Exclusive Breastfeeding Plan of Pregnant Southeast Asian Women: What Encourages Them?

Abstract

Objectives:

This study investigated factors involved in breastfeeding planning of pregnant Asian women.

Subjects and Methods:

A cross-sectional study was conducted on 207 pregnant women visiting the Budi Kemuliaan Hospital, Jakarta, Indonesia, between June and August 2011. The planned breastfeeding duration and determinants were sought using a standardized self-reported questionnaire.

Results:

Most subjects had low income (84.1%) and education (79.7%). Women who had been informed about breastfeeding had a higher likelihood to plan longer (≥6 months) breastfeeding (odds ratio [OR] 1.97; 95% confidence interval [CI] 1.04–3.75; p=0.04), whereas women who had breastfed previous children over a shorter period had a lower likelihood (OR 0.26; 95% CI 0.11–0.59; p=0.001). Age, low education level, first pregnancy, and low income had no association with breastfeeding plans. Working mothers who had to return to work before 6 months and worked for >8 hours/day were less likely to plan longer breastfeeding (OR 0.14; 95% CI 0.02–0.83; p=0.03 vs. OR 0.53; 95% CI 0.17–1.63; p=0.27), whereas those intending to express their milk were more likely to breastfeed longer (OR 16.85; 95% CI 4.21–67.48; p<0.001).

Conclusions:

Planning of prolonged breastfeeding has little to do with maternal age, education, or number of pregnancies. However, mothers who work, who had previously breastfed for a short period, and who are not well informed about breastfeeding tend to plan shorter breastfeeding. Among mothers who work, it is the length of maternal leave and required working hours that determine the plans.

Introduction

The importance of breastfeeding in early child nutrition is widely acknowledged.¹ Evidence regarding its benefits for future health outcomes is also growing.² Breastfeeding has been formally endorsed and promoted globally since the last two decades when the World Health Organization and UNICEF launched the Baby-Friendly Hospital Initiative in 1991 following the Innocenti Declaration of 1990.³ The initiative aims at protecting, promoting, and supporting exclusive breastfeeding for 6 months by developing different tools and materials that were implemented universally in more than 152 countries. It also has measurable and proven impact, increasing the likelihood of babies being exclusively breastfed for the first 6 months.⁴ A 6-month exclusive breastfeeding compared with a shorter duration has been suggested to result in less gastrointestinal morbidity without adverse effects on growth.⁵

Despite the established benefits and intensive campaigning, breastfeeding rates in Asian countries are still very low. For example, a national survey in 2010 conducted by the Ministry of Health of Indonesia revealed that the percentage of women who give exclusive breastfeeding for the first 6 months is only 15.3%.⁶ A study on the secondary data of national demographic and health surveys among Asian countries reported similar rates: Vietnam, 15.5%; Timor Leste, 30.7%; and The Philippines, 33.7%.⁷ The same study suggested several factors that might be associated with non–exclusive breastfeeding: notable are mother's work, first children, low number of antenatal clinic visits, and higher proportions of richer households. However, these studies reflect survey data, and it is important to know about factors that determine women's plans for breastfeeding during their pregnancy as this creates a window of opportunity for intervention and management. Clearly, the planning and lactation instruction about breastfeeding should start then. With a view to future optimization of breastfeeding, it is of relevance to determine whether a woman's circumstances particularly determine breastfeeding plans or whether a woman's beliefs, level of information, or aversion against breastfeeding are determining her plans. Specifically, it is still largely unknown which factors encourage giving 6 months of exclusive breastfeeding.

We analyzed factors influencing a mother's plan for breastfeeding during the phase of pregnancy using data from a feasibility study for a large breastfeeding optimization trial in Indonesian pregnant women.

Subjects and Methods

This cross-sectional study was conducted on pregnant women visiting the antenatal clinic at Budi Kemuliaan Hospital, Jakarta, Indonesia, between June and August 2011. Budi Kemuliaan Hospital is a private hospital in the Jakarta municipality, specialized in mother and child care. Some 7,800 births are registered at Budi Kemuliaan Hospital each year, which is among the highest delivery rates in Indonesia. This study was approved by the Ethics Committee of the Medical Faculty of the University of Indonesia. Informed consent was obtained for every subject.

A short questionnaire about identity and demographic characteristics (eight combined open and closed questions) and breastfeeding plan and previous practice (six closed questions), as well as working situation (six closed questions), was handed out and filled out by the subjects after a brief explanation. We emphasized the importance of giving the true answers reflecting their plan instead of “socially acceptable” ones and told them as researchers that we did not have any specific preference for answers. The questionnaire was first tested on 15 pregnant women to ensure its comprehensiveness, and most could answer the questions within 10–15 minutes. After a pregnant woman filled out the questionnaire, the authors performed a brief review together with the woman and checked for its completeness. We sought for age, pregnancy order, education, income, previous information/education about breastfeeding, previous breastfeeding practice, and working status/situation as the proposed determinants of planning to breastfeed for 6 months or longer (Table 1).

Table 1.

