The influence culture and maternal care on exclusive breastfeeding practice in post caesarean section mothers

Abstract

Objective

The purpose of this study is to identify the influence of socio-cultural factors on the exclusive breastfeeding practice among post-caesarean section mothers on Cibinong West Java region.

Method

This study used a mixed quantitative survey method and qualitative phenomenological approach.

Result

Postpartum caesarean mothers had a good understanding and knowledge of exclusive breastfeeding (84%), but only 23.3% of postpartum caesarean mothers were doing exclusive breastfeeding. There were five themes identified from the qualitative study namely: the practice of breastfeeding, factors that influence mothers in giving breast milk, beliefs and values influencing the breastfeeding practice, experience of breastfeeding, and the mother's return to work and community beliefs.

Conclusion

Exclusive breastfeeding remains low in that city especially in post-caesarean mothers who are influenced by culture, values, and due to the mother having to return to work. They need support to provide exclusive breastfeeding.

Introduction

Shifting the method of infant nutrition from exclusive breastfeeding to non-exclusive breastfeeding is commonplace in the era of globalization.¹ Public knowledge about the benefits of breastfeeding is getting better, several studies have shown that breastfeeding has a positive impact on maternal and infant health, both in the short and long term.^2–5 The rate of exclusive breastfeeding in Indonesia has now increased to 54% for exclusive breastfeeding rates of 0–6 months. This exceeds the global rate of 50%.² However, this phenomenon has not been equal in all regions, for example, the breastfeeding rate in West Java province is still only 33.7%.⁶

National data from the United States suggests that despite an increase in early breastfeeding, but many mothers are unable to continue exclusive breastfeeding and maintain the duration of breastfeeding. The largest average decrease in maintaining breastfeeding occurs in the first week postpartum, especially in mothers who undergo caesarean section.⁶ Currently, in the United States, there is an increase in the incidence of caesarean section, which was about one in five births in the 1980s, then declined in the 1990s, but has now increased again to around one in four births.⁷

This increasing incidence of the caesarean section also indirectly reduced success in breastfeeding. This is supported by research conducted by Hobbs and Zanardo et al. who found that mothers are late to breastfeed a baby and stop breastfeeding because of lack of breast milk production due to several risk factors, namely cancer, overweight mothers, unplanned caesarean section, unexpected birth with a long second stage, where the baby's weight is less than 3.6 kg, and the use of formulated milk.^8,9

Furthermore, social and cultural factors influence the process of breastfeeding. Other factors that can affect the breastfeeding process include support for breastfeeding and support groups which can motivate mothers to be able to breastfeed better. Research conducted by Hill and Humenick¹⁰ states that support from partners is very influential on the success of breastfeeding. Parents, siblings, friends and health workers also have an important role.

Indonesia contains cultures and subcultures that influence people's behaviours. One example is the influence of culture and value of the community on the mother's behaviour while giving exclusive breastfeeding. Culture and beliefs within the community do not directly support women in the practice of breastfeeding. Community and family beliefs portray that as a woman, it is compulsory and natural to breastfeed their babies. The family and community do not need to force them and offer them support. On the other hand, the extensive marketing of formulated milk through media influences women and reduces their inclination to breastfeed their babies. Women want to maintain their physical performance and continue social activities without being disturbed by breastfeeding activity.¹¹ Due to this phenomenon, it is necessary to identify social and cultural barriers and constraints on exclusive breastfeeding in post-caesarean mothers in the Cibinong region of West Java.

