E:\IBUK\NERS DESEMBER 2021\9--j 321Rahmawati, Naimah, Tarsikah, The Effect of Breastfeeding Management Training on the Understanding of ... The Effect of Breastfeeding Management Training on The Understanding of Exclusive Breastfeeding in Third Trimester Pregnant Women Lovy Fiara Zuninda Rahmawati1, Naimah2, Tarsikah3 1,2,3Midwifery Department, State Health Polytechnic of Malang, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 26/05/2021 Accepted, 19/07/2021 Published, 15/12/2021 Keywords: Breastfeeding Management Train- i ng, Un derst a ndi n g, E xl usive Breastfeeding Article Information Abstract Exclusive breast milk is the main food for infants aged 0-6 months. Malang City is one of the cities in East Java which still has less than optimal cover- age of exclusive breastfeeding than the set target. One of the factors that cause mothers not to give exclusive breastfeeding is because the working mother. The purpose of the study was to determine the effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women. The design of the study used a quasi-experimen- tal using one group pre-test – post-test design. The sample was third trimes- ter pregnant women who work and get health services in Pandanwangi Pub- lic Health Center Malang which met the inclusion criteria of 35 people by total sampling technique. Breastfeeding Management Training was con- ducted in three meetings. Most of the pretest results (60%) were in the sufficient category, and almost all of the posttest results (97%) were good. The results of hypothesis testing with the Wilcoxon Signed Rank Test, the Z value obtained -5.166 with a p value (Asymp. Sig 2 tailed) of 0.000 (<0.05), proving that there was an effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Public Health Center, Malang City. © 2021 Journal of Ners and Midwifery 321 Correspondence Address: Politeknik Kesehatan Kemenkes Malang – East Java, Indonesia P-ISSN : 2355-052X Email: lovy.f98@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i3.ART.p321–327 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://doi.org/10.26699/jnk.v8i3.ART.p321-327 https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i3.ART.p321-327&domain=pdf&date_stamp=2021-12-26 322 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 321–327 INTRODUCTION Proper breastfeeding will reduce poverty and hunger. With the level of intelligence and optimal emotional development will affect the readiness of children to go to school. Breast milk contains vari- ous nutrients that are easily digested and needed in the growth and development process for babies (Wiji, 2013). Exclusive breastfeeding can be useful as a source of nutrition, increase the baby’s immune system, increase the baby’s intelligence, and in- crease affection. As for the mother her self, breastfeeding can reduce bleeding after giving birth, accelerate the recovery of the uterus to its original shape, as a method to space pregnancies, reduce the possibility of suffering from cancer (Elisabeth & Purwoastuti, 2017) Exclusive breastfeeding can reduce infant mortality due to infection by 88%. A total of 31.36% of 37.94% of children were sick because they did not get exclusive breastfeeding (Ministry of Health, 2017). According to (Williams & Wilkins, 2011) stated the long-term impact for babies who do not get exclusive breastfeeding will experience growth and development disorders such as children in stunt- ing (short), wasting (thin), stunted brain develop- ment and cognitive impairment. Breastfeeding has many benefits for both mother and baby, but cur- rently there are still many mothers who have not given exclusive breastfeeding. The coverage of exclusive breastfeeding for infants 0-6 months na- tionally in Indonesia is 35.73%, this is still far from the target set, which is 80%. Meanwhile, for East Java Province, exclusive breastfeeding coverage is still lower than the national coverage, which only reaches 34.92% (Kemenkes, 2017). Based on the results of research conducted by (Sulistyowati & Siswantara, 2014) stated that of 34 respondents as many as 22 people did not give ex- clusive breastfeeding because the mother worked and 12 people gave exclusive breastfeeding. This is similar to research conducted by (Holy et al., 2018), which said that mothers felt that breast milk was not sufficient for the baby’s needs, so babies were given supplements from an early age. Their concern occurs because of a poor understanding of the adequacy of breast milk for babies. The low level of public understanding about exclusive breastfeeding should be a concern. The provision of understanding and techniques of breastfeeding management must be conveyed to the community. Breast milk management or what is known as breast milk management is the management of breast milk taken by expressing it from the breast to be stored and later given to the baby (Maryunani, 2017). This breastfeeding management technique can be used as a solution in overcoming the failure of exclusive breastfeeding, especially for working mothers, al- though in the process the mother will give breast milk indirectly to her baby (Merdhika et al., 2014) Based on research conducted by (Merdhika et al., 2014) shows that there is an effect of counsel- ing on exclusive breastfeeding on the knowledge of breastfeeding mothers. However, increasing under- standing of exclusive breastfeeding is not always through counseling, but can also be done through training activities. Training is a series of activities designed to increase understanding, expertise, change in an individual’s attitude (Santoso, 2010). Training can also be used for certain skills for today’s needs. Thus, it can be concluded that breastfeeding management training is an effort to develop and improve the mother’s ability