DOI Number: 10.5958/0976-5506.2019.00614.

Mother’s Knowledge, Attitude, and Practice of Exclusive

Breastfeeding

Rian Diana1, Annis Catur Adi1

1
Department of Nutrition, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia 60112

ABSTRACT
Background: Low prevalence of exclusive breastfeeding was found in Indonesia. Risk factors for suboptimal
exclusive breastfeeding were internal and external factors. Knowledge and attitude of mother are internal
factors that can affect exclusive breastfeeding practice. This study aims to analyze mother’s knowledge,
attitude, and practice of exclusive breastfeeding.
Method: This cross sectional study was done in September-December 2017, 330 mothers who have children
under five in Surabaya and Sidoarjo were participated and selected with simple random sampling. The
association between knowledge, attitude, and practice were analyzed by Chi Square.
Result: More than half (52.7%) of mothers have a moderate knowledge about exclusive breastfeeding.
Half mothers have a positive attitude toward exclusive breastfeeding. Negative attitude to the statements;
breast milk can be replace by infant formula and working mothers can easily give exclusive breastfeeding.
As much as 47.6% mothers had an exclusive breastfeeding. There were association between knowledge
(p=0.003) and attitude (p=0.000) with exclusive breastfeeding practice.
Conclusion: Mothers with good knowledge and positive attitude have a good practice of exclusive
breastfeeding to prevent stunting in the future life.

Keywords: attitude, children under five, exclusive breastfeeding, knowledge, practice

INTRODUCTION on Indonesian Nutritional Status Surveillance 2017,

Breast milk is a nutritious food and it is often
become a gold standard food to support child growth
and development. WHO and Indonesian government
recommend exclusive breastfeeding for 6 months, and
continue until 2 years olds with complementary Feeding(1).
Exclusive breastfeeding support the optimal growth.
Malnutrition prevalence including stunting prevalence
was lower in children with exclusive breastfeeding than
non-exclusive breastfeeding(2). Children who received
exclusive breastfeeding had a better immunity and it
could lower the mortality(3) and morbidity rate(4).
The superiority of breast milk as a nutritious food
for babies has been well studied(5). Nonetheless based
Corresponding Author:
Rian Diana,
Department of Nutrition, Faculty of Public Health,
Universitas Airlangga, Surabaya, Indonesia 60112
Email: rian.diana@fkm.unair.ac.id
the prevalence of exclusive breastfeeding nationally
is only 29.5% in 2016 and 35.7% in 2017. The East
java Province also had a low prevalence of exclusive
breastfeeding (34.9%).
There are several determinant factors of exclusive
breastfeeding such as mothers knowledge, attitude(6),
occupation(7), socio-economic status(8), and normal or
caesarean section(9). Breastfeeding knowledge and attitude
are positively related to exclusive breastfeeding(10).
Some studies about exclusive breastfeeding was done in
Indonesia but it has a contradictory results(11,12) and small
samples(13,14). Therefore this study aims to analyze the
association between mother’s knowledge, attitude, and
practice of exclusive breastfeeding in East Java.
METHOD
This cross sectional study was conducted in Surabaya
and Sidoarjo, Indonesia in September-December 2017.
Ethical clearance was obtained from the ethics committee
 888 Indian Journal of Public Health Research & Development, March 2019, Vol.10, No. 3

of Faculty of Public Health, Universitas Airlangga, no Table 1: Socio-economic characteristics

