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Model Evaluation of "Traditional Midwifery Care Training" asPotential Agent of Change In Implementation of Early

Initation of Breasfeeding In Minasate'ne District, PangkepRegency

Journal: Journal of Midwifery & Women's Health

Manuscript ID: Draft

Wiley - Manuscript type: Original Review

Keywords: Midwifery Education, Midwifery Workforce, Environmental Health

Abstract:

ABSTRACTThe study aims at finding out the effect of Traditional Midwifery CareTraining model in an effort to improve knowledge, attitude and practice oftraditional midwife with her potential capability of being "agent of change"in implementation of early initation of breastfeeding (IEB) for pregnant andpostpartum women. The study on traditional midwife empowerment as"agent of change" for implementation of IEB is carried out by quasi-experimental research (experimental pre post test one design group). ThisIEB training applies a module arranged and designed specially for a targetgroup who has limited literacy (a group with limitation of ability to read

and write). Subject matter presentation method uses some performanceaids like video, pocket book containing pictures of IEB and poster. Thefindings reveal that Traditional Midwifery Care Training has an effect ontraditional midwives' Knowledge, Attitude, and Practice improvement. I t isproved that they are potential to be agent of change for IEBimplementation; the findings found that research hypothesis is proved.Application to the findings hopefully can make public health conditionbetter, especially for moms and babies. Expectedly, the study can suggestthe head of the Health Office in Pangkep and South Sulawesi to makedecision and policy in decreasing maternal and infant mortality rate.

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Ministry of Health of Indonesia, which isset at 88% in 2012. Based on provincial

percentage, the lowest birth rate helped bylabor assistant from medical officer is inPapua Province (32.85%) while the higestrate is in Special Region of Yogyakarta

(99.85%). Specifically in South SulawesiProvince, labor assistant coverage bymedical officer is 93.68%; if it is observed

based on regency/town level, the lowest birth rate helped by labor assistant frommedical officer is in the North TorajaRegency (86.68%) and the highest is inParepare Town (105.57%) and in PangkepRegency (90.85%). (the General Directorateof Nutrition and Mothers and ChildrenHealth, the Ministri of Health of Indonesia,2013).

One of the ways to decrease infantmortality rate is early initiation of

breastfeeding or IEB (PAHO, 2007). Astudy in Ghana proves that all causes ofinfant mortality and pain at 22% can bedeclined by IEB. In addition to that IEB

practice is profitable to prevent infantmortality and pain, IEB relates directly to

breast milk period and exclusive breastmilk. Therefore, IEB is a new program

promoted by the government as one ofinformation to be propagated throughcommunity empowerment; one of themethods is by employing traditionalmidwife who has significant role in neonatalcare. Besides, traditional midwife in ruralarea, culturally, is the closest person tomothers and society.

The same notion is thought by WHO.Since 1970 to 1990, it held training fortraditional midwife as a strategy to decreaseMMRate and IMR (Sibley, 2008).Therefore, based on the findings concerning

on the effect of traditional midwiferytraining found in some countries, thetraining was a failure, and it could notdecrease IMR and MMRate. Strategy failureto break IMR and MMRate throughtraditional midwifery training is caused bysome matters, for example lack of

preparation and studies on characteristic,socio-cultural aspect of traditional midwife,

unsuitable training method and subjectmatter, lack of monitoring and evaluationduring and post training (Kruske & Barclay,2004).

According to Sibley & Sipe (2004),

traditional midwifery training relatessignificantly to knowledge, attitude, behavior and advice improvement of trainedtraditional midwife compared to untrainedone. Behavior change and advice giving bytrained traditional midwife affect neonatalhealth. Okubagzhi (1988) also foundimprovement of indicator for maternal andchild health service when traditionalmidwifery training finished. The indicatorsare traditional midwife's behavior change inassisting delivery process and maternal and

child care.Traditional midwife can give mother

psychological power, which usuallymidwife cannot do; she has significant rolewhen she talks about cultural competency,empathy and psycho-social support sinceher position represents culture and socialstructure in society in addition to her statusas honorable or respected person as well her

power to affect public (mnh.jhpiego.org,2004; Morse, 2003; Okubagzhi, 1988;Syamala 2004). Such background can maketraditional midwife as an agent of change(Stevenson, 2008).

As explored above, it becomes an idealcondition if traditional midwife is trained to

be the agent of change, IEB in this case, in purpose to encourage mothers to do IEBwhen the baby is born. Traditionalmidwifery training shall notice and adaptcharacteristic, socio-cultural backgroundand capability of traditional midwife. IfTraditional Midwifery Care Trainingmethod is made suitable, expectedly thetraditional midwife is comfortable thatallow her to acquire training subject matterwell and easily and then put them into

practice in society.

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MATERIAL AND METHOD

Research Site

The study is carried out in Minasate'neDistrict, Pangkep Regency. Research siteselection is done purposively, i.e. an areawith 18 traditional midwives and deliveryassistance count in great quantities. Directobservation is also carried out.