to under- stand the management of exclusive breastfeeding in order to increase mother’s awareness of the im- portance of breastfeeding her child with breast milk properly and correctly, especially for working moth- ers. Malang City is one of the cities in East Java which still has less than optimal coverage of exclu- sive breastfeeding than the set target. In 2018, the number of babies who were exclusively breastfed was 81.67% or 5421 births. This is something that needs to be considered by both the government and health actors because breastfeeding is still not opti- mal in the city of Malang. According to WHO, there are several factors that cause mothers not to give exclusive breastfeeding, including; Insufficient breast milk, fear of changes in breast shape, prac- ticality of formula milk, weight loss with postnatal exercise and the highest is the high number of moth- ers who have to return to work after giving birth. The factor of mothers who work and look for work has a significant increase from year to year. Based on labor force data sourced from the Malang City BPS in 2017, there were 411,042 working women and an increase in 2018 which was 454,849 people. It is estimated that there will be an increase of 40,000 female workers in 2019 (BPS: 2018). There- fore, more intensive training on the provision of expressed breast milk to mothers since pregnancy 323Rahmawati, Naimah, Tarsikah, The Effect of Breastfeeding Management Training on the Understanding of ... is one of the optimal choices for the success of exclusive breastfeeding, especially for working mothers. Based on the data above, it can be seen that there is an increase in female workers in Malang City, so it is suspected that the increase in female employment opportunities in Malang City is in- versely proportional to exclusive breastfeeding. The phenomenon of the lack of exclusive breastfeeding is caused by several factors, including inadequate knowledge of mother s a bout exclusive breastfeeding, the circula tion of myths tha t breastfeeding is not good for example breastfeeding will reduce the beauty of the breast, as well as busy working mothers and short maternity leave (Roesli, 2004). Given the benefits of breastfeeding, namely the baby gets the best nutrients and enzymes needed, the baby gets immune substances as well as protection and warmth through skin contact with his mother, increasing the mother’s sensitivity to the needs of her baby, reducing bleeding. Working moth- ers do not necessarily become an obstacle to give breast milk every day. One effort that can be done is to express breast milk and then store the ex- pressed milk properly so that the benefits are not reduced. METHODS The study was a Quasi Experiment using one group pretest - posttest design. There was only one experimental group which was given a pretest and posttest and no control group. The respondents were given a pretest before being given training and af- ter being given training, they were given a post test to measure the understanding of milk management. The pretest and posttest were conducted by using a questionnaire. The population in this study was 35 people with a sample size of 35 people. The sam- pling technique used total sampling. The inclusion criteria were the willingness to be research sub- jects and pregnant women who attend training for 2 meetings. The exclusion criteria were respondents who did not attend the training twice. The data col- lection was carried out on February 8 - February 29, 2020. The instrument used a questionnaire. The ques- tionnaire was used for understanding Breastfeeding was compiled by the researcher and tested the va- lidity of the product moment correlation formula from Pearson and reliability in the test instrument with the help of computer software, and analyzed the data with the Cronbach Alpha reliability value. The location of this study was carried out in Puskemas Pandanwangi which is on Jalan Laksda Adi Sucipto No 315 Pandanwangi Blimbing Dis- trict, Malang City. RESULT The study results are grouped into two general data and specific data. General data presents the characteristics of respondents including: age, level of education, type of work and gravida. While the specific data presented are the results of the pre- test and post-test on the understanding of exclusive breastfeeding in third trimester pregnant women. Aspect Keterangan F (%) Age <20 year 3 9 21-30 year 20 57 31-40 year 12 34 Educated Primary School 3 9 Junior High 6 17 High School 16 46 College 10 29 Profession Employees 18 51 PNS 9 26 Wiraswasta 2 6 Dll (laborer, maid) 6 17 Gravida Gravida 1 13 37 Gravida 2 14 40 Gravida > 2 8 23 Table 1 Characteristics of Respondents on Breast- feeding Management Training at Pandanwangi Health Center, Malang City, 2020 Based on the Table above, it is found that most of the respondents are pregnant women who have an age range of 21-30 years, amounting to 57% and almost half of the education level is high school graduates (46%). The type of work of the respon- dents is mostly private employees (51%) and al- most half of the respondents (40%) are the second pregnancy. After knowing the general data, then special data is presented which includes the results of the pre-test and post-test on the understanding of ex- clusive breastfeeding in third trimester pregnant women and the analysis of the effect of training on the management of expressed breastfeeding on the 324 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 321–327 From the results of the posttest, the level of understanding of pregnant women after the train- ing in the management of breastmilk was obtained that almost all their understanding was good (97%). Based on Table 4 it can be seen that prior to the implementation of milk milk