The Meaning of Breastfeeding Self-Efficacy in Working Mothers

A Qualitative Study

Sylvia Dwi Wahyuni

, Budi Santoso

, Mira Triharini

and Novri Susan

Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Faculty of Social and Political Sciences, Universitas Airlangga, Surabaya, Indonesia

Keywords: Breastfeeding, Self-Efficacy, Working Mother.

Abstract: Background: The benefits of exclusive breast feeding is well documented. However, in Indonesia, breast

feeding rates fall well below global recommendations. The aim of this research was to explore the meaning

of breastfeeding self-efficacy from working mothers’ perspective. Method: a qualitative method was used that

is the nature of the phenomenology. Setting: the study was conducted in an outpatient’s department in a

hospital in Surabaya, Indonesia. Participants: the respondents were eight mothers working outside the home

for 40 hours per week, attending lactation classes, Indonesian, with children aged seven months to two years,

and babies born healthy. Results: there were five main themes identified in the women’s stories, relating to

self-efficacy and breastfeeding: 1) the source of breastfeeding self-efficacy; 2) the confidence to breastfeed

her infant; 3) the motivation to breastfeed; 4) perception of workplace control; and 5) the impact of

breastfeeding self-efficacy on breastfeeding behavior. Conclusion: The participants who decided to breastfeed

for at least two years tended to think positively about breastfeeding. The women had realistic expectations of

the commitment that breastfeeding entailed, even though they were faced with many workplace obstacles.

1 BACKGROUND

Self-efficacy is a belief in the ability of an individual

to organize and implement a series of actions that are

necessary to achieve something that is desired

(Bandura, 1997). Breastfeeding self-efficacy is a

confidence that is owned by a mother when

breastfeeding an infant. The impact of breastfeeding

self-efficacy includes: choice of behavior, effort and

persistence, thought patterns, and emotional reactions

(Roesli, 2005). Individual responses to breastfeeding

self-efficacy will determine the behavior of the

mother, beginning at the initiation of breastfeeding,

and the ongoing breastfeeding activity to maintain

consistent lactation. However, breastfeeding self-

efficacy in working mothers in Indonesia has not been

explored.

The number of female workers in Indonesia is

increasing each year. In 2012, based on data from the

Central Bureau of Statistics, there were a total of 112

million workers in Indonesia, 43 million of whom are

women. A woman who works has the potential to be

pregnant, have given birth, and/or lactating. These

statistics are further reinforced by the results of a

study by Susanti (2011) who showed that 70% of

breastfeeding mothers in Indonesia are also working.

Advocates for the World Breastfeeding Week

state that the global target globally is to increase

exclusive breastfeeding rates by at least 50% in

infants aged 0–6 months by 2025. However, in 2012,

globally attainment of exclusive breastfeeding rates

in this group of infants only reached 37%. In

Indonesia, exclusive breastfeeding rates are well

below this target. The National Social Economic

Survey conducted by the Department of Health

showed that in 2006, the rates of exclusive

breastfeeding in Indonesia was only 21.2%. However,

in 2009, breastfeeding rates rose to 34.3%. Similarly,

based on data from the National Social Economic

Survey in 2010, the rates of exclusive breastfeeding

in Indonesia was 33.6%.

The low percentage of working women

exclusively breastfeeding in Indonesia is caused by

many factors. Research by Abdullah (2012) explored

the determinants of breastfeeding in working mothers

in Indonesia and found that factors associated with

exclusive breastfeeding were: attitudes towards

breastfeeding, the availability of facilities in which to

192

Wahyuni, S., Santoso, B., Triharini, M. and Susan, N.

The Meaning of Breastfeeding Self-Efﬁcacy in Working Mothers.

DOI: 10.5220/0008322601920199

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 192-199

ISBN: 978-989-758-336-0

breastfeed, and support for caregivers. However, the

attitude towards breastfeeding was the most dominant

factor in exclusive breastfeeding. Judiastuty (2011)

states that exclusive breastfeeding is related to a

mother’s self-efficacy and self-confidence. Weber

(2011) states that there were many difficulties in the

work place that prevent women from breastfeeding:

inflexible rest times, break times that are too short,

overlapping roles, and access to a private space in

which to breastfeed. Consequently, many working

mothers are forced to switch to formula and stop or

reduce breastfeeding.