Outcome and Determinants

	Definitions
Outcome variables
Exclusive breastfeeding	Infants should receive only breastmilk and nothing else, with exceptions such as oral rehydration solution, syrups, vitamins, minerals, and medicines. This term includes breastfeeding by a wet nurse and feeding by expressed milk.^a
Plan to breastfeed for less than 6 months	Explicit intention to breastfeed for less than 6 months or plan of giving early supplemental formula in case the breastmilk production was perceived as inadequate
Proposed determinants
Age	Time duration between date of birth and date of inclusion
Low education	Primary or secondary school graduate
Low income	Family income was less than IDR 2,960,723/month^b
Having been informed about breastfeeding	Had received any previous information or education regarding breastfeeding, from electronic/print media, health professionals, or peer counselors
Previous breastfeeding of less than 6 months	History of exclusive breastfeeding for less than 6 months with any previous child
First pregnancy	The first pregnancy of mothers at the time of study inclusion, excluding previous abortion/terminated pregnancy
Working mother	Refers to women who are mothers and who work outside of the home for income in addition they perform at home raising their children
Work for more >8 hours/day	Spend more than 8 hours/day for working outside the house (including time spent for travel between home and work place)

Definition based on that of the World Health Organization.⁸

Conforms to “poor” and “poorest” economic classification of the World Bank.

Characteristics of the pregnant women were first classified by breastfeeding planning. These characteristics were then evaluated as possible determinants of breastfeeding using a univariable logistic regression model with breastfeeding plan for 6 months (yes/no) as the dependent variable and characteristics as independent variables. Subsequently, the same logistic regression model was used for multivariable analysis. As previous findings from an Indonesian survey indicated that working by the mothers might be an important determinant of breastfeeding plans, we subsequently analyzed the group of working mothers separately.

Results are expressed as odds ratios and 95% confidence intervals. Intervals not including 1, corresponding to values of p<0.05, were considered statistically significant. Statistical analysis was performed using the IBM^® SPSS^® Statistic Version 19 for Mac computer program (SPSS, Inc., Chicago, IL).

Results

The characteristics of women intending to breastfeed for less than 6 months and of those intending to breastfeed for 6 months or longer are shown in Table 2. We included 207 women during the study period with ages ranging from 17 to 45 years; six women refused to participate because they needed to undergo urgent antenatal evaluation. Most subjects had a low income (84.1%) and education (79.7%), and almost half (43.5%) were working mothers.

Table 2.

Characteristics of the Study Population of Pregnant Indonesian Women According to Planned Duration of Breastfeeding

	Breastfeeding
Variable	<6 months (n=130)	>6 months (n=77)
Age [mean (SD)]	27.71 (5.6)	27.47 (4.9)
Working mother (n=201)	61 (49%)	29 (38%)
First pregnancy (n=205)	46 (35%)	30 (39%)
Low education (n=205)	104 (81%)	61 (79%)
Low income (n=201)	108 (87%)	66 (86%)
Having been informed about breastfeeding (n=201)	72 (58%)	54 (70%)
Previous breastfeeding of <6 months (n=124)	44 (54%)	10 (23%)

Data are number (percentage) unless indicated otherwise.

Table 3 shows that age, low education, first pregnancy, and low income had little or no association with intention to breastfeed for 6 months or longer, either in the univariable or in the multivariable analysis. Having been informed about breastfeeding showed an almost twice higher likelihood of breastfeeding for 6 months or longer. The results also showed that if a mother had breastfed her previous child for less than 6 months, the probability that she planned a long breastfeeding period for the next child decreased by almost 75%. Working affected breastfeeding plans, although not statistically significant.

Table 3.

Predictors of Breastfeeding Plan of More Than 6 Months

	Univariable			Multivariable
Variable	OR	95% CI	p	OR	95% CI	p
Working mother	0.62	0.35–1.11	0.11	0.54	0.29–1.01	0.05
Age	0.94	0.94–1.05	0.76	0.99	0.93–1.06	0.83
Low education	0.88	0.43–1.78	0.72	0.88	0.41–1.92	0.76
First pregnancy	1.17	0.66–2.11	0.59	1.27	0.61–2.66	0.53
Low income	0.89	0.39–2.03	0.78	0.96	0.40–2.31	0.93
Informed about breastfeeding	1.70	0.93–3.10	0.09	1.97	1.04–3.75	0.04
Previous breastfeeding of <6 months^a	0.26	0.11–0.59	0.001

The multivariable analysis for previous breastfeeding was not estimable because of small numbers.

CI, confidence interval; OR, odds ratio.

We further performed a subgroup analysis on 90 working mothers to find out working-associated factors that might determine their breastfeeding plan (Table 4). On multivariable analysis, the length of maternal leave affected breastfeeding plans. If a mother had to return to work before 6 months after delivery, then she had one-seventh times lower chance to plan breastfeeding for 6 months or longer. Working hours of more than 8 hours/day were also related to breastfeeding plans, although not statistically significant. On the other hand, working pregnant mothers who planned to express or pump their milk had a markedly higher chance to breastfeed longer.

Table 4.

