The Effect of Breastfeeding Management Training on The Understanding of Exclusive Breastfeeding in Third Trimester Pregnant Women

Exclusive breast milk is the main food for infants aged 0-6 months. Malang City is one of the cities in East Java which still has less than optimal coverage of exclusive breastfeeding than the set target. One of the factors that cause mothers not to give exclusive breastfeeding is because the working mother. The purpose of the study was to determine the effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women. The design of the study used a quasi-experimen-tal using one group pre-test – post-test design. The sample was third trimester pregnant women who work and get health services in Pandanwangi Public Health Center Malang which met the inclusion criteria of 35 people by total sampling technique. Breastfeeding Management Training was conducted in three meetings. Most of the pretest results (60%) were in the sufficient category, and almost all of the posttest results (97%) were good. The results of hypothesis testing with the Wilcoxon Signed Rank Test, the Z value obtained -5.166 with a p value (Asymp. Sig 2 tailed) of 0.000 (<0.05), proving that there was an effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Public Health Center, Malang City.


INTRODUCTION
Proper breastfeeding will reduce poverty and hunger. With the level of intelligence and optimal emotional development will affect the readiness of children to go to school. Breast milk contains various nutrients that are easily digested and needed in the growth and development process for babies (Wiji, 2013). Exclusive breastfeeding can be useful as a source of nutrition, increase the baby's immune system, increase the baby's intelligence, and increase affection. As for the mother herself, breastfeeding can reduce bleeding after giving birth, accelerate the recovery of the uterus to its original shape, as a method to space pregnancies, reduce the possibility of suffering from cancer (Elisabeth & Purwoastuti, 2017) Exclusive breastfeeding can reduce infant mortality due to infection by 88%. A total of 31.36% of 37.94% of children were sick because they did not get exclusive breastfeeding (Ministry of Health, 2017). According to (Williams & Wilkins, 2011) stated the long-term impact for babies who do not get exclusive breastfeeding will experience growth and development disorders such as children in stunting (short), wasting (thin), stunted brain development and cognitive impairment. Breastfeeding has many benefits for both mother and baby, but currently there are still many mothers who have not given exclusive breastfeeding. The coverage of exclusive breastfeeding for infants 0-6 months nationally in Indonesia is 35.73%, this is still far from the target set, which is 80%. Meanwhile, for East Java Province, exclusive breastfeeding coverage is still lower than the national coverage, which only reaches 34.92% (Kemenkes, 2017).
Based on the results of research conducted by (Sulistyowati & Siswantara, 2014) stated that of 34 respondents as many as 22 people did not give exclusive breastfeeding because the mother worked and 12 people gave exclusive breastfeeding. This is similar to research conducted by (Holy et al., 2018), which said that mothers felt that breast milk was not sufficient for the baby's needs, so babies were given supplements from an early age. Their concern occurs because of a poor understanding of the adequacy of breast milk for babies. The low level of public understanding about exclusive breastfeeding should be a concern. The provision of understanding and techniques of breastfeeding management must be conveyed to the community.
Breast milk management or what is known as breast milk management is the management of breast milk taken by expressing it from the breast to be stored and later given to the baby (Maryunani, 2017). This breastfeeding management technique can be used as a solution in overcoming the failure of exclusive breastfeeding, especially for working mothers, although in the process the mother will give breast milk indirectly to her baby (Merdhika et al., 2014) Based on research conducted by (Merdhika et al., 2014) shows that there is an effect of counseling on exclusive breastfeeding on the knowledge of breastfeeding mothers. However, increasing understanding of exclusive breastfeeding is not always through counseling, but can also be done through training activities. Training is a series of activities designed to increase understanding, expertise, change in an individual's attitude (Santoso, 2010). Training can also be used for certain skills for today's needs. Thus, it can be concluded that breastfeeding management training is an effort to develop and improve the mother's ability to understand the management of exclusive breastfeeding in order to increase mother's awareness of the importance of breastfeeding her child with breast milk properly and correctly, especially for working mothers.
Malang City is one of the cities in East Java which still has less than optimal coverage of exclusive breastfeeding than the set target. In 2018, the number of babies who were exclusively breastfed was 81.67% or 5421 births. This is something that needs to be considered by both the government and health actors because breastfeeding is still not optimal in the city of Malang. According to WHO, there are several factors that cause mothers not to give exclusive breastfeeding, including; Insufficient breast milk, fear of changes in breast shape, practicality of formula milk, weight loss with postnatal exercise and the highest is the high number of mothers who have to return to work after giving birth. The factor of mothers who work and look for work has a significant increase from year to year. Based on labor force data sourced from the Malang City BPS in 2017, there were 411,042 working women and an increase in 2018 which was 454,849 people. It is estimated that there will be an increase of 40,000 female workers in 2019 (BPS: 2018). Therefore, more intensive training on the provision of expressed breast milk to mothers since pregnancy is one of the optimal choices for the success of exclusive breastfeeding, especially for working mothers.
Based on the data above, it can be seen that there is an increase in female workers in Malang City, so it is suspected that the increase in female employment opportunities in Malang City is inversely proportional to exclusive breastfeeding. The phenomenon of the lack of exclusive breastfeeding is caused by several factors, including inadequate knowledge of mothers about exclusive breastfeeding, the circulation of myths that breastfeeding is not good for example breastfeeding will reduce the beauty of the breast, as well as busy working mothers and short maternity leave (Roesli, 2004). Given the benefits of breastfeeding, namely the baby gets the best nutrients and enzymes needed, the baby gets immune substances as well as protection and warmth through skin contact with his mother, increasing the mother's sensitivity to the needs of her baby, reducing bleeding. Working mothers do not necessarily become an obstacle to give breast milk every day. One effort that can be done is to express breast milk and then store the expressed milk properly so that the benefits are not reduced.

