, Introduction
Exclusive breastfeeding (EBF) is an effective and ideal way to provide the best nutritious food at the beginning of life. EBF also protects from infant mortality and morbidity, as well as future health [1,2]. While the importance of EBF has been recognized, the global EBF practice was still considered lower than expected. Globally, less than 50% of infants breastfed exclusively and even lower in upper-middle and high-income countries [2]. The Indonesian government has been supportive of the breastfeeding initiatives by incorporating EBF as a government rule [3]. EBF also has a focus on 1,000 first day of life intervention [4]. In Indonesia, 72% were exclusively breastfed in 2022, however, the rate of EBF was only around 50% in some regions. Moreover, the rate of EBF was also lower in the urban compared to rural [5]. While the country’s economy is growing and more urban areas are emerging, this trend gives rise to some concerns about the future improvement of EBF coverage.
The breastfeeding journey could be challenging. Although in general mothers were aware of the importance of breastfeeding, they could not always maintain exclusively breastfeeding or even continue breastfeeding at all [6]. The barriers to breastfeeding include physical aspects of breastfeeding, limited knowledge of the practice, low self-efficacy, and social environment support. Mother’s social support contributes highly to breastfeeding behaviour [6]. Significant others, especially the child’s fathers support, has been suggested as the key factor to improve the breastfeeding practice and outcome [6-9]. Father’s involvement in breastfeeding practice has been suggested in several literature. A study showed that a mother’s low self-efficacy to breastfeed was associated with a low partner’s involvement in prenatal care [10]. In other studies, the father’s support, attitude, and involvement influenced the mother’s commitment to breastfeeding [9,11].
Although some studies already observed the prominent role of the father in the breastfeeding process, the qualitative exploration of the context was limited. A study in the United Kingdom shows that fathers wanted to support the mothers, but often felt left out and helpless [12]. Meanwhile, in Indonesia, the father’s role in the breastfeeding process and child-feeding practice was still considerably low [13]. Father’s support and breastfeeding have been discussed in some previous literature, however, a very limited number of study provides quantitative measures of father’s support. This study was part of an ongoing cohort, ‘Sawangan Cohort,’ conducted in West Java,Indonesia, observing pregnant mothers since the beginning of their pregnancy until recently their newborn has turned at least 3 months by the time of data collection. The initial aim of the cohort was to observe early life factors to malnutrition and therefore the location selection was based on under-five stunting incidence [14,15]. The availability of comprehensive prenatal history data provide better context of the father’s involvement in EBF, as one of the contributing variable to stunting. The current analysis used a sequential mixed-method design with a primary cohort quantitative phase and proceeded with a qualitative phase using in-depth interviews (IDIs) and focus group discussion (FGD) to explain the significance found in the quantitative phase.
Methods
1. Study design
This study used a sequential mixed-method design with a quantitative phase collected ahead of the qualitative phase as part of an ongoing cohort, ‘Sawangan Cohort,’ [16] observation in 3 districts with high stunting prevalence in Depok, West Java,Indonesia; Pengasinan, Bedahan, and Pasir Putih. The cohort study was conducted since early 2022, observing iron folic acid consumption and its associated variables and its effect on maternal and child health since the first trimester of pregnancy. The study invited all pregnant women with no known chronic disease who visited a community-based health provider (local term: Posyandu) to participate in the cohort. The survey related to EBF was conducted when all of the newborns have reached at least 3 months old, which was the median duration of EBF age based on the Indonesia Demographic and Health Survey 2017 [17]. The baseline survey at the beginning of the pregnancy was joined by 233 mothers who gave informed consent, however, due to loss of follow-up, only 225 parents-infant pairs were included in the analysis. The flow of study population was as presented in Fig. 1.
