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Abstract

INTRODUCTION:

Breastfeeding is the first step to forming children who are not only healthier but smarter, with a better emotional quotient (EQ) and spiritual quotient (SQ). Babies need physical closeness and warmth from their mother as much as optimal nourishment. Poor knowledge and attitudes towards exclusive breastfeeding can result from information that is not intensive and maximal, due to limited breastfeeding counseling staff. Other reasons include cultural factors, especially in coastal areas, such as the belief in prelacteal feeding before the first breastfeeding; the baby has then automatically not exclusively breastfed.

METHODS:

This study used an intervention with a one-group pretest–posttest design. It aimed to analyze the role of breastfeeding counseling in increasing mothers’ knowledge and attitudes regarding exclusive breastfeeding. The participants were pregnant women from the end of the second trimester to the third trimester, selected using stratified systematic random sampling.

RESULTS:

Counseling had a significant effect on mothers’ knowledge (p = 0.004) and attitude (p = 0.000) in changing the behavior of coastal communities towards giving exclusive breastfeeding (p = 0.03). Intensified counseling is recommended for pregnant women in the third trimester to realize exclusive breastfeeding.

CONCLUSIONS:

A positive and significant effect of breastfeeding counseling was found on the level of knowledge, attitudes, and changes in the behavior of coastal communities in exclusive breastfeeding.

Keywords

Counseling behavior exclusive breastfeeding

1. Introduction

Breastfeeding is the first step to forming children who are not only healthier but smarter, with a better emotional quotient (EQ) and spiritual quotient (SQ). Babies in the first 1,000 days of life need physical closeness and warmth from their mother as much optimal food [1].

Research has shown that early initiation of breastfeeding can save 22% of babies or one million babies, as well as minimizing the occurrence of post-partum bleeding. The relationship between early initiation of breastfeeding and infant mortality rate (IMR) relates to the composition of breast milk (colostrum), which can protect infants against infection. In addition, skin-to-skin contact between the baby and the mother prevents hypothermia in the baby. Thus, the early initiation of breastfeeding reduces IMR due to infection and hypothermia [2].

Unfortunately, early initiation of breastfeeding by the community, especially in coastal areas, is almost not practiced. This is due to the influence of culture and tradition, which are still very strong in supporting prelacteal feeding without adequate knowledge and attitude. It also relates to a lack of family support to shape the behavior of mothers and their commitment to planning exclusive breastfeeding in each family because the information available is not intensive and maximal [3,4]. Another factor is the lack of breastfeeding counseling staff. Although early initiation of breastfeeding is a natural behavior that must occur between mothers and their babies, a separate technique is needed to foster these interests and behaviors so that they become attractive and favored by the community, especially for mothers who have just given birth. Therefore, it is necessary to build awareness based on sufficient knowledge and positive attitudes in the community about the early initiation of breastfeeding as part of the effort to realize exclusive breastfeeding [5].

This study intervention addressed early initiation of breastfeeding socialization through training and counseling as an objective measure aiming to shape or change people’s behavior in early breastfeeding initiation. We hypothesized that the effectiveness of breastfeeding counseling would change the tradition of giving prelacteal feeding to infants towards the formation of new habits for the community. This represents an important effort in promoting exclusive breastfeeding for newborns until they reach the age of 6 months. In turn, the results of this study may inform policymakers and complement operational strategies for the implementation of exclusive breastfeeding programs in the community.

2. Materials and methods

2.1. Methods

This study used an analytical observational research model with an intervention approach. Ethical clearance was obtained from the Ethics Committee of the Research and Development Agency of the Ministry of Health of the Republic of Indonesia. The one-group pretest–posttest approach was used to understand the effectiveness of breastfeeding counseling on mothers’ behavior in realizing exclusive breastfeeding for infants in the Mangara Bombang Health Center, Takalar Regency, where the coverage of exclusive breastfeeding is still low (62%). The implementation period was five months, from July to November 2020.

