The Effectiveness of Telemedicine on The Implementation Mother's Hypnobreastfeeding Postpartum COVID-19 in North Tapanuli District

The aim of the research is to analyze and determine the effectiveness of the application of telemedicine to the implementation of hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency in 2023. This type of quantitative research uses a cross sectional design at the Muara and Siborong-borong Community Health Centers March-September 2023. The sample consisted of 50 control group respondents and 50 experimental group respondents. Data processing uses univariate analysis and bivariate analysis with the chi-square statistical test. Result 1). In the Control group, through the pre-test, the Asymp value was obtained. Sig. (2-tailed) 0.378>0.05 and 0.658>0.05, so there is no relationship between knowledge and frequency and duration of breastfeeding. Asymp value. Sig. (2-tailed) 0.446>0.05 and 0.514>0.05, so there is no relationship between attitude and frequency and duration of breastfeeding 2). Experimental Group, through the pre-test, the Asymp value was obtained. Sig. (2-tailed) 0.920>0.05 and 0.042>0.05, there was no relationship between knowledge and frequency and duration of breastfeeding. Asymp. Sig. (2-tailed) 0.742>0.05 and 0.065>0.05, there is no relationship between attitude and frequency and duration of breastfeeding. Through the post test, the Asymp value was obtained. Sig.(2-tailed) 0.002>0.05 and 0.000<0.05 have a relationship between knowledge and the frequency and duration of breastfeeding. The conclusion is that there is a significant influence of Telemedicine on the Implementation of Hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency after receiving treatment.


INTRODUCTION
Background; Each country uses various methods to protect its people in the hope that there will be no crowds that can accelerate the spread of Covid-19, including closing the country by not accepting foreigners into the country, limiting state visits by state officials, limiting people's movement, such as closing markets, closing offices, closing schools, canceling traditional parties and also limiting medical services if it is not an emergency.(Riyanto & Panggabean, 2021) Midwifery services are one of the activities that have an impact on patients, as well as causing a paradigm shift in providing midwifery services.Traditional face-to-face midwifery service visits are limited except in emergency situations.As much as possible, patients do not need to come to health service facilities and are expected to make more use of virtual health services or telemedicine to avoid exposure to Covid-19.
In the United States, there are more than 50 health systems using telemedicine which are used by doctors/health workers to see the patient's condition even at home or without meeting them.Telemedicine functions to provide direct care to save time, reach health facilities, save costs, additional costs such as eating and drinking due to long queues and reduce the risk of exposure to Covid-19. (Judd E. Hollander, M.D., and Brendan G. Carr, 2020) In the midst of the Covid-19 pandemic, postpartum mothers are also feeling the impact.The success of breastfeeding is certainly supported by safe and comfortable environmental conditions.Seeing and hearing or even experiencing for yourself, your family and neighbors, various reports about the impact of Covid-19 also contribute to high feelings of anxiety and worry which can cause stress.Stress can affect the hypothalamus and pituitary glands in releasing Adreno Corticotropic Hormone (ACTH).That's why, it also affects the hormones adrenaline and cortisol.When the amount of the hormone cortisol is high, it will suppress breast milk production.(Nugroho, 2021) To reduce the stress of postpartum mothers, midwives can provide therapy using affirmative sentences.Affirmative sentences are positive words to suggest the mother's subconscious energy in the form of hypnobreastfeeding in the midst of the Covid-19 pandemic.Hypnobreastfeeding is one of the efforts that midwives can carry out in the midst of the Covid-19 pandemic via telemedicine.(Sofiyanti et al., 2019)    Table 4 shows that the percentage of posttest based on knowledge of respondents in the experimental group, the majority had good knowledge, 32 people (64%).

