online http://ejournal. id/index. php/IJND Indonesian Journal of Nutrition and Dietetics The importanceAvailable of motherAos care at: for improving exclusive breastfeeding practices 75 DOI : http://dx. org/10. 21927/ijnd. Vol. No. 3, 2019: 75-84 The importance of motherAos care for improving exclusive breastfeeding practices Winda Irwanti1,2. Kristen M. Hurley3. Tony Arjuna4. Keith P West. Jr3. Jane Chao 5,6,7 . Hamam Hadi1,2* 1Department of Nutrition Science. Faculty of Health Science. Universitas Alma Ata. Jalan Brawijaya No. Yogyakarta 55183. Indonesia. windairwanti@almaata. Alma Ata Centre for Healthy Life and Food. Jalan Brawijaya, no. Yogyakarta. Indonesia : hhadi@almaata. Center for Human Nutrition. Department of International Health. Bloomberg School of Public Health. The Johns Hopkins University. Baltimore. MD 21205. USA. khurley2@jhu. edu (K. H). kwest1@jhu. edu (K. Nutrition Department. Gadjah Mada University. Jalan Farmako. Sekip Utara. Yogyakarta. Indonesia School of Nutrition and Health Sciences. College of Nutrition. Taipei Medical University, 250 Wu-Hsing Street. Taipei 11031. Taiwan. chenjui@tmu. tw (J. -J. Master Program in Global Health and Development. College of Public Health. Taipei Medical University. Taipei 11031. Taiwan Nutrition Research Center. Taipei Medical University Hospital. Taipei 11031. Taiwan *Corresponding author: hhadi@almaata. ABSTRAK Latar Belakang: Secara global, prevalensi ibu yang memberikan ASI . ir susu ib. secara eksklusif untuk bayinya sampai dengan usia 6 bulan masih rendah . %). Di Indonesia, pemberian ASI sudah dipraktikkan secara luas, namun yang memberikan hingga 6 bulan hanya 15,3% dan belum meningkat, meskipun Panduan Pemberian Makan Bayi dan Anak dari WHO telah tersedia. Tujuan: Studi ini bertujuan untuk menginvestigasi pentingnya pengasuhan oleh ibu . aitu ibu memiliki peran terbesar dan menghabiskan waktu terbanyak untuk merawat bayinya sehari-har. untuk meningkatkan praktik ASI Eksklusif pada populasi dengan tingkat ekonomi rendah. Metode: Studi cross-sectional ini dilakukan pada 408 anak usia 6 - 24 bulan dan pengasuhnya di daerah pedesaan Indonesia. Data riwayat ASI, pengasuhan anak, dan status sosio-ekonomi diambil dengan instrumen kuesioner terstruktur oleh pewawancara yang terlatih. Hasil: Lebih dari setengah . %) Ibu di populasi ini memberikan ASI secara eksklusif pada bayinya sampai dengan usia 6 bulan. Hasil menunjukkan bahwa bayi mempunyai kesempatan yang lebih besar untuk diberikan ASI eksklusif jika diasuh oleh ibu kandungnya (OR = 4. , 95% CI = 1. 75 - 12. dan berasal dari keluarga dengan penghasilan rendah (OR = 1. 9 95% CI = 1. 08 - 3. , setelah mengendalikan variabel lain. Kesimpulan : Pada populasi berpenghasilan rendah dimana praktik pemberian ASI telah dilakukan, tetapi pengasuhan anak dilakukan oleh seseorang selain ibu kandung, pentingnya pemberian ASI eksklusif harus terus ditekankan. Edukasi untuk meningkatkan motivasi ibu dan anggota keluarga lainnya dalam memberikan ASI, serta membangun lingkungan kerja yang ramah menyusui adalah hal yang penting untuk dilakukan. KATA KUNCI: ASI eksklusif. ibu kandung. tingkat ekonomi. Indonesia Timur ABSTRACT Background: Globally the prevalence of women who exclusively breastfeed their infants to 6 months of age remains low . %). In Indonesia, breastfeeding is widely practiced but the prevalence of exclusive breastfeeding at 6 months is only 15. 3% and has not increased over time, despite WHO IYCF guidelines. Objective: This study aims to examine the importance of motherAos care i. e mother takes the biggest role and most of time for caring children in daily life, for improving exclusive breastfeeding practices in low-income populations in Indonesia. Methods: This cross-sectional study was conducted to 408 children aged 6 - 24 months and their caregivers in rural Indonesia. Data on breastfeeding history, childcare, and socioeconomic status of families were collected using structured questionnaires by trained interviewers Winda Irwanti. Kristen M. Hurley. Tony Arjuna. Keith P West. Jr. Jane Chao. Hamam Hadi. Vol 7 No. 3, 2019: 75-84 Results: Over half . %) of mothers in this population exclusively breastfed their infant at 6 months. Results showed that infants are more likely to receive exclusive breastfeeding if they were cared by biological mothers (OR = 4. , 95% CI = 1. 