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Practices of Midwives in the Use of Personal Protective Equipment when Aid Labor during the COVID-19 Pandemic

Article Info: ABSTRACT Submitted: 03-08-2021 Revised: 29-08-2021 Accepted: 30-08-2021 In the era of the COVID-19 pandemic, the use of personal protective equipment (PPE) is very important to reduce the risk of transmitting infectious diseases to medical personnel because it can prevent contact with pathogens. This shows that midwives as first-line managers of pregnancy, childbirth and postpartum cases must be vigilant by wearing complete Personal Protection Equipment (PPE) so that there is no transmission of the virus from the patient to the midwife. This study aimed to determine the analysis of midwives' practices in using PPE when assisting labor during the COVID-19 pandemic at the Banten Regional General Hospital 2020-2021. This is a quantitative analytic study using a cross sectional approach. The sample in this study was 102 respondents with purposive sampling technique. Data were analyzed using SPSS with Chi Square, which previously tested the validity and reliability. The results showed that the use of PPE in midwives in Banten Hospital obtained an average value of 84.3. Based on age, the average value was 53.9. Based on the length of service, the average score was 96.1. Based on education, the average score is 55.9. The results of the chi-square test showed that all independent variables had no relationship with the use of PPE including knowledge (p = 0.323), attitude (p = 0.665), availability of PPE (p = 0.740), and supervision (p = 0.603). It can be concluded that the use of PPE in midwives has no relationship with knowledge, attitudes, availability of PPE and supervision. There is a need for socialization about the importance of using PPE to midwives in order to maintain the quality of expected care services. There is a need for an K3 unit in Banten Hospital which is one of the authorities. There needs to be special attention from the Hospital Management regarding the supervision of the use of PPE in midwives.


INTRODUCTION
According to the World Health Organization (WHO), the incidence of cancer from 2008 to 2012 has Corona virus disease 2019 (COVID-19) is a disease that is endemic in almost all of the world at this time so that it has been declared a pandemic, with the name of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARSCOV2) virus. It was starting from the Wuhan area, Hubei province, China which reported the first case of pneumonia of unknown cause.
The main clinical symptoms that appear in Covid-19 patients are fever (temperature > 38°C), cough and difficulty breathing. In addition, it can be accompanied by severe shortness of breath, fatigue, myalgia, gastrointestinal symptoms such as diarrhea and other respiratory symptoms. Half of patients develop shortness of breath within one week. In severe cases rapidly and progressively worsens, such as ARDS, septic shock, uncorrected metabolic acidosis and bleeding or coagulation system dysfunction within a few days. In some patients, symptoms appear mild, not even accompanied by fever. Most patients have a good prognosis, with a small proportion in critical condition or even death.
Initially, this Corona virus mostly attacked the elderly group, but recently it has infected all age groups, ranging from productive ages, teenagers, toddlers, infants, including the group of pregnant women. Data obtained from the Health Office of Banten Province, Tangerang Regency area at most with 30,047 pregnancies. Then, Tangerang City 12,335, Serang Regency 10,163, Lebak 8,843 followed by South Tangerang City 8,411. Furthermore, Pandeglang Regency 8,239, Serang City 4,212, and Cilegon City 2,614 pregnant women during the period January to April 2020. This shows that midwives as first-line managers of pregnancy, childbirth and postpartum cases must be vigilant by wearing complete Personal Protective Equipment (PPE) so that there is no transmission of the virus from the patient to the midwife (Husein, 2020).

