Table 4.2 Bivariate analysis on Prolactin hormone variable, in the intervention group and in the control group in the Work Area of ​​ Bergas CHC Semarang District in 2018

*Man Whitney Test **Wilcoxon Test

Based on table 4.2 the analysis results on the prolactin hormone level in the intervention group before being given treatment showed a mean value of 122.43 ng/ml with a minimum ± maximum value of 62.70-195.03 ng/ml, while the mean of prolactin hormone level in the control group was 130.13 ng/ml with a minimum ± maximum value of 56.43-161.73 ng/ml. The prolactin hormone level in the intervention group after being given treatment obtained a mean value of 152, 69 ng/ml with a minimum ± maximum value of 119. 23-168.91 ng/ml, while the mean of prolactin hormone level in the control group was 131.06 ng/ml with a minimum ± maximum value of 95.86-156.95 ng/ml. The mean difference in prolactin hormone level in the intervention group obtained value of 30.26 ng/ml with a minimum ± maximum value of -42 to 75.11 ng/ml, while the mean difference in prolactin hormone level in the control group was 0.935 ng/ml, with a minimum ± maximum value of -56.85 to -43.23 ng/ml.

From the results of Mann Whitney test, maternal prolactin hormone levels before the treatment was given obtained a p value of 0.196 (p>0.05) which meant that there was no significant difference in the maternal prolactin hormone levels before treatment between the control group and the intervention group. From the results of Mann Whitney test, maternal prolactin hormone levels after the treatment was given obtained a p value of 0.003 (p <0.05) which meant that there was a significant difference in maternal prolactin hormone levels after treatment between the control group and the intervention group.

From the results of Mann Whitney test, the difference in the measurement of maternal prolactin hormone levels obtained a p value of 0.007 (p<0.05) which meant that there was a significant difference in maternal prolactin hormone levels after treatment between the control group and the intervention group. From the results of Wilcoxon test, the prolactin levels before and after treatment in the intervention group showed a p value of 0.005 (p <0.05) which meant that there was a significant difference in prolactin hormone levels before and after treatment in the intervention group. From the results of Wilcoxon test, the prolactin levels before and after treatment in the control group showed a p value of 0.003 (p<0.05) which meant that there was a significant difference in prolactin hormone levels before and after treatment in the control group.

The analysis in this study included infant weight, defecation frequency, urination frequency, infant sleep duration, maternal sleep pattern and breastfeeding frequency in the intervention group and control group.

Table 4.5 Distribution frequency of respondents based on infant body weight, BAB, BAK, length of infant sleep, maternal sleep rest and frequency of breastfeeding of infants in the intervention group and control group in the Work Area of Bergas CHC Semarang District in 2018 .

Characteristics of maternal age, maternal education, and parity of postpartum women in the Work Area of ​​ Bergas CHC, Semarang District

The characteristics that were used as variables in this study were age, education and parity, the age of the respondents included in reproductive age, namely between 20-35 years, with the mean of the age of respondents in the intervention group of 25.5 years with the youngest age of 24 years and the oldest age of 30 years . Whereas the mean of the age of respondents in the control group was 26.13 with the youngest age of 24 years and the oldest age of 31 years. So, all respondents were still in the reproductive age both in the control and intervention groups. Age is one of the factors that can affect breast milk production, mothers who are younger or less than 35 years old will produce more milk than older mothers.[8]

Mothers aged <20 years and > 35 years have a risk factor for complications during pregnancy, labor and postpartum period. The mothers aged <20 years have physical and psychological development which tend to be unprepared and unstable to get pregnant, give birth and care for their babies, while mothers aged > 35 years tend to have relaxed reproductive organs, so that women at that age tend to experience problems in breastfeeding. The age of mothers who gave birth at Bergas CHC Semarang District in the intervention group and the control group showed equal distribution which was in the healthy reproductive age of 20-35 years, the age group has a greater tendency to successfully breastfeed.[9]

The education level characteristic of respondents in this study showed that the dominant education was secondary education, with the lowest education of Senior High School and the highest of Higher Education. Education is one of the factors that can support the convenience of a person to receive information and be motivated towards a better direction, so that it is expected that the higher the mother's education, the better the motivation in making decisions to breastfeed her baby, low education will hamper the interpretation of information obtained and women with low education tend to have low motivation in facing and responding to problems during breastfeeding.[8]

The distribution of postpartum women education who gave birth at Bergas CHC Semarang District showed that the control group and the intervention group had the same distribution between senior high school and higher education. Based on the study results there was no relationship between the level of education with breastfeeding duration and breast milk production (p value = 0.697).[9]

The respondents' parity in the study showed that the dominant parity was primiparous. Primiparous women had more breast milk production than multiparous on the fourth day of postpartum, but after the breastfeeding patterns could be established properly there was no significant difference between primiparous and multiparous mothers, an increase in parity caused changes in breast milk production although it was not significant[28] there was a significant relationship between parity and the intake of breast milk by infants in mothers who were well nourished, further analysis showed that there was no relationship between parity and breast milk production (p value = 0.452). The distribution of parity of postpartum women who gave birth at Bergas CHC in Semarang District in the intervention group and the control group showed the same distribution between multiparous and primiparous.