503-KEPK. The sample of this study was 330 mothers
Characteristics n (%)
who have children under five, which consist of 230
Mothers Occupation
mothers from Surabaya and 100 mothers from Sidoarjo.
Housewife 267 (80.9)
Private employee 37 (11.2)
DATA COLLECTION
Enterpreneur 14 (4.2)
Data were collected through interviews using a Labour 5 (1.5)
structured questionnaire by trained enumerators. The Civil servant 3 (0.9)
questionnaire consists of individual characteristics, Others 4 (1.2)
knowledge, attitude, and practice of exclusive Mothers Education
breastfeeding. Fifteen questions about exclusive Elementary school 34 (10.3)
breastfeeding knowledge and 9 statements of attitude Junior high school 77 (23.3)
were asked to the samples. Three point Likert rating High school 186 (56.4)
scale from agree to disagree were used to assess mothers Diploma 11 (3.3)
attitude. Try out questionnaire was done before data Graduate 21 (6.4)
collection and improvement was made according to the Post-graduate 1 (0.3)
results of try out. Family Income
<IDR, 2,000,000 119 (36.1)
DATA ANALYSIS IDR 2,000,000 – 3,000,000 105 (31.8)
Data were processed and analyzed using IBM > IDR 3,000,000 – 4,000,000 79 (23.9)
program Statistical Package for Social Sciences (SPPS) > IDR 4,000,000 – 5,000,000 12 (3.6)
version 22. Descriptive statistics including estimation > IDR 5,000,000 – 7,500,000 9 (2.7)
of proportion were presented for categorical data. > IDR 7,500,000 6 (1.8)
Breastfeeding knowledge were categorized as good Mean of mother’s age (years) 30.8±7.1
(score>80), sufficient (score 60-80), and insufficient Mean of children’s age (months) 13.4±8.5
(score <60). Breastfeeding attitude from three point
More than 60% samples had a family income less
Likert rating scale from agree to disagree were recode
than IDR 3,000,000 (~ US$ 230.8). This was lower than
into positive (score 2), neutral (score 1), and negative
regional minimum wages either in Surabaya or Sidoarjo.
(score 0). All responses of attitude statements then Only a few samples who had high income (>IDR
summarize, and then times 10 and divided 1.8 so the 4,000,000; ~US$ 307.7).
maximum score was 100. After that, the scores were
categorized as positive (score>80), neutral (score 60- Table 2 showed that more than half (52.7%) mothers
80), and negative (score <60). The association between had a sufficient knowledge with mean score 73.4. The
variables were analyzed by Chi-square test. proportion of mothers with good knowledge (30.3%)
was higher than insufficient knowledge (17.0%). This
implied that most mothers had a sufficient knowledge
RESULTS AND DISCUSSIONS
about breastfeeding.
The mothers mean aged was 30.8 years old,
The items for breastfeeding knowledge instrument
meanwhile their children was under 2 years old (13.4 were comprised of 15 questions including the definition
months). Most of them are housewives (80.9%). Working and benefit exclusive breastfeeding, time to give
as a private employee was the most common among complementary foods, and when to stop breast milk.
the working mothers. More than half mothers (56.4%) There were some items which were not well understood
were graduated from high school, and almost a quarter by the mothers, that is, the definition of exclusive
(23.3%) were junior high school. Only ten percent of breastfeeding, the benefit of breastfeeding for their
mothers who had higher education. children (growth, development, immunity, morbidity,
 Indian Journal of Public Health Research & Development, March 2019, Vol.10, No. 3
and mortality) and for themself (mothers had a longer
time to delay fertility postpartum so it could delayed the
pregnancy and slim faster).
Table 2: Distribution of subjects by category of
breastfeeding knowledge and attitude
Category n (%)
Breastfeeding knowledge