2.2. Population and subjects

The population in this study was pregnant women who were residents of the Banggae, Lakatong, and Tope Jawa Villages: a total of 277 women. The subjects were pregnant women who reached the end of the second trimester of pregnancy in July. The inclusion criteria were pregnant women at 24–32 weeks’ gestation who lived permanently in each village and were willing to participate in breastfeeding until the end of the study, and the exclusion criteria were those who experienced pregnancy complications; 154 pregnant women thus met the subject criteria.

The number of subjects was determined based on the data from previous studies, using a sample size formulation for health research [6], based on the results of the estimated sample sizes from the formulation. A total of 72 pregnant women participated in this study. Sampling was carried out using a stratified systematic random sampling technique.

2.3. Variable identification

The independent variable (intervention) was breastfeeding counseling. The main independent variables were mothers’ knowledge, attitudes, and behavior. The dependent variable was exclusive breastfeeding.

2.4. Instrument

This research used a questionnaire as an observation tool to numerically assess the effectiveness of the counseling intervention on the behavior of exclusive breastfeeding. It assessed the knowledge and attitudes of each mother using questions with a 5-point Likert scale [7]. Data collection was carried out using the techniques of (1) participatory observation to assess the effectiveness of counseling interventions and (2) structured interviews to obtain data on identity and the independent variables of knowledge, attitude, and behavior, including other supporting variables such as age, education, occupation, and parity. Before the questionnaires were distributed to the subjects, a pilot was conducted to identify any questions that were difficult to answer or confusing. Changes or additions were then made to the questions, which was followed up by testing the validity and reliability of the instrument.

2.5. Data analysis

The data collected were processed and analyzed using descriptive analysis to determine the characteristics of this research. Frequency distribution tables and inferential analysis were used to show the relationships between variables using the McNemar test. Normality was first tested using the Shapiro–Wilk test, and homogeneity was tested using the Levene test. The cut-off point was based on the mean value of each pretest variable to meet the categories in the McNemar test, with a p-value <0.05 considered significant [8].

3. Results

Research on breastfeeding counseling was carried out in three coastal villages in the Mangara Bombang Health Center area of Takalar Regency: Lakatong Village, Banggae Village, and Tope Jawa Village. The study took place over 5 months, from July to November 2020, with 72 pregnant women at 24–32 weeks’ gestation. It began with a pre-intervention evaluation (pretest at 24–28 weeks), followed by an intervention in the form of counseling about breastfeeding, and finally a posttest to determine the extent of the intervention impact.

3.1. Descriptive analysis

3.1.1. Characteristics of education, occupation, age, and parity

The respondent characteristic data shown in Table 1 are generally varied. Of the 72 women, nine (12.5%) had never received formal education, and many had only finished elementary or junior high school (each 18; 25%). The occupation of most was domestic activities alone (68; 94.4%). Accordingly, only one (1.4%) was employed as a civil servant, and three (4.2%) worked as private employees.

Table 1
Distribution of respondents by education, occupation, age, and parity

Frequency Percentage

Education level

Never attended school 9 12.5

Graduated from elementary school 18 25.0

Graduated junior high school/equivalent 18 25.0

Graduated high school/equivalent 20 27.8

University 7 9.7

Total 72 100.0

Occupation

Not working (IRT) 68 94.4

Civil servants 1 1.4

Private employees 3 4.2

Total 72 100.0

Maternal age

≤19 years 2 2.8

20–35 years 54 75.0

>35 years 16 22.2

Total 72 100.0

Parity

1–3 62 86.1

≥4 10 13.9

Total 72 100.0

	Frequency	Percentage
Education level
Never attended school	9	12.5
Graduated from elementary school	18	25.0
Graduated junior high school/equivalent	18	25.0
Graduated high school/equivalent	20	27.8
University	7	9.7
Total	72	100.0
Occupation
Not working (IRT)	68	94.4
Civil servants	1	1.4
Private employees	3	4.2
Total	72	100.0
Maternal age
≤19 years	2	2.8
20–35 years	54	75.0
>35 years	16	22.2
Total	72	100.0
Parity
1–3	62	86.1
≥4	10	13.9
Total	72	100.0

Source: Primary data.