Meanwhile, the Maternity Protection Convention

No.183 & 191 states that women have a right to a rest

period of more than once a day or obtain permanent

of working hours to breastfeed their baby or express

breast milk. This is supported by Government

Regulation No 33, 2012 regarding exclusive

breastfeeding (chapter 30, verse 3), in which it

explains that a workplace committee is obliged to

provide special facilities for breastfeeding and/or

expressing breast milk.

Breastmilk is highly recommended for all infants,

and the unique composition of breast milk aids in the

healthy growth and development of the baby. The

World Health Organization (WHO) recommends

exclusive breastfeeding for the first six months of life,

and together with other nutritious foods, breast milk

is recommended until two years of age. Research by

Nurmiati and Besral (2008) shows that, in Indonesia,

the duration of breastfeeding has a great effect on the

overall survival of a baby. These researchers found

that babies who were breastfed for six months or

longer survived 33.3 times longer than babies who are

breastfeed for less than four months.

The Kendangsari Mother and Child Hospital in

Indonesia has a pro-breastfeeding program aimed at

supporting successful breast feeding in women. The

mothers who attend classes gain knowledge about

lactation, including how to express breast milk if they

must work. Verbal persuasion by a lactation

consultant has been shown to increase breastfeeding

self-efficacy (Dennis 2010).

Based on the above, it can be concluded that

working mothers should be supported to breastfeed

exclusively. However, research on breastfeeding self-

efficacy in Indonesia is still in its infancy. The

majority of studies conducted so far have been

quantitative in nature, such as the statistics mentioned

above. In Indonesia, there have been no studies

conducted from within the qualitative paradigm and

therefore, this research aims to address this omission.

2 METHODS

This study was embedded in the qualitative paradigm.

Advantages of this paradigm are that it can dig deeper

for information. Congruent with this paradigm is the

methodological approach of phenomenology, in

which the emphasis is on the subjective nature of

human behavior.

Therefore, the researchers were interested in the

subjective world of working breastfeeding mothers

and their understanding of the phenomenon of

breastfeeding self-efficacy. Phenomenology consists

of several types and the one chosen for this research

was descriptive phenomenology, which attempts to

directly explore, analyze and describe certain

phenomena, as free as possible of the estimated

untested.

The population of this study were all working

mothers who attended lactation classes at RSIA

Kendangsari, Surabaya, between April and

September 2013. The researchers used a purposive

sampling technique. Participants were selected based

on the following inclusion criteria: 1) worked outside

the home for at least 7–8 hours a day or 40 hours per

week; 2) have a child aged between seven months and

two years; 3) attended lactation classes at RSIA

Kendangsari; 4) can speak Indonesian; 5) the baby

was born healthy; and 6) were willing to participate

by signing the consent form after it was read and the

purpose of the study was explained by the researcher.

Ethical clearance was received from the ethics

commission in public health faculty of Airlangga

University. Informed consent was secured from study

participants in their own language after explaining the

purpose of the study, potential risks and benefits of

partaking in the study, and the right to withdraw from

the study at any time. The participants were also

assured that their data would be treated

confidentially.

Semi-structured interviews were used to collect

data. This technique is appropriate in phenomenology

as the participants are given the opportunity to

express their experiences related to the phenomenon

under study, in this case, breastfeeding self-efficacy

in working mothers. The use of open questions was

selected because the participants can then their own

words.

The semi structured interviews were digitally

recorded and later transcribed. The researchers

followed a broad interview guide.

The researchers also used field notes to capture

the participants’ non-verbal responses that would

otherwise have been missed in the digital audio

recording. This also captured the researcher’s own

The Meaning of Breastfeeding Self-Efﬁcacy in Working Mothers

193

responses to the content of the interviews and the

conditions affecting the interview process. Data

analysis followed the nine steps outlined by Collazi

(1978, in Speziale & Carpenter, 2003).

