Profiles of Eight Working Mothers Who Practiced Exclusive Breastfeeding in Depok,Indonesia

Abstract

Exclusive breastfeeding practice is generally low because of multifaceted factors internally within mothers themselves and also the surroundings. In addition, studies have consistently found that maternal employment outside the home is related to shorter duration of exclusive breastfeeding. With all these challenges, it is interesting that there are some mothers who manage to exclusively breastfeed their infants. Therefore, this report aims at exploring the characteristics of working mothers who are able to practice exclusive breastfeeding. The original study population was non-working and working mothers who have infants around 1 to 6 months old. The study design is an observational study with a mixed methods approach using a quantitative study (survey) and qualitative methods (in-depth interview) in sequential order. In addition, in-depth interviews with family members, midwives, supervisors at work, and community health workers were also included to accomplish a holistic picture of the situation. The study concludes that self-efficacy and confidence of the breastfeeding mothers characterize the practice of exclusive breastfeeding. Good knowledge that was acquired way before the mothers got pregnant suggests a predisposing factor to the current state of confidence. Home support from the father enhances the decision to sustain breastfeeding.

Introduction

Factors negatively associated with exclusivity and duration of breastfeeding include poor knowledge and lack of mother's confidence,^1,2 inadequate skills of appropriate breastfeeding techniques (i.e., positioning, latching on) and management of common problems during lactation (i.e., breast engorgement, perception of insufficient breastmilk, sore nipple, etc.),^3,4 lack of physical and psychological supports received during the lactation period (i.e., from family members, peers, health professionals),^5–7 use of teats or pacifiers,^8,9 maternal employment,^1,10 exposure to various sources of information,¹¹ and inappropriate infant feeding norms, especially exclusive breastfeeding practice among family members, peers, and society.^1,12 Data from the developed world state that most women who decide to breastfeed make this decision before or early in pregnancy.¹³ Moreover, breastfeeding plans described by the mother at the time of delivery were significantly associated with the duration of breastfeeding.⁹

Recent data in Indonesia show that the percentage of infants of any age less than 6 months old who were currently exclusively breastfed was 39.5% in 2002¹⁴ and 32.4% in 2007.¹⁵ The data suggest that exclusive breastfeeding practice is generally low but slowly increasing. A rapid survey in DKI Jakarta Province, Indonesia found that although exclusive breastfeeding is also unsatisfactorily practiced among non-working mothers, the practice is worse among working mothers: Exclusive breastfeeding practice rates among working and non-working women were 1.4% and 16%, respectively.¹⁶ Working outside the home consequently influenced mother–infant separation, thus increasing the likelihood of shorter duration of exclusive breastfeeding practice as found in Vietnam,¹⁰ Nairobi,¹⁷ and Singapore.¹⁸

Nevertheless, some working mothers were identified who successfully breastfed exclusively. A study in rural Vietnam found that exclusively breastfeeding women who were working mothers had several important characteristics: They all felt they had enough milk, all knew the appropriate time to introduce liquids and foods, and most of them were supported in their breastfeeding decisions by commune health workers and family members.¹⁰

Hector et al.¹⁹ summarized that the influencing factors in exclusive breastfeeding practice fall into internal and external aspects. The first aspect includes maternal knowledge, motivation, self-efficacy, and confidence, and the latter includes hospital/health services, home, community, and workplace environments that surround the breastfeeding mothers.

The present article is part of a survey finding on a formative research of exclusive breastfeeding practice among working and non-working mothers in Depok, Indonesia. The study found that 42 of 253 non-working mothers did perform exclusive breastfeeding; in contrast, only eight of 168 working mothers were noted to have practiced breastfeeding exclusively.²⁰ Because the number of working mothers who practiced exclusive breastfeeding does not reach an adequate sample for any statistical tests, this case report aims to list and report the patterns found within the relevant profiles of the internal and external factors of these mothers.