Method

This research was designed to include quantitative and qualitative methods. The qualitative research with a phenomenological approach included participation by 14 breastfeeding mothers, three husbands/partners of breastfeeding mothers and FGD was conducted for four mothers-in-law/parents of postpartum caesarean mothers who breastfed. The inclusion criteria of the participants in this study were post-CS mothers who had babies aged 6–24 months. The babies in this study did not have congenital abnormalities and were not undergoing any medical treatment. Participants lived in the Depok-Cibinong area. Quantitative research was performed via a survey conducted on 148 respondents using three types of questionnaires. Namely demographic questionnaires, socio-cultural questionnaires developed our researchers and exclusive breastfeeding questionnaires which were a modified version of the KAP questionnaire developed by Agrina, Kimura and Tsuda. Quantitative data analysis was done by univariate analysis using the frequency distribution of the data percentages. Qualitative data were analyzed using thematic content analysis following the method described by Colaizzi (13). This study was approved after ethical consideration from the Faculty of Nursing, Ethics Committee, University of Indonesia no. 270/UN2.F12.D/HKP.02.04/2018.

Result

Breastfeeding practices

The results of this study showed that most mothers post-caesarean section (76.7%) did not give exclusive breastfeeding until the age of six months (Table 1). Although the respondents’ knowledge was very good regarding exclusive breastfeeding and breastfeeding (84.5%) (Table 2). Only 23.3% of mothers in this study gave exclusive breastfeeding (Table 2). Problems faced included 9% postpartum pain, 19% insufficient breastfeeding, 20.3% replaced breast milk with honey, water and dates, 30% of mothers had to return to work, 8% lacked husband/partner support, 11% were heavily influenced by their mother-in-law and parents, 2% was due to the mother's health problems (Table 3).

Table 1.

Frequency distribution and average demographic of respondents (n = 148).

Characteristic	Frequency (n)	Percentage (%)	Mean	Min–Max
Mother age			29.67 ± 6.22	17–44
Baby age (months)			12.85 ± 4.78	6–24
Salary			5,025,000 ± 3,253,232	600,000–20,000,000
Parity
Primiparous	84	56.8
Multiparous	64	43.2
Education
Elementary	6	0.4
Junior High School	22	16
Senior High School	75	52
University	45	31.6
Religion
Moslem	105	70.1
Christianity	23	16.4
Catholic	16	10.8
Hindu	4	2.7
Occupation
Public servant	28	18.9
Private	54	36.5
House worker	38	25.6
Entrepreneur	28	19
Culture
Sundanis	65	44
Betawi	32	21.6
Jawa	23	15.5
Batak	10	6.8
Padang	12	8.1
Others	6	4

Table 2.

Breastfeeding practices of respondents (n = 148).

Characteristic	Frequency	Percentage (%)
Breastfeeding knowledge
Good	125	84.5
Poor	23	15.5
Breastfeeding
Exclusive breastfeeding	36	23.3
No exclusive breastfeeding	112	76.7
Skin to skin contact
SSC	58	39.1
No SSC	90	60.9

Table 3.

Obstacles to exclusive breastfeeding (n = 148).

Characteristic	Frequency (n)	Percentage (%)
Pain	14	9
Insufficient of breastmilk	28	19
Giving honey/water	30	20.3
Return to work	44	30
Lack of husband support	12	8
Mother in law pressured	16	11
Other maternal diseases	4	2

These conditions were derived from qualitative in-depth interviews with the results of four out of the 14 participants’ statements given below:

… Know that the mother is exclusively breastfeeding … I also want to give exclusive breastfeeding until the baby is 2 years old … but how … the milk is not enough … then later the baby is malnourished and is then yellow … then treated …. since being pregnant, the intention is to give exclusive breastfeeding … (p1, p5, p11, p13)

Factors that influence the choice of respondents

Post-caesarean section mothers decided to give their babies breast milk. This can be seen from the survey where a number of respondents (39.1%) gave breast milk at the beginning of their baby's life, and they even participated in early breastfeeding initiation (EBI) (Table 2). A further probe into what reasons prompted the post section mothers to choose to breastfeed showed that encouragement from their mothers was predominant (21.7%). Social pressure (15.6%) and spousal encouragement (13.5%) attracted similar proportions. Encouragements from their mother-in-law and nurses/midwives accounted for 10.3% and 9.5% respectively (Table 5).

Table 4.

Reasons mother to choose or continue breastfeeding (n = 148).