75 - 12. and reside in low-income households (OR = 1. 95% CI = 1. 08 - 3. , after adjusting for confounding variables. Conclusion: In low-income populations where breastfeeding is common but the provision of child care is provided by someone besides the biological mother, the importance of exclusive breastfeeding should continue to be emphasized. Education to improve motherAos and other family memberAos motivation in breastfeeding is important, as well as establishing breastfeeding-friendly working environment. KEYWORDS: exclusive breastfeeding. biological mothers. economic level. eastern Indonesia INTRODUCTION Child undernutrition remains a public health problem both in the world and in Indonesia. Globally, the prevalence of women who exclusively breastfeed their infants to 6 months of age remainns low . %) . In Indonesia, breastfeeding was widely practiced but the prevalence of exclusive breastfeeding at 6 months is only 15. 3% . and has not increased over time, despite World Health Organization Infant and Young Child Feeding (WHO IYCF) guidelines. For example, the Timor Tengah Selatan (TTS) region has a high prevalence of household food insecurity . and this lack of food security coupled with poor absorption of nutrients due to infectious disease increase risk of child undernutrition . ncluding both macronutrient and micronutrient In 2008. Church World Service (CWS ) found underweight, stunting, and wasting prevalence in children 6-59 months in TTS were high 7%, 61. 3%, and 10%, respectively, and that over half . 2%) of children in TTS had anemia . In 2008, the Action Contre La Faim ACF survey found that most infants were breastfed. However, fewer . %) were exclusively breastfed until age 6 Based on interviews with more than 100 caregivers. ACF found 7% of infants were given complementary foods . n addtion to breast mil. before 1 month, 57% before 2 months, and 76% before 3 months, and that by 4 months of age only 10% of infants were exclusively breastfed . The District Health Office has made efforts to improve the health and nutritional status of children and women in TTS. However, despite comprehensive intervention efforts, the health and nutritional status of children in TTS continues to suggest a need for Therefore, to maximize the impact of interventions at a district level, it is important to identify enablers and barriers to optimal infant feeding practices. The goal of this study was to examine breastfeeding practices among mothers with infants 6 - 24 months of age. MATERIALS AND METHOD Study Population and Sampling Method Both qualitative and quantitative methods were used in this study. A cross-sectional survey was conducted to examine the demographic and socio-economic determinates of breastfeeding behaviors, and Focus Group Discussions (FGD) were then conducted to better understand the quantitative results. Subjects were caregivers of children aged 6-23 months in TTS District. Subjects were taken from West Amanuban and Kie districts, consisting of 11 and 7 villages, respectively. Kie sub-districts were selected because they had the lowest underweight prevalence in TTS based on the 2010 District Health Profile . Conversely. West Amanuban District was selected because it has the highest prevalence of undernutrition in TTS and was categorized as an area with high food insecurity. Seven villages from each district were then selected based on study accessibility . condition of roads, et. which was determined together with the district government In each village, 30 mothers/caregivers of children under 24 months of age were randomly selected, resulting in a total sample of 408 mothers/ The importance of motherAos care for improving exclusive breastfeeding practices A Focus Group Discussion (FGD) was conducted in each village and included 1012 mothers/caregivers of children under age 24 months, resulting in a total of 18 FGDs. Mothers/ caregivers were recruited into the study if they lived in West Amanuban and Kie Districts for at least 1 year before study was conducted anproved informed consent to participate. Data collection Quantitative data was collected on demographic, and socio-economic