METHOD
The research used is a quantitative analytic research using a cross sectional approach, where the researcher measures the independent variables and the dependent variable whose data collection is carried out in a certain period and observations are only made once during the study (Notoatmodjo, 2005). The case in this study was a midwife at RSUD Banten. The population in this study was all midwives in the Maternal Emergency Room, Maternity Room, Inpatient Room and Outpatient Room at Banten Hospital, totaling 102 people. The sample is the total population. The instrument used in this study was a questionnaire about knowledge, attitudes, and practices related to the use of personal protective equipment. The questionnaire was formulated by the researcher and has been tested for validity and reliability. This study has been approved the permission from Universitas Nasional and RSUD banten. There is no conflict of interest for conducting the study. From table 2 it is found that the results of the study indicate that respondents who have good knowledge were 97 respondents (95.1%), compared to those who have less knowledge were 5 respondents (4.9%). Respondents with the right use of PPE have more good knowledge (83.5%) compared to those with less knowledge, (5%). Respondents with inappropriate use of PPE have less knowledge (0%), compared to those who have good knowledge (100%). Based on the results of statistical tests, using the Chi Square (X²) test on the knowledge variable, it was found that the P-value was (0.323), which means the P-value> 0.05. So in this study, it can be concluded that there was no relationship between knowledge and the use of PPE in midwives at Banten Hospital in 2020-2021.

RESULT
The results showed that the respondents who had a good attitude were 101 respondents (99.0%), while the respondents who had less attitudes towards the use of PPE were 1 respondent (1.0%). Respondents in using the right PPE have a good attitude (84.1%) compared to the attitude of respondents who lack (100%). Respondents in using inappropriate PPE showed a lack of attitude (0%), compared to those who had a good attitude (15.9%). The results of data analysis using the chi-square test obtained p value = 0.665 because the p value > 0.05. This shows that there was no relationship between attitudes and the practice of using Personal Protective Equipment in midwives at Banten Regional Hospital in 2020-2021.
The results showed that the number of complete PPE was 73 (71.6%), while the incomplete were 29 (28.4%). The results of data analysis using the Chi-Square test showed that the value (p value = 0.740), because p > 0.05. The interpretation is that there was no relationship between the availability of PPE and the use of PPE in midwives at the Banten Regional General Hospital in 2020-2021.
. The results showed that from the number of people who had supervision (90.2%), while those who did not have supervision were (9.8%). Respondents with the proper use of PPE were 77 respondents (83.7%). Compared to the statement of respondents who said that there was no supervision were 9 (90%). Respondents with inappropriate use of PPE stated that there were 15 respondents (16.3%) supervision, compared to 1 respondent (10%). There was no significant relationship between supervision and the practice of using PPE, where the statistical test results obtained that the value (p value = 0.603), because p> 0.05. This means that there was supervision or no supervision does not affect the practice of using PPE. There is self-awareness in respondents to always use PPE at work.