Subjects and Methods

The study population of the survey as the main study was non-working and working mothers who have infants around 1–6 months old (based on the assumption that working mothers have already returned to work). The mother was categorized as a working mother if she worked outside the home for at least 10 hours/week (five days/week)¹⁰ and received a salary or in kind as payment. The non-working mothers were defined as mothers who stayed at home and did not engaged in any income-earning activities. Based on the survey it was found that eight of 168 working mothers were currently exclusively breastfeeding at the time of interview, which came from a composite of mothers of infants who did not receive any other substances than breastmilk (except medicine or supplements) in the previous 24 hours preceding the survey, were not fed by a bottle with nipple containing other than expressed breastmilk, and were still breastfed in the last 24 hours preceding the survey.²⁰

Therefore, exclusive breastfeeding in this study is regarded as “current exclusive breastfeeding practice” as indicated by the World Health Organization definition.²¹

This article reports the characteristics of these eight mothers in terms of their sociodemographic, maternal knowledge, and psychosocial factors having an effect on exclusive breastfeeding practice, as well as their environmental profiles.

As some specific patterns in the profile of these working mothers were found based on the survey data, the study was followed up with group interviews. Only three of the eight mothers were able to be followed up and interviewed in-depth in the presence of other family members such as the father and, when applicable, the grandmother. Thus, the unit of analysis of this part of the study was the household. The interviews addressed most issues covered in the survey, but more flexible responses from the household members were encouraged to allow a more in-depth analysis.

Aside from obtaining the household in-depth information, some triangulation interviews and/or observations were carried out with the midwife, workplace, community health worker, and nursery room in some malls. An attempt to gather information from two prospective hospitals was initiated but finally canceled because of complicated permission requirements.

The data from the survey are presented in a descriptive display matrix listing all the information from the subjects coded 1–8. The results of the in-depth interviews are presented in the form of quotations to support the pattern found from the survey.

Results

Table 1 shows no explicit similarity pattern in terms of the sociodemographic characteristics of the eight working mothers and their children. However, in terms of the internal factors, all of these working mothers were considered to have good knowledge. These working mothers knew about what exclusive breastfeeding means and until what age a baby should be provided with breastmilk exclusively. All mothers had also shown favorable attitudes toward breastfeeding in general and also toward exclusive breastfeeding practice and its outcome to the child's health. All of them admitted to having no complaints in terms of their breastmilk production. Nearly all of them resorted to expressed breastmilk to resume breastfeeding when separated with the baby, whereas one mother who had never been separated from her baby was able to bring the baby to work.

Table 1.

Profiles of the Internal and External Factors of the Eight Exclusively Breastfeeding Working Mothers