3.1.2. Average value of pre- and post-intervention variables

Table 2 shows the average values for the variables about the respondents’ behavior tendencies. The data shows a difference in the average pretest knowledge of respondents, with a mean value of 37.98 ± 4.29. Their attitudes showed a mean pretest value of 34.00 ± 3.57 and a mean posttest value of 34.60 ± 5.74. Exclusive breastfeeding behavior had a mean pretest value of 6.67 ± 0.97 and a posttest mean of 7.20 ± 0.97.

Table 2
Distribution of pretest and posttest variable mean values

Variables Pretest Posttest

Min Max Mean SD Min Max Mean SD

Knowledge 23.00 44.00 37.97 4.29 28.00 47.00 40.72 4.16

Attitude 14.00 34.00 23.53 3.57 19.00 40.00 34.60 5.74

Exclusive breastfeeding 4.00 8.00 6.67 0.97 4.00 12.00 7.20 0.97

Variables	Pretest	Posttest
Knowledge	23.00	44.00	37.97	4.29	28.00	47.00	40.72	4.16
Attitude	14.00	34.00	23.53	3.57	19.00	40.00	34.60	5.74
Exclusive breastfeeding	4.00	8.00	6.67	0.97	4.00	12.00	7.20	0.97

Source: Primary data.

The data shown in Table 3 is based on the results of the conversion of the frequency distribution to a dichotomy. Among the people who live in these coastal areas, the tendency to intend exclusive breastfeeding of their babies is clear in the pretest. A total of 52 respondents (74.3%) stated their commitment to exclusively breastfeed until the age of 6 months. After counseling was carried out and they gave birth, the posttest showed an increase to 60 respondents (88.6%) who did give only breast milk to their babies and committed to this until the child was 6 months old.

Table 3

Distribution of variable characteristics based on pretest and posttest values

Variables	Pretest		Posttest
Exclusive breastfeeding
High	52	74.3	62	88.6
Low	18	25.7	8	11.4
Total	70		70	100.0
Knowledge
High	33	47.1	48	68.6
Low	37	52.9	22	31.4
Total	70	100.0	70	100.0
Attitude
High	9	12.9	61	87.1
Low	61	87.1	9	12.9
Total	70	100.0	70	100.0

Source: Primary data.

Following the description of various respondent characteristics related to these variables, further analysis used the McNemar test to determine the influence of counseling carried out with the community, especially for pregnant women in the coastal area of Mangara Bombang Takalar, to prepare for breastfeeding their babies.

3.2. Inferential analysis

3.2.1. Effectiveness of counseling against capital knowledge about exclusive breastfeeding

The analysis results about the effectiveness of counseling on maternal knowledge about exclusive breastfeeding at df = 1 obtained the value of X² = 17.6 (>3.84) and the exact sig. (2-sided) p-value = 0.004 (Table 4). These values statistically conclude the rejection of H₀, which means that counseling had an effect on mothers’ knowledge in an effort to realize exclusive breastfeeding for their babies.

Table 4
Effect of counseling on knowledge of breastfeeding among mothers

Pretest knowledge Posttest knowledge Chi-square exact sig. (2-sided) 𝛼 = 0.05

High Low

High 28 5 X² = 17.06

Low 20 17 p = 0.004

Pretest knowledge	Posttest knowledge	Chi-square exact sig. (2-sided) 𝛼 = 0.05
High	28	5	X² = 17.06
Low	20	17	p = 0.004

Source: Primary data.