3 RESULTS

Five main themes were identified in the women’s

stories that related to self-efficacy and breastfeeding:

1) the source of breastfeeding self-efficacy; 2) the

confidence to breastfeed her infant; 3) motivation to

breastfeed; 4) perception of workplace control; and 5)

the impact of breastfeeding self-efficacy on

breastfeeding behavior.

4 DISCUSSION

4.1 Sources of Breastfeeding Self-

Efficacy

There was one sub-theme to the source of

breastfeeding self-efficacy, namely the significance

of breastfeeding. The meaning is the concept of

breastfeeding owned by the mothers. Through this

research, the meaning of breastfeeding are found to

be the role, physical condition, emotional state, socio-

cultural and religious beliefs, support, and exposure

information from the mass media.

The roles were divided into four, namely: the

obligation of parents, children's rights, affection, and

emotional closeness. The Indonesian Government

Regulation (PP) 33/2012 states that the obligation for

mothers is to breastfeed their babies from birth until

the baby is six months old. Breastfeeding is in the

category of children's rights stated by participants one

and six, according to the Child Protection Law

Chapter I Article 1 No. 12 and Chapter II. Article 2

explains that children's rights are part of human

rights, which must be guaranteed, protected, and

fulfilled by parents, families, communities,

governments, and the state. Children's rights include

(1) non-discrimination; (2) the best interests of the

child; (3) right to survival; and (4) development and

respect for the child's opinion. In the Law of the

Republic of Indonesia Number 36 Year 2009 on

Health, Article 128 Paragraph 1, which states: “Every

baby is entitled to exclusive breastfeeding from birth

for 6 (six) months, except on medical indication.”

Advantages and benefits of breastfeeding are

written in the book “Management Guide Lactation”,

by the Directorate of Community Nutrition,

Department of Health (2001), one of which is the

effect of direct contact of mother and infant: a bond

of love between the mother and baby occurs due to a

variety of stimuli, such as the touch of skin (skin to

skin contact), the baby feels safe and satisfied feeling

the warmth of the mother's body and hearing the

mother's heartbeat that has been known since the baby

was still in the womb. The same thing is also

mentioned by Gupte (2004); breastmilk may improve

the baby's health and intelligence and improve

maternal and child affection (bonding). The category

of emotional closeness is conveyed by most

participants in this study. Participants felt by

breastfeeding, they will be closer to their children.

This is in accordance with the opinion of

Worthington-Roberts (1993, in Bobak, 2004) who

states that breastfeeding has many advantages, one of

which is the improvement of maternal contact. In

addition, the secretion of prolactin increases

relaxation and prolactin and oxytocin enhance the

mother and child attachment.

The emotional states experienced by working

mothers are divided into four categories: depression,

anxiety, inner conflict, and despair. Maternal

emotional conditions greatly affect milk production.

Bahiyatun (2009) states that feelings of stress,

distress, and discomfort experienced by a mother can

hinder the amount of milk that is produced. This is

also supported by the opinion of Siregar (2004) who

discusses the things that should be considered for the

smooth production of milk, including avoiding

anxiety and stress because they can hamper the

oxytocin reflex. According to Widyastuti (2008),

working can be a significant source of tension and

stress for mothers. Ranging from rigid work rules,

lack of understanding from management, heavy

workload, perceived injustice in the workplace, peers

that are difficult to cooperate with, and long working

hours. The anxiety category here is consistent with

the opinion of Syarifah (2008) on the phenomenon

that occurs when mothers work. Their first point of

concern is that breastmilk will not be sufficient for the

baby while she is working. Some working mothers

who are breastfeeding are faced with a conflict

between work and family roles. Conflict of roles

found in this study are time-based conflicts and

conflicts due to maternal anxiety in their role as

employees and mothers. Mothers felt uncomfortable

when having to pump breast milk during work time

because mothers feel it is time-consuming work to

their personal interests. Moreover, women also feel

guilty when leaving the child at home in the care of

others.

Physical stress is a condition that is felt by most

participants. This is in accordance with the opinion of

Azisya (2010) who states that, in general, mothers

work eight to ten-hour days, every day, so work

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194

fatigue is a common complaint. According to Ariani

(2011), illness and fatigue can negatively affect milk

production during breastfeeding.