DISCUSSION
Knowledge is one of the factors that shape or influence a person's behavior Ryu, S., Ho, S. H., & Han, I. (2003). Good knowledge or lack of knowledge does not always lead to the discipline to obey using PPE when working. This is because knowledge is only limited to or the first level of knowledge, which is knowing. Knowledge is the result of knowing, and occurs after people sense a certain object. Knowledge or cognitive is a very important domain in shaping one's actions (overt behavior). Knowledge is the result of individual observation and experience of a new thing that can be useful for the individual. This is in line with the research of Arifi & Susanto, 2014) which found there was no relationship between worker knowledge and operator worker compliance in the use of PPE. The researcher assumes that the number of respondents who are not right on duty are mostly midwives who work in the Inpatient Room and in the Outpatient Room at RSUD Banten.
Although through the questionnaire, it was found that the midwife's knowledge of PPE was good, such as knowing the meaning of PPE, the benefits of PPE when working, and midwives also already knowing what standard PPE must be used in the Maternal Emergency Room, Maternity Room, Inpatient Room, Outpatient Room and this set of personal protective equipment is evidenced by the results of the answers to several questions regarding PPE. However, the reality in the field is that there are still midwives who do not use standard PPE when performing actions on patients such as masks, gloves, protective gowns (aprons), head coverings and closed shoes. This research showed that there was no relationship between attitudes and the practice of using Personal Protective Equipment in midwives at the Banten Hospital in 2020-2021. Attitude is a reaction or response that is still closed from a person to a stimulus or object. Mental states and readiness that are regulated through experience, exert a dynamic or directed influence on the individual's response to all objects and situations related to them. Attitudes clearly show the connotation of a suitability of reactions to certain stimuli (Vandermeeren, 2008). This is in line with research conducted by Moore et al., (2o05) which states that there was no relationship between attitudes and compliance with the use of PPE in herbal medicine production workers with the chi-square test, a p value of 0.050 is obtained.
Researchers assumed that the factors that influence the absence of a relationship between attitudes and compliance with the use of PPE are personal experience factors and emotional factors. To be able to form the basis of attitude formation, personal experience must leave a strong impression, therefore attitudes will be more easily formed if the personal experience occurs in situations involving emotional factors. Sometimes attitudes are statements based on emotions (Matta et al., 2006). Someone who has a bad attitude has a tendency to stay away from, avoid, hate or dislike certain objects, the respondent's negative attitude towards personal protective equipment can be caused by a bad experience with the use of personal protective equipment or policies that do not support the use of personal protective equipment.
The results showed that there was no relationship between the availability of PPE and the use of PPE in midwives at the Banten Regional General Hospital in 2020-2021. The availability of PPE is a supporting factor in compliance with using PPE to prevent accidents and work risks that occur in the company, if the company does not provide PPE, it means the company has endangered its workers from the risk of accidents and diseases that will arise in the work environment. Therefore, the company applies rules to provide personal protective equipment in accordance with their respective jobs (Prasetyo, Musyarofah, Muliawati & Widjasena 2020). This is in line with the research conducted by Saputri & Paskarini (2014) which stated that the fisher exact results showed that there was no relationship between the availability of PPE and compliance with the use of PPE for building frame workers. This is because the PPE provided by the company is not adequate available. Another assumption that the availability of PPE is due to a lack of worker motivation.
Motivation will give rise to an urge to do something both from within and from outside the respondent. So if the respondent's motivation is high to do a job, for example in using personal protective equipment, even though there are obstacles to doing so, but because of this motivation, the respondent will try to maintain his health or prevent the risk of work accidents. What is expected will be lacking especially when there are obstacles and obstacles. In addition, motivation can be defined as goal-oriented behavior. Other reasons for not using PPE are busy, unfamiliar, forgetful, and lazy (Hayulita & Frenky, 2014).
The researcher assumes that in this study, midwives who work in the Maternal Emergency Room, Maternity Room, Inpatient Room, Outpatient Room at RSUD Banten assess that the availability of PPE in RSUD Banten is still incomplete, this is evidenced by the answers from the midwives through questionnaires, that although it has been socialized about PPE, some PPE is indeed not available and not enough in hospitals such as gloves, closed shoes, protective gowns/aprons and masks. The availability of PPE that is not in accordance with standard procedures causes the behavior of midwives who do not use PPE when carrying out medical procedures. Another thing that causes the availability of PPE is not enough because one of them, RSUD Banten is still a type C hospital where all the facilities and infrastructure are still limited, and is currently in the process of gradually completing the hospital accreditation process. In addition, the availability of facilities and infrastructure, including PPE, is highly dependent on the capacity of the Banten Province's regional budget. From the results of the research, the problems that occurred were as stated by several midwives at the Banten Regional Hospital that the use of PPE was adjusted to the patients treated by each midwife, for example, the PPE used by midwives who worked in the treatment room for patients suffering from pulmonary TB and COVID-19. The PPE used will be different from the PPE used by midwives who work in inpatient rooms who only treat patients suffering from diseases, for example hypertension. So that the availability of PPE that must be used at work must be in accordance with the needs of every medical procedure performed by the midwife, with the aim of protecting herself and the people around her so as not to risk or endanger health.
Based on research conducted on midwives at Banten Regional Hospital, the results showed that there was no significant relationship between supervision and the practice of using PPE. This means whether by supervision or without supervision will not affect the practice of using PPE. There is self-awareness in respondents to always use PPE at work. Supervision is a motivating or reinforcing factor for the occurrence of a behavior. The existence of a policy can