Analysis of Factors Affecting the Performance of Midwife in the Work Area of the Sipiongot Inpatient Health Center

This study aims to analyze the factors that influence the performance of midwives in the work area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency. This type of research is an analytic survey with a transverse surgical approach. Sampling used a total sampling technique, namely all midwives in the Sipiongot Inpatient Health Center Work Area as many as 69 Midwives. The results showed that the majority of midwives' performance was included in the poor category, namely 39 people (56.5%), the majority of midwives' abilities were included in the capable category, namely 51 people (73.9%), the majority of midwives' knowledge was included in the good category, namely as much as 46 people (66.7%), the majority of midwives' skills were included in the bad category as many as 39 people (56.5%) and the majority of midwives' leadership were included in the bad category, namely 35 people (50.7%). There is a relationship between ability [p (sig) = 0.017], knowledge [p (sig) = 0.000], skills [p (sig) = 0.029] and leadership [p (sig) = 0.022] on the performance of midwives in the working area of the Outpatient Health Center. Sipiongot Inpatient, Dolok District, North Padang Lawas Regency in 2021. The most dominant variable affecting the performance of midwives is knowledge. It is recommended that midwives in the working area of the Sipiongot Inpatient Health Center improve their performance so that they become professional midwives according to their competencies.


Introduction
One way to reduce MMR in Indonesia is to improve the quality of health services, especially examinations of pregnant women by professionals in accordance with ANC service standards, namely weighing, measuring blood pressure, measuring uterine fundus height, tetanus toxoid immunization, giving tablets. adding blood, testing for infectious diseases, and ending with a teleconference in preparation for referrals (Anggraini et al., 2020). The Ministry of Health is determined to shift deliveries at home to deliveries by health workers in health care facilities as an effort to reduce maternal and newborn mortality. The purpose of the delivery program by health workers in health care facilities is to accelerate the access of mothers and newborns in obtaining adequate treatment in the event of an emergency situation for maternity or newborns. The results of the 2017 IDHS show that 79 percent of mothers in Indonesia have given birth with health workers in health care facilities, there is still a gap between urban areas (91%) compared to rural areas (68%) (Niu, 2017).
The proportion of health workers who provide antenatal care services by province and characteristics can be seen in the 2013 Riskesdas book. Communities with characteristics living in rural areas, low education and being in the lowest to middle ownership index quintiles tend Puskesmas have the task of implementing health policies to achieve health development goals in their working areas in order to support the realization of a healthy sub-district. In addition to carrying out these tasks, the puskesmas has a function as the organizer of the first level of Public Health Efforts (UKM) and the first level of Individual Health Efforts (UKP) as well as a vehicle for education of health workers. Public health efforts are every activity to maintain and improve health as well as prevent and overcome health problems with the target of families, groups and communities. Individual health effort is an activity and/or a series of health service activities aimed at improving, preventing, curing disease, reducing suffering due to disease and restoring individual health. According to Satrianegara, (2014) Puskesmas (Community Health Center) should provide comprehensive and integrated health services to the community, where the services provided include levels of promotive, preventive, curative and rehabilitative services.
The role of Human Resources, in this case the midwife, is a determinant for the success of health services carried out in an organizational institution, namely the Puskesmas. Midwives as human resources who carry out activities at puskesmas are influenced by various things, both internal factors or individual characteristics (internal) and work environment factors or characteristics of workers and organizations (external). Likewise with performance, performance is a result achieved by a person in carrying out the tasks assigned to him based on his abilities, skills, experience and abilities and time. Good quality workers not only turn the palm of the hand but it must be done with hard work and high discipline, both in the long term and in the short term (Wibowo, 2014).

Methods
The research design used in this study was an analytical survey with a cross-sectional (crosssectional) surgical approach. The purpose of this study is to analyze the factors that influence the performance of midwives in the work area of the Sipiongot Inpatient Health Center, Dolok District, Padang Lawas Regency. The population in this study were all midwives in the Sipiongot Inpatient Health Center working area as many as 69 midwives. The sample in this study was the total population, namely all midwives in the Sipiongot Inpatient Health Center working area as many as 69 midwives.

