Proceeding International Webinar “The International Conference on Lactation Management (ICLM) in Covid-19 Pandemic Era"

The International Conference on Lactation
Management in COVID-19 Pandemic Era
September 30, 2021, Samarinda, Indonesia

pandemic. Advocay and socialization needed to health facilities as an effort to
support maternal health services. With all the limitations, further research is
needed for this topic.

ETICAL CLEARENCE

This survey was eclared ethically approved with number. No:
001/Etik/IKMI/07/02 from Competencies, Law and Ethical division of IKMI.

CONFLICT OF INTEREST

This is independent survey of IKMI We have no conflict of interest with the
manufacture of the products or any other entitiy to declare.

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Brown, A., & Shenker, N. (2021). Experiences of breastfeeding during COVID-
19: Lessons for future practical and emotional support. Maternal and
Child Nutrition, 17(1), 1–15. https://doi.org/10.1111/mcn.13088

CDC. (2020). Using Telehealth to Expand Access to Essential Health Services
during the COVID-19 Pandemic. https://www.cdc.gov/coronavirus/2019-
ncov/hcp/telehealth.html

Centeno-Tablante, E., Medina-Rivera, M., Finkelstein, J. L., Rayco-Solon, P.,
Garcia-Casal, M. N., Rogers, L., Ghezzi-Kopel, K., Ridwan, P., Peña-
Rosas, J. P., & Mehta, S. (2021). Transmission of SARS-CoV-2 through
breast milk and breastfeeding: a living systematic review. Annals of the
New York Academy of Sciences, 1484(1), 32–54.
https://doi.org/10.1111/nyas.14477

Ceulemans, M., Verbakel, J. Y., Van Calsteren, K., Eerdekens, A., Allegaert, K.,
& Foulon, V. (2020). SARS-CoV-2 infections and impact of the COVID-
19 pandemic in pregnancy and breastfeeding: Results from an
observational study in primary care in Belgium. International Journal of
Environmental Research and Public Health, 17(18), 1–10.
https://doi.org/10.3390/ijerph17186766

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Chmielewska, B., Barratt, I., Townsend, R., Kalafat, E., van der Meulen, J.,
Gurol-Urganci, I., O’Brien, P., Morris, E., Draycott, T., Thangaratinam,

S., Le Doare, K., Ladhani, S., von Dadelszen, P., Magee, L., & Khalil, A.

(2021). Effects of the COVID-19 pandemic on maternal and perinatal

outcomes: a systematic review and meta-analysis. The Lancet Global
Health, 9(6), e759–e772. https://doi.org/10.1016/S2214-109X(21)00079-6

Hull, N., Kam, R. L., & Gribble, K. D. (2020). Providing breastfeeding support

during the COVID-19 pandemic: Concerns of mothers who contacted the
Australian breastfeeding association. Breastfeeding Review, 28(3), 25–35.

Lubbe, W., Botha, E., Niela-Vilen, H., & Reimers, P. (2020). Breastfeeding

during the COVID-19 pandemic - a literature review for clinical practice.

International Breastfeeding Journal, 15(1), 1–9.

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MKEK. (2020). SK MKEK-Fatwa Telemedis.pdf.

Olonan-Jusi, E., Zambrano, P. G., Duong, V. H., Anh, N. T. T., Aye, N. S. S.,

Chua, M. C., Kurniasari, H., Moe, Z. W., Ngerncham, S., Phuong, N. T.

T., & Datu-Sanguyo, J. (2021). Human milk banks in the response to

COVID-19: a statement of the regional human milk bank network for
Southeast Asia and beyond. International Breastfeeding Journal, 16(1), 4–

9. https://doi.org/10.1186/s13006-021-00376-2

Roberton, T., Carter, E. D., Chou, V. B., Stegmuller, A. R., Jackson, B. D., Tam,

Y., Sawadogo-Lewis, T., & Walker, N. (2020). Early estimates of the

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(KIA): Studi Kasus di Lima Wilayah di Indonesia. The SMERU Research
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384c-8fec-

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8acdded20e91/?utm_source=desktop&utm_medium=1.19.4&utm_campai

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Schindler-Ruwisch, J., & Phillips, K. E. (2021). Breastfeeding During a

Pandemic: The Influence of COVID-19 on Lactation Services in the
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https://doi.org/10.1177/08903344211003898

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A., Blencowe, H., Caluwaerts, S., Campbell, O. M. R., Cavallaro, F. L.,

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employers-to-support-breastfeeding-mothers-in-indonesia-during-covid-19

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PROTECT BREASFEEDING
(CASE STUDY: MIDWIVES AND THE INTERNATIONAL CODE OF

MARKETING OF BREAST MILK SUBSTITUTE PRODUCTS)

Kusmayra Ambarwati1
1* Staff_ Midwifery Department University of Respati Indonesia

([email protected])

Abstract: Introduction: Many factors affect success in breastfeeding. Health
care support (midwife) and exposure to the promotion of breast milk substitute
products have a considerable relationship related to the success of breastfeeding.
Midwives as the main provider on maternal and child services should be the main
fulcrum that can support and provide breastfeeding protection. However, there are
still many and often encountered practices. There are still many of them who do
not comply with the International code of marketing of breast milk substitute
products or government regulations related to breastfeeding. This study aims to
find out the background of why there are midwives who do not comply with the
international code of marketing of breast milk substitute products as well as
government regulations related to breastfeeding protection.
Method: This study used qualitative methods with a case study approach. The
study was conducted in sub-district X of East Jakarta. There were eight midwife
informants and eight patients who participated in this study.
Result: The majority of midwives did not know about the international code of
breast milk replacement products and did not have appropriate practice.
Conclusion: Some midwives did not comply with the marketing code of breast
milk substitute products because of their ignorance, regulations in health facilities
where they did not support, also there is no clear regulation related to this
regulation.

Keyword: Breastfeeding, Code, Breastmilk Substitutes

INTRODUCTION

The protection of breastfeeding is a joint task of all components of
government and society. It is in line with all the commitments of the World
Health Organization (WHO), the United Nations Children's Fund (UNICEF) and
the World Alliance for Breastfeeding Action (WABA). Midwives as health
workers have a major role in helping the success of the breastfeeding process. In
addition to health personnel factors, a very influential factor is the exposure to the
promotion of breast milk Substitute (BMS) both in patients and health workers
themselves. Many studies show that improper exposure to BMS promotion affects

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the success of breastfeeding and health care support services related to the
breastfeeding process. (McFadden et al, 2016;Robinson et al, 2019; Rollins et al,
2016).

This has been regulated in the International Code of Marketing of Breast-Milk
Substitutes and subsequent resolutions adopted by the World Health Assembly
(the Code) in 1981. The International Code of Marketing of Breast-Milk
Substitutes is a guide to the protection and promotion of breastfeeding through the
regulation of the marketing of BMS, bottles, and teats. (WHO, 1981). The rules
regarding health facilities and health workers are entirely regulated in articles 6
and 7 of this code. (WHO, 1981). Some of the contents of the article include a
ban on the promotion of formula in Health Care Facilities, a ban on giving gifts or
samples to Health Workers. (WHO, 1981).

By 2020, 136 countries were judged to have had some form of legal action
related to the Code, and 44 countries had strengthened this rule compared to the
2018 report. (WHO; UNICEF; IBFAN, 2018; WHO; UNICEF; IBFAN, 2020)
However, only 79 countries have national laws that include provisions. organize
BMS promotion in health facilities.

Indonesia itself actually has regulations related to breastfeeding protection that
refers to the code. The regulations include Undnag - Law No. 36 of 2009 article
128 on health, Government Regulation No. 33 of 2012 on Exclusive Breast Milk.

However, the implementation, monitoring and evaluation of the government
has not been maximal. Therefore, there are still often found forms of violations of
the management of this government and the international code itself. (UNICEF,
2020) .

In a 2019 study on the practice of feeding babies it is known that there are still
many people who feed babies (including breastfeeding) that are not appropriate.
Specifically, it is known that there are influences from health workers including
midwives who provide inadequate breastfeeding support, including providing
inappropriate breast milk replacement products. (Ambarwati, 2019). So a deeper
study was conducted, especially on midwives related to breastfeeding support and
the application of government regulations and international codes for BMS

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METHOD

The study used qualitative methods with a case study approach complemented
by verification. The study was conducted in sub-district X of East Jakarta. There
were eight midwife informants and eight patients who participated in this study.
Data collection techniques with interviews, observations, verification and
documenting. The validity of the data is done by source triangulation and
triangulation techniques. Data is processed by data induction and reduction
techniques.

RESULT AND DISCUSSION

The results of this study include informant characteristics and forms of code
application in breastfeeding protection. This data was presented in the following
table.