METHODS
The study was a Quasi Experiment using one group pretest -posttest design. There was only one experimental group which was given a pretest and posttest and no control group. The respondents were given a pretest before being given training and after being given training, they were given a post test to measure the understanding of milk management. The pretest and posttest were conducted by using a questionnaire. The population in this study was 35 people with a sample size of 35 people. The sampling technique used total sampling. The inclusion criteria were the willingness to be research subjects and pregnant women who attend training for 2 meetings. The exclusion criteria were respondents who did not attend the training twice. The data collection was carried out on February 8 -February 29, 2020.
The instrument used a questionnaire. The questionnaire was used for understanding Breastfeeding was compiled by the researcher and tested the validity of the product moment correlation formula from Pearson and reliability in the test instrument with the help of computer software, and analyzed the data with the Cronbach Alpha reliability value.
The location of this study was carried out in Puskemas Pandanwangi which is on Jalan Laksda Adi Sucipto No 315 Pandanwangi Blimbing District, Malang City.

RESULT
The study results are grouped into two general data and specific data. General data presents the characteristics of respondents including: age, level of education, type of work and gravida. While the specific data presented are the results of the pretest and post-test on the understanding of exclusive breastfeeding in third trimester pregnant women. Based on the Table above, it is found that most of the respondents are pregnant women who have an age range of 21-30 years, amounting to 57% and almost half of the education level is high school graduates (46%). The type of work of the respondents is mostly private employees (51%) and almost half of the respondents (40%) are the second pregnancy.
After knowing the general data, then special data is presented which includes the results of the pre-test and post-test on the understanding of exclusive breastfeeding in third trimester pregnant women and the analysis of the effect of training on the management of expressed breastfeeding on the From the results of the posttest, the level of understanding of pregnant women after the training in the management of breastmilk was obtained that almost all their understanding was good (97%).
Based on Table 4 it can be seen that prior to the implementation of milk milk management training, the level of understanding of most mothers was in the moderate category (60%) and after being given training there was a significant increase in understanding in the good understanding category, understanding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Public Health Center Malang.

Level of Understanding
Frequency (%)    namely 34 in the good category respondents or 97% of the total study sample. Analysis of the effect of milk milk management training on the study will be tested for normality as a parametric test requirement on the results of the pre test and post test. The results of the normality test using the Shapiro-Wilk test method obtained p = 0.964 with a significance of 0.309 where p> 0.05. These results indicate that the data is normal and can be continued with a parametric test, namely the Wilcoxone test.
Based on the results of the calculation of the Wilcoxon Signed Rank Test, the Z value obtained is -5,166 with a p value (Asymp. Sig 2 tailed) of 0,000 which is less than the critical limit of 0.05. Then a decision can be taken to reject H0. This proves that there is an effect of breastfeeding management training on the understanding of exclusive breastfeeding in third trimester pregnant women at Pandanwangi Health Center, Malang City.