The Effect of Giving Torbangun Leaves Extract on the Changes in Prolactin Hormone Levels among Normal Postpartum Women in Bergas CHC Semarang District

The difference in the mean of prolactin hormone level after treatment between the intervention and control groups was 152.69 ng/ml. Aignificancy value or p value = 0.03 which meant that H0 was rejected, it can be concluded that the group of normal postpartum women who consumed torbangun leaves extract had an effect on the increase in prolactin hormone level.

The normal prolactin hormone value is 95-473 ng/ml, while the study results showed that the mean of prolactin hormone level in the intervention group before treatment was 122.43 ng/ml while the eman of prolactin hormone level in the control group was 130.13 ng/ml. Those values were within normal limits. Based on the theory, in the first week after giving birth, prolactin levels in breastfeeding women decrease by 50% from the normal level. The amount of milk produced in the initial puerperium period correlates with the amount of prolactin released during breastfeeding after birth. The main stimulus that maintains prolactin secretion is released after breastfeeding, the main stimulus that maintains prolactin secretion is sucking, milk production continues as long as the baby continues to suck the nipple of the mother. Every time a mother breastfeeds her baby, nerve signals from the nipple to the hypothalamus will cause a surge of prolactin secretion about 10 to 20 times that lasts about 1 hour, this prolactin acts on the mother's breast to maintain the mammary gland in order to secrete milk [11]

This is supported by the study results that prolactin levels differed in each period, the results of the study were conducted on 16 breastfeeding mothers who had different serum prolactin levels between the breastfeeding mothers in the groups of 1 week postpartum, 4 weeks postpartum, 8 weeks postpartum, during the first menstruation after birth and after weaning. The prolactin level of the breastfeeding mothers during 4 weeks postpartum is higher than the others. [12]

The mean increase in prolactin hormone levels in the intervention group was greater than in the control group, because torbangun leaves capsules contain alkaloid, flavonoid and tannin chemical compounds. Torbangun leaves also containe three main components which have characteristics galactagogue, nutrients and pharmacoseutics.¹⁰ Those active compounds play a role in increasing prolactin levels, in addition 100 grams of torbangun leaves contain 279 mg of calcium, 13.6 mg of iron and total carotene of 13288 µg. The component of steroids active compounds is also contained in torbangun leaves which are steroid chemical messengers synthesized in the gland and delivered by blood flow to the target tissues to stimulate or inhibit a process. The presence of steroid content in torbangun leaves is thought to be related to the effect of increasing breast milk levels among breastfeeding mothers who consume torbangun leaves.

Components of ethyl-3hydroxy-5-alpa andostran-17-one, 3, 4-dimethyl-2-oxocyclopent-3-enylacetic acid, monomethyl succinate and methylpyro glutamate, sterol compounds, steroids, fatty acids, organic acids in torbangun leaves have the power of the galactagogue effect. The mechanism of the galactagogue power of compounds can occur, among others, by: directly stimulating the activity of protoplasm secretory cells of the mammary gland, stimulating the nerve endings of secrotis in the mammary gland so that milk secretion increases, or stimulating prolactin hormone that acts on alveolar epithelial cells. Prolactin or luteotropin or LTH is a lactogenic and proliferative hormone against the mammary gland. Prolactin in humans or mammals has an effect in stimulating lactation. In addition, the galactagogue function can also increase glucose metabolism for lactose synthesis so that milk production increases.

The Effect of Giving Torbangun Leaves Extract on the Changes in breast milk production (indication of the mran of infant weight and the mean of sleep duration) among postpartum women who gave birth at Bergas CHC, Semarang District

The mean of infant sleep duration after breastfeeding obtained p value of 0.239 (p>0.05) which meant that there was no significant difference in the sleep duration before treatment between the control group and the intervention group. After giving the treatment and Mann whitney test was conducted, the results obtained p value of 0.003 (p <0.05) which meant that there was a significant difference in the infant sleep duration after treatment between the control and the intervention group and Mann Whitney test obtained p value of 0.001 (p<0.05) which meant that there was a significant difference in the difference of infant sleep duration after treatment between the control and intervention groups.

It is in accordance with the theory that the assessment indicator of breast milk production can use several criteria as a reference to determine the breast milk secretion and a sufficient amount for the baby, including an increase in infant body weight, frequency and characteristics of urination, frequency, color and characteristics of defecation, sleep duration or the baby is calm after breastfeeding.[8]

Most infants experience weight loss during the first week after birth, and it is expected that in 10-14 days the infant weight will reach the birth weight. Data from the study results showed normal range of body weight decrease by 3% -7%, although a 10% decrease is stated as the normal upper limit. If the lactation process cannot fulfil the baby's needs, especially when the baby needs a larger amount of milk on the third and fourth days, this may cause the baby is in a greater risk of losing weight in the first week.

