Family Support as a Factor Influencing the Provision of Exclusive Breastfeeding Among Adolescent Mothers in Bantul, YOGYAKARTA

The number of adolescent pregnancies in Indonesia is still very high. Sewon Subdistrict had the highest number of adolescent deliveries in Bantul District in 2015-2016. This study aimed to determine factors influencing exclusive breastfeeding among adolescent mothers in Sewon Subdistrict, Bantul District. This study used cross-sectional study design and a sample size of 45 that were adolescent mothers of 6-24-month-old infants. Data was collected using a structured questionnaire. Data analysis involved bivariate analysis using chi-square test and fisher's exact test, while multivariate analysis used logistic regression.Results showed that 53.3% of adolescent mothers did not practice exclusive breastfeeding. Bivariate analysis showed that pregnancy status (p value = 0.029), perception of childbirth experience (p value = 0.045), perception of breastfeeding (p value = 0.005), husband support (p value = 0.009) and family support (p value = 0.000) were correlated to exclusive breasfeeding. Multivariate analysis showed that perception of breastfeeding (p value = 0.015; OR = 9.746) and family support (p value = 0.014; OR = 7.637) as the most influential factors to exclusive breastfeeding among adolescent mothers with a probability of 72.7%.There is low practice of exclusive breastfeeding among adolescent mothers in Bantul, Yogyakarta and family support is the most dominant factors influencing exclusive breastfeeding.


Introduction
The incidence of adolescent pregnancy is still very high. About 16 million adolescents give birth every year and an estimated three million girls aged 11-15 years undergo unsafe abortion. 1 Developing countries had a higher proportion of adolescent pregnancy than developed countries. Around 90% of adolescent pregnancies occur in developing countries. Indonesia ranks the fifth of the top ten countries with the greatest number of adolescent pregnancies in the world. 2 Based on National Basic Health Research in 2013, about 0.02% pregnancies occured at the age of less than15 years and 1.97% at the age of 15-19 years. Pregnancy at the age of 15-19 years increased to 0.3% from the previous year. 3 The high number of adolescent pregnancy would translate to the high rate of adolescent births. In 2015, the number of adolescent births increase to 1,078 from 930 in the preceding year. 4 Of the 2015 births above, 33.7% (364 adolescent births) were recorded in Bantul District, Yogyakarta Province. If compared to the preceding year, there was more than 100% increase in number of adolescent mothers who gave birth in Bantul District. 4 Further analysis indicated that Sewon Subdistrict in Bantul District had the highest number of adolescent births cumulatively from 2015 to 2016. 5 Breastfeeding is a natural process that seems to have been adversely affected by the "modernization" of society. Though it is now widely accepted that breast milk is the best for the infant, it is also a well-known fact that exclusive breastfeeding rates in early infancy are still low. Human milk, or breast milk, is uniquely engineered for human infants, and the biologically 'natural' way to feed infant. Pregnancy and childbirth among adolescents often lead to health problems, such as late prenatal care initiation, poor prenatal health behaviors, lower breastfeeding initiation and duration rates, postpartum depression, and lower folic acid supplementation than adult women. 6 About 34.1% of adolescent mothers provide exclusive breastfeeding up to 3 months, lower than young women (20-24 years) at 46.3% and adult women (≥ 25 years) at 53.3%. 6 Studies suggest that adolescent mothers hardly practice exclusive breastfeeding despite its immense known benefits. 7,8 Among other reasons, this is due to the fact that they are not ready to accept the new maternal roles. 9 Other studies cited that it is also caused by the return to work after delivery, feeling that breast milk alone could not satisfy the infant and in some cases insufficient breast milk production by the mother. 7 Several studies have shown that certain factors affect exclusive breastfeeding among adolescent mothers, such as family support and pregnancy planning. 10,11 The aim of this study was to determine the factors that influencing the provision of exclusive breastfeeding among adolescent mothers using theoretical framework from Green, 12 that progressed predisposing factors and reinforcing factors as independent variables. Predisposing factors include level of education, occupation status, pregnancy status, maternal perception of childbirth experience and perceptions of breastfeeding. Reinforcing factors included the husband support and family support. Behavior studied was the behavior of mothers as regards exclusive breastfeeding.

Method
This study used cross-sectional design. The independent variables included level of education, occupation status, pregnancy status, maternal perception of childbirth experience, maternal perception of breastfeeding, husband support, and family support. The dependent variable was exclusive breastfeeding practice. Target population was the adolescent mothers aged younger than 19 years old according to the World Health Organization (WHO) criteria for adolescents with infants aged 6-24 months in Sewon Subdistrict, Bantul District, Yogyakarta Province, Indonesia. The inclusion criteria were primiparous mothers, mother's consent by signing the informed consent, bound in marriage and residing in Sewon Subdistrict. The calculation of sample size used Lemeshow for hypothesis of two proportions depending on previous study with OR=1.81, P1= 0.489, P2= 0.27, thus giving a minimum sample size of 39 respondents. The sample size for this study was 45 respondents. Sewon Subdistrict has four villages. Therefore, to obtain the 45 adolescent mothers, this study applied proportional sampling technique thus obtaining 8, 11, 15 and 11 respondents from Timbulharjo, Pendowoharjo, Bangunharjo and Panggungharjo Villages respectively. This study was conducted in April to May 2017 with ethical approval from Ethical Commission of Health Research, Yogyakarta Health Polytechnic of Health Ministry No.LB.01.01/KE-02/XXVIII/678/2017. Maternal perception of childbirth experience, maternal perception of breastfeeding, husband support, and family support were categorized based on data distribution. The result of normality data on four variables was normal, so those variables were categorized by the mean limits. The categories were positive/support if score greater than or equal to mean and negative/less support if the score less than mean. The analysis technique used included univariate analysis, bivariate with chi-square test and multivariate logistic regression.