Insufficient (score <60) 56 (17.0)
Sufficient (score 60-80) 174 (52.7)
Good (score >80) 100 (30.3)
Mean±SD score 73.4 ± 17.5
Breastfeeding attitude
Negative (score <60) 37 (11.2)
Neutral (score 60-80) 129 (39.1)
Positive (score >80) 164 (49.7)
Mean±SD score 79.3 ± 14.9
Most mothers know and have heard about exclusive
breastfeeding, but they didn’t know the definition of it.
The low understanding about the definition of exclusive
breastfeeding can make the information bias and not
synchronize when mothers asked if she gave exclusive
breastfeeding for their infants.
Most mothers had a good knowledge about the
timing of giving the breast milk and complementary
foods. They knew that less than an hour after birth they
had to give breast milk. They also knew when the best
time to give the complementary foods, and when to stop
breast milk.
From table 2, we can reveal that less than half
mothers had a positive attitude towards exclusive
breastfeeding. This finding was similar to a study from
Southwestern Ethiopia(15). Meanwhile more than one
third mothers had a neutral attitude. Negative attitude
towards statements; breast milk can be substituted by
infant formulas, it is hard for the working mothers to
give exclusive breastfeeding, and it is need a special
training in giving breast milk. The 3 negative attitude
can be constrains in giving the exclusive breastfeeding.
Many mothers agreed that breast milk can be replace and
substituted with infant formulas.
In normal condition, it is not recommended to give
the infants other than breast milk. In medical indication,
infant formulas were needed. According to the law of
889
Republic Indonesia no 36/2009 concerning health,
article 128 stated “Every infant has the right to receive
exclusive breastfeeding since birth for six months,
except on a medical indication.” The law also suggested
that breast milk should be continued until 2 years old,
together with complementary feeding(1).
This medical indication (babies and or the mothers
condition) described in more detail in the law of Republic
Indonesia no 39/2013 concerning infant formula and
others baby products, article 10-13. Medical indication
are special condition when baby can only receive infant
formula such as inborn errors metabolism (galactosemia,
maple syrup urine disease, phenylketonuria, an others
metabolic disorder), very low birth weight, and preterm
birth. Meanwhile mothers medical indication were
infected by human immunodeficiency virus, had a
severe diseases, infected by herpes simplex virus type
1 and 2 in their breast, had a medical treatment (using
psychotropic drugs, iodine 131 radioactive, iodoform
topical and or cytotoxic chemotherapy drugs), and or
the mothers had passed away, severe mental illness, or
separated from the baby(16).
Table 3: Mother knowledge about exclusive
breastfeeding
Breastfeeding knowledge n (%)
Knowing exclusive breastfeeding 261 (79.1)
Exclusive breastfeeding is no other food
or drink, not even water, except breast 161 (48.8)
milk for 6 months of life
Mothers should give breast milk to the
310 (93.9)
newborn or maximal 1 hour after birth
Breast milk is important for infant 323 (97.9)
Breast milk give nutrition for child
growth and development and increasing 192 (58.2)
infant immunity
Breast milk contain colostrum, antibody,
216 (65.5)
protein, taurine, carbohydrate, and fat
Exclusive breastfeeding made children
smart, independent, and could decrease 155 (47)
infant mortality and morbidity rate
Giving exclusive breastfeeding for 6
303 (92.1)
months are beneficial for mothers
Giving exclusive breastfeeding made
mothers had a longer time to delay
149 (45.8)
fertility postpartum so it could delayed
the pregnancy and slim faster
 890 Indian Journal of Public Health Research & Development, March 2019, Vol.10, No. 3

