Breastfeeding practices and multifaceted determinants among mothers of children under 36 months of age in Indonesia

Abstract

Title of Dissertation: Breastfeeding practices and multifaceted determinants among mothers of children under 36 months of age in Indonesia
Institution: Ph.D. Program in School of Nursing, College of Nursing, Taipei Medical University
Author: Ayyu Sandhi
Dissertation Advisor: Professor Shu-Yu Kuo, Ph.D., RN.

Introduction: Optimal breastfeeding is fundamental for children's growth and development and closely linked to short-term and long-term health outcomes. The breastfeeding patterns and their determinants among various children age group is not well investigated. In particular, examining the influence of breastfeeding self-efficacy among mothers and fathers’ breastfeeding decision helps improve breastfeeding practices. Health professionals’ breastfeeding support is vital for successful breastfeeding practices; effective education programs preparing medical, midwifery, and nursing students become important strategies for sustaining breastfeeding practices.
Objectives: The objectives of this dissertation were to (a) assess the patterns and determinants of breastfeeding practices in different child age groups (study 1); (b) investigate the maternal and paternal breastfeeding self-efficacy and its associating factors (study 2); and (c) examine the effectiveness of educational interventions to improve breastfeeding knowledge, attitudes, and skills of health professional students (study 3).

Methods: Study 1: We conducted a cross-sectional study in public health centers in Yogyakarta City, Indonesia in 2023. A total of 594 mother-child dyads were recruited using quota sampling for mothers of children aged 0-6, 7-12, 13-24, and 25-36 months. Information on demographic and health characteristics and breastfeeding practices, including skin-to-skin contact, initiation of breastfeeding, and exclusive breastfeeding, were gathered through structured questionnaires. Symptoms of depression, anxiety, parental stress, social support, and sleep quality were measured. Multivariable logistic regression analysis was performed. Study 2: A cross-sectional study design was applied on 594 mothers and fathers of children aged 0-36 months. Maternal and paternal version of Breastfeeding Self-Efficacy Scale-Short Form were collected. The components of self-efficacy, i.e., performance accomplishments, verbal persuasions, vicarious experiences, and physiological and affective states were assessed. The breastfeeding information that parents have received were examined. Chi-square test and multivariable logistic regression analysis were performed. Study 3: A systematic review and meta-analysis of experimental studies in breastfeeding educational interventions was conducted using eight electronic databases. Standardized mean differences (SMDs) with a 95% confidence interval (CI) was estimated using random-effects models. Potential moderators were identified through subgroup analyses.

Results: Study 1: Early initiation of breastfeeding was low in all child age groups (44.8% in 0-6 months, 51.3% in 7-12 months, 49.7% in 13-24 months, and 50.3% in 25-36 months), where exclusive breastfeeding rates were relatively high (85.6%) in the 0-6 months age group, but then declined with advancing age. Women who had cesarean section were less likely to practice skin-to-skin contact and early initiation of breastfeeding throughout different age groups (p < .05), also less likely to provide any breastfeeding at 7-12 months (p < .05). Having perinatal complications was negatively associated with skin-to-skin contact and early initiation of breastfeeding at 25-36 months age group (p < .001). Mothers with high depression symptoms (p < .05) or high anxiety (p < .05) will less likely to practice skin-to-skin contact or early initiation of breastfeeding. The variables of ‘very good self-rated health status’ (p < .05) and high social support (p < .05) were positively related with early initiation of breastfeeding. Multiparous mothers were more likely to exclusively breastfeed at 0-6 months (p < .05) and continued any breastfeeding at 25-36 months (p < .05). Mothers with high levels of breastfeeding self-efficacy were more likely to exclusively breastfeed at 0-6 months (p < .05) and any breastfeeding at 7-12 months (p < .001) and 13-24 months (p < .01). Study 2: Mothers and fathers reported similar breastfeeding self-efficacy scores in all age groups. In both parents, parental stress negatively associated with their breastfeeding self-efficacy (BSE) (p < .001), while social support is positively related to BSE (p < .01). Multiparity and reporting good or very good self-rated health status was positively associated with high self-efficacy in mothers (p < .05). Among mothers, previous successful breastfeeding experience (p < .001), having close family members or friends who currently breastfeed (p < .01), receiving information about assessing baby intake appropriately (p = .024) and managing breastfeeding problems (p = .016) were positively associated with high breastfeeding self-efficacy. Among fathers, previous successful experience of supporting wife to breastfeed (p < .001), receiving encouragement to continue supporting wife to breastfeed (p < .05), and receiving information about breastfeeding benefits (p = .001), physiology of breast milk production (p = .014), body changes during breastfeeding (p = .007), and breastfeeding position and proper attachment (p = .003) were significantly related to high efficacy among father. Study 3: In this meta-analysis, thirty three two-group and one-group quasi-experimental studies comprising of 1313 nursing students, 204 midwifery students, and 1066 medical students were included. Compared to control groups, students receiving educational interventions showed significantly higher scores in breastfeeding knowledge (SMD=0.67, 95% CI: 0.46-0.87 for two-group studies; SMD=1.42, 95% CI: 0.91-1.94 for one-group studies), more positive breastfeeding attitudes (SMD=0.43, 95% CI: 0.22-0.63 for two-group studies; SMD=0.98, 95% CI: 0.32-1.63 for one-group studies), and higher scores for breastfeeding skills (SMD=1.52, 95% CI: 0.46-2.58 for two-group studies; SMD=1.33, 95% CI: 0.43-2.23 for one-group studies). Clinical practicums were a significant moderator of both breastfeeding knowledge (p = .035) and skills (p < .001).

Conclusions: The exclusive breastfeeding in the first six months has met the global target, the practice of early breastfeeding initiation remained suboptimal. Breastfeeding self-efficacy was a significant factor for exclusive breastfeeding at 0-6 months and any breastfeeding at 7-12 months and 13-24 months. The assessment of maternal and paternal breastfeeding self-efficacy is warranted. Breastfeeding educational interventions effectively improve the breastfeeding knowledge, attitudes, and skills of undergraduate health professional students. Studies on continue breastfeeding education strategies in health care providers for promoting and enhancing mother’s and father’s breastfeeding are helpful.

Keywords: Breastfeeding, self-efficacy, maternal, paternal, exclusive breastfeeding, education intervention, health professional students.