Analysis of The Traditional Birth Attendants Knowledge Level in Assisting Delivery According to Health Standards and Its Influencing Factors

This study purposed to determine the level of knowledge of TBAs in assisting deliveries according to health standards, and its correlation to personal factors such as age, education, family history, and history of training in Gorom Island, East Seram, Maluku. 25 TBAs in Gorom Island agreed to participate in a survey by filling out questionnaires concerning their personal data and knowledge of delivery assistance according to health standards. The questions include the stages of labor management, the sterility of techniques and tools used, and the emergency responses. The data were then examined by analytical descriptive study with a cross-sectional approach. This study found Only 20% of TBAs had a good level of knowledge to assist delivery according to health standards. The history of training is correlated with the level of knowledge. Discussion: Approximately 80% of TBAs with good knowledge had attended delivery training by health workers. They understood the management, limits, and responses to emergencies in labor. In contrast, most TBAs with moderate (44%) and poor (36%) knowledge with no training history, still had a traditional understanding of labor equipment and methods used. The skills and knowledge of TBAs in assisting deliveries according to health standards are highly dependent on education and guidance from health workers.


Introduction
One indicator of the degree of public health is the Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). The higher the maternal and infant mortality rate in a country, it can be ascertained that the country's health status is poor. The number of maternal deaths in Indonesia collected from the recording of family health programs at the Ministry of Health is increasing every year (Direktorat Kesehatan Keluarga, Direktoran Jendral Kesehatan Masyarakat, 2022). Until now, MMR in Indonesia is still in the range of 305 per 100,000 Live Births (KH), not yet reaching the specified target of 183 per 100,000 KH in 2024. Bleeding during pregnancy and childbirth complications are one of the most common causes of MMR. In Maluku Province, the Maternal Mortality Rate decreased from 238 per 100,000 live births (in 2015) to 137 per 100,000 live births (in 2018). The expected target is a significant reduction, namely in 2024 the Maternal Mortality Rate reaches 114 / 100,000 live births (Indonesia., 2022).
The results of the Indonesian Demographic and Health Survey (IDHS) in 2017 also show that the Neonatal Mortality Rate (NMR) is 15 per 1000 KH has decreased from the original 19 per 1000 KH in the 2012 IDHS. However, it has not yet reached the target of the 2024 National Medium-Term Development Plan (NMTDP), which is 11.1 per 1000 KH. In Maluku Province, IMR dropped from 10 per 1000 KH (in 2015) to 6 per 1000 KH (in 2018). The target expected by IMR in 2024 is 3/1000 KH. In 2019 based on routine data from the District/City was 5 per 1000 KH with 238 deaths, the highest recorded at 40 per 1,000 KH in East Seram Regency. While the lowest is in Ambon City, which is 21 per 1,000 KH (Maluku., 2019).
Some important factors causing maternal and infant mortality are still the process of mothers giving birth who are not helped by health workers and do not give birth in health facilities. Although nationally the coverage of childbirth services in healthcare facilities has reached the target of 89%, there are 19 provinces that have not reached the target, one of which is Maluku province (66.0%). In addition, there are still 3.65% of mothers who gave birth to ALH in the last two years and their last ALH was helped by a birth attendant. In 2022, in Maluku Province, there are 22.62% of mothers who gave birth to ALH in the last two years and their last ALH was helped by a birth attendant (Statistik, 2022). In East Seram Regency (ESR) itself, according to maternity aid coverage data in 2013, birth attendants are still at the highest percentage of birth attendants, which is 83.03%.
Maluku Province is an archipelago with approximately 1,340 islands and an area of 712,479.69 km2. Most of its area is 658,331.52 km2 (92.4%) of water, while the land area is only about 54,158 km2 (7.6%). Meanwhile, another fact shows that of the total population in 2020 of approximately 1,848,923 people, it is known that most of them live on small islands and have not been supported by the availability of adequate transportation and communication infrastructure. One of them is Gorom Island subdistrict which is in the mainland area of Seram Island Maluku, has an area of 91.30 km2 located at an altitude of 15 meters above sea level. It is about 140 Km to the capital of ESR Regency (Bula District). It consists of 23 villages and administrative countries (Seram, 2021).
The high MMR / IMR in Maluku is inseparable from various challenges and opportunities in this region. Maternal mortality is most prevalent in the period of labor and the first 24 hours postpartum also in the puerperium period of 8-42 days. While most infant deaths occur in the first 24 hours after birth and 2-7 days after birth. Access related to difficult geographical conditions is a challenge in maintaining the survival of mothers and infants / toddlers because they are late in reaching health facilities and referrals. The uneven distribution of health workers due to the limited number of workers and the distance of the region is a lack of interest for health workers. Thus influencing the beliefs of people who have long preferred traditional energy such as birth attendants and the use of traditional herbs. The concern is that if there is a problem of complications in childbirth that requires medical assistance in the hospital, if the birth attendant is not sensitive to the problem and tries to deal with it himself, then unwanted things can happen (Maluku., 2021).
This study aims to determine the level of knowledge of birth attendants in helping childbirth according to health standards and the factors that influence it in the Gorom Island District, ESR Maluku. The special purpose is to determine the level of knowledge of birth attendants, age distribution, education level, history of maternity aid training, and family history as birth attendants, as well as the relationship between these factors and the level of knowledge of birth attendants in helping childbirth according to health standards (Rahmadani et al., 2022). This research has benefits as information material for the author, the community, and the government about the level of knowledge of birth attendants in the region, as an evaluation of the midwife-shaman partnership program, as well as a reference for follow-up plans in developing knowledge of birth attendants in helping childbirth according to health standards (Nurhidayanti et al., 2018).