	Subject code:
Characteristic	1	2	3	4	5	6	7	8
Socioeconomic and demographic
Child's sex	Female	Female	Male	Female	Female	Female	Male	Male
Child's age (months)	3.31	5.54	3.08	3.31	3.64	5.51	2.79	2.26
Household income level	High	Fair	Fair	Fair	Fair	High	Fair	High
Mom's education level	College	College	High school	College	High school	College	College	College
Father's education level	High school	College	College	College	High school	College	High school	College
Parity (number of children)	Primipara	Primipara	Primipara	Primipara	Multipara (2)	Multipara (2)	Multipara (2)	Multipara (2)
Household composition	Extended	Nuclear	Extended	Extended	Nuclear	Extended	Nuclear	Extended
Mother's knowledge
Mom's knowledge level	Good	Good	Good	Good	Good	Good	Good	Good
Mother's psychosocial factors
Mom's attitudes toward breastfeeding	Favorable	Favorable	Favorable	Favorable	Favorable	Favorable	Favorable	Favorable
Belief on health status of exclusively breastfed child compared with non-exclusively breastfed	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier	Exclusively breastfed child is healthier
Sufficiency of breastmilk production	Confident	Confident	Confident	Confident	Confident	Confident	Confident	Confident
Perception toward the current infant feeding practice	The best feeding practice	The best feeding practice	The best feeding practice	The best feeding practice	The best feeding practice	The best feeding practice	The best feeding practice	The best feeding practice
Self-efficacy: food left at home when mother is away	Only breastmilk	Only breastmilk	Only breastmilk	Only breastmilk	Never been separated from the baby	Only breastmilk	Only breastmilk	Only breastmilk
Self-efficacy: breastmilk expression	Yes	Yes	Yes	Yes	Never	Yes	Yes	Yes
Self-efficacy: effort to resume breastfeeding	Expressing breastmilk at work using any available space/room	Expressing breastmilk at work using any available space/room	Breastfeeding before and after work	Expressing breastmilk when at home	The baby is always brought to work place	Breastfeeding before and after work	Breastfeeding at home during break time	Breastfeeding before and after work
Environment: health service provider
Mode of delivery	Cesarean	Normal	Normal	Cesarean	Normal	Cesarean	Normal	Normal
Place of delivery	Hospital	Hospital	Midwife's practice	Hospital	Midwife's practice	Hospital	Midwife's practice	Hospital
Prelacteal feeding	Yes (infant formula)	None	Yes (infant formula)	Yes (infant formula)	None	None	Yes (infant formula)	Yes (infant formula)
Breastfeeding initiation after birth	2 days	1 hour	5 days	2 days	Immediately	3 days	1 hour	2 days
Rooming in	No	Yes	No	No	Yes	Yes	Yes	No
Received sample of formula milk after discharged	Received free sample	None	None	None but received information	None	None	Received free sample	Received free sample
Environment: Home
Father's support toward formula for infant <6 months	No	No	No	No	No	No	Yes	No
Grandparents' support toward formula for infant <6 months	No	Yes	No	No	No	No	No	No
The most supportive at home	Father	Father	Father	Father	Father	Father	Father	Father
Environment: Community
Neighbor's support toward formula for infant <6 months	No	Do not know	No	Yes	Yes	Do not know	Yes	Do not know
Environment: Workplace
Type of work	Private company (employed)	Civil servant (employed)	Private company (employed)	Civil servant (employed)	Kindergarten teacher (employed)	Civil servant (employed)	High school teacher (employed)	Private company (employed)
Friend's support toward formula for infant <6 months	Yes	Yes	No	No	No	Yes	Yes	Yes
Availability of a designated lactation room at work	None	None	None	None	Available	None	None	None
Exposure to information
Timing when exposed to information about exclusive breastfeeding	Before getting pregnant	Before getting pregnant	Before getting pregnant	Before getting pregnant	Before getting pregnant	Before getting pregnant	Before getting pregnant	Before getting pregnant

Characteristics printed in boldface are those showing specific similarity patterns among all mothers.

Table 1 also shows that the external factors such as hospital/health service, community, and workplace environments do not resemble any specific patterns. However, in terms of home environment, all mothers admitted that the father was the most supportive family member to their decision to breastfeed. Beyond that, all mothers also noted that each of them was already exposed to sufficient information about appropriate infant feeding choice before they got pregnant.

Furthermore, when interviewed in-depth, mothers responded affirmatively about maternal confidence as a result of good knowledge and favorable attitude towards exclusive breastfeeding:

It's the mother's motivation that matters, even if you are working, you'll find ways how and when to express your breastmilk, and deal with other things. By doing so, you can practice exclusive breastfeeding as recommended [from a working mother who plays as a role model for exclusive breastfeeding at work and are surrounded by supportive husband and parents]

My friends at work and neighbors often teased me that I was a stingy mother for not giving baby food or formula milk earlier. I didn't mind them, I was determined to exclusively breastfeed my baby girl until she is 6 months old, especially when I know that breastmilk can be expressed and stored [from a working mother who was able to bring her baby to work and managed to exclusively breastfeed for 6 months]

In addition, good breastmilk production had seemed to serve as a motivational factor to increase maternal self-confidence:

I was planning to exclusively breastfeed for 4 months because I am returning to work soon after delivery, but the breastmilk production was good that I continued exclusive breastfeeding until my baby girl was 6 months [from a working mother who has nutrition educational background and is planning to quit from work because she wants to take care of the child on her own after the bonding she felt with her baby during the exclusive breastfeeding period]

Support from the home environment as mentioned by the following father suggests partly that it is a result of the negative image of breastmilk's prominent competitor (i.e., formula milk):

I support my wife's decision to breastfeed. That's why I am not worried about recent news on bacteria contamination to some formula milk because my baby is taking breastmilk. This confirms that breastmilk is the best because it cannot be contaminated [from a first-time father of an exclusively breastfed baby boy]