management train- ing, the level of understanding of most mothers was in the moderate category (60%) and after being given training there was a significant increase in understanding in the good understanding category, understanding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Public Health Center Malang. Level of Understanding Frequency (%) Good 10 29 Enough 21 60 Less 4 11 Total 35 100 Table 2 Le ve l of Unde r standing of Exc l usi ve Breastfeeding Before Breastfeeding Manage- ment Training From the results of the pre-test, the level of understanding of pregnant women prior to the train- ing in management of Dairy Milk who was the study respondent, most of them had sufficient understand- ing (60%). Level of Understanding Frequency (%) Good 34 97 Enough 1 3 Total 35 100 Table 3 Le ve l of Unde r standing of Exc l usi ve Breastfeeding After Breastfeeding Manage- ment Training Category Total Good Enough Less f % f % F % f % Before 10 29 21 60 4 11 35 100 After 34 97 1 3 0 0 35 100 Table 4 Cross Table of the Effect of Expressed Breastfeeding Training on the Level of Understanding of Exclusive Breastfeeding in Third trimester pregnant women at the pre-test and posttest stages namely 34 in the good category respondents or 97% of the total study sample. Analysis of the effect of milk milk manage- ment training on the study will be tested for nor- mality as a parametric test requirement on the re- sults of the pre test and post test. The results of the normality test using the Shapiro-Wilk test method obtained p = 0.964 with a significance of 0.309 where p> 0.05. These results indicate that the data is nor- mal and can be continued with a parametric test, namely the Wilcoxone test. Based on the results of the calculation of the Wilcoxon Signed Rank Test, the Z value obtained is -5,166 with a p value (Asymp. Sig 2 tailed) of 0,000 which is less than the critical limit of 0.05. Then a decision can be taken to reject H0. This proves that there is an effect of breastfeeding management tr a ining on the under sta nding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Health Center, Malang City. DISCUSSION The mother’s level of understanding was mostly in the sufficient category (60%) at the beginning of the study and after being given training there was an increase in understanding in the understanding category, namely in the understanding of the good category as many as 34 respondents or 97% of the totalsample. This shows the importance of provid- ing training in increasing understanding, especially the understanding of exclusive breastfeeding in third trimester pregnant women. Based on the calcula- tion of the Wilcoxon Signed Rank Test, the Z value obtained is -5,166 with a p value (Asymp. Sig 2 325Rahmawati, Naimah, Tarsikah, The Effect of Breastfeeding Management Training on the Understanding of ... tailed) of 0.000 so it can be concluded that there is an effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women in Pandanwangi Public Health Center Malang City. This Expression breasfeeding management training can efficiently improve mothers’ under- standing of exclusive stfeeding. It can be seen from all the mother’s answers to the questionnaire that has been given by the researcher. Almost all as- pects of both the technique of expressing, the tech- nique of storing, the technique of breastfeeding and the benefits of breastfeeding have the correct an- swer. This shows that training is effective in in- creasing mothers’ understanding of exclusive breastfeeding. The training carried out can provide knowledge and understanding to mothers about the importance of exclusive breastfeeding to increase immunity and intelligence. This is in accordance with the results of the service activities of Wijayanti, et al (2017) which stated that it was important to in- cr ea se knowledge a nd under sta nding of breastfeeding for breastfeeding mothers because breast milk is the best food that contains nutrients, enzymes, hormones as well as immunological and anti-infective substances. Pregnant women who have received training are expected to be able to provide exclusive breastfeeding to their babies. The period of exclusive breastfeeding is the most sensi- tive period in a mother’s life, both physically and emotionally. Thus, positive support is needed from all parties so that working mothers can feel com- fortable and confident for exclusive breastfeeding. Mothers who work can express breast milk and store breast milk well and can provide breast milk to babies. Pregnant women who work are expected to be able to practice in accordance with the man- agement training of Expressing breast milk (ex- pressing, storing and serving it) so that the baby continues to receive exclusive breastfeeding. Breastfeeding management training that has been provided by the researchers can increase the understanding of pregnant women about exclusive breastfeeding. The benefits of the breastfeeding management training can increase knowledge and open up participants’ insight about exclusive breastfeeding so that it can be maintained and in- crease the health status of the community (mother and baby). In addition, it also motivates maternal and infant health care workers, all groups who care a bout infa nt hea lth a nd the impor ta nce of breastfeeding, as well as relevant policy makers to design future actions so that the success rate of exclusive breastfeeding increases both regionally and nationally and improves the quality of life of Indonesian people since his early life. Breastfeeding management training also in- creases participants’ understanding of breastfeeding management and also improves participants’ abili- ties in breastfeeding counseling and communica- tion skills, especially communication in providing community