Based on the research results, advice obtained

regarding recommended foods, according to tribal

beliefs in Java, is to eat vegetables, especially the

katuk leaves with the aim of facilitating the

production of breast milk. This belief is in accordance

with the results of research conducted by Sa'roni et al.

(2004), who conducted a randomized control trial

(RCT) with 96 mothers who give birth and breastfed

their babies at the Maternity Hospital (RSB) Sleman,

Yogykarta. The treatment group was given katuk leaf

extract, vitamins, and minerals, while the control

group was given a placebo, vitamins, and minerals. In

the treatment group there was an increase in milk

production by as much as 66.7 ml or 50.7% compared

to the control group. This happened because of the

alkaloid content of the katuk leaves (Sauropus

androgynus (L).

Seven of the eight participants are Muslim, and

one participant is Christian. Christian participants

conveyed no religious beliefs related to breast-

feeding children. The role of mothers and religious

statutes, in accordance with Islamic teachings

contained in the Koran, is the holy book of Muslims.

The explanation appears in paragraph 14 of the letter

Luqman.

The origin of support for working mothers was

obtained from family, friends, and a lactation

counselor. Other support was provided in the form of

emotional support, esteem support, and informational

support. Emotional support and informational support

were the most widely available support participants in

this study. The origin of support in this study is like

Kahn & Antonoucci’s opinion (in Orford, 1992) that

sources of social support are divided into three

categories: 1. Sources of social support that come

from the individual who is always there throughout

his life, always together and supportive, e.g. close

relatives, spouse (husband/wife), or close friends; 2.

Sources of social support that come from other

individuals that have a small role in their life and tend

to change according to circumstances. These sources

include co-workers, neighbors, relatives. And peers;

and 3. Sources of social support that come from other

individuals who very rarely give social support and

have a role that is rapidly changing. Where

appropriate, sources of support are supervisors,

experts/professionals, and family away.

Forms of support identified in this study are also

almost the same as the opinion House (in Smet,

1994), who claims there are four types or dimensions

of social support: emotional support, esteem support

(occurs through the expression of respect and

appreciation), instrumental support, and support

information.

The Internet was most frequently accessed by the

participants in this study for ease and speed of

obtaining information about breastfeeding.

Positive and negative beliefs about breastfeeding

are described in one subtheme: the benefits of

breastfeeding. The benefits of breastfeeding for

children found in this study are within three

categories: nutrition, immunity, and health. The

results were in accordance with the opinion of Roesli

(2005) regarding the seven benefits of breastfeeding

for babies. Benefits of the first three are as follows: 1)

As a single food to satisfy all the growing needs of

babies up to the age of six months; 2) Improve health

endurance as breast milk contains antibodies; and 3)

Protecting children from an allergy attack. While the

benefits of breastfeeding for mothers were found in

this study is the health category. While the benefits to

the mother in accordance with the third point: 3) to

decrease the risk of premenopausal breast cancer,

especially if the first lactation occurs before the age

of 20 years and occur for at least six months. This is

also confirmed by Roesli (2007) who states that

breastfeeding up to at least six months reduces the

likelihood of a mother suffering from breast cancer,

uterine cancer, and ovarian cancer. Therefore,

protection against breast cancer is in accordance with

the length of time breastfeeding.

4.2 Motivation to Behave Based on the

Views of Others

Motivation for behavior emerges in mothers based on

their experiences of other women and their

reinforcement through recommendation.

Within this study, other women’s experiences

motivating mothers to breastfeed comes from sisters-

in-law and friends of mothers who gave birth at

Kendangsari hospital. Persistence in breastfeeding

can be hindered by obstacles and the failure of

breastfeeding can occur because of the impact of

separation between mother and baby when the mother

works outside the city. According to the research by

Diana (2007), because women’s experience is

limited, this will affect the attitude and appearance of

women in relation to breastfeeding in the future. If a

woman in the family or the environment regularly

sees other women breastfeed their babies it would

have a positive impact on breastfeeding as part of an

everyday experience.