factors, and on breastfeeding behaviors via a questionnaire carried out by 15 trained enumerators . Nutrition Science graduate. FGDs with mothers/caregiver examining perception, beliefs, barriers, and enablers related to infant feeding practices were conducted by trained data collectors and translaters given that most respondents were less fluent in national Variables Categories Exclusive breastfeeding. It was not easy to explore information on practice of exclusive breastfeeding to mothers or childrenAos daily It was very likely for bias if respondent does not understand the concept of exclusive Therefore, in this study, we use a combination of two questions to conclude whether respondents practice exclusive breastfeeding or Those are Ay Does your child only get breastmilk for the first 6 months after birth?? Ay, and AyUntil what age was your children receive only breast milkAyIn further analysis, we conducted a cross-tabulating and analyse consistent answer, thus exclusive breastfeeding was define when mother or caregiver answer their children also received only breastmilk for the first 6 months after birth, and also stated that their children got food other than breastmilk after 6 months. Type of caregiver. Caregivers were classified as: . biological mother, i. grandmother, . father, i. aunt, or . older sibling of target child. To determine whether the child is cared for by the biological mother or other than biological mother, we ask a question in the form of Au Does this child looked after by his/her mother?Ay, if the answer was AuNoAy, the we asked Auwho looked after this child?Ay Age. We analyzed parental ages as a mean for mothers and fathers. Meanwhile for mothers, we categorized it into under 20 years, 20 - 34 years, and 35 years or above in descriptive analysis. For bivariate and multivariate, we simplified it into two categories, it is under 35 years, and 35 years and above. Birth order. Birth order is the order of children was born in the family. In our analysis, we categorized it into children below or number 2, and children number above 2. Parental education. Education father and mother was categorized as 4 in descriptive analysis, while in bivariate we simplified it into two: . raduate from junior high schoo. or i. raduate from high school or greate. Parental occupation: In descriptive analysis, we describe it into four, they are i: farmer/breeder/ fisherman/laborer, ii:civil servant/police/military/ entrepreneur, i : housewive/unemployed, iv:others Household. Expenditure is household expenses that we investigated through monthly expenditure questions for food and non-food items, then we categorized in into two, i: below and ii: equal to or above regional cut off minimum wage in NTT province. Statistical Analysis Chi-square test were performed to assess demographic differences between children who were exclusively breastfed and children who were not exclusively breastfed. Bivariate and multivariate logistic regression models were then used to examine the associations between exclusive breastfeeding and demographic and socio-econonic. All factors which had a p-value of <0. 25 in the bivariate analysis were included in the model for multivariate analysis. All data analysis was conducted using STATA v. 15 MP Ethical Approvals Informed consent was obtained from all study Respondent were informed that their participation was completely voluntary and that they could refuse to participate or withdraw from the Winda Irwanti. Kristen M. Hurley. Tony Arjuna. Keith P West. Jr. Jane Chao. Hamam Hadi. Vol 7 No. 3, 2019: 75-84 study at any time. All data was kept confidential and was only used for research purposes. In addition, authorization from the Department of Health. State Staffing Agency of Timor Tengah Selatan. Head of West Amanuban District and Kie was also obtained before fieldwork was conducted. Collaboration with head of community health center of West Amanuban and Kie. Department of Education, health cadres, head of villages were also done before or at the same time as the implementation of data collection in field. RESULTS Subjects Characteristics In this study, a total of 408 mothers/caregiver of children 6-23 months of age were interviewed. Approximately half of their children were male, and had an average age of 13. 