and knowledge (Bai et al., 2009). Exclusive breastfeeding is also affected by mother and baby factors. Maternal age, maternal education level, parity, place of delivery and type of delivery are considered to be factors influencing the success of exclusive breastfeeding (Nishimura et al., 2018;Wardani, Hastuti and Adriani, 2017) Recent studies have shown that there was a relationship between the place of delivery and exclusive breastfeeding. Infants delivered in public facilities were three times more likely to be exclusively breastfed than infants delivered in private facilities (Um et al., 2020). Place of delivery plays an important role in reducing the risk of delivery complications and the risk of maternal death, because mothers will receive standard delivery care with adequate equipment and health personnel (Hakim, 2020). The place of delivery can also affect the provision of prelacteal feeding because there are still policies or management of the place of delivery that do not support the success of breastfeeding, such as newborns not being breastfed immediately and giving prelacteal food (Mamonto, 2015). The higher the support for the place of delivery to provide exclusive breastfeeding, the greater the chance that the mother will exclusively breastfeed the baby (Berutu, 2021). Other studies also showed that there was a significant relationship between the place of delivery and exclusive breastfeeding (Emmanuel and Clow, 2021). Another study that divided the place of birth into health facilities and nonhealth facilities showed that there was no relationship with exclusive breastfeeding (Sari, 2019).
The type of delivery can also affect exclusive breastfeeding. Spontaneous delivery had a 2.35 times chance of being successful in exclusive breastfeeding (Warsini, Aminingsih and Fahrunnisa, 2015). Research conducted by Wulandari and Dewanti (2014) showed that on the first day after cesarean section the mother had not given breast milk because the mother had not been in the same room with her baby, the mother had not been able to sit, and breast milk had not come out yet (Wulandari and Dewanti, 2014). Mothers who use painkillers such as epidural analgesics during cesarean section are at higher risk of delayed breast milk secretion (Rosmawaty and Sukarta, 2018). Other studies also showed that there was a significant relationship between type of delivery and exclusive breastfeeding (Amir, Nursalim and Widyansyah, 2018). Different from previous studies, research conducted by Widaryanti (2016) showed that there was no significant relationship between the type of delivery and exclusive breastfeeding (Widaryanti, 2016).
A study showed that there was a relationship between maternal age and exclusive breastfeeding (Khoiriah and Latifah, 2018). Compared with mothers aged <20 or >35, mothers aged 20-35 are more inclined to exclusively breastfeed their babies (Lumbantoruan, 2018). Education was also known to be associated with the practice of exclusive breastfeeding. Mothers with low education have a 3.1 times higher risk of not giving exclusive breastfeeding compared to mothers with higher education (Widaryanti, 2016). Parity or the number of children ever born to a mother can also contribute to exclusive breastfeeding (Widaryanti, 2016). Mothers who have more than one child tend to practice exclusive breastfeeding compared to mothers who have one child (Marwiyah and Khaerawati, 2020). Another study conducted by Arisani and Sukriani (2020) showed that there was no significant relationship between exclusive breastfeeding and parity.
The results of previous research were still not conclusive and research with a large amounts of data in Indonesia was still limited, therefore this study was conducted with the aim to determine the correlation between the place and type of delivery with the success of exclusive breastfeeding practice in Indonesia using data from the 2017 Indonesian Demographic and Health Survey (IDHS).

METHOD
This study was a secondary data analysis using data from the results of the 2017 Indonesia Demographic and Health Survey (IDHS). The type of research in this study was quantitative using a cross-sectional study design. The IDHS 2017 covered 17,848 eligible women aged 15-49. For this study, we selected the data from babies aged 0-6 months, being alive, living with mother, and singleton babies. We excluded participants with missing data on the questions related to the exclusive breastfeeding (EBF). The total sample size for this study was 1,810 women. Data analysis was carried out from June to August 2021 after obtaining ethical approval from the Ethics Commission of the Faculty of Dentistry, Airlangga University, Surabaya with No: The dependent variable in this study was exclusive breastfeeding based on the child's consumption of drinks or food during the period 24 hours before the survey. Those who only gave breast milk were categorized as exclusively breastfeed in the EBF variable while other were categorized as non-exclusive breast-feeding. The independent variable consists of mother's age, mother's education level, parity, place of delivery and type of delivery. Data collection was carried out for all variables by interviewing using a reproductive woman questionnaire.