Tabel 1. Characteristics of Midwife Informants based on knowledge related to the International
Code of BMS and the participation of breastfeeding counselling training

Characteristics

Informants Training Place of Know
Training ledge

M1 Yes NGO A Yes
M2 Yes NGO A Yes
M3 Yes NGO B Yes
M4 Yes NGO B No
M5 Yes Kemkes No
M6 Yes Kemkes No
M7 No NA No
M8 No NA No
Resource: Informant Interview 2021

Table 1 shows that the majority of midwives are not yet aware of the
International Marketing Code of BMS. The majority of midwife informants have
attended WHO's 40-hour breastfeeding counselling training module from three
different training organizing institutions. Midwives who attended training at NGO
A all knew about the International Code of BMS

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Table 2. Characteristics of Midwife Informants based on the workplace and the application of the
International Code of BMS

Informants Characteristics

Place of Application

service Code

M1 Private Clinic obedient

M2 Private obedient

Hospital

M3 Public Hospital obedient

M4 Private disobedient

Hospital

M5 Public Hospital disobedient

M6 PHC disobedient

M7 PHC disobedient

M8 Private Clinic disobedient

Resource: Informant Interview 2021

The majority of informants do not comply with the application of code in
breasfeeding services.

Table 3. Characteristics of Midwife Informants based on Reasons of Non-compliance
with the implementation of the International Code of BMS

Informants Reasons

ignorance workplace BMSMarketing Other

procedure Exposure 

M4   

M5  

M6  

M7  

M8  

Resource: Informant Interview 2021

Table 3 shows that this non-compliance is due to their ignorance and exposure
to the promotion of BMS products to midwives.

The results of informant interviews, generally this non-compliance occurs
outside the health service. This is in line with studies that have been done, that
generally health workers provide less precise BMS in the place of health services.
(Hernandez et al,2019; Pries et al, 2016; Rosenberg et al, 2008).

The majority of non-compliance caused by exposure to BMS promotion is
highly relevant to existing studies. That this exposure greatly affects the attitude
of health workers in providing support and protection of breastfeeding. (Piwoz et
al 2015; Nguyen et al,2016;Tang et al, 2014; Li et al, 2020)

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Table 1 shows that the midwife's knowledge of code-related is different, even
though it has been the same following training with the same materials and
modules. In-depth interview results show that the methods and training times
organized by the three institutions are very different. This ignorance becomes a
very wide opportunity for corporations to use health workers to provide their
products to patients. It's a dilemma where midwives are victims. The same
opinion is also found that generally, many health workers do this due to their
ignorance. Baker et al, 2016; Rothstein et al, 2020; Appleton et al, 2020)

CONCLUSSION

Some midwives do not comply with the marketing code of breast milk substitute
products because of their ignorance, regulations in workplace health facilities, also there
is no clear regulation regarding this regulation. There needs to be special education
included in obstetric education related to breastfeeding protection, especially the topic of
international code marketing of breast milk substitute products to protect valuable
breastfeeding processes.

ETICAL CLEARENCE

This study has obtained ethical approval under the research umbrella of
Feeding Practices in Infants as well as the implementation of the International
Code of Marketing of BMS from the health research ethics committee of Respati
University of Indonesia Number 13/KE/UNR/VII/2019.

REFERENCES

Ambarwati,Kusmayra; Jannah,M.2021. Praktik Pemberian Makanan pada Bayi
di Kecamatan X Jakarta Timur. Jurnal Bidang Ilmu Kesehtan, Vol VII

Appleton J, Fowler C, Laws R et al. (2020) Professional and non-professional
sources of formula feeding advice for parents in the first six months.
Matern Child Nutr 13, e12942

Baker P, Smith J, Salmon L et al. (2016) Global trends and patterns of
commercial milk-based formula sales: Is anunprecedented infant and

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young child feeding transition underway? Public Health Nutr 19, 2540–
2550.
Hernandez-Cordero, S.; Lozada-Tequeanes, A.L.; Shamah-Levy, T.; Lutter, C.;
Gonzalez de Cosio, T.; Saturno-Hernandez, P.; Grummer-Strawn, L.
2019.Violations of the International Code of Marketing of Breast-milk
Substitutes in Mexico.Matern. Child Nutr., 15, e1268
Rivera Dommarco, J.; Grummer-Strawn, L. 2019. Violations of the International
Code of Marketing of Breast-milk Substitutes in Mexico. Matern. Child
Nutr., 15, e12682.
Kemkes.2009. Undang – undang No 36 tahun 2009 pasal 128 tentang Kesehatan
Li J, Nguyen TT, Wang X et al. (2020) Breastfeeding practices and associated
factors at the individual, family, health facilityand environmental levels in
China. Matern Child Nutr 16, e13002.
McFadden, A.; Mason, F.; Baker, J.; Begin, F.; Dykes, F.; Grummer-Strawn, L.;
Kenney-Muir, N.; Whitford, H.; Zehner, E.; Renfrew, M.J. 2016Spotlight
on infant formula: Coordinated global action needed. Lancet , 387, 413–
415.
Nguyen TT, Withers M, Hajeebhoy N et al. (2016) Infant formula feeding at
birth is common and inversely associatedwith subsequent breastfeeding
behavior in Vietnam. J Nutr 146, 2102–2108
Peraturan Pemerintah No 33 tahun 2012 tentang ASI Eksklusif
Piwoz EG & Huffman SL (2015) The impact of marketing of breast-milk
substitutes on who-recommended breastfeedingpractices. Food Nutr Bull
36, 373–386.
Pries, A.M.; Huffman, S.L.; Mengkheang, K.; Kroeun, H.; Champeny, M.;
Roberts, M.; Zehner, E. 2016Pervasive promotion ofbreastmilk substitutes
in Phnom Penh, Cambodia, and high usage by mothers for infant and
young child feeding. Matern. ChildNutr., 12 (Suppl. S2), 38–51.
Robinson, H.; Buccini, G.; Curry, L.; Perez-Escamilla, R.2019. TheWorld Health
Organization Code and exclusive breastfeeding inChina, India, and
Vietnam. Matern. Child Nutr, 15, e12685.

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Rollins, N.C.; Bhandari, N.; Hajeebhoy, N.; Horton, S.; Lutter, C.K.; Martines,
J.C.; Piwoz, E.G.; Richter, L.M.; Victora, C.G.2016. Why invest, and what
it will take to improve breastfeeding practices? Lancet, 387, 491–504.

Rosenberg, K.D.; Eastham, C.A.; Kasehagen, L.J.; Sandoval, A.P. 2008.
Marketing infant formula through hospitals: The impact ofcommercial
hospital discharge packs on breastfeeding. Am. J. Public Health 98, 290–
295.

Rothstein JD, Caulfield LE, Broaddus-Shea ET et al. (2020) “The doctor said
formula would help me”: health sector influences on use of infant formula
in peri-urban Lima, Peru. Soc Sci Med 244, 112324.

Tang L, Lee AH, Binns CW et al. (2014) Widespread usage of infant formula in
China: a major public health problem. Birth 41, 339–343.

UNICEF. 2020. Bottleneck Analysis of Breast-Milk Substitutes Code Monitoring
and Enforcement Systems in Vietnam, Philippines, Indonesia and
Cambodia; UNICEF East Asia and Pacific Region: Bangkok, Thailand

WHO.1981. International Code of Marketing of Breast-Milk Substitutes;WHO
Code;World Health Organization: Geneva, Switzerland

WHO; UNICEF; IBFAN.2018. Marketing of Breast-Milk Substitutes: National
Implementation of the International Code. Status Report 2018; WHO:
Geneva, Switzerland.

WHO; UNICEF; IBFAN.2020. Marketing of Breast-Milk Substitutes: National
Implementation of the International Code. Status Report 2020; WHO:
Geneva, Switzerland

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COMPLIANCE OF BREAST MILK SUBSTITUTES ADVERTISEMENT
IN MEDICAL JOURNALS UNDER THE SCOPE OF GOVERNMENT
REGULATION

Wiyarni Pambudi1), Michelle Ruth Natalie1), Diana Amilia Susilo2)
1Faculty of Medicine Universitas Tarumanagara, Jakarta
2Kendangsari Mother and Child Hospital, Surabaya

Abstract: Breastmilk substitute (BMS) marketing within the health system,
combined with other factors, can undermine breastfeeding. The extent of BMS
advertising in Indonesia’s medical journals was restricted bygovernment
regulations, The purpose of this study was to verify the compliance of BMS
advertisement in medical under the scope of government regulation. This cross-
sectional study was conducted to analyzed the compliance to attributes of the Law
for Food Labeling and Advertising, Marketing of Foods for Infants and Toddlers,
and Advertisement Ethics in three medical journals for pediatrician. The main
attributes assessed were: the presence of. In 30 editions of 2020-2021 medical
journals reviewed, 14% of pages carried advertisements of which 72% were for
BMS. The products varied markedly between different journals, there were two
manufactures dominantly adverts their BMS. The main noncompliance in infant
formula advertisement were the overclaimed statements of health and nutrition
content. All advertisements contained purely promotional statements and none
contained all of the information and warnings about BMS stipulated in the
government regulation. We verified that there were noncompliance BMS
advertisements in medical journal. Health professionals should be aware of
specific regulations for BMS marketing and some advertisements in medical
journals were not in accordance with the regulations.

