Self-Efficacy in Non-Exclusive Breastfeeding Mothers in North Tapanuli Regency

: Mother's milk (ASI) is the best food for babies, the composition of the nutrients contained in it is complete and easy for the body to absorb. In addition, breast milk components can provide immunity for the baby's body. The World Health Organization (WHO) recommends giving only breast milk, better known as exclusive breastfeeding, until the baby is six months old, and continued until the baby is 2 years old. The various benefits of breastfeeding that mothers and babies get do not necessarily have an impact on the percentage of mothers who breastfeed exclusively. According to data from the North Tapanuli District Health Service in 2021, the exclusive breastfeeding coverage rate was 58.9%. One of the positive factors in the success of exclusive breastfeeding is the self-efficacy of breastfeeding mothers. This research aims to analyze the self-efficacy of non-exclusive breastfeeding mothers. The research design was cross-sectional, with a total population of mothers who had babies aged 6-12 months who were non-exclusively breastfeeding and met the inclusion criteria. The results of the bivariate analysis showed that maternal occupation and type of delivery were not related to breastfeeding mothers' self-efficacy, while parity (p-value = 0.004 < 0.05) and breastfeeding problems (p-value = 0.021 < 0.05) were related to efficacy, breastfeeding mother herself. Multivariate analysis shows that parity has a significant influence on breastfeeding mothers' self-efficacy with a p-value = 0.014 < 0.05.


Introduction
Mother's milk (ASI) is the best food for babies, the composition of the nutrients contained in it is complete and easy for the body to absorb.In addition, breast milk components can provide immunity for the baby's body.The World Health Organization (WHO) recommends giving only breast milk, better known as exclusive breastfeeding, until the baby is six months old, and continued until the baby is 2 years old (Jama et al., 2020).The benefits of exclusive breastfeeding are for the mother and baby, where the risk of gastrointestinal infections is lower, postnatal weight loss is faster and the menstrual cycle is delayed (Laksono et al., 2021).The mother also gets the benefits of breastfeeding, although they are not as big as the benefits the baby gets.Clinical evidence shows that women who breastfeed exclusively reduce the risk of postpartum hemorrhage, accelerate uterine involution, reduce stress and delay ovulation.The benefits for mothers who breastfeed for up to two years reduce the risk of type 2 diabetes and cardiovascular disease, reduce the risk of ovarian cancer and breast cancer (Elbeltagi et al., 2023) The various benefits of breastfeeding that mothers and babies get do not necessarily have an impact on the percentage of mothers who breastfeed exclusively.Nationally, only 1 in 2 babies aged less than 6 months are exclusively breastfed and only 5 percent of babies are breastfed until the child is 23 months old (Sari et al., 2021).The same thing can also be seen in the North Sumatra region, although the percentage tends to increase from 50.20 percent in 2019, and to 57.80 percent in 2021, this figure is still below the national figure of 71.58%.The same thing can also be seen in North Tapanuli Regency, data from the North Tapanuli Regency Health Service in 2021, the exclusive breastfeeding coverage rate is 58.9% (Rohmah et al., 2023).Various regulations have been issued by the government to support exclusive breastfeeding, including Government Regulation of the Republic of Indonesia no.33 of 2012 concerning exclusive breastfeeding (Rapingah et al., 2021).as well as Minister of Health Regulation no. 15 of 2014 which regulates procedures for imposing sanctions on those who hinder exclusive breastfeeding (Syahnimar, 2020).
Various factors are associated with breastfeeding practices, including the mother's age, educational background, knowledge of breastfeeding, advice from health workers, complications that occur during breastfeeding, and birth weight (Kapti et al., 2023).One of the positive factors in the success of exclusive breastfeeding is the self-efficacy of breastfeeding mothers.Self-efficacy is an important predictor of the duration of breastfeeding (Zulkarnaini et al., 2023).Selfefficacy is a breastfeeding mother's confidence in her ability to provide breast milk (Awaliyah et al., 2019).The impact of self-efficacy that is formed in breastfeeding mothers is changes in thought patterns and behavior, persistence in efforts to successfully breastfeed, and emotional reactions.

Method
Qualitative research with a cross-sectional research design aims to determine the relationship between determinants and self-efficacy of non-exclusive breastfeeding mothers.The research design and method should be clearly defined.