Predictors of Breastfeeding Plan of More Than 6 Months: Subgroup Analysis in Working Mothers (n=90)

	Univariable			Multivariable
Variable	OR	95% CI	p	OR	95% CI	p
Work hour >8 hours/day	0.57	0.22–1.44	0.23	0.53	0.17–1.63	0.27
Return work in <6 months	0.34	0.09–1.39	0.13	0.14	0.02–0.83	0.03
Job in public places/frequent travel	0.71	0.29–1.73	0.89	2.45	0.67–9.92	0.18
Intention to express/pump milk	8.64	3.1–24.09	<0.001	16.85	4.21–67.48	<0.001
Availability of lactation room	1.06	0.44–2.59	0.89	0.48	0.14–1.70	0.26
Availability of refrigerator	1.52	0.61–3.18	0.37	1.36	0.36–5.14	0.65
Available time to express milk	2.27	0.68–7.55	0.18	2.28	0.47–11.10	0.32

CI, confidence interval; OR, odds ratio.

Discussion

The findings in this cross-sectional study among 207 pregnant Indonesian women suggest that previous breastfeeding duration and extent of receiving information on breastfeeding during antenatal care determine the length of planned breastfeeding period for the next child. In addition, working outside the house predicted the plan for breastfeeding, but in particular the length of maternal leave and working hours affected the planned duration of breastfeeding.

To appreciate these findings some aspects of the study need to be addressed. A limitation of this study is that it only assessed the planning of breastfeeding as an outcome, not the eventual real practice. Although what a pregnant woman plans is likely to determine her actual behavior, there is the possibility that women gave "socially acceptable" answers while they did not really mean to or that they changed their minds later. We tried to minimize this bias by giving an explanation to the mothers prior to the questionnaire administration, emphasizing the importance of giving true answers reflecting their plan and the neutral position of the investigators as to their answers. In addition, to confirm whether they indeed did not intend to breastfeed for less than 6 months, we also asked an implicit question regarding their view toward early supplemental formula feeding. However, the inquiry regarding breastfeeding planning during pregnancy is, on the other hand, a strength of this study because early prediction will make early, directed intervention more feasible.

To our knowledge there are limited published studies focusing on the evaluation of the determinants of exclusive breastfeeding in Indonesian women. Most studies were part of a multipurpose national survey. The 1987 National Indonesia Contraceptive Prevalence Survey revealed that household economic level, language, place of delivery, type of birth attendant, mother's education, mother's occupational experience, spouse's education, spouse's occupation, mother's age at the time of birth, parity, child's sex, and “wantedness” of pregnancy were associated with duration of breastfeeding.¹⁰ Another more recent study also used secondary data of the national demographic survey and found that mother's work, first children, low antenatal clinic visits, and higher proportion of richest households were associated with non–exclusive breastfeeding.⁷ Compared with those studies, our findings are different and more pertinent, which may have been caused by differences in design, time setting, subject characteristics, and different determinants studied. Other studies regarding the determinants of exclusive breastfeeding, as expected, showed various results.^11–13 In fact, one study⁷ that tried to pool the determinants of exclusive breastfeeding in five East and Southeast Asian countries could not reach a consensus because of the large heterogeneity in results. This suggests that determinants of breastfeeding have strong ethnic, cultural, and local characteristics. However, the heterogeneity may also have been caused by different factors of interest explored by each national survey.

The Indonesian health authorities have expressed an urge for improving the breastfeeding habits of Indonesian women, and interventions to achieve that have already been initiated. We believe that for these interventions to be successful, detailed knowledge of what drives pregnant women in their breastfeeding plans is indispensable. It is particularly important to know whether it is issues like information about breastfeeding or whether it is, for instance, circumstances at work. Such knowledge may fuel campaigns from several angles and strategies.

Our findings suggest that more breastfeeding education should be given to pregnant women regardless of their background education or socioeconomic level. This strategy was also found to be successful in other studies.¹⁴ Moreover, our findings suggest that there is a concentration of poor breastfeeding habits among women who had breastfed for less than 6 months with previous children, and they seemed not likely to change the poor practice into longer breastfeeding for the next child. Although we performed a subgroup analysis on a relatively small number of working mothers, our findings do suggest that regulations regarding maternal leave and work should be reviewed to facilitate the success of 6 months of exclusive breastfeeding.

In conclusion, planning of prolonged breastfeeding appears to have little relation with maternal age, education level, or number of pregnancies. However, mothers who work, those who previously had breastfed for a short period, and those who are not well informed about breastfeeding tend not to plan longer periods of breastfeeding. Among mothers who work, it is not so much the circumstances at work that determine the plans for breastfeeding, but the length of maternal leave, required working hours, and intention to pump/express milk that determine the plans.

Footnotes

Disclosure Statement

No competing financial interests exist. N.S.I., C.S.P.M.U., R.S., I.S., and F.H. made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data. N.S.I., C.S.P.M.U., D.E.G., R.S., S.S., and I.S. drafted the article or revised it critically for important intellectual content. N.S.I., C.S.P.M.U., D.E.G., and S.S. gave final approval of the version to be published.

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