6 (SD Ae 5,2 months. Most children . 8%) were in age group Ou 12-24 months, and were classified as the first . 9%), second . 6%) or third . 6%) child. Mother reported having between 1-10 children with most reporting having one . 9%), two . 5%), or three . 6%). Most mothers . were 20 to 35 years of age with a elementary school . 4%) or junior high school . 3%) level FatherAos educational background were not much different from motherAos, mostly graduated from elementary school . 5%) and junior high school . 4%). Most mothers . 8%) reported not working outside of the home, while most fathers . 5%) worked as farmers, ranchers, or This condition has significant implications for household income and expenditure levels. More than 80% of households in this study had expenditure below Regional Minimum Wage in NTT . of IDR 850,000 (AUS $ . per month. The Prevalence of Exclusive Breastfeeding Prevalence of exclusive breastfeeding was determined through two questions asked to When asked AuDoes your child only get breastmilk for the first 6 months after birth?Ay, 279 respondents answered AyyesAy. up to 6 months. However, when the next question was asked AuUntil Table 1. Subjects and Parents Characteristics Characteristics Number of Children who Depend on Family FatherAos age . ears ol. Mean ASD = 34. 67 A8. 7 Minimum = 19. Maximum = MotherAos age . ears ol. Mean ASD =30. 69 A 8. 0 Minimum = 17. Maximum = Categorized MotherAos age <20 > 35 MotherAos Education DidnAot finished elementary school Graduated from elementary school Graduated from junior high school Graduated from senior high school Graduates from university or equal FatherAos Education DidnAot finished elementary school Graduated from elementary school Graduated from junior high school Graduated from senior high school Graduates from university or equal MotherAos Occupation Farmer/breeder/fisherman/laborer Civil servant/Police/Military/ Entrepreneur Housewives/unemployed Others FatherAos Occupation Farmer/breeder/fisherman/laborer Civil servant/Police/Military/ Entrepreneur Housewives/unemployed Others Household expenditure . ean ASD) IDR 529. 649 A385. Household expenditure percentile 6 mo n (%) n (%) n(%) n(%) n(%) 33. Figure 1. Reasons for not giving exclusive breastfeeding 1. Total n (%) Winda Irwanti. Kristen M. Hurley. Tony Arjuna. Keith P West. Jr. Jane Chao. Hamam Hadi. Vol 7 No. 3, 2019: 75-84 Table 3. Bivariate analyses of exclusive breastfeeding, sociodemographic and daily caregiving Variable ChildrenAos caregiver Mothers Other than mothers Sex Male Female Birth order 1 and 2 >=3 Number of children who depend on the family 1 and 2 >=3 MothersAos age 20-35 years old Under 20 and above 35 years old MotherAos education Low ( below graduated from junior high schoo. High . enior high school and abov. FatherAos education Low ( below graduated from junior high schoo. High . enior high school and abov. MotherAos occupation Farmers/breeder/fisherman/labour and others . riest and studen. Private sector, civil servant/miltary/ police, entrepreneur, and housewife FatherAos occupation Farmers/breeder/fisherman/labour, unemployed and others . riest and studen. Private sector, civil servant/miltary/ police. Household expenditure < Rp. Ou Rp. Exclusive . (%) Not exclusively . (P-valu. (%) that infant crying was often used as indicator for the early introduction of complementary foods. The association between exclusive breastfeeding and demographic/socio-economic factors In bivariate analyses, we found that younger mothers were more likely to exclusively breastfeed than older mothers (OR=1. 79, p=0. , and that while parental education and occupation were not significantly related to exclusive breastfeeding . >0. , caregivers reporting lower household % CI) (<0. 2 Ae 14. 7 - 1. 6 Ae 1. 0,067 6,62 1,79* 1 Ae 2. 0,223 5 Ae 1. 0,24 5 Ae 1. 1,68 8 Ae 2. 5 Ae 1. 