Breastfeeding facilities were divided into two

categories: means and infrastructure. Means of

supporting breastfeeding in the workplace can take

the form of a lactation room. In the Job Agency Act

No. 13 of 2003 and Article 83 of Law No.13 of 2003

regarding labor states, “One of the protection of

female workers after childbirth are still breastfeeding

The Meaning of Breastfeeding Self-Efﬁcacy in Working Mothers

195

their children should be given proper opportunities to

breastfeed the baby, if it must be done during working

time.” This was further strengthened by Act 36 of

2009, Section 128, subsection (3), which states, "The

provision of special facilities referred to in paragraph

(2) is held in workplaces and public facilities."

However, many workplaces do not provide space for

female employees who are in the phase of lactation.

In this study, only one participant reported a

workplace that provides a lactation room. Thus,

working mothers must find a place that can be utilized

to express their breast milk. Places commonly used

include toilets, rooms, warehouses, empty rooms, or

even under a table. Such conditions can hinder the

process of expressing breastmilk because the mother

needs a quiet and comfortable atmosphere. This is

consistent with research by Basrowi Ray (2013) who

states that approximately 72.3% of respondents

consider that their workplace does not provide a

designated space to express milk. Subsequently, this

discomfort causes mothers to consider not expressing

milk at their workplace.

Opportunities to express breastmilk at workplace

are divided into two categories: time and frequency.

The time is limited to recess and in the afternoon

before returning home. The frequency is divided into

two times, three times, and more than three times. The

highest frequency twice express the milk. In this

study opportunities for working mothers to express

milk were identified as break times and evenings

before leaving work. However, mothers complained

of difficulties in dividing their time between prayers,

lunch, and expressing breastmilk. Mothers do not get

a designated time or shorter working hours to express

milk. This is contrary to ILO Convention No. 183 of

2000 Article 10 of the breastfeeding mentioned that:

1) "A woman should be entitled to one or more daily

breaks or reduction of daily hours of work to

breastfeed her child"; 2) "rest period for breastfeeding

or reduction of daily hours of work should be

quantified and duration of nursing breaks and

prosedure reduction of working hours should be

determined by national laws and practices. Breaks or

reductions in hours worked per working day will be

counted as working time and paid accordingly."

Estimates ability of self-confidence of

participants is continue breastfeeding. Confidence is

divided into two categories: optimism and pessimism.

Participants who were optimistic to breastfeed for two

years always think positive, think realistically, and

take concrete actions to achieve these goals despite

many obstacles. In addition, mothers who are

optimistic also forge friendships with fellow nursing

mothers through group communication about breast

milk, breastfeeding, sharing experiences, and seeking

the support of surrounding people and friends to

encourage successful breastfeeding in children, even

when the mother must work. However, a pessimistic

mother can breastfeed for up to two years but seems

resigned and desperate and decides to give formula to

their child.

4.3 The Impact of Breastfeeding Self-

Efficacy

Behavioral choices are the decision regarding

breastfeeding children. There are three categories

according to the revelations of the participants: giving

only breast milk, a combination of breastfeeding and

formula, and formula feeding alone.

Esterik (1990) states that working mothers are

more likely to provide complementary food to their

babies. This is also reinforced by research by Liubai

et al. (1998) who suggest that the chance of working

mothers not breastfeeding exclusively are 2.44 times

greater than mothers that are not working.

The effort and failure which was conducted by

mother category firmness. In the context of this

theme, the firmness is demonstrated by an intent to

maintain breastfeeding while also working. This can

be seen from the persistence of the participants in this

study. The third participant continued breastfeeding

even though her breasts blistered and bled when

pumped. This participant endured pain when

breastfeeding or pumping breast milk, but she was

determined to continue breastfeeding. Meanwhile,

five participants continued trying to pump breast milk

by hand when he was on his way out of town and left

behind even though she had not pumped breast milk

by hand before. This was also demonstrated by the

five participants who patiently learned to stimulating

the nipples are small through frequent breastfeeding

and pumping.