Keywords: breast milk substitutes, regulation, compliance

INTRODUCTION

Optimal nutrition during a baby’s first year of life is critical for future health
outcomes. Despite the strong health message that breast is best for growing
infants, we know that marketing of breast-milk substitutes (BMS) especially
within the health system, combined with other factors, has a negative impact on
optimal breast-feeding behaviours. Breastmilk substitute (BMS) marketing within
the health system, combined with other factors, can undermine breastfeeding.

The extent of BMS advertising in leading medical journals was restricted by
several government regulations. Infant Formula is prohibited from being
advertised in any mass media except in special print media for health

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professionals. Legislation on particular nutritional purposes (medical foods/infant
formula) is implemented on guidance applied across the country in response to
WHO policies and WHA resolutions.

The purpose of this study was to verify the compliance of BMS advertisement
in medical under the scope of government regulation.

METHODS

We conducted a content analysis of BMS advertisements in three leading
medical journals for paediatrician, as described by the acronym: PI, SP, and BI.
For each of the three journals, researchers identified all pages related to BMS
advertisements. Data were collected from January 2020 until September 2021
editions.

This cross-sectional study was conducted to analysed the compliance to these
five interrelated government regulations: 1) Law 18/2012 for Food, 36/2009 for
Health and 8/1999 for Consumer Protection; 2) Government Decree 69/1999 for
Food Labeling and Advertising, 33/2012 for Exclusive Breastfeeding; 3) Ministry
Regulation 39/2013 for Infant Formula and 15/2014 for Administrative Sanction
for Health Professionals; 4) Food and Drug Supervisory Agency Regulation
3/2014 Labeling and Advertising of Foods, 24/2019 and 6/2021 for Special
Nutritional Needs for Infants and Toddlers; 5) Advertisement Ethics 2020.

Descriptive statistics were calculated for frequency and percentage for specific
BMS advertisement and for each BMS manufacturer within the three medical
journals.

RESULTS AND DISCUSSION

A total of 2,525 pages were investigated, and BMS advertisements were found
in 30 editions of three paediatric medical journals reviewed. Table 1 shows that
430 (14%) of all pages carried advertisements of which 309 (72%) were for BMS
products. The 24 products varied markedly between different journals, two (N1
and KN) were dominantly among 7 BMS manufactures adverts their brands.

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Figure 1 illustrated the proportion of advertisements for BMS, growing up milk
(GUM), complementary food (CF), vaccine, and paediatric medicine.

Iterative process was done to identify five types of content: 1) information
regarding indication; 2) statement: breastfeeding is superior; 3) information:
"consult with health professional” or "on medical prescription”; 4) information
that infant formula is not a substitute for breast milk; 5) accurate information or
data that is evidence-based, communicative, informative, educative and
responsible. Five prohibitions of BMS advertisement also investigated: 1)
idealizing their products as if they were the best; 2) information or statements that
are untrue, false, deceptive, and misleading; 3) using pictures of healthy babies
who seem to be healthy because of the use of their products; 4) using health
workers to provide information about infant formula in the advertisement; 5)
advertising infant formulas that use the same trade names as follow-up and
growing-up formulas

Table 2 shows the main noncompliance attributes assessed in infant formula
advertisement were the presence of overclaimed health and nutrition content
(42%), or references to the nutritional benefit of human milk (0%). Claims are
regulated wherever they appear on the labelling, on a website or in advertising or
presentations. Required information on infant formula products are following
these six elements: 1) the words ‘important notice’; 2) statement on superiority of
breastfeeding; 3) statement on using only on the advice of a health worker; 4)
instructions for appropriate preparation; 5) warning on health hazards of
inappropriate preparation; 6) warning that powdered formula may contain
pathogens. Prohibition of pictures that may idealize the use of infant formula on
label of infant formula products. (Crawley 2016)

All advertisements contained purely promotional statements and none
contained all of the information and warnings about BMS stipulated in the
government regulation. Some known risks of using infant formula in place of
breast milk are: increased gastrointestinal diseases, including necrotising
enterocolitis, increased infectious diseases, including respiratory tract infection,
altered adiposity and intellectual development, increased maternal breast cancer

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through reduced duration of breastfeeding, adverse effects related to formula
contamination or reconstitution problem eg, bacterial infection or burn injury, and
increased cost of purchasing milk. (Munblit 2020) While it is understood that
health workers do need information on BMS, the Code clearly states that product
information must be restricted to scientific and factual matters. (Crawley 2016)

Health and nutrition claims are commonly made for a wide variety of food
products, and the level of evidence supporting such claims is variable. However,
special consideration is needed for claims related to infant formula products,
which we define as breastmilk substitutes for use in the first year of life, including
follow-on formula and foods for special medical purposes. Infant formula is
consumed by a substantial proportion of the world’s infants, often in large
volumes in relation to their body weight, typically 150-200 mL/kg/day for a
young infant fed solely on formula milk, the equivalent of 11-14 L/day for a 70 kg
adult. (Munblit 2020)

The current advertisement environment is permissive and associated with
poorly substantiated and potentially harmful claims. Action is needed to break the
current cycle of weak scientific evidence and unreliable claims and move to a new
era where carers of infants are given accurate information about infant formula
products in a manner that does not undermine breastfeeding. (Munblit 2020)

Although Indonesia has adopted many provisions of the International Code
into its law and regulations, the scope only covers breastmilk substitutes up to 12
months. Loopholes in the law and inadequate enforcement (partly due to its
decentralised system) also allow company circumvention and infiltration, thus
promotional activities are rampant. (IBFAN 2018) The government regulation
aligned with WHO code on marketing of breastmilk substitutes in context of: 1)
informational and educational materials intended to reach pregnant women and
mothers of infants and young children should not use any pictures or text which
may idealise the use of breastmilk substitutes, 2) information provided by
manufacturers and distributors to health professionals should be restricted to
scientific and factual matters, and not imply or create a belief that bottle feeding is
equivalent or superior to breastfeeding, 3) neither the container nor the label

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should have pictures of infants; nor should they have other pictures or text which
may idealise the use of infant formula, 4) there should be no advertising or other
form of promotion to the general public of products within the scope of the code,
5) nutrition and health claims should not be permitted for breastmilk substitutes,
except where specifically provided for in national legislation. (WHO 2020)

As is still the practice today, the inclusion of medical testimonials by the
profession in the advertising copy added a veneer of “scientific” and medical
respectability. (Hasting 2020, van Tulleken 2021). Our objective is not to drive an
anti-formula campaign, as we recognize that formula milks are essential products
for children with complex medical or nutritional needs and for those women for
whom breastfeeding is not possible. But decisions on when and how to use infant
formula are best informed by sources of unbiased evidence rather than
commercial advertisements.

Despite the criticisms of formula milk, including the associations with greater
weight gain, it is necessary to consider the whole picture and not to be too quick
to demonize formula milk completely. First, for some mothers, breastfeeding is
difficult or even impossible, which can result in infants experiencing weight loss.
In such situations, formula milk can be used to supplement the infant’s nutritional
needs, which can reduce hospital readmittance, and has been found to not interfere
with breastfeeding. In addition, for some infants, such as those born to mothers
who are infected with HIV or those with classic galactosemia (galactose-1-
phosphate uridyltransferase deficiency), formula feeding could provide a safer
source of nutrition. (Beattie 2019, Bridge 2021)

We believe this is the right thing to do based on our desire to support the
WHO code, actively promote breastfeeding, and campaign against industry
influence in this area. Instead of being part of the problem, we want to be part of
the solution. To confirm the study findings, more research of other platforms
should be done. (Vinje 2017) Likewise, advertising campaigns on online
applications, professional organization websites, scientific meetings, medical
research, education and social events at medical meetings should be addressed to
map the extent of government regulation and Code violations. The influence of

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marketing of such products on the recommended breast-feeding behaviour should
hence be further investigated.

CONCLUSION
We verified that there was noncompliance BMS advertisement under the
scope of government regulation. Health professionals should be aware that there
are specific regulations for BMS marketing and some advertisements in medical
journals were not in accordance with the regulations. All of these appear in spite
of government regulations prohibiting them indicating a failure of monitoring
and/or enforcement. The marketing of BMS must be actively monitored to be
effective.

ACKNOWLEDGEMENT

The authors would like to thank to the anonymous reviewers for their
contributions which helped to improve this manuscript.

SOURCE OF FUNDING
This was entirely self‐ funded research, authorship, and/or publication of this
this study or manuscript.

DISCLOSURE AND CONFLICTS OF INTEREST

None of the authors had potential conflicts of interest related to any part of
this study or manuscript.