2. Data collection
The quantitative data for this study was collected by the enumerators when the newborn was at least aged 3 months. The dependent variable was EBF practice, and the observed predictor was the father’s support for breastfeeding. The data collection used a validated structured questionnaire (Cronbach alpha=0.611) explained elsewhere [16]. EBF practice was defined as no other food and drinks given yet to the infant other than breastmilk since birth up to at least 6 months or until the time of data collection for infant aged less than 6 months, which in this study was 3 months. Father’s support variable was based on 15-point questions to be answered on a Likert scale one, represents never, to four, represents always, with possible scores ranging from 15 to 60. All continuous scoring variables were analyzed as binomial variables using each defined cutoffs using the mean score in the current population. High support was defined as score ≥mean, otherwise low. The question components are presented in Fig. 2. Other potential confounding variables were also included in the analysis: child’s sex, birth weight (low birth weight [LBW] or normal), mother’s consumption of lactation-support milk and vegetables (katuk leaf, kelor leaf, spinach) consumption, mother’s nutritional status, gestational age at birth, maternal parity, number of children delivered, mother’s age, the gap between pregnancies, mother’s knowledge of breastfeeding, mother’s attitude to breastfeeding, mother’s experience of breastfeeding, mother’s self-efficacy, mother’s occupation, father’s occupation, the health-related decision maker in the family (based on mother’s perception), and family income. Mother’s knowledge, attitude, and experience were based on true or false questions each topic consisted of 5, 8, and 10 questions respectively, with the right answer scoring 2 and the wrong answer scoring 1. High knowledge, attitude, and experience, each, were defined as score ≥mean, otherwise low.
The qualitative phase was conducted after the newborns turned 3 months in the form of IDIs and FGDs. Based on the quantitative result, 14 fathers and 20 mothers who were respondents for the quantitative survey were randomly picked and invited for IDIs. Three midwives, 1 nutritionist, 1 health promotion staff, 2 heads of the community health centers, 3 Health Office staffs, and 1 representative of nongovernment organization (NGO) for lactation support also invited to participate in IDIs. An FGD was conducted with 23 cadres. The IDIs and FGD were conducted by experienced and trained researchers from Universitas Indonesia who were fluent in the local language (Bahasa Indonesia). The IDIs were conducted privately, while the FGD was conducted in the local hall. All IDIs and the FGD were conducted in Bahasa Indonesia and audio recorded, which were then transcribed verbatim and translated into English for publication by the interviewers and cross-checked with 2 experienced transcribers fluent in Bahasa Indonesia and English. The triangulation involved results from the questionnaire and quotations from IDIs and the FGD.
3. Data analysis
This study used IBM SPSS Statistics ver. 29.0 (IBM Co., Armonk, NY, USA) for data analysis. Variable with missing data was still included in the study, therefore the number of analyzed subjects for each variable may differ. All variables were nominal and presented in number and percentage. The association between observed variables and outcomes was analyzed using logistic regression to find the odds ratio (OR). Variables with P<0.25 were included in the multivariable model and were treated as confounders for the adjusted OR (aOR) analysis. By using a 95% confidence interval, the level of significance for this study was at P<0.05. Category for qualitative data categorization was selected based on the triangulation. The Authors looked for patterns and recurring comments to be further interpreted. The important or saturated quotation(s) was presented in paragraphs with reference to the individuals for IDIs or noted as ‘FGD’ for FGD results.
Results
1. Quantitative results
Table 1 shows the study population’s characteristics. Only 47.8% still adhered to EBF, while 52.2% were no longer exclusively breastfed. Among the 117 mothers who no longer provide EBF, 2 of them had stopped breastfeeding entirely. Father’s high support for breastfeeding was experienced by 52.9% of the infants with a mean score of 38.7±6.7 standard deviation (SD) out of 60. Father’s support score in infants with EBF failure was for 37.5±6.3, and 40.2±6.8 in infants remained EBF. Low father’s support was associated with failed EBF (OR, 2.36; 95% CI, 1.38–4.06) compared to fathers with higher support. Based on the support components breakdown (Fig. 2), 43.5% of fathers did not search for information related to breastfeeding. Support from the father was mostly in the form of providing nutritious food (41.7%).