Bivariate Analysis
Bivariate analysis was carried out to determine the influence between the independent variable and the dependent variable studied, namely the effectiveness (influence) of Telemedicine on the Implementation of Hypnobreastfeeding in Postpartum Mothers during the Covid-19 Pandemic in North Tapanuli Regency.To find out whether there is an influence of Telemedicine on the Implementation of Hypnobreastfeeding, use a pre-test and post-test on the knowledge and attitudes of postpartum mothers about breastfeeding, seen from the success of exclusive breastfeeding based on the frequency and duration of breastfeeding in the control group and experimental group.The control group was not given hypnobreastfeeding via telemedicine while the experimental group was given hypnobreastfeeding via telemedicine.So, results of the bivariate analysis for the variable Breastfeeding Knowledge of Postpartum Mothers on the Frequency of Giving Breast Milk to Postpartum Mothers in the Control Group used the chisquare test, because there were cells that had an expected frequency (Expected Count) of less than 5, so to answer the hypothesis, the researcher used an alternative Another is the Manna-Whitney Test, the SPSS results are as follows: Because there are no cells that have an expected frequency (Expected Count) of less than 5, the hypothesis has been answered.SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.000, this value is smaller than 0.05 (0.000<0.05) so there is a significant relationship between knowledge and duration of breastfeeding, so it can be concluded that there is an influence of postpartum mothers' breastfeeding knowledge on the duration of breastfeeding in postpartum mothers.Experimental Group Post Test.
f.The influence of post-partum mothers' breastfeeding knowledge on the frequency of breastfeeding in post-partum mothers during the Covid-19 pandemic in North Tapanuli Regency in 2023 in the experimental group posttest.Because there are no cells that have an expected frequency (Expected Count) of less than 5, the hypothesis has been answered.SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.000, this value is smaller than 0.05 (0.000<0.05), so there is a significant relationship between knowledge and duration of breastfeeding.It can be concluded that there is an influence of postpartum mother's breastfeeding knowledge on the length of breastfeeding in the experimental group post test.So, based on the results of the research, it shows that there is an influence on the effectiveness of Telemedicine on the Implementation of Hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency after treatment in the experimental group.

Analysis of The Application of Telemedicine to The Implementation of Hypnobreastfeeding in Postpartum Mothers During the Covid-19 Pandemic.
In 2017 the World Health Organization (WHO) reported that the average rate of exclusive breastfeeding was only 30%.By 2025, WHO targets exclusive breastfeeding in the first 6 months after birth to increase by at least 50%.(Organization, 2020) In 2019, the national coverage of babies receiving exclusive breastfeeding was 67.74%.West Nusa Tenggara Province is the province with the highest percentage of exclusive breastfeeding coverage at 86.26%, while West Papua Province has the lowest percentage.(Ministry of Health, 2020).
There are many factors that influence breastfeeding, including the inability to breastfeed immediately after birth due to poor breastfeeding techniques, the mother's flat or inverted nipples, the mother's occupation, and the influence/promotion of breast milk substitutes.The mother's mental and psychological factors during breastfeeding have a great impact on the smooth progress of the breastfeeding process and milk production.A mother's level of stress, anxiety, and depression can reduce breast milk production.More than 80% of the reasons why mothers do not breastfeed their babies are psychological factors.(Lawrence & Lawrence, 2021).
Based on the results of the research conducted by the researchers, the results showed that in the control class, namely postpartum mothers without hypnobreastfeeding via telemedicine, it showed that there was no influence of telemedicine on the implementation of Hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency.Meanwhile, the experimental class showed that there was a significant influence of Telemedicine on the Implementation of Hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency after receiving treatment.This indicates the importance of implementing Hypnobreastfeeding via Telemedicine during the Covid-19 Pandemic so that mothers' knowledge and attitudes regarding the frequency of breastfeeding and the duration of breastfeeding can be understood by postpartum mothers in North Tapanuli Regency.
The obstacles that researchers found when carrying out hypnobreastfeeding for postpartum mothers were 1) The internet network was inadequate so that sometimes when providing hypnobreastfeeding guidance via telemedicine, the video stopped or the sound could not be heard clearly.2) If there is heavy rain or strong winds in the patient's area or in the midwife's area, then hypnobreastfeeding can be postponed because the internet network is disrupted.3) An internet package must always be available because if the postpartum mother or midwife does not have an internet package, hypnobreastfeeding via telemedicine cannot be implemented.4) If the postpartum mother's family only has 1 (one) smartphone and the husband who uses it more actively, then hypnobreastfeeding via telemedicine must be postponed because the husband or other family members really need the smartphone at the same time.5) There are still postpartum mothers who are not fluent in using a smartphone specifically using the WhatsApp application, especially if the mother is asked first to start a video call.
The five obstacles above mean that the hypnobreastfeeding schedule via telemedicine often changes so that it has to be rescheduled.So, even though the Covid-19 pandemic is still around, midwifery care for postpartum mothers can still be provided, especially hypnobreastfeeding via telemedicine so that babies can still get their mother's rights, namely exclusive breastfeeding.In addition, hypnobreastfeeding via telemedicine is a safe and cost-effective service.

