BARRIERS AND IMPLEMENTATION OF EARLY BREASTFEEDING INITIATION IN

MIDWIFE’S PRACTICE, BULELENG REGENCY BALI

Putu Dian Prima Kusuma Dewi1, Putu Sukma Megaputri2

1STIKes Buleleng, Jl Raya Air Sanih Km 11, Singaraja dan 81171, Indonesia
2STIKes Buleleng, Jl Raya Air Sanih Km 11, Singaraja dan 81171,, Indonesia

A B S T R A CT

Indonesia has still the Infant Mortality Rate (IMR) high and not reach from achieving the global targets.
Efforts could be made to decrease IMR was give exclusive breastfeeding and early breastfeeding
initiation (EBI) within hour after birth. The purpose of this study was to determine the barriers and
implementation of EBI in Midwife’s Practice in Buleleng Regency, Bali. This research method used
descriptive study with cross sectional approach in Midwife’s Practice with 63 people of sample selected
by random sampling. Data was collected through interviews using a questionnaire on socio-demographic
characteristics,then observations implementation of EBI. Data were analyzed by univariate analysis using
the software. In this study showed that as many as 7.9% of the midwifes do EBI appropriately. Most
clinical procedure are not implementation of EBI such as not applied baby hats and blankets (46%) and
the time to do skin to skin on the mother's chest is less than 1 hour (46%). The barriers of EBI were
reported by midwifes in the implementation of the EBI are suspected HIV colostrom (100%) and delivery
rooms were busy (36.5%) Conclusion only a few of midwifes implementation EBI with appropriate
clinical measures, other than the most barrier reported by midwifes was suspected colostrom HIV.

Keyword : Early Breastfeeding Initiation, Midwife’s Practice, Implementation, Barrier

INTRODUCTION The Indonesian government was generally

Indonesia have still the problem low degree
of serious health, there are still high infant
mortality rate (IMR) and far from achieving the
global targets. Indonesia has decreased from 34
per 1,000 live births in 2007 to 32 per 1,000 live
births in 2012, but still far from the targets
agreed by the Millennium Development Goals
(MDG's) at 23 per 1,000 live births in 2015
(Board & National Population planning, 2013).
One of the efforts undertaken to accelerate the
decline of IMR is breastfeeding. Breastfeeding
also improves quality of human and food source
for infants up to the first 6 months of life. Factors
affecting success in exclusive breastfeeding is by
doing eraly breastfeeding initiation (EBI) which
is a strong enabling factor to the success of
exclusive breastfeeding (Fikawati et al., 2010).
The results showed that infants who were given
the opportunity to suckle within the first hour
with the baby skin contact is left to the mother's
skin, then 22% of the lives of infants aged less
than 28 days might be saved (Sejatiningsih &
Raksanagara, 2007).
very supportive policies of the World Health
Organisation (WHO) recommends EBI as a
lifesaving measure. This is realized by the
Government Regulation No. 33 of 2012 article 9
paragraph (1), which requires all health
professionals and providers of health care
facilities to perform EBI to newborns minimum
during the first hour after birth (Health minister's
decision, 2012). Although the EBI shall be done
by midwives as birth attendants, but not all
midwives perform well.
Breastfeeding early have a positive impact
for both mother and baby. Skin contact between
mother and baby will stimulate the hormone
prolactin in the blood of the mother to produce
milk. Breastfeeding has an important role that is
fundamental to the survival of the baby, because
the milk contains colostrum, which is rich in
antibodies, good growth, health, and infant
nutrition. EBI also plays an important role for the
mother to stimulate uterine contractions that can
parse postpartum hemorrhage and can improve
the inner relationship between mother and baby
