The Role Of Midwives And Participation Of Postpartum Mothers In Postpartum Family Planning

Background: Postpartum birth control is one of the family planning programs that still have low coverage. Midwives have a big role in increasing postpartum family planning coverage. Postpartum mothers will often contact the midwife so that the midwife can advise the postpartum mother to use postpartum birth control. The aim of this study is to evaluate the role of midwives and postpartum mothers in the use of postpartum family planning in the Asahan regency Methods: This study used a cross-sectional design, the location study was Asahan regency, and the population was 81 postpartum mothers in Asahan Regency. The researcher used purposive sampling with the criteria of giving birth in the last one month and having more than two children. The instrument used was a questionnaire. This research will conduct crosstabulation distribution. Results: The results of the cross-tabulation showed that 24 birth control users at the midwife's clinic gave birth at a midwife clinic, 18 people gave birth at a midwife clinic (22.2%), and 21 people had postnatal health checks (25, 9%), received advice on using postpartum family planning as many as 15 people (18.5%) and received family planning counselling after delivery as many as 14 people (17.3%). This study indicated that postpartum family planning was carried out in the midwife clinic as many as 18 people (22.2%) and in the hospital or public health centres as many as nine people (11.1%). Conclusion: Postpartum mothers who do postpartum health checks to midwives are more likely to use postpartum family planning than postpartum mothers who do not undergo postpartum health checks. Postpartum mothers who advised to use postpartum family planning from a midwife will have a greater risk of using postpartum FP than postpartum mothers who do not receive postpartum FP. ARTICLE HISTORY Received : May 10 th , 2021 Accepted : October 21 th , 2021


INTRODUCTION
The population explosion phenomenon is a social phenomenon that has attracted a lot of world attention from year to year. This is marked by a drastic increase in the world's population. In the early 19th century, the world's total population crossed the 1 billion people threshold for the first time in history. Since then, the growth rate has been increasing steadily, reaching very high peaks in the 20th century and slowing slightly after that. The total world population reached 7 billion after 2010 until now, and it is estimated that this figure will continue to grow to reach 9 billion by 2045 ( Van Bavel, 2019).
Based on data from the Population Reference Bureau (PRB), Indonesia has a major influence on the high world population. Indonesia is in the fourth rank as a country that contributes to a fairly large population of 268.4 million after China (1,398.0 million), India (1,391.9 million) and the United States (329.2 million) (Population Reference Bureau, 2019). The total population of Indonesia based on BPS data in 2018 was 265.0 million people with a population growth rate of 1.33 per year (Badan Pusat Statistik, 2019). Indonesian population experts estimate that the population will continue to increase between 293-384 million people in 2050.
With an uncontrolled growth rate and an unbalanced population distribution according to the carrying capacity of nature and the carrying capacity of the environment, a large population will become a problem and a burden for the people and state of Indonesia (Tjaja, 2020). In terms of quantity, the large population means that there will be problems in providing clothing, food and shelter. Meanwhile, in terms of quality, it can be seen from Indonesia's competitiveness with other nations in the world. It will impact the social, economic, political and state defence and security sectors (Dirjen Kemenkeu RI, 2015).
Postpartum family planning services are part of the postpartum service using contraceptives by mothers or husbands immediately after birth until 42 days after that. Previously during pregnancy, mothers should also receive counselling and counselling about postpartum family planning. According to Noriani (2017), postpartum mothers are motivated to use postpartum family planning, especially for homemakers and higher education. Agustina (2017) said that mothers and their husbands get advice about when the fertile period will return in postpartum family planning services, the right time to start sexual activity, and the right contraception during the lactation period. Postpartum contraception aims to reduce unmet need, a group of women who need but not fulfilled. Kusumaningrum (2017) said that there are so many postpartum mothers who are resistant to postpartum family planning. This is attributed to postpartum mothers' lack of understanding about postpartum family planning or their use of postpartum family planning outside of the recommended three months postpartum period.