Research Design, Population and Sample

Research design applied herein is experimental pre post test one design group with longitudinalapproach in purpose to find out degrees oftraditional midwife's knowledge, attitude and

practice on IEB, and to find out partnership between traditional and modern midwives before and after Traditional Midwifery CareTraining on IEB.

Population in this study is all midwivesliving in Minasate'ne District, PangkepRegency. When the study is conducted in 2014,

there are 18 people. Traditional midwifesampling is given to those who meet inclusiveand exclusive criteria; thus sample is 12 people.

Data Collection and Analysis

Data is obtained by direct interview given to

respondents through observation and byquestionnaire as an instrument prepared bytaking the arranged variables based on researchobjectives. Data processing is carried out incomputer in which data processing steps consistof editing, coding and the making/transfer ofquestionnaire codes to the code table (mastertable). Data analysis is aimed at finding out theeffect of independent variable on dependentvariable by applying Wilcoxon test.

FINDINGS

Below is the outcome of data processing whichis presented systematically;

Table 1. Distribution of Research Respondent Characteristic

Karacteristik Total (N=12) Percentase (%=100)

Age40-59 years60-79 years>=80 years

555

41,741,716,7

Education Not Schools Not The End ElementaryComplete Primary School

Not The End Junior

3621

25,050.016,78,3

Being old Shaman10-20 years>20 years

93

75,025,0

Originally Science Being Shamanderivative 12 100The number attending births per month3 people

8

4

66,6

33,3 Number of Pregnant Mother Check IntoShaman / Month3 people

93

7525

Partnering With MidwivesYes

No 93

7525

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Work apart TBAsFarmerMerchantHousewife

129

8,316,775,0

Work apart TBAsMassageCare for sick childrenSort, wash clothesMassage and female circumcisionMassage and care for the child's fever

None

511113

41,78,38,38,38,3

25,0 Number of other services / Month346

None

5313

41,725.08.3

25,0Primary Data Source

Table 1 shows that the largest respondentgroup ranges between 40 and 59 years oldand 60 to 69 years old (41.7% respectively),while minority group is more than 80 yearsold (16.7%). Most of them are graduatingfrom elementary school (50%), becomingtraditional midwife for a long time around1020 years (75%), while 100% of them

becomes traditional midwife because ofascribed status. Most of birth attendants and

pregnancy examiners are

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good 6 50.0 11 91.7Category Knowledge Partnership Regarding Shaman Shaman Baby Baby With Village Midwife

less 4 33.3 1 8.3

enough 8 66.7 11 91.7

Category Attitudes Regarding Baby Shaman Partnership

negative 2 16.7 0 0 positive 10 83.3 12 100.0

Practice category Shaman Shaman Baby Baby Regarding Partnership With Village Midwife

poorly 5 41.7 2 16.7

good 7 58.3 10 83.3

Source: Primary Data

Traditional midwife's attitude toward partnership between modern and traditionalmidwives is 16.7% negative and 83.3%

positive, and it reaches 100% positive afterthe training. Partnership practice between

modern and traditional midwives before thetraining is 41.7% poor and 58.3% good, andafter the training, it changes into 16.7%

poor and 83.3% good.

Table 3. Average comparison table for traditional midwife's knowledge, attitude and practice on IEB before and after "Traditional Midwifery Care Training"

Shaman knowledge Babies About IMD Mean Range (SD) Value p

before Training 11.92 6.4310.033

after Training 20.25 6.676

Shaman Attitude Babies About IMD Mean Range (SD) Value p

before Training 10.67 2.8710.005

after Training 13.83 1.193

Practice Shaman Baby About IMD Mean Range (SD) Value p

before Training 3.42 2.7780.036

after Training 5.50 1.679 Information: Wilcoxon Test: It depicts meaningful difference (p

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midwife when the training is done(5.501.679 SD). Based on wilcoxon test,there is significant difference between IEB

promotion and implementation practices bytraditional midwife before and after thetraining is done (p=0.0360.05).

Partnership practice between modern andtraditional midwives before the training is

2.832.406SD; it is lower than the average partnership practice of both midwives afterthe training, i.e. 4.750.622SD. Wilcoxontest result shows no any significantdifference of modern-traditional midwives

partnership practice before and after thetraining (p=0.027

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midwives will not be in vain. According toGreent, (2005) training approach byinvolving people of local community as

participant will be more beneficial to spreadthe information than when the training isonly given to some medical professionals

with their limited number and participationin community. This limitation, for sure, willobstruct information spreading accelerationto society as the object and subject of health

program.Furthermore, to improve training

effectiveness, this aspect depends on somefactors: who is trained, where the trainingtakes place, the topic learnt, how to deliverthe information, follow-up process, andassessment on the training output andoutcome. The training shall be initiated bycomprehension on participant's capability,environment needs and condition of the

place they live in. One of training needsanalysis is COPE (Client-Oriented,

Provider-Efficient ) (Greent, 2005).Training evaluation is commonly carried

out by: comparing pre-post training skillsscore; asking the participant about theirsatisfaction on the training they join with;analyzing participant attitude or practicechanges in the real life; interviewing ordoing observation, and so forth. Concerningon skill quality maintenance (attitudechange sustainability), it can be handled by:a) refresh training, b) follow-up after thetraining (Greent, 2005).