Research Methods
This study employs a descriptive analytical research design with a cross-sectional approach to evaluate factors associated with the level of knowledge among traditional birth attendants (TBA) in assisting deliveries according to health standards in the Pulau Gorom Sub-district, South Buru Regency, Maluku, in May 2023. The target population consists of all TBAs in the area, and the research is conducted in every village that has TBAs. A total sample is used due to the relatively small population under study. Data is collected through interviews using a questionnaire guide, and data processing involves editing, verification, and coding using the SPSS computer program. Research findings are presented in textual, tabular, and graphical forms, with data analysis conducted both univariately and bivariately.

Results and Discussions
The data collection process carried out in May 2023, obtained a sample of 25 birth attendants spread across 14 villages in the Gorom Island sub-district area who were willing to participate in the research. Here are the results of the study presented in the table:

Univariate Analysis of the Distribution of Knowledge Level of Birth Attendants in Helping Childbirth according to Health Standards in the Gorom Island District, ESR Maluku in May 2023
Based on the results of the research presented in table. 1 above, it was found that the percentage of knowledge level of birth attendants in Gorom Island sub-district in assisting childbirth according to health standards was mostly sufficient (44%) and less (36%), while those with good knowledge were only a small part (20%). This means that childbirth assistance according to health standards is still not widely understood by birth attendants. Based on data from interviews with questionnaires, it was found that most birth attendants did not understand the process and management during childbirth I and III. Most argue that if the stomach feels heartburn or the mother screams in pain is a sign of cervical opening, so the order to strain is done early. Not a few also give herbs that are believed to facilitate placental production, without understanding the correct management of placental birth or kala III. In carrying out their work continuously with a minimal level of knowledge, it is feared that it can affect the security and safety of maternity mothers and babies. For this reason, there needs to be follow-up from the local government, both sub-district and district, on this matter (Moegni & Ocviyanti, 2013).

Univariate Analysis of Age Distribution, Education Level, Family History, and Training History of Birth Attendants in Assisting Childbirth according to Health Standards in Gorom Island District, ESR Maluku in May 2023
Based on the results of research on the table. 2 It was found that most of the birth attendants in the Gorom Island sub-district area were aged ≥ 45 years (80%) this is in line with previous research in Lembang Jaya Regency which explained that a baby shaman acquired knowledge of childbirth in general when he was 40 years old through inheritance by ritual and learning. None of the birth attendants had higher education, most only attended elementary and junior high school (60%). Most birth attendants have a history of parents who are also birth attendants (80%) skills about childbirth are obtained through practical learning when accompanying parents to help childbirth, and are provided with knowledge in concocting childbirth smoothing drinks in the form of water mixed with leaves and water only read prayers. The results of the study also informed that many (60%) birth attendants in the Gorom Island sub-district area have received training in the form of education on the correct methods and management of childbirth assistance / according to health standards with limitations that can be done by non-medical personnel or birth attendants themselves, but this has happened many years ago, there have been no similar activities in the last 5 years nor monitoring and evaluation by officers health.