Results
Respondents of this study were mothers aged 17-19 years with 6-24-month-old infants. The univariate analysis is presented in Table 1.
Based on univariate analysis, the percentage of mothers who did practice exclusive breastfeeding was 53.3%.
The majority (60%) of respondents in this study had completed secondary education, about 88.9% did not work, and 75.6% had planned their pregnancies. About 55.6% of respondents had a positive perception of childbirth experience, while 51.1% of respondents had a negative perception of breastfeeding. About 55.6% of respondents felt that they received good supports from their husband and 53.3% of respondents felt the lack of support from their family.
Shown in the Table 2, education level did not influence the practice of exclusive breastfeeding among adolescent mothers (p value = 0.143). Most of adolescent mothers with elementary education level did not breastfeed exclusively (66.7%). Occupation status also was not statistically associated with exclusive breastfeeding in adolescent mothers (p value = 0.352). About 80% of working mothers did not breastfeed exclusively.
Pregnancy status was related to exclusive breastfeeding in adolescent mothers (p value = 0.029). Majority (81.8%) of mothers with unwanted pregnancies did not practice exclusive breastfeeding.
Exclusive breastfeeding among adolescent mothers was related to maternal perception of childbirth experience (p value = 0.045). As many as 7 in 10 mothers who had a negative perception of childbirth experience did not practice exclusive breastfeeding.
Maternal perception of breastfeeding was related to maternal behavior to provide exclusive breastfeeding (p In this study, husband support was one of the factors influencing exclusive breastfeeding practice among adolescent mothers (p value = 0.009). The majority of mothers who received less support from their husbands did not practice exclusive breastfeeding (75%). Similarly, most mothers who received less support from their families did not practice exclusive breastfeeding (79.2%). Family support was strongly associated with exclusive breastfeeding in adolescent mothers (p value = 0.000). Table 3 shows that respondents with good perception of breastfeeding were 9.75 times more likely to exclusively breastfeed their infants than mothers with negative perception of breastfeeding. Further, adolescent mothers who received good support from their family about breastfeeding were 7.64 times more likely to exclusively breastfeed their infants than those who felt they received less family support in breastfeeding. Regarding personal perceptions of breastfeeding, adolescent mothers with positive perception of breastfeeding and received good family support had 72.2% probability to provide exclusive breastfeeding.