Based on the analysis results the difference in the mean increase in breast milk production (indication of body weight and sleep duration) the infant weight in the 7th day of the control group showed babies who experienced a decrease of more than 10% due to the amount of milk of the mother could not meet the babys’ needs. Neonates have brown adipose tissue, which helps metabolize heat sources (called free fatty acids and glycerol). Weight loss will have an impact on the supply of brown tissues so that the baby's ability to control body temperature will be disrupted (susceptible to hypothermias), besides the ability the baby to shiver is still limited and baby is unable to increase the contraction of the vascular muscles to produce heat.

Brown fat burning requires three times more oxygen than other body tissues, which has an unexpected effect that is the flow of oxygen and glucose from vital regulatory centers such as the brain and heart, besides vasoconstriction results in decreased lung function and respiratory acidosis when pH and PaO2 increase which may result in respiratory distress characterized by tachypnea. All of the above conditions can result in the reopening of the left to right shunt across the arterious duct. Anaerobic glycolysis (glucose metabolism in the absence of oxygen) causes acid production which aggravates the condition by increasing the incidence of metabolic acidosis.

Breast milk is the best baby food. Breast milk production will be faster and more when stimulated as early as possible by breastfeeding from birth to as long as possible.[1] The administration of torbangun leaves extract is one of the alternatives in increasing breast milk production. The study result showed that infant body weight in the intervention group increased, it might reduce the risk of metabolic acidosis disorder.

Based on the independent test of t test on the infant weight in 14th day, the results before and after treatment and the Wilcoxon test showed a p value of 0.00 (p <0.05) which meant that there was a significant difference in the infant body weight before and after treatment in the intervention group. Infant body weight before and after treatment in the control group and Wilcoxon test obtained a p value of 0.000 (p<0.05) which meant that there was a significant difference in the infant body weight before and after treatment in the control group. Prentice observed the relationship of infant weight and breast milk production. Breast milk production is influenced by the prolactin hormone which is continuously secreted into the breast alveoli, but milk cannot flow easily from the alveoli into the ductal system so that milk does not drip continuously in the nipple. The draining of milk from the alveoli to the duct requires the merging process of neurologic and hormonal reflexes involving the posterior pituitary hormone namely the oxytocin hormone, when the oxytocin reflex does not work, the baby will not get adequate breast milk, even though the milk production is sufficient.[1]

The results are in line with the study conducted by Ade Chandra Iwansyah entitled The potency of torbangun leaves (coleus amboinicus l.) ethyl acetate fraction in increasing breast milk production, maternal body weight, and infants in mice which showed a gradual increase in the growth and significant body weight gain.[14]

The results are in line with the study conducted by Tiurlan Farida Hutajulu entitled The benefits of the bangun bangun leaves extract (Coleus Amboinicus Lour) to increase the production of breast milk among female mice which showed that there was a significant effect of bangun bangun leaves extracts on the weight of experimental mice. The weight of the mothers that received fresh bangun bangun leaves extract still experienced a slight increase during the breastfeeding process, while the weight of the mothers that did not receive bangun bangun leaves extract decreased with the largest decrease compared to the weight of the mothers that given bangun bangun leaves extract. Weight gain of the mice babies whose mothers were given bangun bangun leaves extract powder was 5% which showed a higher growth compared to other treatments.[15]

The study results are in accordance with a study conducted by Rizal Damanik entitled Effect of consumption of torbangun (Coleus amboinicus Lour) soup on the micronutrient intake of the bataknese lactating women which showed that torbangun leaves soup could increase the consumption of micronutrients of the study subjects. The average consumption of micronutrients (calcium, magnesium, potassium and iron) increased beyond the recommended dietary allowances rate (RDA). The study results indicated that torbangun leaves soup could improve the micronutrient status of breastfeeding mothers.[16]

The production of breast milk by the breast glands does not have the same time. The breast milk that is firstly sucked by a baby in the first minute is different compared to the last minute production. First-minute breast milk dilutes faster, then it will be thicker. Mother's milk at the last minute contains 4-5 times of protein and 1.5 times more than the first minute milk. So, the right breastfeeding technique and proper suck of the baby may lead the baby to get all the benefits of breast milk in each phase of breastfeeding from the first minute to the last minute.

The study results in the intervention group showed that the mean of infant sleep duration in the intervention group before and after treatment in the control group had a p value of 0.007 (p <0.05) which meant that there was a significant difference in the sleep duration before and after treatment in the control group. Based on the above theory it is possible that infants in the intervention group received all the benefits of breast milk in each phase of breastfeeding from the first minute to the last minute. A higher fat content at the end of the suckle gives the baby a feeling of satisfaction, so that the baby will calm down or fall asleep 2-3 hours after breastfeeding. The study result related to infant sleep duration showed a significant value but it could not describe smooth breast milk production, because breast milk production is said to be smooth if at least 4-7 indicators observed in the infants are met. In addition to breastfeeding habits, weight gain and sleep patterns of each baby are not the same because every baby is a unique individual and there are wide variations.