The mother’s knowledge mean score was 5.6±1.5 SD out of 10, the mother’s attitude mean score was 13.8±1.8 SD out of 16, and the mother’s experience distribution was 16.4±2.4 SD out of 32. As father’s support was associated with failed EBF, some other variables were found to be associated as well, including LBW (OR, 5.8; 95% CI, 1.66–20.53), low mother’s knowledge (OR, 2.5; 95% CI, 3.04–10.44), low mother’s attitude (OR, 5.6; 95% CI, 3.04–10.44), low mother’s self-efficacy (OR, 7.26; 95% CI, 3.95–13.35), mother with less experience in breastfeeding (OR, 1.94; 95% CI, 1.14–3.30), and mother’s with lower education (OR, 2.49; 95% CI, 1.11–5.60) as presented in Table 2. Incomplete Antenatal Care, low family income, firstborn, lower father’s education, employed father, and obese mother were showing tendency to increased odds to failed EBF (P<0.25),therefore, included in the multivariable analysis as confounding variables.
Father’s support, gestational age at delivery, birth weight, mother’s knowledge, mother’s attitude, mother’s self-efficacy, mother’s experience, ANC, family income, mother’s parity, mother’s education, father’s education, father’s occupation, and mother’s body mass index were included in the initial multivariable model (Supplementary Table 1). After adjustment with confounding variables, father’s support remained a significantly associated variable. Fig. 3 shows the forest plot of the final model variables to the event of EBF failure in 3 months old infant. Low father’s support was associated with increased failed EBF (aOR, 2.84; 95% CI, 1.46–5.54), other variables that remained as a predictor in the final mode were LBW (aOR, 7.35; 95% CI, 1.73–31.20), lower mother’s attitude (aOR, 3.31; 95% CI, 1.63–6.75), lower self-efficacy (aOR, 4.82; 95% CI, 2.43–9.57), and lower mother’s education (aOR, 2.87; 95% CI, 1.03–8.03).
2. Qualitative results
The IDIs and FGD explored the father’s support, the father’s knowledge and perception, and other reasons contribute to EBF.
1) Father’s support
Father’s support was mentioned by the mothers as one of the factors in planning and practicing breastfeeding. Most mothers already planned for EBF since pregnancy. Some discussed with the father and had his support, but some perceived that their husband did not care.
“We planned since pregnancy and delivery to exclusively breastfeed the baby until 6 months, she [the wife] told me if she had plans and we discussed” (Father 1)
“I did not know. We never talked about it” (Fathers 2, 3, 4)
“I did not talk about it with my husband, he never asked either” (Mother 6)
“Husband’s involvement is very important, many lactating mothers were confused, but the husbands think it was women’s business” (FGD)
“Men do not want to know about it [breastfeeding]” (FGD)
The father’s support was mentioned as a reason for remaining exclusively breastfed.
“Because I followed what the midwife advised to give only breastmilk for 6 months. The baby had no problem and my husband supported.” (Mothers 1, 4, 7)
“I gave support and gave motivation, listened, and encouraged her [mother]” (Father 8)
“My husband encouraged me” (Mothers 4, 9)
“My husband worked far away but he sent things as support, such as dates” (Mother 19)
“I was told [by father] to eat nutritious food to boost the breastmilk” (Mothers 9, 2, 11, 13, 14, 15, 16)
“I asked if the breastmilk is plenty, take a lot of vegetables if you [mother] were lactating. And also encourage [the mother] to breastfeed the baby so my wife does not feel exhausted … If I was not working, I helped with sweeping, washing clothes, and taking care of the baby” (Father 1)
The father’s support provides happiness and comfort to the mother. The mother felt less stressed and felt the attention increased their bonding as a couple which encouraged the mother to breastfeed.
“I am just happy. It affects my breastfeeding” (Mothers 7, 15, 16, 19)
“I just tried to make her [mother] happy and comfortable so she feels encouraged to breastfeed” (Father 8)
However, the father’s decision also mentioned being involved in EBF failure and early complementary feeding at 3 months. Most mothers asked for the father’s permission to give early complementary feeding.