Effectiveness of Telemedicine on the Implementation of Hypnobreastfeeding in Postpartum Mothers During the Covid-19 Pandemic
Hypnobreastfeeding carried out by postpartum mothers via telemedicine guided by midwives is very helpful.Helps postpartum mothers to continue to provide breast milk to their babies with feelings of comfort and happiness.A mother who is comfortable and happy when giving breast milk will also have an impact on the smooth flow of breast milk, the amount of breast milk coming out will be greater, breastfeeding will last longer and the frequency of breastfeeding will also be more frequent.(Manurung et al., 2022) In accordance with the results of research conducted by researchers, the control group who provided breast milk without hypnobreastfeeding via telemedicine had no effect on the duration and frequency of breastfeeding.Meanwhile, the experimental group who gave breast milk first received Hypnobreastfeeding training.Postpartum mothers in the control group and experimental group were first interviewed for how long (minutes) they breastfed each time and how many times they breastfed in a day.
Many mothers are worried about giving breast milk to their babies even though the Covid-19 condition has decreased.This worry arises because mothers who work or leave the house will meet many people who may have been exposed to Covid-19.So when you return home and meet your baby or even breastfeed your baby, even though you have cleaned yourself first, the worry is still there.Apart from meeting people who may have been exposed to Covid-19, postpartum mothers' concerns are family members who are active outside the home and meeting other people who may also be exposed to Covid-19.Mothers' anxiety after giving birth is also increasing because of the large number of people who have died due to Covid-19.To reduce or reduce postpartum mothers' feelings of worry about successfully providing exclusive breastfeeding during the Covid-19 pandemic, hypnobreastfeeding therapy needs to be given as relaxation via telemedicine. .(Kambera et al., 2021).
Feelings of worry, anxiety and even depression will have detrimental effects on the mother's physiology after breastfeeding.The hypothalamic-pituitary-adrenal axis influences the biological and hormonal reactions of stress and anxiety to the psychosocial environment, which increases catecholamines such as epinephrine.(Huang et al., 2020) Because this axis is more sensitive to postpartum stress than women in general, this causes a decrease in secretion prolactin and oxytocin, thereby reducing breast milk supply during breastfeeding.(Nagel et al., 2022) To reduce or reduce postpartum mothers' feelings of worry about successfully providing exclusive breastfeeding during the Covid-19 pandemic, it is necessary to provide relaxation using the hypnobreastfeeding method via telemedicine.Hypnobreastfeeding via telemedicine is a safe and effective alternative that can prevent mothers and babies from being exposed to Covid-19 if the mother has to leave the house to meet a midwife to get midwifery services.
With hypnobreasfeeding via telemedicine, midwives can still provide midwifery care to postpartum women.The conditions for carrying out hypnobreasfeeding via telemedicine are the same as when offline (outside the network), namely vital signs (respiration, pulse and temperature) within limits (previously the mother has been given education on how to measure body temperature, how to count breathing and pulse) and there are no other complaints.can worsen the condition of the mother after giving birth.(Asih, 2020) Based on the results of research conducted by researchers, the majority of the experimental group, after hypnobreastfeeding via telemedicine, had good knowledge.The frequency of breastfeeding increased to >12x/day for 17 people (53.1%) and the duration of breastfeeding increased by >20 minutes each time they gave breast milk.Meanwhile, based on attitudes, the majority of postpartum mothers had a good attitude with the frequency of breastfeeding increasing to 15 people (51.7%) with a breastfeeding frequency of > 12 times/day and a breastfeeding duration of > 20 minutes each time they breastfed their babies.
The relaxation technique with Hypnobreastfeeding is one technique to facilitate the release of breast milk.The relaxation technique with Hypnobreastfeeding is one technique to facilitate the release of breast milk.One method of hypnobreastfeeding therapy is to insert positive affirmation sentences which will enter the mother's subconscious mind in a hypnotized state.These positive affirmation sentences can maintain a positive attitude during breastfeeding so that endorphin hormones can influence breast milk production.When breastfeeding provides more effects and the baby becomes comfortable and calm.(Rangkuti et al., 2022) Similar to research conducted by Virgian (2022), the effect of Hypnobreastfeeding is that apart from improving sleep quality, it can also increase breast milk production, making exclusive breastfeeding a success.
Prolactin hormone levels were measured on the eighth day after giving birth, namely 2 (two) hours after breastfeeding in the morning.Hypnobreastfeeding was started on the eighth day after measuring the hormone prolactin.The intervention lasted for 7 (seven) days after giving birth and was carried out 2 (two) times per day.Hypnobreastfeeding is done by postnatal mothers while listening to music.During the intervention, it will be monitored via social media groups.Prolactin hormone levels will be measured again on the 15th day.There will be changes in prolactin hormone levels before and after hypnobreastfeeding.(Virgian, 2022).