North Sumatra Province is one of the provinces that has experienced a decline in the number of family planning users in Indonesia. In 2014 the number of family planning users in North Sumatra Province was 51.87%, then decreased to 49.06% in 2015, then decreased again in 2016 to 48.65% than in 2017 to 47.61%, and in 2018 it again experienced a decline to 47.84% (BPS RI, 2019). The decrease in the number of family planning users in North Sumatra Province followed by an increase in the population growth rate in North Sumatra Province in 2000-2010 from 1.1 to 1.27 in 2010-2018% (BPS RI, 2019).
The low postpartum family planning in the Province of North Sumatra has made the BKKBN of North Sumatra Province make a breakthrough by training on postpartum family planning for districts or cities in North Sumatra Province. Asahan District was one of the first three districts to receive postpartum family planning training in 2016 together with Medan City and Deliserdang Regency. It hoped that postpartum family planning training could improve the skills of family planning field officers to provide family planning counselling to pregnant women so that pregnant women are willing to plan a family planning program during childbirth. Agustina (2017) said one of the health services provided during the postpartum period is postpartum visits conducted by midwives by providing counselling and counselling to mothers and families regarding postpartum family planning. Midwives advice regarding birth spacing or termination of subsequent fertility will strengthen their wishes about postpartum family planning adaptation. Midwives are the personnel who provide services to postpartum mothers; the role of midwives will significantly impact the decision of postpartum mothers in using postpartum birth control dua (Juliaan, 2015).
Midwives should be more intense in disseminating the use of post-birth and postmiscarriage contraceptives through advocacy for information, education and communication, especially MKJP instruments (MOP, MOW and IUD). According Stephen (2017) said postpartum mothers who have good attitudes and knowledge will have a high tendency to use postpartum family planning. Midwives have a big role in increasing the knowledge and attitudes of postpartum mothers in using postpartum family planning so that postpartum mothers will tend to use postpartum family planning.
The results of the Wahyuni (2019) research found that poor postpartum family planning achievement was attributed to postpartum mothers' lack of awareness about postpartum family planning. Midwives who do not have postpartum care contribute to the poor rate of postpartum family planning. The results of the Sari (2017) study show that there are still many midwives who have not carried out their duties in counselling mothers who are prospective family planning acceptors, so that the public's knowledge about postpartum family planning is still lacking. The aim of this study is to evaluate the role of midwives and postpartum mothers in the use of postpartum family planning in the Asahan regency.

MATERIAL AND METHOD
This research conducted using a cross-sectional study design because this research was conducted simultaneously for the dependent and independent variables. This study used a quantitative research approach in Asahan Regency, especially West Kisaran and Rawang Panca Arga districts, North Sumatra Province. This research conducted in the District of West Kisaran and Panca Arga Rawang District of Asahan Regency for the District of West Kisaran is one district that has field officers who never received training in FP postpartum. Panca Arga Rawang District, where midwives have not received training but located close to West Kisaran District. Asahan Regency also has a fairly high population rate compared to other districts in North Sumatra Province. This research conducted from September 2020 to November 2020.
This study population were all postpartum mothers who had just given birth in Asahan Regency during the last three months. Based on data from the Health Profiles of North Sumatra Province in 2020, the number of deliveries from August to October 2020 in Asahan District was 416 postpartum mothers, then postpartum data in West Kisaran and Panca Arga districts were 81 postpartum mothers. Researchers took samples in this study as many as 81 postpartum mothers. The researcher used purposive sampling with the following criteria: postpartum mothers were in the study area for the last six months, gave birth in the last one month and gave birth to more than two children.
This study used primary data, which contains a questionnaire about the role of midwives in postpartum maternal participation in postpartum family planning, characteristic postpartum mothers and the participation of postpartum mothers in following postpartum family planning. Secondary data in this study used data from the Family Planning Office of Asahan Regency, data from West Kisaran and Panca Arga Districts. This study used a standard questionnaire instrument, namely the Program Performance and Accountability Survey (SKAP) questionnaire from the National Population and Family Planning Board. Researchers did not test the validity and reliability of the research instrument because they had used a standard questionnaire.