“Most often, the mother was stressed, the nipple was cracked, and the husband was not supportive or supportive only when there was a problem” (NGO)
“It is my initiative to buy formula because the breastmilk seemed too little and the baby was crying a lot.I was confused and panicked and had no experience with the first child. I discussed with my wife after and stopped the formula and went back to breastfeeding.” (Father 3)
“There were times the breastmilk was little, we tried to find the solution together [decide to give early complementary feeding]” (Mother 14)
“I gave my child fruits because the father insisted, he thought the baby already craved [for food]” (Mother 15)
“I gave the baby formula without my husband knowing, because the baby was crying a lot” (Mother 16)
“Some mothers gave the formula with their initiative” (Midwife 1)
“Some mothers stopped exclusive breastfeeding because no support from husband and family” (Midwife 2, FGD)
“Father’s role is very important because a lot of lactating mothers were uncertain especially for the first breastfeeding. But some husbands think that it is women’s business” (FGD)
Other than breastfeeding, some mothers hoped that fathers would help them do the house chores, such as laundry, washing dishes, sweeping, and others. Some fathers help with chores and taking care of the newborn, however, some mothers do all the chores including looking after and nurturing the baby by themselves.
“I sometimes help with household chores, I did her work before went to work” (Fathers 5, 8)
“We share tasks” (Mothers 7, 9, 16)
“Some fathers since the wife got pregnant helped with laundry, dishes, and taking care of children” (FGD)
“It is the wife’s duty,I will help when I can” (Father 2)
“It was exhausting because I did it all on my own” (Mother 17)
“My husband was working and rarely at home” (Mother 18)
2) Father’s knowledge and perception
Fathers were more familiar with breastfeeding for at least 2 years compared to EBF. Some fathers knew the benefit of breastfeeding from midwives during ANC, while others were informed through digital social media.
“Never heard at all about exclusive breastfeeding” (Fathers 2, 3, 4, 10)
“Some father gave honey to the newborn” (FGD)
“Honey is safe for the newborn” (Fathers 3, 4
“Yes, I know from the midwife and also television advertisement that exclusive for 6 months [breastfeeding] so the baby could be close the his mom” (Father 8)
Father’s perception of early complementary feeding was diverse. Some did not object because the breastmilk was not plenty, but some others believe that breastmilk is best and healthier.
“When the breastmilk was still not plenty we gave formula. The information from the midwife, it is okay. My wife also gave food,Ithink it was okay” (Father 8)
“I feel that breastmilk is safer. Formula milk, I am afraid it could lead to obesity and digestive problems, I don’t know but I am afraid. Breastmilk is also cheaper” (Father 14)
“Breastfed baby is healthier” (Fathers 10, 13)
The lack of programs aiming to educate the father was a reason for the misconception about breastfeeding from the father’s perspective.
“There were no maternal and child health programs that involved the father in the community health center” (Midwife 2, Community health center representative, Health Office)
“Husbands mostly waited outside” (Health Office, FGD)
“Maybe if there was a male cadre, fathers would be more involved” (FGD)
3) Other reasons to remain exclusively breastfeeding
Some other reasons to remain exclusively breastfeeding the baby were explored, including mothers’ self-efficacy, mother’s knowledge, and experience, baby’s health, breastmilk still plenty, following the midwives’ advice, found no barriers to breastfeeding, the baby did not like formula milk, other milk caused an allergy and economical reason.
“No problem with breastfeeding, the breastmilk also still flowing” (Mothers 2, 13, 17, 11)
“I am sure I can provide breastmilk” (Mothers 7, 16, 20)
“Since this was not my first [baby], I already get used to it” (Mothers 4, 9, 16, 19)
“My baby did not like milk [formula] and also the skin was red when consumed [formula]” (Mother 8)
“Formula milk is expensive” (Mother 21)
“I was thinking about the baby, so the baby could be healthy. Breastmilk is good for immunity.” (Mother 12)
“Only breastmilk until 6 months, I was afraid of infection, the baby’s stomach is not ready yet for food.” (Father 1 and Mother 1)
“Mothers understood that breastmilk is cheaper” (Midwife 2)
“Breastfeeding and exclusive breastfeeding were explained during ANC” (Midwife 1, Midwife 2, FGD, Mother 2)
Discussion
Based on this quantitative longitudinal observation and qualitative interviews, more than half of the 3-month-old babies had breastfeeding failure to achieve EBF. Low father’s support, along with the history of LBW, the mother’s low attitude, low self-efficacy, and low education, was a significant factor that affected EBF failure.