Conclusions
Through the control class, all analyzes both before treatment and after treatment showed that postpartum mothers' knowledge about the frequency and duration of giving breast milk was still lacking, this was proven by testing that there was no influence of Telemedicine on the Implementation of Hypnobreastfeeding in Postpartum Mothers during the Covid-19 Pandemic in the Regency.North Tapanuli.Through the experimental class, the results of the analysis before treatment and after treatment were different, namely before treatment that there was no influence of Telemedicine on the Implementation of Hypnobreastfeeding in Postpartum Mothers during the Covid-19 Pandemic in North Tapanuli Regency, but after treatment it showed that there was a significant influence of Telemedicine on Implementation of Hypnobreastfeeding for postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency.Telemedicine provides an overview of midwives' activities in providing midwifery services to patients through technology.Telemedicine can help patients in disaster conditions by consulting, getting timely treatment, preventing critical patients, stabilizing the patient's condition.The implementation of Hypnobreastfeeding begins by giving positive suggestions or affirmation sentences.The purpose of these positive affirmations is to make the breastfeeding activity of postpartum mothers an easy, simple and enjoyable activity.The implementation of Hypnobreastfeeding is very necessary for postpartum mothers so that mothers' knowledge and attitudes can increase in giving breast milk through the frequency and duration of giving breast milk.

Suggestions
For Midwives to increase their knowledge of technology, because through technology they can increase patients' understanding of the importance of knowledge and attitudes in providing breast milk, for Community Health Centers to improve their services to support improving the quality of maternal and baby health in their work areas, for mothers to increase their understanding of knowledge and skills of postpartum mothers regarding the use of telemedicine in the implementation of hypnobreastfeeding to support consultations on exclusive breastfeeding and to leaders of Health agencies to provide the facilities needed by midwives to make the work program they carry out a success.
a.The Effect of Telemedicine on the Implementation of Hypnobreastfeeding in Post-Delivery Mothers during the Covid-19 Pandemic in North Tapanuli Regency based on Control Group Knowledge.