Conted…
Breastfeeding could be replace by other
food such as complementary foods
Breast milk better than breast milk
substituted
Breastfeeding are nutritious, practical,
cheap, and could increase bonding
between mother and baby
Complementary feeding are best given
at >6 months
Mothers should breastfed their baby
frequently
Baby should be given breast milk until 2
years old
Table 4: Mother attitude towards exclusive
breastfeeding
Statements
Complementary foods for infants can be
given at 4 months
Breast milk cannot be substituted with
infant formula
Working mother can give an exclusive
breastfeeding easily
Mothers gave their first breastmilk
which were yellowish
Every infants have the right to accept
exclusive breastfeeding
There was no need expertise or special
training in giving breast milk
Breast milk should be given
continuously until 2 years old
There was a differences in growth and
development between breast milk and
non breast-milk children
There was a differences in immunity
between breast milk and non breast-
millk baby
Another negative attitude toward exclusive
breastfeeding were the working mothers cannot continue
from Malaysia also revealed that work place and short
maternity leave can be the causes of not continuing
exclusive breastfeeding(8).
200 (60.8)
Table 5 showed that the prevalence of exclusive
324 (98.5) breastfeeding was 47.6% and it was higher than the
national prevalence(17). There was a tendency that
mothers who had a good knowledge have a higher
205 (62.3)
proportion of giving exclusive breastfeeding than the
lower knowledge level. The same trend also found in
breastfeeding attitude. Mothers who had positive attitude
288 (87.8)
have a higher proportion of exclusive breastfeeding than
a negative ones.
265 (80.8)
Chi square analyzed showed that there was a
279 (85.1) significant association between breastfeeding knowledge
(p=0.003) and attitude (p=0.000) with exclusive
breastfeeding practice. This result was similar with
study Zhang et al. in Shanghai, China(10). This significant
association implied that improvement in knowledge and
attitude become an important factors in increasing the
n (%) prevalence of exclusive breastfeeding.
82 (25)
Study from Malawi and Indonesia confirmed that
exclusive breastfeeding was associated with stunting(18,14).
126 (39)
Children who had a frequent infections could cost a lot
of energy to protect and repair the clinical symptoms and
112 (34.1)
tissue damage. This condition may impair the children
growth(19). Therefore it is necessary for the children
307 (93.6) to receive exclusive breastfeeding. Mothers transfer
the immunity to their child through breastfeeding.
322 (98.2) Breastfeeding made the maternal IgG actively transport
to the fetus. This antibodies are important for the infant
90 (27.5) during several months to protect their health(19). A longer
duration of exclusive breastfeeding correlate with lower
305 (93) prevalence of stunting(2).
259 (79.2) Table 5: Association between breastfeeding
knowledge and attitude with breastfeeding practice
Exclusive Breastfeeding p
287 (88) Variables
Yes No Total value
Breastfeeding knowledge
Insufficient 16 (28.6) 40 (71.4) 56 (100)
0.003

