Journal of Health Technology Assessment in Midwifery ISSN 2620-8423 (print) | 2620-5653 (online)

Vol. 1, No. 1, May 2018, pp. 17-22 17

Factors associated with failure of exclusive breastfeeding

practice
Desy Purnamasari 1,*, Mufdlilah 2
Universitas ‘Aisyiyah Yogyakarta, Indonesia
1
desypurnamasarie@gmail.com*; 2 mufdlilah.stikes@gmail.com
* corresponding author

ARTICLE INFO ABSTRACT

Failure of exclusive breastfeeding has become a significant issue in

Article history Indonesia. There are several factors lead to such issue occured.
Received 13th April 2018 This cross-sectional analytical survey study aimed to investigate
Revised 13th April 2018 the relationship of mother's knowledge, mother's education and
Accepted 31st May 2018 mother's job to unsucessful exclusive breastfeeding. There were 31
mothers with infants aged 0-24 months participated in this study.
Data were collected by employing closed-ended questionnaire and
Keywords analysed by applying chi-square test. The results revealed that
Factors knowledge, maternal education and maternal job associated with
Failure of exclusive breastfeeding unsuccessful breastfeeding (p< 0.05). The failure of exclusive
Breastfeeding breastfeeding were influenced by mothers’ knowledge, mothers’
education and mothers’ occupation.

This is an open access article under the CC–BY-SA license.

1. Introduction
Nutrition is a very important factor for baby's growth and development. World Health
Organization (WHO) and United Nations Children's Fund (UNICEF), and the Indonesian
Government recommends exclusive breastfeeding (EBF) to be provided for infants aged 0-6 months,
without additional fluids or other foods (WHO, 2007). However, the global coverage of EBF was
only 39% in 2012. In some low middle income countries (LMIC’s), the numbers of EBF coverage
varied. In China, the coverage number of EBF was 28% and Cambodia was 74%. Whilst, in African
countries such as Togo and Zambia the coverage was up to 60% (UNICEF, 2011). On the other
hand, in Tunisia the EBF coverage was only 6.2% (Stuebe, 2009). In Indonesia, the EBF coverage
was higher than global coverage (48.6%), but it was still extremely far from the WHO’s target
(80%).
Several advantages are identified in EBF for both mothers and children. Evidence reveals that
EBF could contribute to adequate children’s nutrition and also important support for children’s
growth, physical development and intelligence (Felice, 2014). Meanwhile, EBF is also beneficial for
mothers as an effective method of birth control, reducing the risk of breast cancer and psychological
mother-infant attachment (UNICEF, 2011). Based on scientific evidence several negative outcome
such as malnutrition has significant association with poor breastfeeding practice and children who
were not exclusively breastfeed have higer risk on chronic illness such as cancer, hypertension,
diabetes after adulthood, malnutrition and obesity (Stuebe, 2009)
Failure of EBF could be caused by several factors such as lack of education resulted in low level
of knowledge, employment, social culture, and lack of access to healthcare providers. This study
focuses on three factors including level of education, level of knowledge and employment. Low
level of education could contribute to poor EBF practice because mothers with low level of

http://dx.doi.org/10.31101/jhtam.443
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education might have difficulties to understanding information regarding EBF practice. Meanwhile,
well educated mother has associated with better understanding about the benefit of EBF practice.
Consequently, it is believed that EBF brings difficulties when mothers has lack of adequate
knowledge on managing EBF practice. Mothers often take a decision to stop EBF when they
experience problems (Oche, Umar, & Ahmed, 2011). Moreover, employment could also contribute
to failure of EBF when there was no specific breastfeeding support around full time working
mothers. In Indonesia, working mothers are expected to work 7-9 hours per day and they have
limited support to access day care around their working places. As a result, work time limits them to
practice EBF (Murtagh & Moulton, 2011). Having understanding about issues explained in this
introduction section, there is a need explore factors related to failure of EBF pratice.

2. Method
This study employed an analytic survey by using cross-sectional time approach. Sample of this
study were 31 mothers with children aged 0-24 months experienced failure of EBF. All respondents
were recruited at a Primary Health Center in Yogyakarta. Data were collected by using closed-ended
questionnaires from December 2014 until June 2015. Before the questionnaires employed, they were
tested for validity and reliability. Data were analysed by using descriptive statistic and Chi-Square
test. This study was approved by Institusional Review Board of Aisyiyah University of Yogyakarta.