Bivariate Analysis of the Relationship between Age, Education Level, Family History and Training History on the Level of Knowledge of Birth Attendants in Assisting Childbirth according to Health Standards in the Gorom Island District, ESR Maluku in May 2023
Based on the results of research presented in the table. 3 Information was obtained that, in the chi square test on the relationship between the level of knowledge and the variables of age, level of education, family history, and training history of birth attendants, only the variable of training history had a P value of < 0.05 so that H0 was rejected and H1 was accepted, which means that there is a relationship between the history of maternity assistance training and good / lack of level knowledge of lambing shamans. In contrast, there was no significant relationship between age (p value = 0.469), education level (p value = 0.580), or family history (p value = 0.076) on the correct maternity assistance knowledge of birth attendants. In other words, maternity skills inherited by families are more traditional and do not meet existing health standards. Most respondents (80%) have a family history as a birth attendant, but the level of knowledge possessed is relatively insufficient, there are still methods of giving potions to give birth to the placenta, the use of equipment such as bamboo and sewing thread. and lack of understanding of signs and treatment of birth canal hemorrhage.
As many as 4 out of 5 (80%) well-informed respondents were birth attendants who had received maternity assistance training by health workers, while as many as 7 out of 9 (77.8%) less knowledgeable respondents were birth attendants who had never received maternity assistance training by health workers. A well-informed birth attendant can understand the signs and management of Kala I-IV labor, the limits of what can be done and the correct response when facing complications / emergencies in labor. On the other hand, birth attendants who are less knowledgeable and have never received training by health workers do not understand the signs or proper management of childbirth, and are more traditional in terms of equipment and methods used. This proves that the skills of birth attendants in assisting childbirth according to health standards depend on education and guidance from health workers themselves. Because the process of childbirth is a physiological process but there can also be pathological conditions in the form of complicators or medical complications that cannot be handled in layman. Theoretical briefing from health workers, both midwives and doctors who better understand these conditions, is needed, so that birth attendants can better understand their role in producing safe childbirth. This is in line with research conducted in (Zubir & Devi, 2015) which explains the collaboration between village midwives and birth attendants resulting in a childbirth referral system from birth attendants to village midwives with the role of shamans is to assist midwives in caring for mothers and babies after childbirth (Indonesia., 2007).

Conclusion
From the results of research on the analysis of the level of knowledge of birth attendants and the factors that influence them in the Gorom Island sub-district, ESR-Maluku, in May 2023, using a sample of 25 people, it was found that 5 birth attendants (20%) had a good level of knowledge about health assistance according to health standards, 11 people had sufficient knowledge (44%), and 9 others had less knowledge (36%). Based on the distribution of age, education, family history, and training history, the highest age was ≥ 45 years old (80%), most of them had low education, namely elementary and junior high schools (60%), on average had a family history as a birth attendant (80%), and more than half of the population had attended maternity assistance training by health workers (60%).
From the results of the analysis of the relationship between the level of knowledge of birth attendants with variables of age (value p = 0.469), education (value p = 0580), family history (value p = 0.076) and training history (value p = 0.023), it was found that training history was the only variable that had a relationship with the level of knowledge of birth attendants in helping childbirth according to health standards.
It can be concluded that there is still a lack of good knowledge from birth attendants in the Gorom Island sub-district area regarding medical standards for childbirth assistance. The skills and knowledge of birth attendants in assisting childbirth according to health standards depend heavily on the education and guidance of the health workers themselves. Factors that exist in birth attendants such as age, education, and family background of skill inheritors do not affect the understanding of these birth shamans to work according to health standards, because they are still traditional both from the equipment and methods used.