Result and Discussion
The distribution of respondents by region can be Seen in the following table: From the data above, the majority of respondents work in the non-formal sector, namely 72 people (74.2%), based on parity, the majority of respondents are multipara, namely 58 people (59.80%), based on the type of birth, the majority of respondents gave birth normally, namely 50 people (51.50%), based on problems related to breastfeeding, the majority are in the severe category, 65 people (67%), while the majority of mothers' self-efficacy is in the low category, namely 58 people (59.80%).The results of the bivariate analysis are displayed in table 3.
From the table 3, it can be seen from the analysis of the relationship between maternal employment and selfefficacy, obtained p-value = 0.413 > 0.05, so it can be concluded that there is no significant relationship between employment status and self-efficacy in breastfeeding mothers.
The results of statistical analysis of the relationship between parity and breastfeeding self-efficacy obtained p-value = 0.004 < 0.05, thus it can be concluded that there is a significant relationship between parity and breastfeeding self-efficacy.Breastfeeding experience is related to the breastfeeding mother's self-efficacy, good breastfeeding experience in the past tends to have high self-efficacy in breastfeeding currently.In contrast to primigravida mothers, the process of breastfeeding is new for the mother, experience may be gained through other people.The results of statistical analysis of the relationship between type of delivery and self-efficacy using the chisquare test obtained a value of p = 0.160 > 0.05, which can be concluded that there is no significant relationship between parity and breastfeeding self-efficacy.
The results of statistical analysis of the relationship between breastfeeding problems and breastfeeding selfefficacy resulted in a p-value = 0.021 < 0.05, thus it can be concluded that there is a significant relationship between breastfeeding problems and breastfeeding selfefficacy.The results of this study by (Li et al., 2022), where there is an influence between breastfeeding problems and maternal self-efficacy.Problems encountered during the breastfeeding process, if they can be handled, provide a good experience and satisfaction for the mother, however, if the problems that arise are not handled properly, they can lead to negative experiences that reduce the mother's self-confidence.From the results of the multivariate test using multiple logistic regression, it was found that the independent variable was parity with a p-value of 0.014 (p < 0.05) while the variable breastfeeding problems had a p-value of 0.081 > 0.05.Thus, it can be concluded that the parity variable has the most dominant influence on the self-efficacy of non-exclusive breastfeeding mothers in the North Tapanuli district.
Mother's milk is the best food for babies up to 6 months old.Balanced nutritional composition, protein content in colostrum is 8.5%, with high immunoglobulin A (IgA) (Guberti et al., 2021), which functions as the first line of defense against the entry of pathogenic germs that are inhaled or swallowed through vulnerable mucosa (Cabillon & Lazado, 2019).A mother's decision to breastfeed exclusively is influenced by many factors, both from within the mother and outside the mother.For mothers who work in the formal sector, the limited time for maternity leave, which is only given for 3 months, limits mothers to only breastfeeding until the baby is 6 months old.
The results of univariate analysis show that the majority of respondents in this study work in the nonformal sector, namely 72 people (74.2%).This is possible because the cities of Tarutung and Sipahutar are small cities with the majority of female residents working as farmers and weavers of traditional cloth (ulos).Law Number 13 of 2023 in article 82 paragraph 1 states that female workers have the right to rest for 1.5 (one and a half) months before giving birth and 1.5 months (one and a half) months after giving birth according to the doctor or midwife's calculations (Ayele et al., 2019).Mothers who work in the non-formal sector are more likely to be with their babies 24 hours a day, there are no restrictions on leave, flexibility in working hours and the availability of breastfeeding rooms should make it easier for mothers to breastfeed exclusively.
Bivariate analysis showed there was no relationship between maternal employment and breastfeeding mothers' self-efficacy where the p value = 0.413 < 0.05.Breastfeeding self-efficacy in pregnant women from the third trimester to breastfeeding, where there is a relationship between mother's work and breastfeeding mother's self-efficacy (Asih & Nurlaila, 2022).Parity is the number of children ever born alive.In this study, the highest parity of respondents was multi-para, namely 58 people (59.8%).This is possible because demographically, North Tapanuli Regency has the majority of the population being the Batak tribe who have the principle "anakhonki do hamoraon diau" which means my child is a treasure for me.Even though the family planning program is already running, it is common for Batak people to have more than two children.