In this study, the univariate analysis used to see the role of midwives for postpartum family planning programs and the participation of postpartum mothers in postpartum family planning programs. This analysis conducted to provide a descriptive description or describe the characteristics of each of the variables studied. The description of these characteristics depends on the type of data categorical. In this study, the data to be analyzed are categorical data types so that the description of this data uses a frequency distribution with a percentage or proportion. The data analysis that will use in this research with cross tabulation.

RESULTS
This analysis aims to describe each variable's characteristics, namely knowing the age, education, knowledge, attitudes, training and performance of midwives in providing antenatal care services as many as 81 postpartum mother (Table 1). In the table 1, most respondents were 19-34 years old, as many as 56 people (69,1%), and those over 35 years old were 25 people (30,9%). Most education in this study was in higher education as many as 48 people (59.3%) and low education as many as 33 people (40.7%). Health insurance ownership found to have health insurance for 41 people (50.6%), and 40 people (49.4%) did not have health insurance. The results of this study indicate that respondents who work as many as 11 people (13.6%) and respondents who do not work as many as 70 people (86.4%).
Respondents who had previously used contraception were 57 people (70.4%), and respondents who had never used contraception before giving birth were 24 people (29.6%). Respondents who used postpartum family planning were 27 people (33.3%), and respondents who did not use postpartum family planning were 54 people (66.7%). The results of this study indicate that the last pregnancy check was carried out by respondents at the midwife's clinic as many as 73 people (90.1%), and the last pregnancy examination was carried out at the hospital or Puskesmas as many as eight people (89.9%). This study indicates that the most respondent places for delivery are in the midwife clinic as many as 57 people (70.4%), and the place for delivery in the hospital or public health centre is 24 people (29.6%). The results of this study indicate that 62 postpartum mothers did postpartum health checks (76.5%) and postpartum mothers who did not undergo postpartum health checks were 19 people (23.5%). The results of this study showed that 49 midwives advised on the use of postpartum family planning (60.5%) and 32 midwives who did not provide advice on the use of postpartum family planning (39.5%).
This study showed that the midwives explained the use of postpartum family planning to as many as 46 people (56.8%), and the midwives did not explain the use of postpartum family planning as many as 35 people (43.2%). The results of this study indicate that the place of mothers who get postpartum family planning at the midwife clinic is 18 people (22.2%) and nine people get postpartum FP at the hospital or public health centre (11.1%) and postpartum mothers who do not use family planning postpartum as many as 54 people (66.7%). This study shows that there were 73 respondents (90.1%) who conducted examinations at the midwife's clinic and 24 respondents who used postpartum family planning (29.6%), and those who did not use postpartum family planning were 49 respondents (60.5%). There were eight respondents (9.9%) who performed antenatal care at the hospital or public health centre, three respondents (3.7%) who used postpartum family planning and five respondents who did not use postpartum family planning (6.2 %). This study shows that there are 57 respondents (70.4%) who gave birth at a midwife clinic and 18 respondents who used postpartum birth control (22.2%), and 39 respondents who did not use postpartum family planning (48.1%). 24 respondents gave birth at the hospital or public health centre (29.6%), nine respondents used postpartum family planning (11.1%) and 15 respondents did not use postpartum family planning (18.5%). ).
This study shows that there are 62 respondents (50.6%) who conducted postpartum health checks at the midwife's clinic and 21 respondents (25.9%) who used postpartum family planning, and those who did not use postpartum family planning were 41 respondents (50, 6%). There were 19 respondents (23.5%) who gave birth at the hospital or public health centre, six respondents (7.4%) who used post-delivery family planning and 13 respondents (16%) who did not use postpartum family planning. This study shows that there are 49 respondents (60.5%) who get suggestions for using postpartum family planning from midwives, and respondents who use postpartum family planning are 15 respondents (18.5%), and respondents who do not use postpartum FP are 34 respondents (42 %). There were 32 respondents (39.5%) who did not get advice on the use of postpartum family planning from midwives, 12 respondents who used postpartum family planning (14.8%) and 20 respondents who did not use postpartum family planning (24, 7%).