The Effect of Intervention on Traditional Midwife's IEB Knowledge

Pre-test and post-test traditional midwife'sIEB knowledge shows significantimprovement (p value of < 0.05). It depictsthat "Traditional Midwifery Care Training"method can significantly upgrade traditionalmidwife's knowledge. The differences can

be explained by looking at averageknowledge score difference increasing from11.92 to 20.25 in the end of research.Accordingly, differences appear due toaverage score escalation on traditionalmidwife's IEB knowledge.

The findings is same as meta-analysisconducted by Sibley (2004) who makesconclusion that traditional midwiferytraining relates significantly to knowledge,attitude, behavior and advice improvementgiven by the trained traditional midwife

compared to those who are untrained.The same finding is proposed by

Okubagzhi (1988). His research objective isto find out the effect of trained traditionalmidwifery on the improvement of indicatorfor maternal and child health in Gondararea, Ethiopia. He found that indicator ofmaternal and child health is increasing astraditional midwifery training is carried out.The indicator is trained traditional midwife'sattitude change in assisting delivery processand maternal and baby care as well.Okubagzhi also suggests that traditionalmidwifery training shall be continued with

post-training coaching. Besides, trainingdesign shall be made suitable with localculture.

The Effect of Intervention on Traditional Midwife's Attitude to IEB

In this study, traditional midwife attends"Traditional Midwifery Care Training"

packet. The training covers listening and

watching movies sections, simulation andinformation collection class to all aboutIEB. After having assessment on traditionalmidwife's IEB attitude, there is significantdifference between pre-test and post-testattitude (p value is

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society are becoming public figure andhaving influence over the people to make achange. However, one of condition to beagent of change is that traditional midwifeshall respect local socio-cultural factor. It isin conformity with opinion proposed by

Stevenson (2008) that traditional midwifecan be agent of change because she has thecriteria of becoming agent of change, forexample patient, great empathy, capable ofcommunicating to the culture andmatriarchal backgrounds, directinvolvement in maternal and baby care bygiving assistance and persuasive approachand also becoming honorable and respected

person.

Strengths and What Has to be Noticed in

Performing Intervention Model of Traditional Midwifery Care Training

Every training design, for sure, hasstrengths and weakness, and the upcomingdiscussion will identify every strength andweakness to be used as future leaning.Considering that the research targets areunique people because of their age (morethan 40 years old), most of them areilliterate people, but they have leading

position amongst the people. Accordingly,

the training is designed specially by payingattention to and taking consideration to thefactors mentioned. This training model iscalled Traditional Midwifery Care Training.Training subject matters are Knowledge,Attitude, Promotion practice and IEB

practice consisting of basic principles. It isonly the basic will be delivered to make itsimple but still pay close attention of someimportant things that shall be known andimplemented during IEB. This method isimportant considering that memory strengthof research target (traditional midwife) isrelatively limited. Training method will beheld interactively and participatoryapproaches, for example group discussion,question and answer section, casediscussion, simulation, and testimony.Media used herein will not require writingand reading skills consisting of some media

like video, pocket book, conic strips andstorytelling about IEB.

Subject matter is delivered little by littleand reviewed to make participant easy inunderstanding and remembering. Everyopening and close session will have analysis

section in form of question and answer anddiscussion in purpose to help participant inreviewing some previous subject matters.Communication is held in two-way thatcommunication will be more balanced,without blaming people, accommodatingevery aspiration, opinion, experience and

practice they have done. If there is anindication that the practice they do can harmmother, explanation will be delivered inrational and logic in purpose not to makethem forced into a difficult position.

In order to continue this traditionalmidwifery care training, it involvesmodern midwife employed in the villageand local figures. Expectedly, involvementof modern midwifery will make traditionalmidwife capable of practicing theknowledge with colleague. If it is possible,this traditional midwifery training modelor form can be developed or applied withother IEB subject, such as immunization,family planning program, tetanusneonatorum and other programs. Besides,

public figures involvement (villageofficials) will allow them to monitor theresult of training implementation in societyand to socialize the program to a broadersociety.

What Has to be Noticed in Performing Intervention Model of Traditional MidwiferyCare Training

This training model applies active participative approach. Thus, it needsserious facilitator/party who will beinvolved to pay attention to the training

process and to identify inappropriate andunsuitable matters that can obstruct thetraining fluency. In general, organizingcommittee (facilitator) often misses tonotice and to monitor development oftraining implementation. Consequently,

participant goes "as they are". This is

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