giving exclusive breastfeeding. Most of the samples said Sufficient 84 (48.3) 90 (51.7) 174 (100)
that it was hard to give an exclusive breastfeeding among Good 57 (57.0) 43 (43.0) 100 (100)
working mother. This result was in-line with study from
Total 157 (47.6) 173 (52.4) 330 (100)
South Jordan which showed that working mother were
less likely to practice exclusive breastfeeding compared Breastfeeding attitude
to non-working mother. They perceived that insufficient Negative 7 (18.9) 30 (81.1) 37 (100)
0.000

amount of milk, end of maternity leave and no appropriate Neutral 54 (41.9) 75 (58.1) 129 (100)
place for breastfeeding, wanted to improve babies weight Positive 96 (58.5) 68 (41.5) 164 (100)
gain, busy with work and no time for breastfeeding were
the causes of premature breastfeeding cessation(7). Study Total 157 (47.6) 173 (52.4) 330 (100)
 Indian Journal of Public Health Research & Development, March 2019, Vol.10, No. 3
CONCLUSIONS
Improvement in knowledge and attitude will
increase exclusive breastfeeding. Good practice of
exclusive breastfeeding can be an entry point to prevent
growth retardation particularly stunting. Therefore it is
important to increase mother knowledge and positive
attitude towards breastfeeding. Particularly knowledge
about exclusive breastfeeding definition and the benefit
of breastfeeding for their children (growth, development,
immunity, morbidity, and mortality). Increasing positive
attitude about exclusive breastfeeding in working
mother, the use of infant formula appropriately and
everyone can give breast milk for their baby without any
special expertise or special training.
Conflict of Interest: We declare no conflict of interest.
ACKNOWLEDGEMENTS
We would like to thanks to Ministry of Health for
funding this research.
Ethical Clearance: This research had received an
ethical approval from Faculty of Public Health ethics
committee No 503-KEPK.
REFERENCES
1. Ministry of Health. Indonesian Law on Health No
36/2009. 2009.
2. Vesel L, Bahl R, Martines J, Penny M, Bhandari
N, Kirkwoodd BR, et al. Use of new World Health
Organization child growth standards to assess
how infant malnutrition relates to breastfeeding
and mortality. Bull World Health Organ.
2010;88(1):39–48.
3. Edmond K, Newton S, Hurt L, Shannon CS,
Kirkwood BR, Mazumder S, et al. Timing of
initiation, patterns of breastfeeding, and infant
survival: Prospective analysis of pooled data
from three randomised trials. Lancet Glob
Heal [Internet]. 2016;4(4):e266–75. Available
from: http://dx.doi.org/10.1016/S2214-
109X(16)00040-1
4. Khan J, Vesel L, Bahl R, Martines JC. Timing
of Breastfeeding Initiation and Exclusivity of
Breastfeeding During the First Month of Life:
Effects on Neonatal Mortality and Morbidity—A
891
Systematic Review and Meta-analysis. Matern
Child Health J. 2014;19(3):468–79.
5. Horta BL, Victora CG. Long-term health effects
of breastfeeding. World Heal Organ [Internet].
2013;129(8–9):57–64. Available from: http://
www.ncbi.nlm.nih.gov/pubmed/20960419
6. Asfaw MM, Argaw MD, Kefene ZK. Factors
associated with exclusive breastfeeding practices
in Debre Berhan District, Central Ethiopia: A cross
sectional community based study. Int Breastfeed J
[Internet]. 2015;10(1):1–9. Available from: http://
dx.doi.org/10.1186/s13006-015-0049-2
7. Altamimi E, Al Nsour R, Al Dalaen D, Almajali
N. Knowledge, Attitude, and Practice of
Breastfeeding among Working Mothers in South
Jordan. Work Heal Saf. 2017;65(5):210–8.
8. Leong TK. Knowledge, attitude and practice
on breastfeeding in Klang, Malaysia. Int Med
J [Internet]. 2009;8(1):17–22. Available from:
http://journals.iium.edu.my/imjm/index.php/
eimj/article/view/58
9. Khassawneh M, Khader Y, Amarin Z, Alkafajei A.
Knowledge , attitude and practice of breastfeeding
in the north of Jordan : a cross-sectional study.
2006;1(17):1–6.
10. Zhang Z, Zhu Y, Zhang L, Wan H. What factors
influence exclusive breastfeeding based on the
theory of planned behaviour. Midwifery [Internet].
2018;62(April):177–82. Available from: https://
doi.org/10.1016/j.midw.2018.04.006
11. Yulianah N, Bahar B, Salam A. Relationship
between knowledge, attitudes, and trust of
mothers with exclusive breastfeeding in Health
Community Center of Bonto Cani working area
of Bone Rege. 2013;1–13.
12. Thaha ILM, Razak R, Ansariadi A. Determinants
of exclusive breastfeeding among multiparous
in Jeneponto. Media Kesehatan Masyarakat
Indonesia. 2015;11(4):247–52. Available from:
http://journal.unhas.ac.id/index.php/mkmi/
article/view/534
13. Hasniati Y, Indah MF, Asrinawaty A, Kasman K.
Determinant exclusive breastfeeding in Barito
Kuala South Kalimantan. Media Kesehatan
Masyarakat Indonesia. 2015;11(1):39–43.
Available from: http://journal.unhas.ac.id/index.
php/mkmi/article/view/514
 892 Indian Journal of Public Health Research & Development, March 2019, Vol.10, No. 3
14. Damayanti RA, Muniroh L, Farapti. The
difference of nutritional adequacy level and
history of exclusive breastfeeding among stunting
and non-stunting children under five. Media Gizi
Indonesia. 2016;II:61–9.
15. Tadele N, Habta F, Akmel D, Deges E.
Knowledge, attitude and practice towards
exclusive breastfeeding among lactating mothers
in Mizan Aman town, Southwestern Ethiopia:
Descriptive cross-sectional study. Int Breastfeed
J. 2016;11(1):5–11. Available from: http://dx.doi.
org/10.1186/s13006-016-0062-0
16. Ministry of Health. Minister of Health Regulation
No 39/2013 on infant formula milk and other baby
products. 2013.
17. MInistry of Health. Indonesia heath profile 2016.
2017. 1-220 p.
18. Kuchenbecker J, Jordan I, Reinbott A, Herrmann
J, Jeremias T, Kennedy G, et al. Exclusive
breastfeeding and its effect on growth of
Malawian infants: results from a cross-sectional
study. Paediatr Int Child Health [Internet].
2015;35(1):14–23. Available from: http://www.
tandfonline.com/doi/full/10.1179/204690551
4Y.0000000134
19. Hanson LÅ, Korotkova M, Lundin S, Håversen
L, Silfverdal SA, Mattsby-Baltzer I, et al. The
transfer of immunity from mother to child. Ann N
Y Acad Sci. 2003;987(May):199–206.