CONTRIBUTIONS

WP conceived, conceptualized, and designed the study, collected data, advised
in the analysis and interpretation of the results, wrote and finalized the
manuscript. MRN analysed and interpreted the data, write up of initial results of
this manuscript. DAS drafted the manuscript and provided critical intellectual
feedback to help revise the manuscript. All authors have read and approved the
final manuscript.

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ORCID ID

Wiyarni Pambudi https://orcid.org/0000-0001-9544-084X

ETHICS

Ethical clearance has been approved by the Ethical Committee of the Faculty
of Medicine, Universitas Tarumanagara (No. 034/KEPK/UPPM/FK
UNTAR/VIII/2021)

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Ching C, Zambrano P, Nguyen TT, Tharaney M, Zafimanjaka MG, Mathisen R.
(2021). Old Tricks, New Opportunities: How Companies Violate the
International Code of Marketing of Breast-Milk Substitutes and
Undermine Maternal and Child Health during the COVID-19 Pandemic.
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Crawley H, Westland S. (2016). ‘Scientific and factual’? A Review of Breastmilk
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Nutrition Trust.

Durako SJ, Thompson M, Diallo MS, Aroson KE.(2016). In-Country Assessments
of BMS Companies’ Compliance with the International Code of
Marketing of Breast-milk Substitutes. Final Indonesia Report. Rockville,
Westat.

Godlee F. (2018). Editor’s choice. Disentangling Ourselves from “Big Formula”.
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Godlee F, Cook S, Coombes R, El-Omar E, Brown N. (2019). Editorials. Calling
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Government of the Republic of Indonesia. (2012). Regulation Number 33 on
Exclusive Breastfeeding. Jakarta: Government of the Republic of
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Greer FR, Apple RD. Physicians, Formula Companies, and Advertising. (1991). A
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Grummer-Strawn LM, Holliday F, Jungo KT, Rollins N. (2019). Sponsorship of
National and Regional Professional Paediatrics Associations by
Companies that Make Breast-Milk Substitutes: Evidence from A Review
of Official Websites. BMJ, 9, e029035.

Hastings G, Angus K, Eadie D, Hunt K. (2020). Selling second best: how infant
formula marketing works. Global Health 16, 77.

Hickman N, Morgan S, Crawley H, Kerac M. (2020). Advertising of Human Milk
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Hidayana I, Februhartanty J, Parady VA. (2016). Violations of the International
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IBFAN. (2018). Report on the Monitoring of the Code in 11 Countries of Asia
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IBFAN. (2019). Protecting Infant Health: A Health Worker’s Guide to The
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Jasani B, Simmer K, Patole SK, Rao SC. (2017). Long Chain Polyunsaturated
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Michaud‐ Létourneau I, Gayard M, Pelletier DL. (2019). Translating the
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Ministry of Health of the Republic of Indonesia. (2013). Regulation Number 39
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report. https://www.who.int/ publications/i/item/9789240006010 viewed
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Table 1. Frequency of BMS Advertisements in paediatric medical journal

Journal Pages of BMS advertisements

(number Number FF KN MJ N1 N2 SH WN All Non BMS/ BMS/

of of pages (n=2) (n=2) (n=3) (n=7) (n=2) (n=6) (n=2) BMS BMS Non BMS all adv.

volumes) adv. adv. adv.

PI (10) 887 3 3 6 53 3 17 12 97 34 285,3% 72.9%

SP (10) 947 5 36 4 59 6 10 0 120 42 285,7% 73.2%

BI (10) 691 5 33 2 30 7 4 11 92 45 204,4% 69%

Total (30) 2525 13 72 12 142 16 31 23 309 121 255,4% 71.9%

Note. Page is defined as one side of a physical page. BMS adv. = Breast Milk Substitutes
advertisement. Non BMS adv. = GUM (Growing Up Milk), CF (ComplementaryFood), vaccine,

medicine advertisement.

Figure 1. Proportion of all products advertised in paediatric medical journal.

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Tabel 2. Content of advertisement for specific BMS products

Statement appeared on the Slides of BMS advertisements All
advertisements (n=24)
FF KN MJ N1 N2 SH WN 83.3%
(n=2) (n=2) (n=3) (n=7) (n=2) (n=6) (n=2) 91.7%
95.8%
Contain information regarding indication 1 0 3 7 1 6 2
0%
Include the statement: breastfeeding is 2237 2 6 0 79.2%
superior
100%
Include the information: "consult with 2237 1 6 2 41.7%
health professional” or "on medical
66.7%
prescription”
95.8%
Contain information that infant formula 0 0 0 0 0 0 0
is not a substitute for breast milk 91.7%

Contain accurate information or data that 1 2 3 6 1 6 0
is evidence-based, communicative,
informative, educative and responsible

Not doing promotions by idealizing their 2 2 3 7 2 6 2
products as if they were the best

Not provide information or statements 0025 2 0 1

that are untrue, false, deceptive, and
misleading
Not using pictures of healthy babies who 2 2 3 6 1 0 2
seem to be healthy because of the use of
their products

Not using health workers to provide 2237 1 6 2

information about infant formula in the
advertisement
Not advertise infant formulas that use the 2 2 3 6 1 6 2
same trade names as follow-up and
growing-up formulas

Figure2.Example of BMS advertisementswith non-scientific or misleading information

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THE EFFECT OF BREASTFEEDING TECHNICAL GUIDANCE ON
BREASTFEEDING MOTHERS TO KNOWLEDGE, SKILL AND

BREASTFEEDING SELF-EFFICACY IN OLAK KEMANG MEDICAL
CENTRE IN 2021

Yuli Suryanti, Ajeng Galuh W, Puja Nala Sari
Jurusan Kebidanan, Poltekkes Kemenkes Jambi
Email : [email protected]

Abstract: Breastfeeding problems that often occur are due to lack of family
support, especially husbands, lack of knowledge of mothers about the importance
of breastfeeding for babies, and lack of skills in breastfeeding techniques that
cause mothers not to be confident to breastfeed. Efforts to increase breastfeeding
self-efficacy can be done by providing guidance or counseling to breastfeeding
mothers. This research is a pre-experimental research with the approach used is
One Group Pretest-posttest. The population in this study were all breastfeeding
mothers who had babies aged less than 6 months who were found in the working
area of the Olak Kemang Health Center totaling 120 mothers. There are 30
samples or respondents in this study. The sample used in this study is random
sampling random. Analysis of the data used is the result of univariate analysis
with frequency distribution before and after being given guidance on
breastfeeding techniques on knowledge of breastfeeding mothers, frequency
distribution before and after being given guidance on breastfeeding techniques on
breastfeeding mothers' skills, frequency distribution before and after being given
guidance on breastfeeding techniques on breastfeeding self-efficacy. efficacy.
Bivariate analysis with Wilcoxon test to see the effect of the given intervention on
a variable. The results showed that breastfeeding technique guidance was very
influential in increasing knowledge, skills and breastfeeding self- efficacy with a
value of = 0.00 (ρ < 0.05). Suggestion: it is hoped that breastfeeding mothers can
maintain exclusive breastfeeding, and share knowledge and skills in
breastfeeding.

Keywords: breastfeeding technique, breastfeeding self-efficacy, guidance and
counseling.

INTRODUCTION

According to the World Health Organization (2017), globally only 40% of

infants under the age of 6 months are exclusively breastfed. United Children's
Fund (UNICEF), only 42% of infants in Indonesia are exclusively breastfed for up

to 6 months. In 2019, exclusive breastfeeding in Indonesia was 67.74%
(Kemenkes RI, 2019).

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The Jambi Province exclusive breastfeeding rate in 2019 was only 56.01%
(Jambi Province Health Office, 2019). Report from the Head of Health and
Nutrition regarding exclusive breastfeeding in Jambi City in 2019, only 69.67%
of infants received exclusive breastfeeding for <6 months and only 56.64% of
infants were given exclusive breastfeeding for 6 months. The working area of the
Olak Kemang Health Center is an area where the exclusive breastfeeding rate is
low, namely only 43.84% of infants given exclusive breastfeeding <6 months,
while 38.10% (Jambi City Health Office, 2019).

Breastfeeding problems develop in the postnatal phase and have a negative
impact on the breastfeeding period (Shafaei & Mirghafourvand, 2020: 2). Mothers
who do not breastfeed effectively can cause problems when breastfeeding such as
sore nipples, babies continue to cry because they are still hungry and finally
mothers are interested in trying to give formula milk to babies (Pradanie, 2015:21).
Meanwhile, according to (Awaliyah et al., 2019: 2), states that breastfeeding
problems are related to feelings of satisfaction for mothers when breastfeeding
their babies.

Lack of family support, especially husbands, lack of mother's knowledge about
the importance of breastfeeding for babies, and lack of mother's breastfeeding
technique skills that lead to lack of enthusiasm for breastfeeding. The thing that is
very influential on the satisfaction of breastfeeding mothers is the mother's
confidence in the ability to breastfeed her baby, or commonly called breastfeeding
self-efficacy.