3. Results
3.1. Characteristics of Respondents
3.1.1. Knowledge of mothers related to exclusive breastfeeding
Table 1 shows the distribution of the frequency characteristics of knowledge of mothers about
exclusion of exclusive breastfeeding. The majority of mothers had moderate knowledge related to
exclusive breastfeeding i.e. 20 respondents (64.5%) and there were 11 mothers (35%) had low
knowledge related to breastfeeding.

Table 1. Distribution of the frequency characteristics of knowledge of mothers about exclusion of

exclusive breastfeeding
No. Knowledge n %
1 High 0 0
2 Moderate 20 64.5
3 Low 11 35.5

Total 31 100.0
Source: Primary Data 2015

3.1.2. Education of mothers

Table 2 shows the distribution of frequency characteristics of mother’s education. The majority
of mothers completed junior high school i.e. 19 respondents (61.3%), followed by mothers with
experienced no formal education i.e. 12 respondents (38.7%).

Table 2. Distribution of frequency characteristics of mother’s

No. Education N %
1 No formal education-primary school 12 38.7
2 Junior- senior high school 19 61.3
3 College 0 0
Total 31 100.0

Source: Primary Data 2015

3.1.3. Characteristics mother's occupation

Table 3 shows the distribution of frequency characteristic of maternal works with exclusive
breastfeeding. The majority of working mothers were 19 respondents (61.3%) and 12 (38.7%) of
mothers had no employment .

Desy Purnamasari et.al (Factors Associated With Failure of Exclusive Breastfeeding Practice)
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Table 3. Distribution of frequency characteristic of maternal works with exclusive breastfeeding

No. Occupation N %
1 No employment 12 38.7
2 Work 19 61.3

Total 31 100.0

Source: Primary Data 2015

3.2. Bivariate Analysis

3.2.1. The correlation between mother's knowledge and the failure of exclusive breastfeeding
Table 4 shows Cross-tabulation and chi-square test of knowledge factors and exclusion of
exclusive breastfeeding. The result of chi square test was 6.039 with p-value equal to 0.014 (p
<0,05). This means that there was a relationship of mother's knowledge with failure of exclusive
breastfeeding.

Table 4. Cross-tabulation and chi-square test of knowledge factors and exclusion of exclusive
breastfeeding
Exclusive Not Successful Successful Total
Breastfeeding x2 p
Knowledge F % F % F %
1. High 0 0 0 0 0 0
2. Moderate 20 64.5 0 0 20 64.5 6.093 0.014
3. Low 11 35.5 0 0 11 35.5

Total 31 100 0 0 31 100

Source: Primary Data 2015

3.2.2. The correlation between maternal education and the failure of exclusive breastfeeding
Table 5 shows the cross-tabulation and chi-square test of maternal education factors to failure of
exclusive breastfeeding. The result of chi square test was 3.97 with significant p-value was 0.031 (p
<0.05). This means there is a relationship of mother's education with failure of exclusive
breastfeeding.

Table 5. Cross-tabulation and chi-square test of maternal education factors to failure of exclusive
breastfeeding
Exclusive Not Successful Successful Total
Breastfeeding x2 p
Education F % F % F %
1. College 0 0 0 0 0 0
2. Junior-senior high school 19 61.3 0 0 19 61.3 3.97 0.031
3. No education primary school 12 38.7 0 0 12 38.7

Total 31 100 0 0 31 100

Source: Primary Data 2015

3.2.3. The correlation between mothers work with the failure of exclusive breastfeeding
Table 6 shows the cross-tabulation and chi-square test of occupational factors against exclusion
of exclusive breastfeeding. The result of chi square test was 5.259 with significant p-value i.e. 0.022
(p <0.05). This means that there was a relationship between occupation and failure of exclusive
breastfeeding.