Characteristic	Frequency	Percentage (%)
Encouragement from mother	32	21.7
Social pressure on mothers	23	15.6
Personal determination/experience	13	8.7
Husband encouraged	20	13.5
Nurse and midwife	14	9.5
Encouragement from mother-law	16	10.8
Neighbours encouraged	8	5.4
Members of religious affiliation encouraged mother	12	8.1
Media	10	6.7

Table 5.

Correlation among breastfeeding, education, salary, occupation and cultural (n = 148).

Characteristic	Breastfeeding
	No exclusive		Exclusive		Totally	P value
	n	%	n	%
Education
Low	20	71.4	8	28.6	28	0.001
Middle	47	62.6	28	37.4	75
High	30	66.7	15	33.3	45
Salary
Low	48	75	16	25	64	0.014
High	68	80.1	16	19.9	84
Occupation
At home	66	80.5	16	19.5	82	0.023
Out side	25	37.9	41	62.1	66
Cultural
Yes	56	70	24	30	80	0.018
No	25	36.8	43	63.2	68

From the result of the qualitative study, it can be seen that motherhood and the instinct of a woman to breastfeed their babies and to want to be close to their babies are the main reasons why they chose to breastfeed their babies, as stated by six out of the 14 participants below.

… Indeed, women have a natural urge to give breastmilk to their babies, our parents used to be the same … if we give breastmilk the baby is close to us … we know what our babies want … always heard the story from people before that if the child is not given breastmilk, they do not obey their parents and will fight with them (p2, p4, p7, p9, p12, p14)

Beliefs and values influence the practice of breastfeeding

Many post-caesarean section mothers could not continue their exclusive breastfeeding for various reasons, the main reason was found to be the lack of a supportive environment and family beliefs. Traditional infant feeding practices are often influenced by myths and misconceptions. Mothers believe that feeding foods such banana and giving liquids such honey and dates with water or dates chewed by their parents before the age of 6 months would keep a child healthy and strong and that exclusive breastfeeding would not provide sufficient nutrition to the newborn. This is illustrated in Table 3 were 20.3% of mothers gave their babies honey and also dates mixed with water. Another reason was peer pressure, and the influence of the woman's mother or mother in law were also important factors in feeding decisions as shown in Table 3. Peer pressure from the mother-in-law affected exclusive breastfeeding, and also 8% were negatively influenced by the lack of spousal support.

This condition was revealed from qualitative in-depth interview results of all four grandmothers and shown in the statements below:

The baby cries…and continues crying…she is still so hungry even though the baby was already breastfed …so I gave her banana or honey…after that, she was quiet and fell asleep… (GM2, GM7)

It has become a custom in our family … and most of the people here also suggest that … that it should be given honey or dates chewed by their parents first and then given to the baby … so that the baby doesn’t slow down … moreover, her mother's milk had not yet come out … (GM1, GM3)

Breastfeeding experiences

Post-caesarean section mothers had some experiences related to breastfeeding that influenced their decision to continue or discontinue breastfeeding. Among the mothers, 8.7% had personal experiences that encouraged them to give breastmilk to their babies (Table 5). Some participants revealed that breastfeeding was a very memorable and pleasant experience. Others reported that it was very challenging especially for mothers who had male babies because male babies need more breast milk than female babies and are also physically larger. Others say that breastfeeding is a stressful experience and often makes mothers cry. As stated by the following participants:

Fun it is… it's really fun … I really relax when I breastfeed … sometimes until I fall asleep … even the baby hasn’t gone to sleep we already slept first … then it feels really happy when I see the baby sleeping soundly with milk that melts from the cheeks because it's full of milk … there is no substitute for that pleasure … (p2, p5, p8, p10)

Challenging … and so exciting … especially baby boys … really different with girls … they drink a lot… so we should stock breastmilk more…. eat more … drink breastmilk booster supplements to increase the production of breastmilk… regularly pumping …and more breastfeeding… (p4, p6, p7)