According to Dennis, breastfeeding self- efficacy is an important component in
breastfeeding because it can predict mothers will choose to breastfeed, how much
energy will be expended by mothers, self-reinforcing or destructive mentalities,
and emotional responses when they face difficulties during breastfeeding. This
shows that the higher the breastfeeding self-efficacy, the harder the mother's
efforts to be able to breastfeed successfully, and vice versa.

Research conducted by (Handayani et al., 2010:3), proves that there is a close
relationship between social support, knowledge, attitudes and self-efficacy with
breastfeeding behavior. In addition, research conducted by (Rahayu, 2018:249)

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showed very significant results between breastfeeding self-efficacy and the
success of exclusive breastfeeding. The results of these studies prove that
breastfeeding self-efficacy is closely related to the success of breastfeeding
practices. Efforts to increase breastfeeding self-efficacy can be done by providing
guidance or counseling to breastfeeding mothers.

RESEARCH METHODS

The type of research used in this research is pre-experimental with the
approach used is One Group Pretest-posttest. The population in this study were all
breastfeeding mothers who had babies aged less than 6 months who were found
in the working area of the Olak Kemang Health Center totaling 120 mothers.
There are 30 samples or respondents in this study. The sample used in this study
is random sampling random. The place of this research was carried out in the
working area of the Olak Kemang Health Center, Jambi City in April 2021-May
2021.

RESULTS AND DISCUSSION

Table 1. Frequency Distribution of Knowledge Level ofBreastfeeding Mothers Before Giving
Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health Center Jambi

City in 2021

Variable frequency Average
(n) Minimum-
Maximum

Knowledge of 30 8,87
breastfeeding 5-15

mothers

Table 2. Frequency Distribution of Knowledge Level of Breastfeeding Mothers After being

Provided with Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health

Center Jambi City in 2021

Variable frequency Average
(n) Minimum-
Maximum

Knowledge of 30 13,43
breastfeeding 11-15

mothers

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Table 3. The Effect of Breastfeeding Technical Guidance on Knowledge of Breastfeeding Mothers

in the Work Area of the Olak Kemang Health Center in 2021

Variable Average Score
Minimum- ρ
Knowledge Before Maximum
Intervention 0,00
8
Knowledge After 5-15
13,50

Intervention 11-15

Table 4. Frequency Distribution of the Skill Level of Breastfeeding Mothers Before Giving

Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health Center Jambi City

in 2021

Variable frequency Average
(n) Minimum-
Maximum

Nursing mother 30 4
skills 0-7

Table 5. Frequency Distribution of the Skill Level of Breastfeeding Mothers After being Provided

with Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health Center in

2021

Variable frequency Average
(n) Minimum-
Maximum

Nursing mother 30 6,80
skills 4-9

Table 6. Pengaruh Bimbingan Teknik Menyusui Terhadap Keterampilan Ibu Menyusui di

Wilayah Kerja Puskesmas Olak Kemang Tahun 2021

Variable Average Score
Minimum- ρ
Maximum

Skills Before 4

Intervention 0-7
Skills After 7 0,00

Intervention 4-9

Table 7. Frequency Distribution of Breastfeeding Self-efficacy Levels Before Giving

Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health Center in 2021

Variable frequency Average
(n)
Minimum-
Maximum

Breastfeeding 30 52,67
Self-efficacy of 44-59
breastfeeding

mothers

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Table 8. Frequency Distribution of Breastfeeding Self-efficacy After being Provided with

Breastfeeding Technical Guidance in the Work Area of the Olak Kemang Health Center in 2021

Variable frequency Average
(n) Minimum-
Maximum

Breastfeeding 30 56,83
Self-efficacy 52-60
of
breastfeeding

mothers

Table 9. The Effect of Breastfeeding Technical Guidance on Breastfeeding Self-efficacy of

Breastfeeding Mothers in the Work Area of the Olak Kemang Health Center

in 2021

Variable Average Score
Minimum- ρ
Maximum

Breastfeeding self- 52
efficacy Before 44-59
Intervention
0,00

Breastfeeding self- 57
efficacy After 52-60
Intervention

Table 3 above shows the results of data analysis using the Wilcoxon test to see
the effect of an intervention given on the variables. The effect of breastfeeding
technique guidance on the knowledge of breastfeeding mothers in the work area of
the Olak Kemang Health Center was obtained with a value of ρ=0.00 (ρ<0.05).
This means that there is a very significant effect before and after being given
guidance on breastfeeding techniques.

This study is in line with research from (Matdoan & Wiwin, 2019) regarding
the effect of correct breastfeeding technique counseling on knowledge and
attitudes in postpartum mothers with the results of the value ρ=0.00 because
<0.05, which means that there is an influence from the provision of technical
counseling. correct breastfeeding on the knowledge of postpartum mothers in the
working area of the Rujali Health Center Ambon.

The results of this study are also in line with the results of research (Himawati
& Mawarti, 2011:10) about the effect of health education on breastfeeding
techniques on knowledge and behavior of breastfeeding techniques in
primiparous mothers at BPS Kalibawang District, Kulonprogo which shows that

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there is an increase in health education on breastfeeding techniques on mother's
knowledge. primiparous breastfeeding.

Table 6 above shows the results of data analysis using the Wilcoxon test to
see the effect of an intervention given on the variables. The effect of
breastfeeding technique guidance on the skills of breastfeeding mothers in the
work area of the Olak Kemang Health Center was obtained with a value of
ρ=0.00 (ρ<0.05). This means that there is a very significant effect before and after
being given guidance on breastfeeding techniques.

The results of this study are in line with research conducted by (Mulyana &
Irmayani, 2019:84) about the effect of the demonstration method on breastfeeding
technique skills in postpartum caesarean mothers at the Mataram City Hospital.
can affect breastfeeding technique skills in post sectio caesarea mothers. So that
with this influence there can be behavioral changes in post sectio caesarea
mothers to carry out the correct breastfeeding technique.

Table 9 above shows the results of data analysis using the Wilcoxon test to see
the effect of an intervention given on the variables. The effect of breastfeeding
technique guidance on breastfeeding self- efficacy of breastfeeding mothers in the
work area of the Olak Kemang Health Center was obtained with a value of ρ=0.00
(ρ<0.05). This means that there is a very significant effect before and after being
given guidance on breastfeeding techniques.

This study is in line with research by (Shafaei & Mirghafourvand, 2020:2)
about the effect of prenatal counseling on breastfeeding self-efficacy and the
frequency of breastfeeding problems in mothers who previously failed to
breastfeed that there is an influence of counseling or guidance given to
respondents which can affect self-efficacy. efficacy of breastfeeding mothers.

The advantage of this research is that researchers directly provide guidance on
breastfeeding techniques door to door to respondents to get maximum results.
Researchers conducted 2-4 meetings to provide guidance on breastfeeding
techniques and were given pretest and posttest questionnaires for knowledge of
breastfeeding techniques, breastfeeding technique skills and breastfeeding self-
efficacy.

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CONCLUSION

1. Most of the respondents had sufficient knowledge of breastfeeding techniques
before being given breastfeeding technique guidance.

2. Most of the respondents experienced significant progress in their knowledge
of breastfeeding techniques when they were given guidance on breastfeeding
techniques to become good.

3. There is an influence of breastfeeding technique guidance on the knowledge
of breastfeeding mothers before and after being given breastfeeding technique
guidance.

4. Most of the respondents had poor skills in breastfeeding techniques before
being given breastfeeding technique guidance.

5. Most of the respondents experienced significant progress in their skills on
breastfeeding techniques when they were given guidance on breastfeeding
techniques to become good.

6. There is an influence of breastfeeding technique guidance on the skills of
breastfeeding mothers before and after being given breastfeeding technique
guidance.

7. Most of the respondents had high breastfeeding self-efficacy before being
given breastfeeding technique guidance.

8. Most of the respondents experienced significant progress in breastfeeding
self-efficacy when after being given guidance on breastfeeding techniques it
became high with increasing scores.

9. The influence of breastfeeding technique guidance on breastfeeding self-
efficacy of breastfeeding mothers before and after being given breastfeeding
technique guidance.

THANK-YOU NOTE
Praise and gratitude the author prays to Allah SWT for the abundance of His
grace and gifts so that this research can be completed. The author also does not
forget to thank all those who have provided support in the form of thought and
material.

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R. (2020). Hubungan Self-Efficacy Ibu Menyusui Dengan Pemberian Asi
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Wahyuningsih, H. P. (2018). Asuhan Kebidanan Nifas dan Menyusui (Pertama).
Kemenkes RI.