This study shows that there are 46 respondents (56.8%) who get explanations of postpartum family planning from midwives and 14 respondents who use postpartum family planning (17.3%), and 32 respondents who do not use postpartum family planning (39, 5%). Respondents who did not get an explanation of postpartum family planning from midwives were 35 respondents (43.2%), then respondents who used postpartum family planning were 13 respondents (16%), and respondents who did not use postpartum family planning were 22 respondents (27.2%).

DISCUSSION
Midwives play an important role in the implementation of postpartum family planning. Midwives are health care professionals who assist mothers during pregnancy and childbirth. When the midwife suggests a suggestion, it hoped that postpartum mothers could follow it, including postpartum family planning. According to Tawakal (2018), midwives play an important role in providing postpartum family planning, especially when midwives provide health services when the mother performs pregnancy and postpartum examinations. Through promotion and information, midwives can provide knowledge and support to postpartum mothers to change their behaviour and decide to use postpartum family planning. According Abbas, (2017) said postpartum mothers do not immediately use contraception because they are still confused about which contraceptive method they will use, so it is necessary to provide information about the choice of contraceptive method or method at this time. This study shows that there are 49 respondents (60.5%) who get suggestions for using postpartum family planning from midwives, and respondents who use postpartum family planning are 15 respondents (18.5%), and respondents who do not use postpartum FP are 34 respondents (42 %). There were 32 respondents (39.5%) who did not get advice on the use of postpartum family planning from midwives, 12 respondents who used postpartum family planning (14.8%) and 20 respondents who did not use postpartum family planning (24, 7%).
The results of the Azizah (2018) study indicate that the information provided by midwives will have an impact on the use of postpartum contraception. The results of the Lestari (2018) study show that the intention to use family planning after delivery is very good; if the midwife provides good information, it will increase the use of postpartum birth control. Wahyuni (2019) research results showed that someone who received family planning counselling would have a 1.544 risk of using postpartum family planning than postpartum mothers who did not receive family planning counselling.
The midwife did counselling at home, but the postpartum mother turned out to be giving birth services to the hospital. The midwife stated that she had visited the maternity house several times; however, the maternity mother stated that she had received delivery services from the hospital, so she did not receive delivery services from the midwife. Mingchilina (2017) revealed that the way midwives carry out activities in providing contraception is already good; it is just that sometimes officers are not consistent in providing services, so acceptors do not feel comfortable. Midwives who have received training in the latest contraceptive techniques (CTU) will greatly impact contraceptive services.
The results of the Sembiring (2020) study show that postpartum mothers who get information from good health workers will become postpartum family planning acceptors. The need for information and counselling about sexual life and contraception is one of the most frequently asked questions in postpartum. There is a high probability that most mothers avoid sexual intercourse during pregnancy and after delivery. Wulandari (2020) said health workers play an important role in providing information about postpartum family planning methods to family planning acceptors; this must be started from the beginning of the antenatal visit and continued until labour and postpartum . According to Manik, (2019), the counselling provided by the midwife will help clients choose a suitable family planning method and help them continue to use this method correctly.
According Sitorus (2018) said postpartum birth control is very important because the return of fertility to a mother after giving birth is unpredictable and can occur before the arrival of the menstrual cycle, even in breastfeeding women. The first ovulation in a non-breastfeeding woman occurs 34 days postpartum, even earlier. This causes during breastfeeding; women often experience unwanted pregnancies at intervals close to previous pregnancies. Contraception should be used before sexual activity begins; therefore, it is very strategic to start contraception as early as possible after delivery.
This study shows that there are 46 respondents (56.8%) who get explanations of postpartum family planning from midwives and 14 respondents who use postpartum family planning (17.3%), and 32 respondents who do not use postpartum family planning (39, 5%). Respondents who did not get an explanation of postpartum family planning from midwives were 35 respondents (43.2%), then respondents who used postpartum family planning were 13 respondents (16%), and respondents who did not use postpartum family planning were 22 respondents (27.2%). Midwives do not provide postnatal family planning counselling because many postpartum mothers provide postnatal services to hospitals so that midwives do not come to postpartum mothers' homes. When postpartum mothers provide postpartum services, it turns out that many postpartum mothers stated that they did not get an explanation about post-delivery family planning by health workers (doctors and midwives) at the hospital.