2 Ae 3. incomes were more likely (OR=2. to practice exclusive breastfeeding than caregivers reporting higher incomes . =0. In addition, we found that the prevalence of exclusive breastfeeding did not differ significantly . >0. by child sex, birth order, or number of children in the family (Table . However, exclusive breastfeeding differed by Autype of caregiverAy . biological mother vs. that the prevalence of exclusive breastfeeding was 8 times more likely . <0. in children cared for primarily by their biological mothers as compared The importance of motherAos care for improving exclusive breastfeeding practices to children cared for primarily by someone other than their biological mothers as seen in Table 3. Reasons for children were not looked after by their mother is that mother was not at home for working, either working to look for money or domestic activity, such as work in field, look for firewood and water to distance location that is quite far from home. The role of motherAos care for improving exclusive To determine the role of AycaregivingAy in exclusive breasfeeding, multivariate logistic regression analysis was conducted. Findings suggest that respondents reporting either biological mother as the primary caregiving (OR=4. or lower household income (OR=1. had a greater likelihood of exclusive breastfeeding than those reoporting a non-biological mother as primary caregiver or a higher household income . <0. (Table . DISCUSSION The prevalence of exclusive breastfeeding in this study was 61. Coverage of exclusive breastfeeding in this study was higher when compared to NTT provincial figures in 2018 . and in 2013 . 2%), and the national figure for rural areas was 33. 6% in 2018 . In this study, the most common reason for giving other foods besides breast milk were caregiver perceptions of child hunger and fussiness, and that the mother was not at home. These findings were similar to data collected in 2018 in the province of NTT that reported reasons for nonexclusive breastfeeding including insufficient milk . 1%), children separated from their mothers . 7%), and medical reasons . 4%) . Similarly, another study found that 93,2% of respondents reported insufficient milk production as reason for cessation of exclusive breastfeeding . Some studies also stated that inhibiting factors of exclusive breastfeeding were insufficient of knowledge, nipple wounds, receiving formula milk samples at beginning of birth, motherAos at the workplace, motherAos sick and lack of support from grandmothers to provide exclusive breastfeeding . We found that the likelihood of exclusive breastfeeding was higher among infants who were cared for by their biological mother and from household with low income levels. This was in accordance to another study stated that cared by biological mothers gave a greater chance to provide Table 4 . Multivariate analysis of exclusive breastfeeding and caregiver, parental age and socio-economic family (Including variables whose p value <0. 25 at the time of bivariate analysi. Variables Caregivers ChildrenAos biological mothers Other than mothers MotherAos age 20-35 years old < 20 or > 35 years old MotherAos occupation Farmers/breeder/fisherman/labour and others . riest and studen. Private sector, civil servant/miltary/ police, entrepreneur, and housewife Household expenditure* < 850. Ou 850. Exclusive Non-exclusive breastfeeding breastfeeding COR. % CI) n=249 n=159 AOR. % CI) 6 . 75 Ae 12. 2 Ae 8 . 4 Ae 2. 89 Ae 2. 82 Ae 3. 8 Ae 1 . 2 Ae 3. 08 Ae 3. COR: Crude Odds Ratio. AOR: Adjusted Odds Ratio, *) Based on Regional Minimum Wage of NTT Province Winda Irwanti. Kristen M. Hurley. Tony Arjuna. Keith P West. Jr. Jane Chao. Hamam Hadi. Vol 7 No. 3, 2019: 75-84 exclusive breastfeeding . In this study, children who were not looked after by biological mothers were cared by grandmothers, aunts, fathers or By good lactation management practice, in fact, exclusive breastfeeding can still be given by mothers who have no full-time with children, for example working mothers . In order to continue breastfeeding while working, mothers need to have a plan, become organized, and have the process to maintain breast milk for breastfeeding successfully. This requires facilities such as refrigerator to store, breast-milk pump, and private room for pumping . However, this was technically difficult to be practiced in study area, because there were inadequate facilities at respondentAos house and workplace to accommodate breast milk stock. Electric power sourcesAithat should be used to keep breast milk in refrigeratorAionly reach 63. 