Table 2
shows the percentage of breastfeeding duration for respondents in both groups, most of the control group was > 20 minutes, 29 people (58%).Meanwhile, the majority of breastfeeding duration in the experimental group was > 20, with 17 people (34%).c.Frequency Distribution of Postpartum Mothers Based on Pre-Test Knowledge

Table 3 .
Percentage of Pre-Test Knowledge of Mothers after Childbirth

Table 3
shows that the percentage of pre-test (initial test) knowledge of postpartum maternal respondents was sufficient, the majority being 25 people (50%) for the control group.Meanwhile, the majority had sufficient knowledge, 27 people (54%) for the experimental group.d.Frequency Distribution of Postpartum Mothers Based on Knowledge Post TestBased on the results of research on 50 people in the experimental group, in the following table the percentages are as follows:

Table 4 .
Percentage of Post-Test Knowledge of Mothers after Childbirth

Table 5 .
Mann-Whitney Test of Breastfeeding Knowledge on Frequency of Breastfeeding in Control group SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.378, this value is greater than 0.05 (0.378>0.05), so there is no relationship between knowledge and frequency of breastfeeding.It can be concluded that there is no influence of postpartum mother's breastfeeding knowledge on the frequency of breastfeeding in the control group.b.The Influence of Postpartum Mothers' Breastfeeding Knowledge on the Length of Breastfeeding in Postpartum Mothers During the Covid-19 Pandemic in North Tapanuli Regency in 2023 in the Control Group

Table 6 .
Mann-Whitney Test of Breastfeeding Knowledge on Length of Breastfeeding in Control group SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.658, this value is greater than 0.05 (0.658>0.05), so there is no relationship between knowledge and duration of breastfeeding.So it can be concluded that there is no influence of postpartum mothers' breastfeeding knowledge on the length of breastfeeding in the control group.c.The Influence of Breastfeeding Knowledge of Post-Natal Mothers on the Length of Breastfeeding in Post-Baby Mothers During the Covid-19 Pandemic in North Tapanuli Regency in 2023 in the Pre-Test Experimental Group

Table 7 .
Mann-Whitney Test of Breastfeeding Knowledge on Breastfeeding Duration in the Experimental Group Pre-Test .The Influence of Postpartum Mothers' Breastfeeding Knowledge on the Frequency of Breastfeeding in Postpartum Mothers During the Covid-19 Pandemic in North Tapanuli Regency in 2023 in the Experimental Group Post Test.
SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.042, this value is greater than 0.05 (0.042>0.05), so there is no relationship between knowledge and duration of breastfeeding.It can be concluded that there is no influence of post-partum mothers' breastfeeding knowledge on the duration of breastfeeding in post-partum mothers in the pre-test experimental group.d

Table 8 .
Chi-Square Test of Breastfeeding Knowledge on Breastfeeding Frequency in the Post Test of the Experimental groupBecause there are no cells that have an expected frequency (Expected Count) of less than 5, the research hypothesis can be answered.SPSS output analysis is Asymp Value.Sig.(2-tailed) of 0.042, this value is greater than 0.05 (0.042>0.05), so there is no relationship between knowledge and duration of breastfeeding.It can be concluded that there is an influence of postpartum mothers' breastfeeding knowledge on the frequency of giving breast milk to postpartum mothers in the experimental group posttest.e.The influence of post-partum mothers' breastfeeding knowledge on the duration of breastfeeding in post-partum mothers during the Covid-19 pandemic in North Tapanuli Regency in 2023 in the experimental group posttest.

Table 9 .
Chi-Square Test of Breastfeeding Knowledge on Length of Breastfeeding in Experimental group post test

Table 10 .
Chi-Square Test of Breastfeeding Knowledge on Breastfeeding Frequency in the Experimental Group Post TestBecause there are no cells that have an expected frequency (Expected Count) of less than 5, the research hypothesis can be answered.The SPSS output analysis is the Asymp Value.Sig.(2-tailed) of 0.002, this value is smaller than 0.05 (0.002>0.05), knowledge has a significant relationship with the duration of breastfeeding.It can be concluded that there is an influence of postnatal maternal knowledge of breastfeeding on the frequency of breastfeeding in the experimental group posttest.Based on the research results, it shows that there is an influence of the effectiveness of Telemedicine on the Implementation of Hypnobreastfeeding in postpartum mothers during the Covid-19 pandemic in North Tapanuli Regency after receiving treatment in the experimental group.

Table 11 .
Chi-Square Test of Breastfeeding Knowledge on Length of Breastfeeding in Experimental group post test