(MOH, 2010).
 Data in Indonesia there are more than 95% of
mothers who never breastfed her baby, but
breastfeeding within the first hour after birth
only 43% of mothers who give birth. Prevalence
of EBI in other countries such as India (51.7%)
and Nepal (42.2%) (Khanal, Scott, Lee, Karkee,
& Binns, 2015; Neelima, 2016). Data EBI
according Riskesdas year 2013 shows the
coverage process starts to suckle <1 hour (EBI)
after the baby is born by 34.5% of mothers who
gave birth, this percentage has increased from
the previous year of 29.3% of mothers who gave
birth at in 2010. Although the target EBI
coverage are increasing but still far short of the
50% when the EBI is key to the success of early
breastfeeding. Province of Bali get ranked fifth,
namely 42.2% of mothers who gave birth in the
category of early feeding process <1 hour (EBI)
(MoH RI, 2013). The condition of the data in
absolute figures show that overall, especially
Bali have EBI performance is still below 50%
compared to exclusive breastfeeding although
there is an increasing trend.
Childbirth mother in the last five years shows
that 55.4% are done at health facilities (public
and private hospitals, maternity hospitals, health
centers, pustu, home office and practice nurses),
43.2% at home and 1.4% in polindes or
Poskesdes. Based on the criteria that physician-
assisted birth attendants as much as 2.1%, 51.9%
midwives, paramedics another 1.4%, 40.2%
shamans, as well as families 4.0% (Basic Health
Research, 2010). This suggests that the more
dominant mothers giving birth in a health facility
compared to Polindes or Poskesdes, and birth
attendants more assisted by a midwife.
Midwives are health care workers who have
emotional closeness with clients served in this
are women. Women are much more open,
trusting and cooperative when it gets the services
of a midwife who incidentally are women.
EBI success or failure largely depends on
health workers which midwives, because the
midwives who help birth mothers do EBI
(Sudemi, 2015). Research in India also mentions
that this type of delivery, place of birth and
advice given during the childbirth to determine
the success EBI (Neelima, 2016). Post partum
mothers who did not receive information about
the EBI resulting mother is not able to explain
about the EBI so no maternal motivation to do
the EBI. Babies who do EBI at birth in 50
minutes was able to suckle better than those who
do not do EBI. EBI is very beneficial for the
sustainability of exclusive breastfeeding, where
50% of the infants who did the EBI will succeed
in exclusive breastfeeding (Wulandari in Aryani,
2013). This condition indicates that the midwife
is very important role in providing information
and support regarding EBI. EBI affecting the
mother sala post partum as a determining factor
for the success of exclusive breastfeeding. The
purpose of this study was to determine the
barriers and the implementation of the EBI.
METHOD
Research conducted at the Independent
Midwife Practice (BPM) Buleleng regency in
2016. This research is a descriptive cross
sectional approach. The population is all BPM as
many as 171 BPM to 63 BPM number of samples
taken by random sampling (random). The data
collection was obtained through interviews using
a structured questionnaire and observation.
Univariate data analysis using the software.
RESULTS AND DISCUSSION
Buleleng regency is divided into 9
districts which is the largest district in Bali with
171 Provision for independent practice
midwives (BPM), BPM is divided by the
working area health centers, health departments
and hospitals in Buleleng.
Table 1
Characteristics of Respondents by Age,
Education, Place of Work, Long of Time
Midwife’s Practice, Join in birth Training,
Number Assistants and Childbirth Average Implementation of EBI
Done right 5(7.9)
Number of Monthly Do not correct 58(92.1)