DISCUSSION
The mother's level of understanding was mostly in the sufficient category (60%) at the beginning of the study and after being given training there was an increase in understanding in the understanding category, namely in the understanding of the good category as many as 34 respondents or 97% of the totalsample. This shows the importance of providing training in increasing understanding, especially the understanding of exclusive breastfeeding in third trimester pregnant women. Based on the calculation of the Wilcoxon Signed Rank Test, the Z value obtained is -5,166 with a p value (Asymp. Sig 2 tailed) of 0.000 so it can be concluded that there is an effect of breastfeeding management training on understanding of exclusive breastfeeding in third trimester pregnant women in Pandanwangi Public Health Center Malang City.
This Expression breasfeeding management training can efficiently improve mothers' understanding of exclusive stfeeding. It can be seen from all the mother's answers to the questionnaire that has been given by the researcher. Almost all aspects of both the technique of expressing, the technique of storing, the technique of breastfeeding and the benefits of breastfeeding have the correct answer. This shows that training is effective in increasing mothers' understanding of exclusive breastfeeding. The training carried out can provide knowledge and understanding to mothers about the importance of exclusive breastfeeding to increase immunity and intelligence. This is in accordance with the results of the service activities of Wijayanti, et al (2017) which stated that it was important to increase knowledge and understanding of breastfeeding for breastfeeding mothers because breast milk is the best food that contains nutrients, enzymes, hormones as well as immunological and anti-infective substances. Pregnant women who have received training are expected to be able to provide exclusive breastfeeding to their babies. The period of exclusive breastfeeding is the most sensitive period in a mother's life, both physically and emotionally. Thus, positive support is needed from all parties so that working mothers can feel comfortable and confident for exclusive breastfeeding. Mothers who work can express breast milk and store breast milk well and can provide breast milk to babies. Pregnant women who work are expected to be able to practice in accordance with the management training of Expressing breast milk (expressing, storing and serving it) so that the baby continues to receive exclusive breastfeeding.
Breastfeeding management training that has been provided by the researchers can increase the understanding of pregnant women about exclusive breastfeeding. The benefits of the breastfeeding management training can increase knowledge and open up participants' insight about exclusive breastfeeding so that it can be maintained and increase the health status of the community (mother and baby). In addition, it also motivates maternal and infant health care workers, all groups who care about infant health and the importance of breastfeeding, as well as relevant policy makers to design future actions so that the success rate of exclusive breastfeeding increases both regionally and nationally and improves the quality of life of Indonesian people since his early life.
Breastfeeding management training also increases participants' understanding of breastfeeding management and also improves participants' abilities in breastfeeding counseling and communication skills, especially communication in providing community services. This shows that the better the training on Expressing Breastfeeding followed by the third trimester pregnant women who work, the more skilled and qualified the pregnant women will be in understanding exclusive breastfeeding.
This study is in line with the research of (Fatwa & Darti, 2019) that training through the process of providing knowledge and changing behavior can increase pregnant women's understanding of exclusive breastfeeding. Based on the journal conducted by (Santosa et al., 2019) also stated the importance of breastfeeding training because it significantly increases the knowledge of training participants about breastfeeding, proper and correct breastfeeding procedures, and how to manage breastfeeding when mothers have to work.
Training can motivate mothers to give exclusive breastfeeding and be improved by providing health promotion or counseling widely in the community through various media such as television, radio, magazines, tabloids, newspapers and books on breastfeeding. This is in line with research conducted by (Tiruye et al., 2018), that mothers who received training on breastfeeding were better at understanding exclusive breastfeeding than those who did not attend training.
Giving lectures by expert resource persons and combined with giving demonstrations that can be directly practiced make mothers as training participants able to receive the information conveyed so that mothers understand the importance of exclusive breastfeeding. The process of explaining the knowledge or information that has been given during the training to pregnant women is expected to be translated, interpreted and concluded in the practice of exclusive breastfeeding. The demonstration method is a development strategy by providing a learning experience through the act of seeing and listening followed by imitating the work being demonstrated. This method is also a method used to show a process or the workings of an object related to learning materials (Lisa & Putri, 2019).
Lecture and demonstration methods and exercises, this method is a combination of describing teaching materials with demonstration activities and direct training (practice). There are many benefits from the combination of lectures and demonstrations, among others, the teacher is easy to master the class and easy to organize the class, besides that it is easy to prepare and carry out and is more economical in terms of time. In addition, it provides opportunities for teachers to use their experience, knowledge and wisdom. The combination of training methods with lectures and demonstrations can help trainees to listen accurately, critically, and attentively and can stimulate and increase understanding about exclusive breastfeeding. The coach or instructor can emphasize the things that are important so that time and energy can be used as well as possible. Mothers as trainees can be more focused on the material so that understanding of the material will increase.
The results of Slavin's research (1994) cited in (Subrata, 2016), by showing something new in demonstration activities to students will be able to attract the attention of students to pay attention to the lesson and this attention has an important role in the stimulus captured by sensory motor. It is hoped that by having an interest in this activity, it can arouse the motivation and curiosity of mothers about exclusive breastfeeding. Mother's interest in the material provided encourages mothers to be physically and mentally ready to give exclusive breastfeeding to their babies. This is the main focus that the training provided by the right people will give the right results. So that the breastfeeding management training that has been given is very effective in increasing understanding about exclusive breastfeeding for third trimester pregnant women who work at Pandanwangi Public Health Center Malang City.

CONCLUSION
The conclusion of this study is that the understanding of pregnant women in the third trimester who work before being given milk milk management training is mostly in the moderate understanding category of 60% of the total mothers studied. The understanding of third trimester pregnant women who work after being given training in the management of breastmilk has a good level of understanding at 97%. Breastmilk management training has an effect on increasing understanding of third trimester pregnant women regarding exclusive breastfeeding. Increased understanding of breastfeeding management including the benefits of breastfeeding, expressing breastmilk, storing breast milk and giving breastmilk that has been frozen.

SUGGESTION
Suggestions for health workers, namely milking breastfeeding training can be continued by involving certified instructors and collaborating with local village midwives. Pandanwangi Public Health Center Malang can periodically provide promotions, counseling, and training on breastfeeding in order to increase understanding of exclusive breastfeeding for mothers. Reinforcement of breastmilk support group activities can be carried out at integrated health post activities by following the integrated health post flow.
Suggestions for further researchers The results of this study can be used as comparison and reference material for research, as well as consideration for further deepening further research by focusing on training on breastfeeding management training and understanding of exclusive breastfeeding. As well as linking these variables with different variables and research objects.