Discussion
The results of this study indicated that over half (53.3%) of adolescent mothers interviewed did not practice exclusive breastfeeding in Sewon Subdistrict and only 46.7%. Although Sewon Subdistrict seems to be doing well in terms of exclusive breastfeeding (46.7%) if compared to national estimates (38%), the proportion was way below the Special Region of Yogyakarta Province estimates which stands at 71.62% and still lower than those of the larger Bantul District. 3,4 These low numbers of exclusive breastfeeding in Sewon Subdistrict could be attributed to the fact that the adolescent mothers are still in the process of formation of body image and sexual identity and they may not be ready to accept a new role as a mother. 9,13 The results of the bivariate analysis in this study showed that education level and employment status were not associated with exclusive breastfeeding among adolescent mothers. Working mothers often face the chal-lenge of not being able to stay at home longer after their maternity leave to take care of the infant including exclusive breastfeeding. 14 There are several possibilities for them even if all respondents had primary education up to secondary level, but 51.1% said strongly agree that they feel comfortable and happy while caring her infant.
This study has demonstrated several factors related to exclusive breastfeeding among adolescent mothers, which include pregnancy status (wanted or unwanted), maternal perception of childbirth experience, the maternal perception of breastfeeding, husband support, and family support. These results are consistent with several studies that found several reasons and factors influencing adolescent mothers in providing exclusive breastfeeding to their infants, such as feelings that breast milk alone cannot satisfy the infant, feelings that there have inadequate breast milk supply, family support issues, and whether or not the pregnancy was planned. 7,10,11 Pregnancy status has been associated with exclusive breastfeeding in adolescent mothers. Mothers with wanted pregnancies had a higher likelihood of breastfeeding exclusively. This is because women who have planned for the pregnancy are often more prepared to care of the infant, including the commitment to breastfeed after birth. 15 According to Robbin, 16 a person's perception is the process of organizing and interpreting the sensations felt with the aim to give meaning to the environment. Perception is one of predisposing factors that influence a person's behavior. 12 Maternal perception of childbirth experience is associated with exclusive breastfeeding. 17 According to Mercer, 18 the maternal perception of childbirth experience is one of variables that affect maternal role attainment after birth. Childbirth experience is unforgettable for most women. A good experience will often strengthen confidence in the mother, while a bad one will affect the mother's feelings to escape and possibly refuse to breastfeed the infant. 19 Qualitatively, this study has also unearthed further insights into the image of an adolescent mother's perception of childbirth experience. Most of mothers have negative perception of the birth experience and respondents claimed to often feel tired during labor. Some said they did not have a pleasant experience at the time of labor, while others still felt scared when they recalled the pain of labor and generally concluded that childbirth was a painful process. Some perceptions of breastfeeding expressed by adolescent mothers in this study include feelings that an adolescent mother is unable to provide exclusive breastfeeding for 6 months, there was insufficient milk production, and feeling embarrassed when one had to breastfeed her infant. This is consistent with findings found elsewhere and the perceptions are considered barriers to exclusive breastfeeding. 7,20,21 They are barriers because these perceptions affect the mother's decision to provide exclusive breastfeeding to her infant, also considering the fact that about 80% to 90% of milk production is actually determined by the mother's emotional state associated with maternal oxytocin reflex in the forms of thoughts, feelings, and sensations whereby if it increases, it facilitates the excretion of breast milk. 22 According to Mercer, 18 social support is one of the variables that influence the achievement of the mother's role. The social support is the support given by the people closest to the mother, such as her husband and family, including informative support, assessment, physical, and emotional. In this study, social support of both husband and family has been shown to be associated with exclusive breastfeeding. This implies that fundamentally, breastfeeding is not a reserved exercise for only mother and infant, but also an important process which the father and family have a role to play in.
The association demonstrated by this study between exclusive breastfeeding and husband support is consistent with a study by Ramadani and Hadi 23 ,which showed that the husband support associated with exclusive breastfeeding. The support adolescent mothers get from their husbands vary and the mothers attach some importance to various actions by those who are close to them and interpret them as necessary. For instance, most respondents reported that they had received good support from their husbands, for example, their husband did not accompany during labor, never to find information about the benefits of breastfeeding for mothers and infants and did not get a right way explanation from her husband about breastfeeding, did not give praise when the mother was feeding her infant, and let the mother care of the baby alone when the infant awakened at night. This is major concern in this study because the husband support tends to influence the success of exclusive breastfeeding since in many cases it affects the mother's decision to breastfeed and her emotional condition which often inadvertently affects milk production. 22 Beside the husband support, the family has an important role, especially for adolescent mothers. The main function of the family as proposed by Friedman, 24 is to play the role of providing the affective function, psychosocial care of each other, show love, ensure mutual ac-ceptance as well as support. An adolescent mother who feels they have good family support in their new role of being a mother, tend to feel more receptive and able to adapt better. As disclosed by Friedman, 24 that the positive impact of family support is to increase one's ability to adapt to the events in his life. This study found that respondents whoever found the following deficits as far as family support was concerned that were lack of effort by the family members to search for information about benefits of exclusive breastfeeding for both mother and infant, lack of praise for the mother after she had breastfeed the infant, and inadequate support when the infant woke up at night and she had to care of the infant all alone. There were some evidences that comparatively, experiences of adolescent mothers in breastfeeding were not much different from adult mothers. Rather what distinguishes adolescent mother from adult mothers in breastfeeding practices is the fact that adolescent mothers need more social support, especially from families. 20 There were three matters affecting breastfeeding among adolescent mothers, such as maternal perception of the benefits of breast milk, maternal perception of problems of breastfeeding, and support from influential people. 20 Being an adolescent mother is certainly not easy. This often creates a conflict between adolescent developmental tasks and parental duties. Therefore, young people need the support of those closest especially families in order to help in achieving the maternal role, one of which is practicing exclusive breastfeeding which has immense benefits to the infant as well as the mother. 25

Conclusion
Among adolescent mothers of infants aged 6-24 months in Sewon Subdistrict, Special Region of Yogyakarta, this study finds the exclusive breastfeeding low compared to the entire district. This has been found to be associated with several factors. These factors include pregnancy status, i.e. whether wanted on unwanted, maternal perception of childbirth experience, the maternal perceptions of breastfeeding itself, husband support, and family support. Of these factors, family support is the most significant determinant that influences exclusive breastfeeding practice among adolescent mothers.

Recommendation
From the findings, first, government and other related stakeholders should promote family planning to reduce unwanted pregnancies which tends to negatively impact exclusive breastfeeding. Second, more awareness programs especially at the antenatal clinic level should be improved among adolescent mothers to not only offer them psychological support, but also address some of the perceptions which tend to negate the practice and bene-fits of exclusive breastfeeding. Further, health workers handling adolescent mothers should involve family members and husbands in the promotion of exclusive breastfeeding to motivate and support the mothers' efforts. Lastly, further study needs to be carried out to examine the most feasible and culturally sensitive interventions that promote continued practice of breastfeeding among working mothers once they return to work.