I felt pity when the baby cried …and the mother didn’t come home yet from her office … the baby looked hungry… I said I couldn’t wait until her mother came… I gave the baby milk formula… because sometimes the stock was empty …… (GM1, GM3)

At first, I got excited … but once the breastmilk didn’t run smoothly…there was just a little bit of breastmilk released from my breast … the baby cried… I was also crying … very sad … can’t give… so felt guilty … can’t be a good mother … especially when the baby doesn’t want to suckle … kept on crying … getting panicked … so I’m stressed … (p11, p14)

Mother's return to work and community beliefs as the most significant barriers to exclusive breastfeeding practice among postpartum caesarean women

As indicated in Table 4, multiple factors were implicated as barriers to exclusive breastfeeding. These comprised 9% due to pain, 19% due to insufficient breastmilk, 20.3% giving honey and dates with water, 30% returning to work, 8% lacking husband/partner support, 11% heavily influenced by mother-in-law and parents, and 2% due to the mothers’ health problems.

Based on in-depth interviews, five primiparous mothers elucidated their difficulties in breastfeeding after caesarean section surgery because they felt pain and did not know how to breastfeed properly and comfortably after surgery, they confirmed that they really needed the help of nurses and other health workers in the first weeks to post-caesarean section.

Confused at the beginning of how to feed the right way … I don’t know … it's all wrong … I am afraid to be tilted … where there is the pain from being wounded again … so it's better to give formula milk … even though it's OK. …but why does the baby cry constantly sist… Want to be assisted with the nurse or midwife sist… (p1, p4, p6, p12, p14)

The participants in this study generally had good knowledge about breastfeeding and exclusive breastfeeding, they also had a strong determination to breastfeed exclusively. But in line with the time the social support influences also affect them in providing exclusive breastfeeding especially for mothers who live together with their mother-in-law as stated by the five respondents below:

You know … I know very well that breastmilk is great for babies because I often read on the internet and often ask questions and have discussions with the nurse and neighbours who have been breastfeeding … but how come yesterday I got a little upset when the baby cried constantly … finally, my mother-in-law told me that I should give bananas only, so the baby is not starving … (p1, p2, p7, p8, p11)

Spousal support is also one of the factors that influence exclusive breastfeeding, as stated by three informants and their partners:

…… I want to pay attention to my husband, but how … my husband is a driver for an online transportation company (GO-JEK) … he works all day … when he comes home he is tired … I couldn’t ask him to take care of the baby … he looks very tired … I also cannot ask him to help the house work … so all the tasks were done … alone by myself… I also took care of the baby and his siblings too … I felt lonely and tired… (p3, p9, p13)

…… My wife didn’t give exclusive breastfeeding… she also used formulated milk … not enough my wife said … Honestly, I want my wife to give exclusive breastfeeding, but I didn’t know how to increase the quantity of breastmilk….I also rarely carried the baby … fear … it was really small especially to help take a baby bath….I was really scared… and also my wife was afraid that I couldn’t do that job well … (H1, H13)

Furthermore, among certain ethnic groups in west Java particularly in more remote areas in Cibinong (Nanggewer areas), we have found that they are more likely to practice an early introduction of feeding foods and liquids, (in the first six months of life) with starched water, honey and chewed dates as described by 4 of 14 informants:

This is the sunnah sist … gave the baby dates that are chewed by his parents … the mother also gave them starched water because that food has many nutrients … it comes from rice extract … this tradition has been passed down for generations (p3, p6, p11, p13)

Discussion

In this study it was found that exclusive breastfeeding in post-caesarean section mothers is still low, this is in line with research conducted by Ahluwalia¹² that mothers who breastfeed post-caesarean section tend not to breastfeed exclusively. This is also supported by research conducted by Evans and Chertok¹³ stating that mothers who deliver via caesarean section, are three times more likely to stop breastfeeding in the first month postpartum. This is due to the absence of early breastfeeding initiation and delay in breastfeeding compared with mothers who give birth normally. The low percentage of mothers who exclusively breastfed in this study is largely due to social and cultural factors. The most common reason for a mother not to give exclusive breastfeeding is because the quantity of breastmilk is not sufficient.^4,14,15 Bonuck's¹⁶ study of mothers with caesarean section stated that smooth milk production and the support of health workers were able to increase maternal satisfaction. Likewise with the study conducted by Lin¹⁷ found that the psychological conditions of mothers with caesarean section and smoothness of ASI are mutually dependent, the smoother the production of breast milk the better the mother's milk production. Likewise, a better psychological condition of the mother also has a positive effect on breastmilk production. This result is in line with Budiati's research that a mother's perception affects breast milk production.¹¹