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EFFECTIVENESS OF TREATMENT USING TOPICAL BREAST MILK
AND DRY GAUZE AT THE TIME OF RELEASE NEW BORN
UMBILICAL CORD AT PMB MISLIANA

Inna Muthmainnah1, Hilda2, Rosalin Ariefah Putri3
Student of the Applied Midwifery Study Program, Poltekkes Kaltim

Lecturer of the Department of Nursing, Poltekkes Kaltim
Lecturer of the Department of Midwifery, Poltekkes Kaltim

E-mail: [email protected]

Abstract: Introduction : The technique of umbilical cord care, cutting and
tying the umbilical cord, is the main principle that is very important to prevent
sepsis due to umbilical cord infection. Improper care of the umbilical cord causes
the umbilical cord to become detached for a long time. WHO recommends
treating the umbilical cord with the topical method of breast milk because breast
milk contains a significant number of complementary components, acts as a
natural antimicrobial agent and is also equipped with protective factors that
provide specific and nonspecific passive immunity. And using sterile dry gauze
has the benefit of protecting the umbilical cord from exposure to bacteria and can
accelerate wound healing.
Method : This type of research is a quasi-experimental research design with a
post-only control design. The population in this study are all Newborns in March-
July 2021, The research sample in this study was 20 newborns and The sampling
technique in this study is Total Sampling.
Results : Results The average of umbilical cord detachment with umbilical cord
care using topical breast milk was on average 4 days and dry gauze was 7 days
seen from test statistics Mann Whitneywith the two tail hypothesis shows p value
0.000 < alpha 0.05.
Discussion : care for the umbilical cord using sterile dry gauze is to keep the
umbilical cord dry and clean and avoid exposure to bacteria and viruses, The
content in breast milk is more effective in accelerating the release of the
newborn's umbilical cord, because in breast milk there are natural anti-microbials
so as to avoid infection of the umbilical cord in newborns which can affect the
length of the release of the umbilical cord in newborns.
Conclusion : There is a significant difference in umbilical cord care using topical
breast milk and dry gauze on the timing of the release of the umbilical cord for
newborns.

Keywords: Newborn Baby, Umbilical Cord Care, Topical Breastfeeding, Kassa

INTRODUCTION

The umbilical cord is a lifeline for the fetus during the womb, because it is

through the umbilical cord that all the needs for the fetus are met. The umbilical

cord extends from the fetus to the placenta and contains the umbilical blood

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vessels, namely two arteries and one vein. The umbilical cord is protected and
covered by Wharton's jelly, a sticky substance formed from the mesoderm. The
umbilical cord is completely covered by the amnion layer along with that which
covers the placenta(Umrah, 2017).

Treatment techniques at the time of cutting and tying the umbilical cord, as
well as umbilical cord care are the main principles that are very important to
prevent sepsis due to umbilical cord infection. Improper care of the umbilical cord
causes the umbilical cord to become detached for a long time. The risk when the
old umbilical cord is separated is the occurrence of umbilical cord infection and
neonatal tetanus. So the care of the umbilical cord needs to be considered. If the
umbilical cord is wet, smells and shows signs of infection, be aware of umbilical
cord infection. Proper care of the umbilical cord is based on aseptic and dry
principles and it is no longer recommended to use alcohol or other ingredients,
and not tightly closed. Although it can be closed, it is okay to use sterile gauze
and not tie it too tightly.(Maharani et al., 2018).

WHO also recommends one way to treat the umbilical cord, namely the
topical method of breast milk. The topical method of breastfeeding is one of the
cultural umbilical cord care practices used in Turkey. This is beneficial because of
the anti-bacterial factors found in breast milk. In addition, breast milk has many
immunological and anti-infective agents. Breast milk contains a significant
amount of complementary components, acts as a natural antimicrobial agent and
is also equipped with protective factors that provide specific and nonspecific
passive immunity(A. Allam, 2015)

The best way to treat the umbilical cord after birth is a controversial issue,
especially in developing countries where there are local beliefs. Efforts to identify
and implement affordable, effective, and community-based umbilical cord care
interventions are still being carried out so as to reduce infections related to
neonatal mortality in developing countries. Mother's Milk (ASI) contains
leukocyte cells, proteolytic enzymes, and immunological substances that help
speed up the release of the umbilical cord. The faster the umbilical cord comes off
will reduce the risk of infection, by paying attention to cleanliness around the

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umbilical cord and washing hands before and after caring for the umbilical
cord.(Dewi et al., 2018).

The timing of umbilical cord removal is influenced by the way the umbilical
cord is cared for, the humidity of the umbilical cord, the sanitary conditions of the
environment around the neonate, and the incidence of infection in the umbilical
cord due to actions or treatments that do not meet hygiene requirements. and
umbilical cord infection (Hartanto & Purwanto, 2016)

According to the Normal Childbirth Care (APN) standards, the umbilical cord
that has been cut and tied is not given anything. Before the APN method is
applied, the umbilical cord is treated with alcohol and other antiseptics. In terms
of evidence-based practice, traditional umbilical cord care using breast milk has
an effect on preventing infection and the length of time the umbilical cord is
released(Simanungkalit & Sintya, 2019).

The umbilical cord care using a dry technique is covered with sterile gauze.
The advantages of using a dry umbilical cord treatment are that some mothers feel
safer using sterile gauze, they are afraid to handle their newborn because the
baby's umbilical cord has not been separated. While the drawback of umbilical
cord care with a dry technique is that it requires sterile gauze(Noorhidayah et al.,
2015).

Sterile dry gauze in several studies has the benefit of protecting the umbilical
cord from exposure to bacteria and can accelerate wound healing. Caring for the
umbilical cord using sterile dry gauze can keep the umbilical cord dry and clean,
thereby reducing the risk of infection which can affect the length of time the
umbilical cord is released in newborns.(Megalina Limoy, 2019)

Neonatal deaths caused by tetanus neonatorum in Southeast Asian states were
581 infants. Health Profile of Indonesia in 2019 there were 56 babies affected by
tetanus neonatorum, Tetanus Neonatorum occurred because of birth attendant
factors, childbirth with traditional birth attendants, poor hygiene of umbilical cord
care, unsterile delivery equipment and when cutting the umbilical cord still using
bamboo(Ministry of Health of the Republic of Indonesia, 2020)Based on the
results of the 2018 Basic Health Research (Riskesdas) The proportion of umbilical

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cord care for newborns in children aged 0-59 months according to the province of
East Kalimantan regarding umbilical cord care for newborns is given nothing and
dry 44.8% is given betadine/alcohol 46.5% is given sows 1 ,2% were given
herbs/traditional medicine 1.3% did not know 6.1%. Kutai Kartanegara was given
nothing and dry 51.95% was given betadine/ alcohol 39.01% was given sowing
medicine 1.28% was given herbs/traditional medicine 1.07% Don't know
6.68%(Provincial Ministry of Health, 2018).

Based on the Preliminary Study from the maternal register book data at PMB
Misliana In 2020 there were 140 maternity mothers, from the results of interviews
conducted, from 10 maternity mothers there were 6 mothers who said how to take
care of the umbilical cord at home still following the advice of parents to carry out
umbilical cord care routinely. Traditionally, and some do not understand about
proper umbilical cord care. With incorrect and incorrect umbilical cord care, it is
one of the factors that causes neonatal tetanus as one of the causes of newborn
death.

In a study conducted by Intan Nurul Ilma, the umbilical cord treatment with
topical breast milk accelerated the release time of the umbilical cord compared to
open dry treatment. Breast milk can be used for safe, effective and efficient
umbilical cord care(Ilma, 2020).

In research conducted by Vedjia MedhyaThe average time to release the
umbilical cord using breast milk is 4 days, while the average time to release the
umbilical cord using dry gauze is 7 days. There was a significant difference in the
length of time the umbilical cord was released using breast milk with dry gauze
with p-value = 0.05. It shows that the length of time the umbilical cord is removed
using breast milk is faster than the dry gauze treatment. It is hoped that umbilical
cord care with breast milk can be recommended as a standard for newborn care, as
an effort to prevent umbilical cord infection(Medhina, 2020).

Based on the results of research conducted by Diana Putri et al, stated that the
average length of umbilical cord detachment with topical use of breast milk was
5.03 days, and the average length of umbilical cord detachment with dry care was
6.00 days. There is a difference in the length of the release of the baby's umbilical

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cord with the use of topical breast milk 0.97 days faster than the dry treatment.
Mother's Milk (ASI) is proven to contain bioactive substances and cells that have
effective functions as anti-infective and anti-inflammatory. With a variety of
content of these beneficial substances, breast milk can be used as an alternative
material for umbilical cord care(Sari et al., 2018).

Based on the description above, the research is interested in "Is there a
difference in umbilical cord care using topical breast milk and dry gauze on the
timing of the release of the umbilical cord for newborns at PMB Misliana".

RESEARCH METHODS
This type of research is a quasi-experimental research design with a post-
only control design. The population in this study are all Newborns in March-July
2021, The research sample in this study was 20 newborns and The sampling
technique in this study is Total Samplig. The research group was divided into 2
groups, namely the umbilical cord care group with topical breastfeeding
(intervention) and the umbilical cord care group with dry gauze (control). and
each group has 10 respondents, This study uses the Mann Whitney test.