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Table 6. Cross-tabulation and chi-square test of occupational factors against exclusion of exclusive
breastfeeding
Exclusive Not Successful Successful Total
Breastfeeding x2 p
Occupation F % F % F %
Work 19 61.3 0 0 19 61.3
No employment 12 38.7 0 0 12 38.7 5.259 0.022

Total 31 100 0 0 31 100

Source: Primary Data 2015

4. Discussion
4.1. The relationship of mother's knowledge and failure of exclusive breastfeeding
It is believed that knowledge could influence a person's mindset or actions. Mothers with
sufficient knowledge about exclusive breastfeeding benefit would potentially exclusively breastfeed
the baby. As a consequence of that, the baby would have more opportunity to get breastfeeding up to
6 months. Evidence show that breastfeeding is a beneficial for baby to develop a good immune
system. According to Notoatmodjo (2007) knowledge is the result of people’s sensing in a particular
object or the result of people’s understanding about object using their senses. In this study,
knowledge is more likely lead to the mothers’ experiences on how to exclusively breastfeed of their
baby. It is more likely that mothers were motivated to breastfeed their baby voluntarily. This
experience seems to provide knowledge, views and values that will give a positive attitude toward
breastfeeding problems.
Failure on practicing exclusive breastfeeding could be caused due to lack of mothers’ knowledge
about exclusive breastfeeding. This might be resulted from lack of information provided by health
workers about the benefits of breastfeeding for infants and mothers. It could also be caused by the
lack of visit of health workers. Additionally, mothers turns into formula milk due to lack of
knowledge or information about breastfeeding pregnancy or postpartum period (Fonseca-Machado,
Haas, Stefanello, Nakano, & Gomes-Sponholz, 2012).
The result of chi square test was 6.039 and the p-value was <0.05 (Table 4). This means that
there is a relationship between knowledge and the failure of exclusive breastfeeding in the
Pakualaman Primary Health Care in Yogyakarta. It is inline with a previous study conducted shows
that mothers who breastfeed exclusively have moderate knowledge about breast milk (Modupe
Rebekah Akinyinka, Foluke Adenike Olatona, & Esther Oluwakemi Oluwole, 2016). Failure of
exclusive breastfeeding mothers had high knowledge about breastfeeding were minority, whereas
mothers who had low knowledge and nursing their children and non-exclusively breastfeed were
majority. Furthermore, there is a significant relationship between mother's knowledge about
breastfeeding and exclusive breastfeeding practice (Vijayalakshmi, Susheela, & Mythili, 2015).
4.2. The relationship of mothers’ education and failure of exclusive breastfeeding
It is believed that education influences knowledge, whilst knowledge is associated to education.
It is expected that people with a high education would potentially be more knowledgeable.
However, a low educated person is more likely to have less knowledge than those higher education
counterpart. It is needed to be highlighted that the level of knowledge is not always formed by a
formal education, but it could be obtained through non-formal education (Notoatmodjo, 2007).
However, formal education could affect level of people’s knowledge because it could potentlially
provide more experiences including knowledge of exclusive breastfeeding (Murtagh & Moulton,
2011). Mothers who have a high education would probably exclusively breastfeed to the baby.
Attitude and behaviour of women could be influenced by their experiences and education since
childhood. A woman who raised in a family or social environment which support breastfeeding, will
probably have a positive view of breastfeeding (Hunegnaw, Gezie, & Teferra, 2017).
Formal education is very important, because it could influence a person with better critical
thinking. The low education and lack of information are factors that affect the failure of exclusive
breastfeeding (Tewabe et al., 2017). The level of formal education forms the progressive values for a
person, particularly in judging new knowledge. The level of formal education is a factor that helps

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people to understand a particular knowledge or experience. The level of mothers’ education could
influence the attitude in managing various problems. A mother has an important role in the health
and growth of children, in particular exclusive breastfeeding. This can be demonstrated by the fact
that children from mothers with higher education backgrounds would have a better chance to live
and receive a broader insight toward exclusive breastfeeding (Elyas, Mekasha, Admasie, & Assefa,
2017).
This study shows that level of education influence the failure of exclusive breastfeeding (x2 =
3.97; p <0,05). This means that there is a significant relationship between mothers’ education and
failure of exclusive breastfeeding.
4.3. The relationship of the mother's occupation and the failure of exclusive breastfeeding
The results showed that among 31 mothers experienced failure of exclusive breastfeeding, 12
(38.7%) had no employment and 19 (61.3%) were working mothers. The results provide an evidence
that the mothers who work may have challenges to practice exclusive breastfeeding. This study
shows that occupation has influenced on failure of exclusive breastfeeding practice (x2= 5.25; p <
0,05). This means that there is a relationship between working status and failure of exclusive. This
result is inline with the opinions of Roesli (2008) and Weber et al. (2011) that the mother have to
give supplementary food for their baby as their working place were far away, no child care, and has
to return to work due to short maternity leave.