Descriptive and inferential statistics were applied. Descriptive statistical analysis was conducted to describe the frequency distribution and percentage of each variable. Inferential analysis was conducted in this study to determine the relationship between the independent variable and the dependent variable. Inferential analysis was performed using the chi square test. P-values<0.05 were considered as statistically significant. Statistical analyses for this study were performed using IBM SPSS software version 20. Table 1 showed the rate of exclusive breastfeeding in Indonesia according to the results of IDHS 2017. Based on Table 1, it can be shown that 48.2% of mothers gave exclusive breastfeeding. Meanwhile, more than half of mothers did not give exclusive breastfeeding, namely 51.8%.  Table 2 showed the general characteristics of mothers as respondents in the form of age, last education taken, parity, place of delivery, and type of delivery with a total of 1810 respondents. Mother's age was derived from the current age of the female respondent in the children dataset, and classified into two categories: the age group at risk and the age group with no risk. Mother's level of education was classified into two categories namely low and high level of education. Parity was classified into three categories: mother who has 1 child, 2 children, and ≥3 children. Place of delivery was based on the place where the mother gives birth. Type of delivery was classified into two categories: spontaneous and cesarean section. Most participants in this study were 20-35 years old (78.0%), had a high level of education (53.9%), had three or more children (35.0%), gave birth in public health facility (39.1%) and gave birth spontaneously (81.7%).  Table 3 showed bivariate analysis of exclusive breastfeeding and characteristics of respondents according to mother's age, mothers level of education, parity, place of delivery, and type of delivery.

RESULT AND DISCUSSION
In the mother's age, the variable showed that the majority of respondents who gave exclusive breastfeeding are aged 20-35 years (38.6%). In the mother's level of education, the variable showed that the majority of respondents who gave exclusive breastfeeding had a high level of education (25.2%). Mothers who had two children are more likely to give exclusive breastfeeding (17.4%). Mothers who gave birth in the public health facility provide the most exclusive breastfeeding (19.8%). Meanwhile, mothers who gave birth by spontaneous delivery gave more exclusive breastfeeding compared to mothers who gave birth by cesarean delivery (41.2%).
Furthermore, this study showed that exclusive breastfeeding was significantly associated with mother's age (p-value=0.048), place of delivery (p-value=0.045) and type of delivery (p-value<0.001). On the other hand, no associations were found between exclusive breastfeeding with mother's education level (p-value=0.211), and parity (p-value=0.054). Research showed that there was a significant relationship between place of delivery and exclusive breastfeeding (Berutu, 2021). The place of delivery is expected to provide comfort support in providing exclusive breastfeeding to newborns. The better the place of delivery, the better the exclusive breastfeeding for the baby (Hakim, 2020). Places of delivery that do not implement the Baby Friendly Initiative program or there are policies that do not support Early Initiation of Breastfeeding (EIB), the provision of prelacteal feeding and promotion of formula milk will be intensively carried out (Mamonto, 2015). Mothers and babies who are late or do not do Early Initiation of Breastfeeding can cause breast milk production to be not stimulated properly. Mothers will choose to give drinks other than breast milk to their babies on the grounds that breast milk has not come out (Pusporini, Pangestuti and Rahfiludin, 2021).
Furthermore, the results showed that mothers who gave exclusive breastfeeding were more common in mothers who gave birth in public health facility (19.8%) compared to private health facility (16.7%). On the other hand, mothers who did not give exclusive breastfeeding were more common in mothers who gave birth in private health facility (21.3%), compared to public health facility (19.3%). Research Um, et al. (2020) showed that infants born in public hospitals are three times more likely to be exclusively breastfed than those born in private facilities. This is because usually private clinics tend to be poorly regulated and monitored. Some places are also given financial incentives by the company to be able to advertise breast milk substitutes to mothers (Um et al., 2020). Research Kudarti, Kartasurya and Pradigdo (2015) who examined the analysis of differences in the implementation of ten steps towards successful breastfeeding between private and public hospitals in Kudus Regency showed that in private hospitals there was still formula milk available without indications, inpatient admission was still done partially (2 hours per day), the availability of pacifiers, and the breastfeeding support group has not been formed (Kudarti, Kartasurya and Pradigdo, 2015). The results of this study was in line with research conducted by Mamonto (2015) which stated that there was a significant relationship between the place of delivery and exclusive breastfeeding behavior (p-value = 0.016).
Based on the Chi-square test, type of delivery also has a relationship with exclusive breastfeeding. Research showed that there was a significant relationship between the type of delivery and the success of exclusive breastfeeding. The type of spontaneous delivery has 2.53 times the probability of successful exclusive breastfeeding compared to the type of delivery by cesarean section (Warsini, Aminingsih and Fahrunnisa, 2015).
Delivery by cesarean section can reduce the success of exclusive breastfeeding. This can be because the post cesarean section condition makes the mother feel pain and it becomes difficult to breastfeed her baby, thus mother delaying early breastfeeding which can reducing the secretion of prolactin (Wulandari and Dewanti, 2014). Mothers who give birth by cesarean section under general anesthesia was also unlikely to be able to immediately breastfeed their babies, because mothers are not fully aware of the effects of anesthesia (Warsini, Aminingsih and Fahrunnisa, 2015). Delay in initiating early breastfeeding can reduce prolactin secretion thereby reducing milk production (Dewi, 2016). Meanwhile, mothers who give birth spontaneously can mobilize more quickly so that they can immediately breastfeed their babies. Babies who get breast milk as soon as possible after the mother gives birth will prevent the baby from giving prelacteal food intake which can thwart exclusive breastfeeding (Novianti and Rizkianti, 2014). Spontaneous delivery will reduce the chance of giving breast milk substitutes so that mothers who give birth spontaneously will be more successful in giving exclusive breastfeeding to their babies (Warsini, Aminingsih, and Fahrunnisa, 2015).