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RESULTS AND DISCUSSION

Table 1. Frequency Distribution of Respondents' Characteristics Based on Newborn Weight

EXPERIMENT GROUP

NO CHARACTERISTICS Breastmilk Kassa TOTAL %
Topical
7 35%
N% N % 13 65%
20 100%
1 Gender
11 55%
Woman 5 50.0 2 20.0 8 40%
5 50.0 8 80.0 1 5%
Man 10 100 10 100 20 100%

Total 15 75%
5 25%
2 Birth Weight 20 100%

2500-2999 6 60 5 50 11 55%
4 40 4 40 5 25%
3000-3499 001 10 4 20%
10 100 10 100 20 100%
3500-4000
0 0%
Total 20 100%
20 100%
3 Amniotic fluid color

Clear 6 60.0 9 90.0
4 40.0 1 10.0
Green 10 100.0 10 100.0

Total

4 Cord Diameter

1 cm 6 60.0 5 50.0
2 20.0 3 30.0
1.5cm 2 20.0 2 20.0
10 100.0 10 100.0
2 cm

Total

5 Umbilical Cord
Infection

Infection 0 0% 0 0%
10 100% 10 100%
No Infection 10 100% 10 100%

Total

Source: Primary Data in 2021

Based on table 1 above, it can be seen that the characteristics of the
respondents are known to the majority of respondents male sex totaling 13 people
(65%), the majority of body weight 2500-2999 totaling 11 people (55 %),
majority of respondents The color of the amniotic fluid is clear, 15 people (75%),
the majority of respondents with the diameter of the umbilical cord is 11 people
(55%) and all respondents did not experience infection in the umbilical cord
amounted to 20 respondents (100%)of a total of 20 respondents. The umbilical

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cord detachment time in this study was categorized into 3, namely <5 days = fast,
5-7 = normal, and >7 = long, with the following frequency distribution.

Table 2. Category of the length of the release of the umbilical cord for newborns using topical
breast milk and dry gauze

Umbilical Cord Breastmilk Dry Gauze
Detachment Topical N%
Time
N%

< 5: hurry 7 70.0 0 00.0

5-7: normal 3 30.0 6 60.0

>7: Old 0 00.0 4 40.0

Total 10 100.0 10 100.0

Source: Primary Data 2021

Based on Table 2, it shows that newborns who were respondents in the
umbilical cord care group with topical breastfeeding (intervention) most of their
umbilical cord detachment were in the fast category, namely 7 respondents (70%),
respondents in the umbilical cord care group with dry gauze (control). ) most of
the umbilical cord detachments were in the normal category, namely 6
respondents (60%).

Table 3. Research Data Normality Test

Research Kolmogorov-Smirnova Shapiro-Wilk
Group
Statis
Statistics df Sig. tics df Sig.

Breastmilk .416 10 .000 .650 10 .000
Topical

Kassa .245 10 .091 .820 10 .025

Source: Primary Data 2021

From the output, it is known the value of sig. For the topical breast milk group,
0.000 <0.05 and sig. For the gauze group of 0.025<0.005Which means that the data
distribution is not normal because the results of the sig. Less than 0.05 so that the
bivariate analysis using the independent t test did not meet the requirements, then the
bivariate analysis was replaced using Mann Whitney.

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Table 4. Average length of umbilical cord release using Topical ASI and Kassa

Variable N mean median SD Min-

Max

Breastmilk 10 4,400 4.00 0.699 4-6

Topical

Kassa 10 6.9000 7.00 0.994 5-8

Source: Primary Data 2021

Based on Table 4. shows the average time of umbilical cord detachment in the
topical breastfeeding intervention group with a total of 10 respondents, the mean or
average value is 4,400, the median is 4.00, the standard deviation is 0.699 and the
minimum umbilical cord separation time is 4 days and the maximum is 6 days,
while for the control group which uses Kassa with a total of 10 respondents with a
mean or an average value of 6,9000, a median value of 7.00, a Standard Deviance of
0.994 and a minimum value of 5 days for umbilical cord separation and a maximum
of 8 days.

Table 5. Analysis of Differences in Baby's Umbilical Cord Care Using Topical Breast Milk and
Dry Gauze Against the Time of Release of the Newborn's umbilical cord

Research N Mean Sum of P-
group Rank Ranks Value

Breastmilk 10 5.60 56.00
Topical

Sterile 10 15,40 154.00 0.000
Gauze

Total 20

Source: Primary Data 2021

Based on table 5 it is known The mean rank forlompok Topical Breast milk
5.60 and sum of rank 56.00 while group kcontrol (gauze) the mean rank is 15.40
and the sum of ranks is 154.00. and fromThe results of statistical tests with the
two tail hypothesis show a p-value of 0.000 which is smaller than alpha 0.05, so
that Ho is rejected which means There is a significant difference in umbilical cord
care using topical breast milk and dry gauze on the timing of the release of the
umbilical cord for newborns.

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Discussion

Characteristics of Respondents

Based on table 1 shows that Based on table 1 above, it can be seen that the
characteristics of the respondents are known to the majority of respondents male
sex totaling 13 people (65%), the majority of body weight 2500-2999 totaling 11
people (55 %), majority of respondents The color of the amniotic fluid is clear, 15
people (75%), the majority of respondents with the diameter of the umbilical cord
is 11 people (55%) and all respondents did not experience infection in the
umbilical cord amounted to 20 respondents (100%)of a total of 20 respondents.

The diameter of the umbilical cord is between 1cm -2.5cm, with a length
range between 30cm-100cm, an average of 55cm, consists of rudimentary
allantoin, remnants of the omphalo mesenteric, covered with a thin mucous
membrane, the rest is filled with a gelatinous substance as mucoid connective
tissue called Wharton's jelly, Wharton's jelly is a sticky, sticky substance that
surrounds the umbilical cord slowing down the fall of the umbilical cord (Asia,
2017)

According to the author's assumption, there are 11 respondents (55%) who
have an umbilical cord diameter of 1 cm, the smaller the diameter of the umbilical
cord, the faster the umbilical cord will dry because the Wharton jelly that
surrounds the umbilical cord is not thick, thus accelerating the drying process of
the baby's umbilical cord.

Amniotic fluid is an unfavorable culture medium for bacteria, but if there is a
certain amount of meconium present in it, it can increase the growth of bacteria,
especially Escherichia coli and Listeria monocytogenes. Fetuses exposed to
meconium-stained amniotic fluid have a higher risk of infection than infants with
unclouded amniotic fluid.(Kosim et al., 2016)

According to the authors' assumptions, respondents with green and cloudy
amniotic fluid (25%) in green amniotic fluid contain bacteria that can cause
infection so that it will be one of the factors that can make the umbilical cord
loose longer.

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When to remove the umbilical cord for newborns using Topical breast milk

Based on Table 2 shows that newborns who were respondents in the umbilical
cord care group with Topical Breastfeeding (Intervention) most of their umbilical
cord detachment were in the fast category, namely 7 respondents (70%). the
average time of umbilical cord detachment in the topical breastfeeding
intervention group with a total of 10 respondents with a mean or average value of
4,400, a median value of 4.00, a standard deviation of 0.699 and a minimum value
of 4 days for umbilical cord separation, a maximum of 6 days.

This study is in line with research (Medhyna, 2020) The average time of
releasing the umbilical cord using breast milk is 4 days while the average time of
releasing the umbilical cord with dry gauze is 7 days. There is a significant
difference in the length of umbilical cord release using breast milk with dry gauze
with p-value = 0.05(Medhina, 2020).

After the baby is born the umbilical cord is cut, then there will be a process of
tissue death. Here the umbilical cord is treated using colostrum/breast milk. This
is done by applying breast milk to the newborn's umbilical cord and keeping it
clean and dry to prevent infection and speed up the release of the umbilical cord
from the baby's stomach.