The results of the bivariate analysis showed a p value = 0.004 < 0.05, thus there was a relationship between maternal parity and breastfeeding mothers' self-efficacy.This is different from the research results of where there was no relationship between maternal parity and self-efficacy of breastfeeding mothers with a value of p = 0.993 > 0.05 (Nisman et al., 2021).Breastfeeding experience is related to the breastfeeding mother's self-efficacy, good breastfeeding experience in the past tends to have high self-efficacy in breastfeeding currently (Ika Setyarini et al., 2023).In contrast to primigravida mothers, the process of breastfeeding is new for the mother, experience may be gained through other people (Jacobzon et al., 2022).
This type of delivery limits the mother's ability to mobilize after delivery, including breastfeeding activities.In this study, the largest number of respondents were in the normal type of delivery, namely 50 people (51.5%).Even though the majority of respondents had a normal type of delivery, the number was not much different from the number of caesarean section deliveries.Currently, there is a tendency to shift the type of delivery from normal to caesarean section delivery.This figure is far above the national figure, where the number of caesarean section deliveries in Indonesia according to Nakphong et al. (2020) was 17.6%.When submitting a questionnaire with interviews, almost all respondents with section deliveries stated that the hospital also facilitated the provision of formula milk on the first day of the baby's birth considering that milk production was still small (Walker, 2015).
Breastfeeding problems can occur due to baby factors, as well as maternal factors, including breast anatomical abnormalities (Wilson et al., 2020).Inverted nipples, sores or dams in the breasts.There can be more than just one breastfeeding problem that arises, in fact several problems can arise at the same time.The research results showed that the largest number of respondents with breastfeeding problems were in the severe category, namely 65 people (67%).Bivariate analysis showed a p value = 0.021 < 0.05, thus there is a relationship between breastfeeding problems and maternal self-efficacy.The results of this study are in accordance with (Aulia Fitroningtyas, 2021).Where there is an influence between breastfeeding problems and maternal self-efficacy.Problems encountered in the breastfeeding process, if they can be handled, provide a good experience and satisfaction for the mother, however if the problems that arise are not handled properly can lead to negative experiences that reduce the mother's self-confidence (James et al., 2020).
Self-confidence describes a person's belief in his ability to carry out an action to achieve the expected results (Barni et al., 2019).Dennis developed the theory of Brastfeeding Self Efficacy (BSE), namely the mother's confidence in her ability to provide breast milk to her baby.Breastfeeding Self Efficacy is a description of the decision to give breast milk, the efforts made by the mother to breastfeed the baby and the mother's emotional picture regarding the problems she has in the process of giving breast milk (Pérez-Escamilla et al., 2023).The results of this study showed that the largest number of respondents were in the low category, namely 58 people (59.8%).Nursing mothers' self-efficacy can be formed through breastfeeding experiences.Experiences of successful breastfeeding in the past increase a mother's current self-confidence, whereas experiences of breastfeeding failure in the past can reduce a mother's self-confidence in breastfeeding in the present (McKinley et al., 2019).Breastfeeding experience is gained through personal experience and the experiences of other people (Badr & Alghamdi, 2022).Multi-parity mothers who have successful breastfeeding experience will increase their self-confidence compared to primiparous mothers who have no experience (Tsai & Wang, 2019).Multivariate test results show that maternal parity has a significant influence on breastfeeding mothers' self-efficacy with a value of p = 0.014 < 0.05.

Conclusion
This study concludes that there is no relationship between the mother's occupation, type of delivery, baby's gender, and baby's birth weight and with breastfeeding mother's self-efficacy.There is a relationship between parity breastfeeding problems and breastfeeding mothers' self-efficacy.Maternal parity has a significant influence on breastfeeding mothers' selfefficacy.
visualization, and E. S. and R. M. U. All authors have read and agreed to the published version of the manuscript.

Table 1 .
Number of Mothers Who Breastfeed Non-Exclusively in Each Health Center

Table 2 .
Characteristics of Non-Exclusive Breastfeeding Mothers

Table 3 .
Relationship between Characteristics and Self-Efficacy of Non-Exclusive Breastfeeding Mothers

Table 4 .
Influence of Parity and Breastfeeding Problems on Self-Efficacy of Non-Exclusive Breastfeeding Mothers