5% of Timor Tengah Selatan Regency area . , inadequate sources of clean water in several locations, as well as the unavailability of standard breastfeeding pumps and storage bottles . ased on qualitative observations and interview. Families that have lower income levels, have greater likelihood of exclusively breastfed compared to families that have higher expenditure levels. Similar to other research that stated that families that have high economic levels were less likely to breastfed exclusively than families from middle and low economic groups . Ae. This can be explained by study of Ukegbu . in Lenggogeni . which stated that poorer mothers did not want to spend money for milk formula . Similarly. Titaley . stated that exposure to various variants of formula foods together with financial ability to purchase these foods, could explain the existence of less optimal breastfeeding practices in high economic levels families . Maternal age were not determinants of exclusive breastfeeding. This was in accordance with research by Ferreira et al . and Hikmawati . , but not with research conducted by Lenggogeni. Naanyu and Suliasih, et al . ,23,. A study in Kenya stated that mothers over 20 years old have greater chance for exclusively breastfed, and the greatest opportunity was for mothers over 31 years of age . , whereas in Indonesia, opportunity to provide exclusive breastfeeding was greater in mothers aged 30-39 years . In this study, motherAos occupation was not determinants of exclusive breastfeeding. This result contrast to study used Indonesian Demographic and Health Survey (IDHS) 2012 . and in Ethiopia which stated that working mothers may reduce the chance of exclusive breastfeeding . Mothers who work all day . ffice hour. were more at risk (AOR: 1. for not giving exclusive breastfeeding compared to mothers who didnAot work after controlling maternal age, household welfare index, and frequency of antenatal care . = 0. 95% CI = 1. 0 - 2. In Ethiopia, mothers who were unemployed (AOR: 1. 98 x, p <0. 95% CI = 1. 21 were more likely to practice exclusive breastfeeding than their counterparts . This discrepancy may occur due to several Based on qualitative interview, mothers who unemployed or werenAot work for gain money, remain preoccupied by other domestic activities that consume energy and time, for example looking for firewood, looking for water, cooking, cleaning and These mainly done when child is under one year-old, and when the child is getting older, number and type of motherAos activities will increase. In fact, some mothers also have to work in field or farm during daytime. As a result, mothers only have little time to caring their children, only in the morning . or giving breakfast and bathin. and evening to night when returning from the fields or working place . or feeding and bathin. During the day, most children were looked after and take nap with other people in family such as grandmother, sibling or aunt. conclusion, at this location, being a housewife still could not increase opportunity to provide exclusive Study Limitations This study suffers some limitations. The study was carried out on a single locality not on national level and on remote location far from capital city. means it has special conditions such as low access to clean water and electricity, thus it results cannot be generalized. The importance of motherAos care for improving exclusive breastfeeding practices CONCLUSIONS In low-income populations where breastfeeding is common but the provision of child care is provided by someone besides the biological mother, the importance of exclusive breastfeeding should continue to be emphasized. Education to improve motherAos and other family memberAos motivation in breastfeeding is important, as well as establishing breastfeeding-friendly working environment. Acknowledgment This study was a part of larger scope of research that conducted by Alma Ata Centre for Healthy Life and Food (ACHEAF), supported by United Nations World Food Program (UN-WFP), entitled Study on Behavioral Analysis and Food Consumption/Dietary Practices amongst Children under five. Elementary School Age Children. Pregnant and Lactating Women in Timur Tengah Selatan District of Nusa Tenggara Timur Province in Indonesia. REFERENCES