Most of the respondents who did not give exclusive breastfeeding in this study were mothers young and primiparous. This differed from previous research¹⁷ which stated that mothers at a young age tended to breastfeed exclusively and also with research conducted by Sutherland, Pierce, Blomquist, and Handa¹⁸ which revealed that multiparous women experience a greater decrease in breastfeeding than primiparous women. The study explained that if a multiparous woman who is not successful in exclusive breastfeeding, this can be attributed to a failure in exclusive breastfeeding in a previous child and she tends not to try to exclusively breastfeed the next child. In this study, there were still many babies who did not benefit from the early breastfeeding initiation (EBI). Several studies have been conducted to gauge the effectiveness of early breastfeeding initiation (EBI) on the success of exclusive breastfeeding such as research conducted by Edmond, who showed that delaying EBI can increase infant mortality. Likewise, research conducted by Rowe, Murray, Fisher, and Exavery showed that infants who breastfed early showed an increase in the success of exclusive breastfeeding over the next 2–3 months.^14,19–21

While knowledge of exclusive breastfeeding was high, especially among mothers and grandmothers in the study population, exclusive breastfeeding was not always practiced. Husbands did not know as much about exclusive breastfeeding as their wives and the grandmothers. It is possible that past campaigns about the importance of exclusive breastfeeding have led to this high level of awareness, but were not successful in helping women actually practice the desired behaviours. Despite a high knowledge of exclusive breastfeeding, it was not always put into practice. This research is in agreement with other research done in Cambodia.²² This study highlights the barriers to exclusive breastfeeding practices. While almost all women understood the meaning of exclusive breastfeeding, many did not practice it and introduced solid foods and liquids before their children were 6 months of age. This practice was mainly driven by the belief that foods such as dates, and honey and also starched water were important for the health and development of babies. Educational campaigns should emphasize that breast milk can provide complete nutrition for the baby within the first 6 months.

Other obstacles to providing exclusive breastfeeding to postpartum caesarean women include the need to return to work, workplaces that are not friendly to breastfeeding mothers, difficulties in expressing breastfeeding, facilities that are less supportive and a lack of support for breastfeeding mothers who work by managers and co-workers.²¹ Mothers who work have good/high income, but this does not make mothers able to provide exclusive breastfeeding. The same result was found in the study by Tewabe et al.²³ which proved that mothers with low family income tend to provide exclusive breastfeeding more than mothers with a higher family income.

The results of this study are in line with the research conducted by Otto¹⁴ and Kealy²⁴ which found that breastfeeding mothers perceive diverse experiences, ranging from fun, full of challenges to stressful situations that sometimes make mothers cry. Obstacles to breastfeeding are important and should be of concern to health workers. Mothers express their desire to be assisted by health workers when they first breastfeed, and this is in line with the research conducted by Lin.²⁵

Conclusion

This study provides important insight into the practices and barriers for women in Cibinong West Java regarding breastfeeding. Exclusive breastfeeding remains low in that city especially in post-caesarean mothers who are influenced by culture, values or beliefs in that community and also by the mothers need to return to work. They need support to help them continue to provide exclusive breastfeeding especially from nurses and health workers who provide a front line service when the post-caesarean mothers were struggling.

Funding

This study is funded by DRPM Universitas IndonesiaHibah Pitta 2018 No. 1855/UN2.R3.1/HKP.05.00/2018.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1855/UN2.R3.1/HKP.05.00/2018.