The low practice of breastfeeding in post cesarean section mothers was also related to the support of health workers. This can be caused by birth attendants who do not provide information about the practice of Early Initiation of Breastfeeding (EIB) and the benefits of exclusive breastfeeding (Wulandari and Dewanti, 2014). Health workers who do not recommend breastfeeding as soon as possible can also result in a delay early initiation of breastfeeding (Dewi, 2016). The first hour of a baby's life is the optimal time for babies to learn to breastfeed (Nurcahyani, 2017). Skin contact between baby and mother during this period can increase the baby's chances of breastfeeding in the first hour and in the long term, therefore can support the success of exclusive breastfeeding for six months (Deslima, Misnaniarti and Zulkarnain, 2019).
Based on the Chi-square test, mother's age has a relationship with exclusive breastfeeding. The study results were in line with research conducted by Wardani, Hastuti, and Adriani (2017) which showed that there was a relationship between mother's age and exclusive breastfeeding. Mothers aged 20-34 years can increase exclusive breastfeeding success in their infants almost 4 times than mother <20 years old or ≥35 years old (Wardani, Hastuti, and Adriani, 2017).
The group of mothers who are 20-35 years old is an age that is considered mature both physically and mentally, so this age group is said to be the best and has the lowest risk for pregnancy and breastfeeding (Pangesti, 2019). At that age, breastfeeding mothers will usually be more active in seeking various information, especially regarding how to breastfeed and how long should the mother give breast milk to her baby (Nurbayanti Roseprilla, Mahmudiono, Rachmah , Bagaimana dan Dimana Proses....... 332 and Muhartati, 2016). While the group of mothers aged <20 years and >35 years were considered as the age group at risk. The group of mothers who are under 20 years of age are considered immature and not psychologically ready to enter the period of pregnancy and breastfeeding (Utari, 2016). Meanwhile, the group of mothers who are >35 years old is considered to have a greater risk of getting pregnant and breastfeeding. This can be caused by a decrease in reproductive health, the ability of mothers to breastfeed also begins to decrease and breast milk production is lower due to a decrease in the hormone prolactin (Utari, 2016;Puspitasari, 2018). The process of degeneration of the size of the breast glands and regression of the alveoli also begins at the age of 30, so the breasts are less likely to produce breast milk (Suryani et al., 2017).
Based on the Chi-square test, mother's level of education has no relationship with exclusive breastfeeding. This study was in line with research conducted by Kusumayanti (2017) which showed that there was no relationship between education and exclusive breastfeeding. This study only examines the mother's formal education level and is not based on the mother's knowledge. A mother with low education may have high knowledge about the practice of exclusive breastfeeding from informal education (Astuti, 2015). A high level of maternal education does not guarantee that a mother has better knowledge about breastfeeding (Sriningsih, 2011). Roesli (2000) states that education has a positive impact that educated mothers increasingly understand the importance of health care, including exclusive breastfeeding (Roesli, 2000). But the level of education also has a negative impact, the higher the mother's education has an impact on changes in social values such as the assumption that breastfeeding is not considered modern and can affect the shape of the mother's breast (Andayani, Emilia, and Ismail, 2017) Based on the Chi-square test, parity has no relationship with exclusive breastfeeding. This study was in line with research by Utari (2016). Research showed that there was no relationship between parity and exclusive breastfeeding. Mothers, especially those who are experiencing motherhood for the first time, are usually very sensitive when it comes to their children. This makes the mother very vulnerable to various provocations. Unfriendly comments related to exclusive breastfeeding made by various parties can make mothers less confident, thus making mothers not motivated to give exclusive breastfeeding (Utari, 2016). The results of research conducted by Rahayu and Apriningrum (2014) also found that there was no significant relationship between parity and exclusive breastfeeding. This is probably because the mother cannot give exclusive breastfeeding due to her busy schedule and condition of her body (Rahayu and Apriningrum, 2014). There are many factors that affect mothers breastfeeding behavior, which are related to parity, such as the mother's breastfeeding behavior during the first few deliveries, the mother's understanding of the benefits of breastfeeding, and whether there are family habits of breastfeeding, etc (Aga and Alifariki, 2019). Therefore parity has implications for maternal behavior even though in this study was not related.

CONCLUSION
We can conclude that factors affecting the success of exclusive breastfeeding among infants in Indonesia were place of delivery, type of delivery, and mother's age. The government and health workers can work together to increase the success of exclusive breastfeeding. Mothers are advised to increase their awareness and willingness to exclusively breastfeed so that they can continue to breastfeed their babies until they are 6 months old. For mothers who gave birth by cesarean section, it is recommended that they continue to give exclusive breastfeeding by adjusting the position of breastfeeding according to the mother's condition, for example with a lying down position, sitting position, and football hold so that it does not become a barrier to breastfeeding practice.

ACKNOWLEDGEMENT
The author's thank are given to the Measure DHS, ICF International, for providing the data for this study, and all staff and lecturers of the Nutrition Study Program, Faculty of Public Health, Airlangga University, especially the supervisors for the directions that have been given.