5. Conclusion
The failure of exclusive breastfeeding were influenced by mothers’ knowledge, mothers’
education and mothers’ occupation.

References
Chatterji, P. and Frick, K. D. 2005. Does Returning to Work After Childbirth Affect Breastfeeding
Practices?. Review of Economics of the Household 3, 315-335.2005.
Elyas, L., Mekasha, A., Admasie, A., & Assefa, E. (2017). Exclusive Breastfeeding Practice and
Associated Factors among Mothers Attending Private Pediatric and Child Clinics, Addis Ababa,
Ethiopia: A Cross-Sectional Study. International Journal of Pediatrics, 2017, 1–9.
https://doi.org/10.1155/2017/8546192
Felice, J. P. (2014). NIH Public Access, 60(1), 31–48. https://doi.org/10.1016/j.pcl.2012.09.010.
Breastfeeding
Fonseca-Machado, M. de O., Haas, V. J., Stefanello, J., Nakano, A. M. S., & Gomes-Sponholz, F.
(2012). Breastfeeding: Knowledge and practice. Revista Da Escola de Enfermagem, 46(4), 809–
815. https://doi.org/10.1590/S0080-62342012000400004
Hunegnaw, M. T., Gezie, L. D., & Teferra, A. S. (2017). Exclusive breastfeeding and associated
factors among mothers in Gozamin district, northwest Ethiopia: A community based cross-
sectional study. International Breastfeeding Journal, 12(1), 1–8. https://doi.org/10.1186/s13006-
017-0121-1
Modupe Rebekah Akinyinka, M. M. F., Foluke Adenike Olatona, M. M. F., & Esther Oluwakemi
Oluwole, M. M. F. (2016). Breastfeeding Knowledge and Practices among Mothers of Children
under 2 Years of Age Living in a Military Barrack in Southwest Nigeria. International Journal of
MCH and AIDS (IJMA), 5(1), 1–13. https://doi.org/10.21106/ijma.79
Murtagh, L., & Moulton, A. D. (2011). Working mothers, breastfeeding, and the law. American
Journal of Public Health, 101(2), 217–223. https://doi.org/10.2105/AJPH.2009.185280
Oche, M. O., Umar, A. S., & Ahmed, H. (2011). Knowledge and practice of exclusive breastfeeding
in Kware, Nigeria. African Health Sciences, 11(3), 518–523. https://doi.org/10.4314/tjmr.v15i2.
Stuebe, A. (2009). The risks of not breastfeeding for mothers and infants. Reviews in Obstetrics &
Gynecology, 2(4), 222–231. https://doi.org/10.3909/riog0093

Desy Purnamasari et.al (Factors Associated With Failure of Exclusive Breastfeeding Practice)
22 Journal of Health Technology Assessment in Midwifery ISSN 2620-5653
Vol. 1, No. 1, May 2018, pp. 17-22

Tewabe, T., Mandesh, A., Gualu, T., Alem, G., Mekuria, G., & Zeleke, H. (2017). Exclusive
breastfeeding practice and associated factors among mothers in Motta town, East Gojjam zone,
Amhara Regional State, Ethiopia, 2015: A cross-sectional study. International Breastfeeding
Journal, 12(1), 1–7. https://doi.org/10.1186/s13006-017-0103-3
UNICEF. (2011). Breastfeeding the best start for your baby, 30.
Vijayalakshmi, P., Susheela, T., & Mythili, D. (2015). Knowledge, attitudes, and breast feeding
practices of postnatal mothers: A cross sectional survey. International Journal of Health Sciences,
9(4), 364–374. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid=4682591&tool=pmcentrez&rendertype=abstract
WHO. (2007). Planning Guide for national implementation of the
Global Strategy for Infant and Young Child Feeding, 1–46. Retrieved from
http://www.who.int/maternal_child_adolescent/documents/9789241595193/en/

Desy Purnamasari et.al (Factors Associated With Failure of Exclusive Breastfeeding Practice)