The current number of babies with EBF was lower compared to the national report, 72.0% [18]. The gaps suggest a need for further plans to improve the EBF practice in this population. Improving the father’s support, the mother’s attitude toward breastfeeding, the mother’s self-efficacy, as well as LBW prevention could be included in future maternal and child health plans.
Father’s support of breastfeeding has been suggested as a predictor for EBF in a previous review. Father’s involvement since the planning of breastfeeding was expected, however, some mothers felt that the father did not care. In line with the current findings, another Indonesian-based research also reported that the prenatal period was important in determining the intention to exclusively breastfeed the future newborn [19]. Intention to EBF was not only required from the mother but also father. A previous study shows that male partner attitudes and intention to breastfeed were correlated with the mother’s [20]. While the current study found that the mother’s attitude was also a predictor for EBF, the qualitative exploration suggested that the father’s support does improve the mother’s attitude to breastfeeding. As found in this population, previous studies explained that the father’s support affected the mother’s will and acted as a moral boost to the mother’s breastfeeding practice [20,21].
Fathers’ support was expected, however, whether or not a father could be supportive may depend on their knowledge about breastfeeding [11,22]. This study explored father’s knowledge and perspective on EBF and found that most fathers did not have proper knowledge of EBF. Based on the current interview with community health centers and the Health Office, to date, there have been no maternal and child health programs that targeted fathers. Fathers in different populations also experienced inadequate levels of information from health providers related to breastfeeding. Meanwhile, several intervention studies targeting fathers have shown a positive influence on mothers’ breastfeeding practice [23,24].
Mother’s attitude, self-efficacy, and education were identified as factors that also affected the success of EBF practice. These findings were also reported in a previous study observing that suboptimal knowledge, a positive maternal attitude, and a strong intention to breastfeed since prenatal were predictors of breastfeeding practice [25]. Breastfeeding is a complex physiological, social, and psychological process that could be challenging and would benefit from mother’s positive attitude and self-efficacy that helps with the bonding experience with the newborn [26].
LBW was a factor that increased the events of failure in EBF, however, LBW was not come out as a direct reason in the IDIs and FGD. Parents’ perception that the breastmilk was not enough and their child was not fulfilled by breastmilk were the direct reasons that came out in the qualitative exploration.There was a possible connection that LBW was affecting the breastfeeding process but not EBF failure directly. Based on the available evidence, breastmilk production was influenced by the baby’s development in sucking reflex and further affected breastmilk production. Moreover, stress associated with having LBW baby was also known as a factor that could impacted mothers [27-29]. The World Health Organization provides a strong recommendation that LBW and very low birth weight (VLBW) newborns be fed their mother’s breastmilk [30]. However, it is a common practice to give formula to LBW and VLBW newborns to help boost the weight [31]. Exclusive breastfed infants did exhibit a slower weight gain compared to the formula-fed infants, although, they had better metabolic and neurological outcomes compared to the formula fed [32].
This study has some limitations in that the observation was conducted at 3 months old and not 6 months old to see the overall EBF failure or success, therefore, different variables may affect the overall EBF success. The study population also limited to 3 districts, and may not be applicable in wider Indonesian population. Despite the limitations, this study was among the limited studies that provide a quantitative measure for fathers’ support of breastfeeding with qualitative exploration. Although observed at 3 months old, the current result already shows a proportionate number of newborns without EBF. The use of cohort data allowed a comprehensive data collection since before birth, while, the qualitative approach provide information on the problem from the perspective of the parents and health-workers. In most times, mother has been identified as the person of interest in the topic of breastfeeding. However, the current qualitative approach shows that father has a prominent role in breastfeeding success and both parents’ coordination was important in child nurturing. The current result encourages public health approach in breastfeeding education targeting fathers. ANC programs also needs to include father to improve both parents’ knowledge and preparedness for the upcoming newborn.
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