Umbilical cord care using breast milk is a new method in umbilical cord care.
This is because the nutritional content in breast milk in the form of lactose,
protein, fat and minerals directly into the cells so that breast milk can be used as a
medium for umbilical cord care. The protein in breast milk is high enough to play
a role in the process of repairing damaged cells, accelerating the healing process
so as to speed up the release time of the umbilical cord.(Hartanto & Purwanto,
2016)

Proteins in breast milk will bind to proteins in the umbilical cord, thus forming
an immune reaction and an apoptotic process occurs. Cell division and growth are
under genetic control, cells experience programmed death. Genes in these cells
play an active role in the process of cell death. So that it will speed up the drying
of the remaining tissue of the umbilical cord and the umbilical cord will quickly

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shrivel and become black or mummify the umbilical cord, then release it. Protein
as a form of essential body bonds in breast milk will accelerate the wound healing
process at the base of the umbilical cord so that the release of the umbilical cord is
faster(Simanungkalit & Sintya, 2019)

In addition, breast milk has the advantage of being anti-infective and anti-
inflammatory, and contains antibodies so that it can protect the baby's umbilical
cord from infection and help the healing process. In the process of leukocyte
infiltration at the base of the umbilical cord, IgA is the most important
immunoglobulin and direct antibacterial against pathogenic bacteria in the
umbilical cord. T and B lymphocytes function as antibody synthesis, these
antibodies will form specific immunoglobulins against antigens that cause
bacteriostatic effects. This effect can prevent the growth of pathogenic bacteria,
thereby preventing infection and accelerating the release of the umbilical
cord(Simanungkalit & Sintya, 2019)

According to the author's assumption, by using breast milk as a medium for
umbilical cord care, the faster the umbilical cord is needed, to accelerate the
release of the newborn's umbilical cord so as to prevent infection in the newborn's
umbilical cord.
When removing the umbilical cord of a newborn using gauze

Based on Table 4 shows that newborns who were respondents in the umbilical
cord care group with dry gauze (control), most of their umbilical cord
detachments were in the normal category, namely 6 respondents (60%). the
average time of umbilical cord detachment in the control group using Kassa with
a total of 10 respondents, the mean or average value of 6,9000, the median value
of 7.00 Standard Deviance 0.994 and the minimum value of 5 days of umbilical
cord separation and a maximum of 8 days.

This research is in line with the research results (Budiarti, Astrida, 2017)the
average umbilical cord release with sterile gauze is 5-7 days, while the average
umbilical cord removal with alcohol gauze is > 7 days. Mann Whitney statistical
test showed that there was a difference in the effectiveness of using sterile dry

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gauze compared to alcohol gauze on the length of umbilical cord detachment p =
0.000 (p<a=0.05).

Sterile dry gauze in several studies has the benefit of protecting the umbilical
cord from exposure to bacteria and can accelerate wound healing. (Megalina
Limoy, 2019)

Caring for the umbilical cord properly and according to standards, namely
using sterile dry gauze is to keep the umbilical cord dry and clean. Caring for the
umbilical cord using sterile dry gauze can keep the umbilical cord dry and clean,
thereby reducing the risk of infection which can affect the length of time the
umbilical cord is released in newborns.(Megalina Limoy, 2019)

According to the author's assumption, umbilical cord care using sterile dry
gauze is to keep the umbilical cord dry and clean. Caring for the umbilical cord
using sterile dry gauze can keep the umbilical cord dry and clean throughout the
day, so that the umbilical cord in newborns will be released normally without any
side effects.

Differences in the length of the release of the baby's umbilical cord using
topical breast milk and dry gauze

Based on table 5 it is known The mean rank forlompok Topical Breast milk 5.60
and sum of rank 56.00 while group kcontrol (gauze) the mean rank is 15.40 and
the sum of ranks is 154.00. and fromStatistic test results Mann Whitneywith the
two tail hypothesis shows a p value of 0.000 which is smaller than alpha 0.05, sso
that Ho is rejected which means There is a significant difference in umbilical cord
care using topical breast milk and dry gauze on the timing of the release of the
umbilical cord for newborns.
The results of this study are in line with research conducted by (Medhina,
2020)The average time to release the umbilical cord using breast milk is 4 days,
while the average time to release the umbilical cord using dry gauze is 7 days.
There was a significant difference in the length of time the umbilical cord was
released using breast milk with dry gauze with p-value = 0.05.

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The use of breast milk as a medium for umbilical cord care is due to the
nutritional content contained in breast milk itself. One of the contents of breast
milk is protein, protein functions as a form of essential body bonds, regulates the
balance of body fluids, maintains neutralization of the body by reacting to acids
and bases so that the body's pH is balanced, forms antibodies, and plays an
important role in transporting nutrients into tissues.
Sterile dry gauze in several studies has the benefit of protecting the umbilical cord
from exposure to bacteria and can accelerate wound healing. sterile dry gauze is to
keep the umbilical cord dry and clean. Caring for the umbilical cord using sterile
dry gauze can keep the umbilical cord dry and clean, thereby reducing the risk of
infection which can affect the length of time the umbilical cord is released in
newborns.(Megalina Limoy, 2019)

Breast milk also contains lymphocytes which consist of 2 cells, namely B
cells and T cells. B cells function as homomoral immunity, immunoglobulin
receptors that can recognize foreign antigens and can develop as plasma cells
forming anibodies. T cells function as helper B cells in forming antibodies, have
special receptors for antigens and play a role in suppressing the immune response.
Physiologically when there are foreign objects in the body, B cells or T cells will
be activated and make a response to macrophages to fight foreign objects, as a
result B cells and T cells will proliferate with macrophages and mitotic division
occurs. After division occurs, the umbilical cord will dry quickly so that this
process will accelerate the release of the umbilical cord(Medhina, 2020)

The nutritional content in breast milk such as fat, carbohydrates, minerals,
vitamins, and proteins as well as the composition of breast milk that changes at
each stage such as colostrum, transitional / transitional breast milk, mature breast
milk plays an important role in every phase of wound healing in the talcent.
Nutrients such as colostrum (formation of antibodies / globulins), fat (formation /
regeneration of cells), lactobacillus (activator of the immune system), lactoferin
(inhibits bacterial growth) and carotene (inhibits the growth of germs) indirectly
play an active role in cell regeneration and help wound healing process in the
umbilical cord. By using breast milk as a medium for umbilical cord care, the

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required umbilical cord release time is faster, cost-efficient and proven to be
effective and safe to use as an alternative media for umbilical cord care.(Hartanto
& Purwanto, 2016)

According to the author's assumptions, protein content, nutrition, rich in
nutrients contained in breast milk are more effective to be used as a way of caring
for the newborn's umbilical cord to accelerate the release of the newborn's
umbilical cord, perform topical treatment of breast milk using sterile techniques,
and wash hands first. thus avoiding infection of the umbilical cord in newborns.
so that it can reduce the risk of infection which can affect the length of the release
of the umbilical cord in newborns.

RESEARCH LIMITATIONS

During this research, there were limitations that hindered the course of the
research faced by researchers, namely at the time this research was carried out it
was still in good condition The Covid-19 pandemic which caused a limited
number of respondents who gave birth at PMB Misliana because before giving
birth the Covid 19 screening was carried out and an antigen swab examination
was carried out to detect the Sars virus. Cov-2 so that researchers need a lot of
time to meet the number of respondents required in this study

CONCLUSION

The average umbilical cord detachment with umbilical cord care using topical
breast milk was an average of 4 days and using gauze an average of 7 days, There
is a significant difference in umbilical cord care using topical breast milk and dry
gauze on the timing of the release of the umbilical cord for newborns because
treatment using topical breast milk releases faster than using only dry gauze.

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THE RELATIONSHIP OF EXCLUSIVE BREAST MILK WITH BABY
GROWTH AND DEVELOPMENT 6-12 MONTHS AGES IN BUKIT BIRU

SUB-DISTRICT TENGGARONG YEAR 2021

Dwi Astuti1, Hj. Umi Kalsum2, Nursyahid Siregar3, Joko Sapto Pramono4
Student of the Applied Midwifery Study Program, Poltekkes Kemenkes Kaltim

Lecturer of the Department of Nursing, Poltekkes Kemenkes Kaltim
Lecturer of the Department of Midwifery, Poltekkes Kemenkes Kaltim

Lecturer of the Department of Nursing, Poltekkes Kemenkes Kaltim

Abstract: Preliminary :Mother's Milk is a liquid milk produced naturally by the
breast glands which is highly nutritious and good for babies. Breastfeeding should
be given to infants because it greatly affects the growth and development of
babies. The age of 0-24 months is a period of rapid growth and development, so it
is often termed the golden period as well as a critical period. So it is necessary to
increase knowledge and awareness for mothers to provide exclusive breastfeeding
to support the growth and development of babies.
Methods :The research method was retrospetive, the population of infants aged 6-
12 months in the Bukit Biru Public Health Center.
Results:From the results of the Chi Square Test with the Alternative Likelihood
Ratio Test, it was found that p value = 0.077 > 0.05, Ha failed to be accepted and
Ho was accepted, meaning that exclusive breastfeeding was not related to infant
growth. The results of the chi square statistical test with Fisher's exact test value
obtained p value = 0.028 (p < 0.05). This means that there is a relationship
between exclusive breastfeeding and infant development.
Conclusion: Babies who get exclusive breastfeeding with a good stimulus will
also have better development.

Keywords:: Exclusive Breastfeeding, Growth, Development

INTRODUCTION

Mother's Milk (ASI) is a liquid in the form of milk that is produced naturally
by the breast glands which is highly nutritious and very good for babies
(Mufdlilah et al, 2019). Breastfeeding is one of the efforts to prevent death and
malnutrition in infants and toddlers. The World Health Organization (WHO)
recommends that newborns be breastfed until the age of 6 months without
providing other food or fluids. According to the United Nations Children's Fund
(UNICEF), in 2012 as many as 30,000 infant deaths in Indonesia and 10 million
under-five deaths in the world each year could be prevented through exclusive

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