3.2.2. Effectiveness of counseling on attitudes about exclusive breastfeeding

Table 5 shows the results of data analysis to examine the effect of counseling on attitude to exclusive breastfeeding. Using the McNemar test on the significance (𝛼 = 0.05) with df 1 obtained the value of X² = 50.16 (>3.84), and the exact sig. (2-tailed) p-value = 0.000, which means that H₀ is rejected. Breastfeeding counseling carried out from when the mother is pregnant until the time of delivery had an effect on changing the mother’s attitude in realizing exclusive breastfeeding.

Table 5
Effects of counseling on mothers’ attitude to exclusive breastfeeding

Pretest attitude Posttest attitude Chi-square exact sig. (2-tailed) 𝛼 = 0.05

High Low

High 7 2 X² = 50.16

Low 54 7 p = 0.000

Pretest attitude	Posttest attitude	Chi-square exact sig. (2-tailed) 𝛼 = 0.05
High	7	2	X² = 50.16
Low	54	7	p = 0.000

Source: Primary data.

3.2.3. Effectiveness of counseling on maternal behavioral changes for exclusive breastfeeding

Based on the data analysis in Table 6, showing the trends in maternal exclusive breastfeeding behavior demonstrated using the McNemar test, the results showed the value of X² = 6.72 (>3.84) and the exact sig. (2-tailed) p-value = 0.031. This means that H₀ is rejected, which means that breastfeeding counseling tended to create behavioral changes to realize exclusive breastfeeding.

Table 6
Effect of counseling on behavior change to realize exclusive breastfeeding of infants

Pretest breastfeeding behavior Posttest breastfeeding behavior Chi-square exact sig. (2-tailed) 𝛼 = 0.05

High Low

High 48 4 X² = 6.72

Low 14 4 p = 0.031

Pretest breastfeeding behavior	Posttest breastfeeding behavior	Chi-square exact sig. (2-tailed) 𝛼 = 0.05
High	48	4	X² = 6.72
Low	14	4	p = 0.031

Source: Primary data.

4. Discussion

Based on the empirical results of this study, the demographic distribution in the three coastal villages was varied. This can be seen in the relatively low level of education of the respondents, which affected the knowledge and attitudes of the community in adopting positive behaviors that support their family’s health status, especially in preparing their children early in life for quality development through exclusive breastfeeding.

Bivariate testing has shown counseling to be one of the most appropriate methods to increase public interest in realizing exclusive breastfeeding [9,10], especially in coastal communities. Unfortunately, based on the Health Center nutrition coordinator’s report, the rate of exclusive breastfeeding in 2017 was still low at 62.0%, especially in the community health centers Mangara Bombang area. This was the same as the proportion shown in Noor’s research in 2018, with even lower coverage in the community health centers [4].

This condition is apparently still impacted by various factors, including the limited level of knowledge of the community, especially mothers of toddlers. This lack of knowledge affects their attitude, especially with the condition of the community based on the results of interviews from this study. The existing traditions and culture are still considered something valuable from generation to generation in people’s lives.

This condition should be understood because according to Notoatmodjo, a person’s education has an impact on their knowledge and attitudes toward positive behavior, including their behavior in realizing the implementation of exclusive breastfeeding for infants [11]. However, after counseling, the results show a very significant presentation of especially public intention to adopt behaviors that support achieving the conditions leading to healthy baby development, through meeting their early life nutrition needs with exclusive breastfeeding. The results of this study are in line with Yotebieng et al. (2015), which showed that people, especially mothers who understand the importance of complete breastfeeding, tend to apply exclusive breastfeeding [12,13].