The results of the Wahyuningsih (2017) study showed that the low postpartum family planning coverage was due to postpartum mothers not getting enough information about postpartum family planning. Postpartum mothers are still afraid of foreign objects in the uterus, afraid that the IUD will come out by itself. The explanation of the midwife is an important part of increasing the knowledge of postpartum mothers about postpartum family planning. Rufaindah (2019) the study showed that postpartum family planning counselling affects the use of postpartum contraception.
Providing family planning counselling and contraceptive methods during the perinatal period can increase maternal awareness to use contraception. Khotimah (2016) and Musmundiroh (2019) the study showed that postpartum family planing counselling will significantly impact the use of postpartum family planning; when given postpartum family planing counselling, it will increase the use of postpartum family planning. The results of the Kurnia (2015) study showed that an increase in the use of injectable contraceptives as the main choice in using postpartum family planning. Mothers consider injection contraceptives to be simpler and more comfortable, not complicated; mothers are afraid to use IUDs because there are stories in the community that fail to use IUDs, when menstruation is more blood and tends to be longer, can run around in the stomach, uncomfortable with intercourse and pain stomach. Midwives in providing postpartum family planning explanations have a very important role in providing comfort for mothers in determining and using postpartum family planning.
According Abbas, (2017) said counselling gives knowledge to mothers who do not know and reminds mothers who already understand about family planning. This new knowledge will be tried for mothers who know and understand about family planning, especially if they feel it will be useful or needed. Counselling using midwife by trained personnel when given during labour is certainly very effective in a mother's memory because shortly after counselling, she immediately experiences labour which most women consider as a painful experience. Counselling to midwives will provide the widest possible opportunity for mothers to choose and use the family planning method that best suits their needs (informed choice) and their medical conditions. According Sulistyorini (2018) said postpartum mothers can increase their knowledge about postpartum contraception through various media and be more active in visiting midwives to get correct and accurate information about postpartum contraception. The high interest in postpartum contraception should be followed up immediately by following or being one of the acceptors for postpartum contraception to avoid risks due to unplanned pregnancy. Midwives have a very important role in providing services to the community, especially at the public health center. The role of these officers includes promotive, preventive, curative and rehabilitative efforts. The role of health workers for pregnancy and childbirth women is to increase knowledge, change behaviour, and increase compliance to improve the quality of life.
It hoped that the increasing frequency of ANC visits would increase exposure to family planning information. Three models of respondents' exposure to family planning information during MCH service visits, namely counselling for health workers, discussions with patients and exposure to information, education and communication. During pregnancy and baby health visits, nearly 80% of women reported seeing information, education and communication material. Efforts are needed to improve the quality of ANC services by providing information about family planning from health workers. It can be concluded that counselling during ANC visits is used as a strategy to introduce contraception to increase the use of post-partum contraception; this is also an effort to support labour planning programs and prevention of complications.

CONCLUSION
The majority of postpartum mothers receive postpartum family planning at midwife clinics (29,6%) and hospitals or health centres (3,7%), but many postpartum mothers do not use postpartum family planning (66,7%). Postpartum mothers who do postpartum health checks to midwives are more likely to use postpartum family planning than postpartum mothers who do not undergo postpartum health checks. Postpartum mothers who advised to use postpartum family planning from a midwife will have a greater risk of using postpartum FP (60,5%) than postpartum mothers who do not receive postpartum FP (39.5%). Counselling given by midwives will make postpartum mothers use postpartum family planning (56,8%)compared to postpartum mothers who do not receive counselling from midwives (43,2%).
Midwives are expected to continue to provide services for postpartum visits to postpartum mothers and then provide postpartum family planning counselling to postpartum mothers to increase the use of postpartum family planning. Postpartum mothers should actively ask about the postpartum family planning program to increase the utilization of postpartum family planning.

ACKNOWLEDGEMENT
The researcher would like to thank the North Sumatra Provincial BKKBN for assisting in financing this research and the UINSU FKM for permitting to carry out this research. Researchers would like to thank the Asahan district government for assisting with the administration of this research.