services. This shows that the better the training on Expressing Breastfeeding followed by the third trimester pregnant women who work, the more skilled and qualified the pregnant women will be in understanding exclusive breastfeeding. This study is in line with the research of (Fatwa & Darti, 2019) that training through the process of providing knowledge and changing behavior can increase pregnant women’s understanding of ex- clusive breastfeeding. Based on the journal con- ducted by (Santosa et al., 2019) also stated the im- portance of breastfeeding training because it sig- nificantly increases the knowledge of training par- ticipants about breastfeeding, proper and correct breastfeeding procedures, and how to manage breastfeeding when mothers have to work. Training can motivate mothers to give exclu- sive breastfeeding and be improved by providing health promotion or counseling widely in the com- munity through various media such as television, radio, magazines, tabloids, newspapers and books on breastfeeding. This is in line with research con- ducted by (Tiruye et al., 2018), that mothers who received training on breastfeeding were better at understanding exclusive breastfeeding than those who did not attend training. Giving lectures by expert resource persons and combined with giving demonstrations that can be directly practiced make mothers as training partici- pants able to receive the information conveyed so that mothers understand the importance of exclu- sive breastfeeding. The process of explaining the knowledge or information that has been given dur- ing the training to pregnant women is expected to be translated, interpreted and concluded in the prac- tice of exclusive breastfeeding. The demonstration method is a development strategy by providing a learning experience through the act of seeing and listening followed by imitating the work being dem- onstrated. This method is also a method used to show a process or the workings of an object re- lated to learning materials (Lisa & Putri, 2019). 326 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 321–327 Lecture and demonstration methods and exer- cises, this method is a combination of describing teaching materials with demonstration activities and direct training (practice). There are many benefits from the combination of lectures and demonstra- tions, among others, the teacher is easy to master the class and easy to organize the class, besides that it is easy to prepare and carry out and is more economical in terms of time. In addition, it provides opportunities for teachers to use their experience, knowledge and wisdom. The combination of train- ing methods with lectures and demonstrations can help trainees to listen accurately, critically, and at- tentively and can stimulate and increase understand- ing about exclusive breastfeeding. The coach or instructor can emphasize the things that are impor- tant so that time and energy can be used as well as possible. Mothers as trainees can be more focused on the material so that understanding of the mate- rial will increase. The results of Slavin’s research (1994) cited in (Subrata, 2016), by showing something new in dem- onstration activities to students will be able to at- tract the attention of students to pay attention to the lesson and this attention has an important role in the stimulus captured by sensory motor. It is hoped that by having an interest in this activity, it can arouse the motivation and curiosity of mothers about exclusive breastfeeding. Mother’s interest in the material provided encourages mothers to be physically and mentally ready to give exclusive breastfeeding to their babies. This is the main focus that the training pro- vided by the right people will give the right results. So that the breastfeeding management training that has been given is very effective in increasing un- derstanding about exclusive breastfeeding for third tr imester pr egna nt women who wor k a t Pandanwangi Public Health Center Malang City. CONCLUSION The conclusion of this study is that the under- standing of pregnant women in the third trimester who work before being given milk milk manage- ment training is mostly in the moderate understand- ing category of 60% of the total mothers studied. The understanding of third trimester pregnant women who work after being given training in the management of breastmilk has a good level of un- derstanding at 97%. Breastmilk management train- ing has an effect on increasing understanding of third trimester pregnant women regarding exclu- sive breastfeeding. Increased understanding of breastfeeding management including the benefits of breastfeeding, expressing breastmilk, storing breast milk and giving breastmilk that has been fro- zen. SUGGESTION Suggestions for health workers, namely milk- ing breastfeeding training can be continued by in- volving certified instructors and collaborating with local village midwives. Pandanwangi Public Health Center Malang can periodically provide promotions, counseling, and training on breastfeeding in order to increase understanding of exclusive breastfeeding for mothers. Reinforcement of breastmilk support group activities can be carried out at integrated health post activities by following the integrated health post flow. Suggestions for further researchers The results of this study can be used as comparison and refer- ence material for research, as well as consideration for further deepening further research by focusing on training on breastfeeding management training and understanding of exclusive breastfeeding. As well as linking these variables with different vari- ables and research objects. REFFERENCES Elisabeth, S., & Purwoastuti, E. (2017). 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