Nevertheless, such subjective norms in the community still prevail as reflected from the following response:

Nowadays, more people know about exclusive breastfeeding compared to years before. More working mothers are exposed to it compared to non-working mothers, but only few of them can practice it because it is difficult for them [from a senior community health worker who has been serving for about 10 years]

The above prevailing subjective norms in the community may be imparted to influence the proposition of the hospital/health service environment to exclusive breastfeeding practice as shown by the midwife's response below:

I have suggested to my patients who are working mothers to express their breastmilk. Some of them even bought a fancy breast pump, but what can I say … after few days back to work they came to me complaining about the breastmilk production that is getting lesser and lesser. Perhaps it is the stress at work that influences the production. That's why I think it is difficult for a working mother to resume exclusive breastfeeding at work [from a sought-after private midwife in one of the studied areas]

Discussion

A previous study found that parity is one of the contributing factors to exclusive breastfeeding. This means that a first-time mother is less likely to practice exclusive breastfeeding compared with her multiparous counterpart, suggesting that previous breastfeeding experience has an important role in shaping the current feeding practice.²² Other sociodemographic characteristics such as the child's age and household composition, which had been suspected to contribute to influencing the practice of exclusive breastfeeding, varied among these eight mothers, suggesting that these characteristics may not be substantial for motivating current breastfeeding practice. Nevertheless, the education level of the mothers and the fathers tended to be consistent among all subjects as either high school or college graduates. This information suggests that these parents had acquired a relatively high level of formal education that may be sufficient to be of importance in the infant feeding mode.²³

The formal education combined with a good level of breastfeeding knowledge and attitude as found in this study indicates that maternal self-efficacy to practice breastfeeding appropriately increases the mother's confidence in the current practice. Clearly, all mothers in this study had acquired a predisposing factor to embark on a good feeding practice.²⁴ This fact is enhanced with the effort to gather information on infant feeding long before the women got pregnant. This suggests that unless the mothers had been highly motivated to perform the appropriate infant feeding practice, then the attempt to gain such information may not have happened.^24,25

Aside from the above internal aspects supportive of the current feeding practice, some of these exclusively breastfeeding mothers were also exposed to environments unsupportive to the practice. Prelacteal feeds, formula samples received from the place of delivery, insults from neighbors, and the lack of a lactation room at the workplace were some instances of negative environments. The first two unsupportive practices taking place at the health service facility are no longer secretive acts. This is very much understandable because based on the World Breastfeeding Trend Report in 2008,²⁶ Indonesia does not have a so-called Baby Friendly Hospital. Although Indonesia has Health Ministry Decree Number 450/MENKES/SK/IV/2004 mentioning about the Ten Steps to Successful Breastfeeding, there is no program or support system to make sure that the program runs well. In brief, the profile shown indicates that the hospital/health service, community, and workplace environments may have had less of an influence compared with the strong internal factors of the mothers in directing their decision toward the current breastfeeding practice.¹⁹ In addition, the father's role in providing a supportive home environment enhances the decision to sustain breastfeeding.^22,27

In general, the findings from this study are in line with the experiences from Vietnam.¹⁰ However, two quantitative studies from Nairobi¹⁷ and Singapore¹⁸ highlighted the work-related factors as the unsupportive environment for exclusive breastfeeding practice among working mothers, especially for those working outside home. Mothers who were separated from the infant for some time had an increased likelihood that the duration was shortened and the practice of exclusive breastfeeding was reduced.

Conclusions

Self-efficacy and confidence of the breastfeeding mothers characterize the practice of exclusive breastfeeding. Good knowledge about exclusive breastfeeding practice that was acquired way before the mothers got pregnant suggests a predisposing factor to the current state of confidence. Home support from the father enhances the decision to sustain breastfeeding. In addition, a certain level of knowledge on the solutions to potential problems faced during breastfeeding practice is important to equip mothers with options to breastfeeding success.

Footnotes

Acknowledgments

The authors thank all volunteers and their families for their willingness to take part in and make this study possible, as well as their surrounding institutions and individuals. We also acknowledge funding support from the Neys-vanHoogstraten Foundation, The Netherlands.

Disclosure Statement

No competing financial interests exist.

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