Midwife Performance
The frequency distribution of midwife performance variables in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table: Based on table 2. it can be seen that the majority of midwives' performance is included in the poor category, namely 39 people (56.5%), while the rest are included in the good category, namely 30 people (43.5%).

Ability
The frequency distribution of the variable ability of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table: Based on table 3. it can be seen that the majority of midwives' abilities are included in the capable category, namely 51 people (73.9%), while the rest are included in the poor category as many as 18 people (26.1%).

Knowledge
The frequency distribution of the knowledge variable of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table: Based on table 4. it can be seen that the majority of midwives' knowledge was included in the good category, namely 46 people (66.7%), while the rest were included in the bad category, namely 23 people (33.3%).

Skills
The frequency distribution of the midwife skill variable in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table: Based on table 4.4. it can be seen that the majority of midwives' skills are included in the bad category as many as 39 people (56.5%), while the rest are included in the good category as many as 30 people (43.5%).

Leadership
The frequency distribution of the midwife leadership variable in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table: Based on table 5. it can be seen that the majority of midwives' leadership included in the bad category as many as 35 people (50.7%), while the rest were included in the good category as many as 34 people (49.3%).

Bivariate Analysis
Bivariate analysis was conducted to determine the relationship between each independent variable or independent variable, namely ability, knowledge, skills and leadership with the dependent variable or the dependent variable, namely the performance of the midwife through crosstable or cross tabulation. Statistical tests were carried out in this bivariate analysis using the chi square test with a 95% confidence degree (α = 0.05).

The Effect of Ability on Midwife Performance in the Working Area of Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021
The frequency distribution of the ability relationship to the performance of midwives in the work area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table:

Relationship between Knowledge and Performance of Midwives in the Working Area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021
The distribution of the frequency of the relationship between knowledge and the performance of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table:

Relationship between Skills and Performance of Midwives in the Work Area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021
The distribution of the frequency of the relationship between skills and the performance of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table:

Source: Primary Data (processed) 2021
Based on table 9, it can be seen that from 69 respondents (100%) there were 30 midwives who had skills included in the good category, the majority with good performance, namely 18 respondents (26.1%), while 39 midwives who had skills included in the majority category is not good with poor performance as many as 27 respondents (39.1%). Statistical test results obtained p value (sig) = 0.029 (ρ value <0.05). This shows that there is a statistically significant or significant relationship between skills and the performance of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021.

Leadership Relationship to Midwife Performance in the Working Area of Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021
The distribution of the frequency of leadership relationships on the performance of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 can be seen in the following table:

Multivariate Analysis
Multivariate analysis in this study used multiple logistic regression test. The logistic regression analysis step is carried out in 2 (two) stages, namely the first stage (enter method) to determine the independent variable that has a significance level (sig.) or value < 0.25, and the second stage (forward method: conditional). The results of the first stage of analysis (enter method) can be seen in the following table:

Source: Primary Data (processed) 2021
Based on the results of the output (variables in the equation) in the first stage, it can be seen that the variable which has a sig value. <0.25 is the ability variable (0.188), knowledge variable (0.004) and leadership variable (0.159). While the skill variable has a value of sig. > 0.25 which is 0.317 so that the skill variable is not eligible to enter the next multivariate test model. The next step is to include the variables of ability, knowledge and leadership in the second stage of logistic regression (forward: conditional method).
The results of the second stage of analysis can be seen in the following table:

Source: Primary Data (processed) 2021
Based on the output results above, the Nagelkerke R Square value is 0.416 and the Cox & Snell R Square value is 0.310, which indicates that the ability of the knowledge variable to explain the performance variable of the midwife is 0.416 or 41.6%.
Based on the Multivariate Analysis that has been carried out, it can be concluded that all variables that enter the model or who pass the candidate selection, have an influence on the performance variable of the midwife (dependent), namely the ability variable, knowledge variable and leadership variable but the most dominant variables affect the performance of the midwife. in the Working Area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 is the knowledge variable.
Knowledge is a result of desire through sensory processes, especially in the eyes and ears for certain objects. At the time of sensing to produce knowledge is strongly influenced by the intensity of attention perception of the object. Purwoastuti & Walyani (2015) stated that A person who has a good level of knowledge about his job will make it easier for him to do his job, while someone who has a poor level of knowledge about his job will make it difficult for him to do his job, which in turn will reduce the quality of his work which will ultimately affect his performance.
The midwifery profession is a noble profession that is intellectual in nature based on science that requires special skills. The midwife profession requires training and mastery of a special knowledge. Therefore, the knowledge of a person who works as a midwife must continue to be developed so that it can support its duties in meeting the demands/needs of a very dynamic society and the development of science and technology.
From the results of respondents' answers, it can be seen that the highest score on the skills questionnaire is for statement item number 1, namely the leader gives permission to the midwife to attend training. This statement implies the importance of support from the leadership, in this case the head of the puskesmas or the coordinating midwife, to contribute more in providing support or stimulation so that the performance of the midwife will be better. Skilled midwives will try to develop and improve their performance and they will try to give the best results in their work, so that the goals that have been set can be achieved, otherwise unskilled midwives will not try to give the best results. Skills are strengths from within a person that can direct that person's behavior. Pro and positive behavior towards the work situation that strengthens his work skills to achieve maximum performance (Griffin et al., 2007). A permit or a sign of appreciation from the leadership will motivate the midwife to take part in the existing trainings so that she can eventually become a professional midwife.
From the results of respondents' answers, it can be seen that the lowest score on the leadership questionnaire question is for statement item number 10, namely midwives whose performance is good get praise from the leadership. If it is associated with the performance of the midwife, it means that the praise given by the leadership will spur the midwife to achieve higher work performance. Of course, giving praise must adjust the conditions (not excessive). Leaders who behave pleasantly, protect, educate and guide will certainly make the people they lead feel happy and follow what the leader tells them to do, this will certainly improve performance, and vice versa.
Good leadership in an organization which in this case is the leader at the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency, of course, can regulate, manage and provide direction to midwives in the work area of the Sipiongot Inpatient Health Center wisely to carry out maternal and reproductive health services for women. ; family planning services; infant and child health services; and public health services. In evaluating the performance of human resources at the puskesmas, the leadership holds the highest position so that it is responsible for whether or not the performance of the puskesmas is good. Midwives as technical implementers in the field of midwifery services at health service facilities must be able to provide professional services that are an integral part of health services, which are provided to mothers during the reproductive period, newborns, infants, and toddlers.
The development of midwifery services is in line with the progress of obstetrics and gynecology services (Marshall et al., 2012). Midwives as a profession that continues to grow, always maintain their professionalism by following the development of science and technology (Ross et al., 2013). Professionalism is closely related to the competencies that must be possessed by a professional (professional competence). Professional midwives in question must have clinical competence (midwifery skills), socio-cultural skills to analyze, advocate and empower in finding solutions and innovations as an effort to improve the welfare of women, families and communities.

Conclusion
After doing research on the factors that affect the performance of midwives in the Work Area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency, it can be concluded as follows, There is an influence of ability, knowledge, skills, leadership on the performance of midwives in the work area of the Sipiongot Inpatient Health Center, Dolok District North Padang Lawas Regency. The most dominant variable affecting the performance of midwives in the Work Area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency in 2021 is the knowledge variable with a value of sig < 0.05, which is 0.001.

Suggestion
In an effort to improve the performance of midwives in the working area of the Sipiongot Inpatient Health Center, Dolok District, North Padang Lawas Regency, it is recommended to be more active in making training and seminars for midwives, especially for midwives in the work area of the Sipiongot Inpatient Health Center, Dolok District to improve the performance of midwives so that later they do not feel left behind in terms of science and technology