Characteristics f (%) Table 2 shows that the implementation of the

Age (Mean±SD) 45.62 EBI only by 7.9% and the BPM of the most
(±4.271) commonly caused by kolostrom suspected in
Long of Time Midwife’s 11,22 (±5,23) HIV (100) and delivery rooms were occupied
Practice (years) (36.5%). Measurement of the implementation of
Number of Assistants 1.16 (±0,37) the EBI in this research is to perform
Number of Childbirth 5.65 (±2,30)
observations with clinical measures EBI is
Average
Education supposed to do. Based on the results that the
D-III 52 (82.5) implementation of the EBI mostly in BPM is
D-IV/ S1 11 (17.5) done incorrectly, it is because of several reasons
Place of Work including not paired hat when doing EBI and
Public Health center 57 (90.5) EBI time to less than one hour. Judging from the
Hospital or Ministry of 6 (9.5)
Health study and implementation of the policy of
Join in birth Training exclusive breastfeeding seems to have done in
No 5 (7.9) the presence of the Minister's decision, but the
Yes 58 (92.1) policy for the implementation of the EBI soon
after birth has not entered explicitly in the policy
Table 1 shows that the average age of the (Fikawati & Syafiq, 2010). Similar results
respondents is 45.62 years with a standard
deviation of 4,271. The average length of regarding the implementation of the EBI is also
respondents are open 11:22 BPM year. The demonstrated by the research Semarang that the
number of assistants who owned that one person. implementation of the EBI by midwives do with
Total deliveries an average of 6 people in one not optimal because it is not implemented
month. Last midwife education still largely correctly on every delivery assistance (Rahayu,
diploma III (82.5), most midwives also work in 2012). Other clinical measures is often not done
community health centers (90.5%). A total of
by midwives when aid delivery was the
92.1% of midwives never participated birth
Training to improve skills in assisting with installation of hats and blankets during the
delivery and implementation of the EBI. implementation of the EBI, but the
implementation of this clinic is very important to
Table 1 prevent hypothermia in newborns when brought
Frequency Distribution and Implementation near to the mother's chest (MOH, 2008).
Barriers EBI in Midwive’s Practice Buleleng
The accuracy measures do EBI is key to
Variable f (%) successful implementation of the EBI. EBI's
Barriers success is strongly supported by the role of a
Baby hipotermy 5 (7.9) birth attendant or health workers because the
Mothers feel tired 19 (30.1)
Lack of assisten 3 (47) mother can not do without the help and
Birth room was busy 23(36.5) facilitation EBI from birth attendant (Fikawati et
Mothers should be sewn 0 (0)
Injecting Vit K and eye ointment 0(0) al., 2010). Study says that more skilled birth
Babies must be cleaned, measured
2(3.2) attendants, the higher the success rate of EBI,
and weighed
baby was sleep 0(0) including the help of information from birth
Colostrum not out 7 (11.1) attendant can increase the confidence of mothers
Colostrum suspected in HIV 63 (100)
do EBI (Brooke Swails, 2016; Khanal et al.,
2015). The highest qualification of birth
attendants in Indonesia is the midwife reached
68.6% of deliveries (MoH RI, 2013). That is why
the midwife's role in facilitating the mother did
EBI become a critical success.
Judging from the barriers did not commit
EBI one of which is the delivery room busy. It is
like the number of patients served by the
maternity midwife so the midwife did not have
time to do the intensive care of the EBI. These
results also demonstrated similar results of
research in Makassar, that the opportunity to do
EBI takes a long time approximately 1-2 hours.
Conditions busy delivery room will be very
difficult to direct the mother to do EBI (Yuntas
Dachlan and Sukmawati, 2013). Some studies
say the barriers to such EBI colostrum is not out,
the lack of access and information of health
personnel related EBI, false perception of
colostrum, and supports from the formula
(Fikawati et al., 2010; Sharma & Byrne, 2016).
The study also showed that barriers to not doing
EBI is colostrom suspected HIV / AIDS.
Colostrom is of paramount importance given by
the mother at the beginning of the birth, but there
is one problem that is not allowed to feed the
views from the mother's condition is suspected
of mothers who have hepatitis or HIV / AIDS. So
it is very essential to not give milk to baby
(Soetjiningsih, 1997).
Limitations of this study can only
describe as descriptive of the barriers and the
implementation of the EBI did not analyze the
relationship on several variables. It is expected
to further research looking for the relationship
between several variables to the implementation
of EBI.
CONCLUSION
Barriers dominant mentioned by midwives in the
implementation of the ebi is colostrum suspected
HIV and delivery rooms were occupied. Judging
from the implementation of the EBI, that most
midwives do ebi inappropriately.
ACKNOWLEDGEMENTS
Acknowledgements to the Branch Executive
Chairman of the Indonesian Midwives
Association Buleleng and the entire Midwives
Practice respondents in this study.
REFERENCE
Aryani, Fitria. 2013. Overview Behavior In
Early Initiation of Breastfeeding
Midwives (EBI) in the sub-district
Puskesmas Pesanggrahan Jakarta Year
2013. (Skripsi) : FK UIN
Agency, and the National Population Planning.
2013. The Indonesian Demographic and
Health Survey.
MOH. 2010. Basic Health Research (Riskesdas)
in 2010.
MOH. 2008. Normal Delivery Care, JNPK-KR.
Jakarta.
Agency, and the National Population Planning.
2013. The Indonesian Demographic and
Health Survey.
Brooke Swails. 2016. The Golden Hour : Early
Initiation of Breastfeeding.
MOH. 2010. Basic Health Research (Riskesdas)
in 2010.
Fikawati, S., Syafiq, A.2010. Implementation
and Policy studies BMS Exclusive And
Early Initiation of Breastfeeding In
Indonesia, 14(1), 17–24.
MoH RI. (2013). Basic Health Research.
Ministry of Health. 2012. Government
Regulation No. 33 Year 2012 About
 Giving breast milk exclusively. Bureau of
Law and Organization: Jakarta.

Khanal, V., Scott, J. a, Lee, A. H., Karkee, R.,

& Binns, C. W. 2015. Factors associated
with Early Initiation of Breastfeeding in
Western Nepal. International Journal of
Environmental Research and Public
Health, 12(8), 9562–74.
http://doi.org/10.3390/ijerph120809562

Neelima, T. 2016. To Assess the revalence and

factors determining timely initiation of
breastfeeding among the mothers in
resettlement colony in Delhi, 3(2), 147–
153.

Sejatiningsih, S., & Raksanagara, A. S. 2007, in

order to Reduce Neonatal Mortality, 1-10.

Sharma, I. K., & Byrne, A. 2016. Early

initiation of breastfeeding: a systematic
literature review of factors and barriers in
South Asia. International Breastfeeding
Journal, 11, 17.
http://doi.org/10.1186/s13006-016-0076-7

Yuntas; Dahlan Djunaidi, M; Sukmawati.2013.

Midwives behavior in the Implementation
of Early Initiation of Breastfeeding Case
Study in Public Health Center Batua
Makassar, 1-12