The results of the inferential analysis showed that the provision of counseling had a significant effect on increasing the knowledge of pregnant women in preparing for exclusive breastfeeding for their babies until they reached the age of 6 months. It also affected the attitudes of pregnant women, which ultimately had an impact on their behavior in building a commitment to breastfeeding exclusively. The results of this study are supported by the results of research by Masthalina and Agustina, in the working area of the Lubuk Pakam Health Center, which found that counseling had a significant effect in increasing mothers’ knowledge and attitude toward the application of exclusive breastfeeding for infants [14]. Educationally, socialization about exclusive breastfeeding is needed in various places, especially in coastal areas, because of the current social conditions that have a very large influence along with the era of freedom of information. This shows a tendency of people to obtain information more easily, especially in the epidemiological transition. On the one hand, in relation to disease and spread factors, certain problems have been successfully reduced. On the other hand, problems arise, including information that can prevent the achievement of exclusive breastfeeding for infants, namely the promotion of formula milk, which is easily available to the public. Information about problems related to breastfeeding is also less balanced. Most respondents said that they did not understand breastfeeding, while the promotion of formula milk is becoming more prominent and tempting [15,16].

In addition to direct intervention as the best strategy to increase public awareness and behavior towards the implementation of exclusive breastfeeding by the community, the dissemination of information is currently very easily accepted by the community. This is supported by the report of Sudarwati et al. (2019), which found that the use of health promotion media had a significant effect on people’s behavior, especially breastfeeding mothers, in relation to exclusive breastfeeding [17,18]. The results of this study are also supported by the results of research by Thomas et al. (2015) in Bangladesh, which found that adequate knowledge and attitude of mothers during pregnancy greatly affected exclusive breastfeeding [12,19].

The results of the study recommend the need for intensive breastfeeding counseling by health workers to pregnant women from the third trimester to childbirth, followed by regular monitoring until the child is 6 months old, in an effort to realize exclusive breastfeeding.

5. Conclusions

Breastfeeding counseling had a positive and significant effect on the level of knowledge, attitudes, and behavior regarding exclusive breastfeeding in coastal communities.

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Breastfeeding counseling changes breastfeeding behavior of babies in coastal communities in the area of Mangara Bombang community health centers,Takalar regency

Abstract

INTRODUCTION:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Materials and methods

2.1. Methods

2.2. Population and subjects

2.3. Variable identification

2.4. Instrument

2.5. Data analysis

3. Results

3.1. Descriptive analysis

3.1.1. Characteristics of education, occupation, age, and parity

3.2.1. Effectiveness of counseling against capital knowledge about exclusive breastfeeding

Table 4 Effect of counseling on knowledge of breastfeeding among mothers Pretest knowledge Posttest knowledge Chi-square exact sig. (2-sided) 𝛼 = 0.05 High Low High 28 5 X2 = 17.06 Low 20 17 p = 0.004

Table 5 Effects of counseling on mothers’ attitude to exclusive breastfeeding Pretest attitude Posttest attitude Chi-square exact sig. (2-tailed) 𝛼 = 0.05 High Low High 7 2 X2 = 50.16 Low 54 7 p = 0.000

Table 6 Effect of counseling on behavior change to realize exclusive breastfeeding of infants Pretest breastfeeding behavior Posttest breastfeeding behavior Chi-square exact sig. (2-tailed) 𝛼 = 0.05 High Low High 48 4 X2 = 6.72 Low 14 4 p = 0.031

5. Conclusions

References

Table 4
Effect of counseling on knowledge of breastfeeding among mothers

Pretest knowledge Posttest knowledge Chi-square exact sig. (2-sided) 𝛼 = 0.05

High Low

High 28 5 X² = 17.06

Low 20 17 p = 0.004

Table 5
Effects of counseling on mothers’ attitude to exclusive breastfeeding

Pretest attitude Posttest attitude Chi-square exact sig. (2-tailed) 𝛼 = 0.05

High Low

High 7 2 X² = 50.16

Low 54 7 p = 0.000

Table 6
Effect of counseling on behavior change to realize exclusive breastfeeding of infants

Pretest breastfeeding behavior Posttest breastfeeding behavior Chi-square exact sig. (2-tailed) 𝛼 = 0.05

High Low

High 48 4 X² = 6.72

Low 14 4 p = 0.031