The mindsets of mothers are included in the

category of commitment and perception. Results of

this experiment found that three participants were

committed to breastfeeding their children for up to

two years. Mothers’ commitment to breastfeeding is

one factor contributing to the success of breastfeeding

during work. These mothers adapt to find solutions to

problems because they have a strong desire to

breastfeed their children until the age of two years.

This is in accordance with the opinion of Roesli

(2005), who believes factors of success in

breastfeeding are: (1) commitment of mothers to

breastfeed; (2) breastfeeding early (early initiation)

that begins at birth; (3) engineering nursing positions

that are correct for both mother and baby; (4)

breastfeeding on infant demand; and (5) granted

exclusively.

In this study, maternal perception identified is the

perception that breastmilk was out in accordance with

the mindset or her mind. This is in accordance with

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196

the opinion of Moehji (1988), who states that the

production of breast milk is influenced by maternal

psychological factors. Mothers who are continually

anxious, lacking in confidence, distressed, or

suffering other forms of emotional tension, will

probably fail to breastfeed her child.

5 CONCLUSIONS

Based on the research and analysis discussed in the

previous chapter, it can be concluded that the sources

of breastfeeding self-efficacy for working mothers

are: the meaning of breastfeeding, such as the

meaning of the role, emotions, physical condition,

socio-cultural and religious beliefs, social support,

and exposure to information produced by mass

media. Meanwhile, confidence to breastfeed the child

in terms of the benefits of breastfeeding are divided

into two category: benefits for child nutrition,

immunity, and health and maternal benefits in the

form of health categories, including avoiding breast

cancer.

Motivation for behavior is based on the views of

others and experiences of other women, while the

perceptions of control appear to be divided into three

categories: 1). Facility breastfeeding lactation; 2) the

availability of time and frequency to breastfeed at the

workplace; and 3) estimate one’s own levels of

optimism and pessimism.

The impact on maternal breastfeeding self-

efficacy is as follows: 1) the decision of breastfeeding

children is divided into three categories:

breastfeeding, a combination of breastfeeding and

formula, and formula feeding; 2) effort and

persistence when breastfeeding; and 3) the mindset in

the form of commitment and perception. The

commitment is to breastfeed a baby until it is two

years old. Perceptions that arise in working mothers

regarding the mother's breast milk; this comes from

the appropriate mindset.

Mindset was divided into two categories: the

mindset that reduced milk supply so there was not

enough for the child and the mindset that

breastfeeding mothers can still meet the needs of their

children. In addition, optimistic participants were

able to breastfeed for two years by always thinking

positively, think realistically, and taking concrete

actions to achieve the goal regardless of many

obstacles.

The hospital should provide a pre-natal

breastfeeding program for pregnant women who

work. The program can be continued with the

lactation class after delivery. Lactation classes should

use a variety of techniques to deliver the material and

promote two-way communication between

participants and counselors so the material presented

is easily understood. Variations can include games

among the participants, quizzes, video playbacks,

discussions within a group of participants, and so

forth. In addition, the maternity health services in the

community such as a midwives, doctor can work with

specialist maternity nurses to draw up a program to

improve breastfeeding self-efficacy in women

working in their area. This can be achieved through

the provision of leaflets or booklets with a variety of

themes of breastfeeding for working mothers in

health care facilities within the community,

midwives’ private practice, and in the practice of

obstetrician and gynecology. Counseling on a regular

basis on working mothers associated breastfeeding

should continue, as well as providing facilities for

breastfeeding counseling and preparation for mothers

who wish to breastfeed at work.

The local government should control the

provision of lactation rooms in workplaces and the

opportunity to breastfeed or express breastmilk that is

already regulated by the Act. In addition, through the

health authority, the government should make a

program to support successful breastfeeding for

working mothers. Programs that can be made routine,

for example, counseling related to breastfeeding for

groups of working mothers, the availability of leaflets

or booklets about breastfeeding in the workplace, and

the establishment of peer group support, comprising

of working mothers and maternity specialist nurses.

The program can increase mothers’ knowledge about

breastfeeding, which will ultimately have an impact

on their self-efficacy towards breastfeeding.

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