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JURNAL KEDOKTERAN DIPONEGORO
(DIPONEGORO MEDICAL JOURNAL)
Online : http://ejournal3.undip.ac.id/index.php/medico
E-ISSN : 2540-8844
DOI : 10.14710/dmj.v12i6.38163
JKD (DMJ), Volume 12, Number 6, November 2023 : 343-349
Alnaora Tanjinna Zulfihda, Nurul Setiyorini, Ari Budi Himawan, Nahwa Arkhaesi
343
CORRELATION BETWEEN KNOWLEDGE, ATTITUDES, AND BEHAVIOUR OF
MOTHERS ABOUT EXCLUSIVE BREASTFEEDING AND ITS SUCCESS RATE IN
KARANGMULYO VILLAGE
Alnaora Tanjinna Zulfihda1* Nurul Setiyorini2 Ari Budi Himawan3 Nahwa Arkhaesi4
1Undergraduate Program, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia
2Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia
3Department of Public Health, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia
4Department of Pediatrics, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia
* Correspondence Author : E-mail: alnaora4321@gmail.com
ABSTRACT
Background: Exclusive breastfeeding (ASI) is a condition when the baby only receives breast milk from his mother or
foster mother for the first 6 months. The rate of exclusive breastfeeding is 37% worldwide and 54.1% in Jakarta. Infants
who are not breastfed are associated with an increased incidence of infectious morbidity. Knowledge is one of the basic
factors that determine a person's reaction and decision-making when faced with a situation. Knowledge will bring up a
person's attitude to determines the behavior or action to be taken. Aim: To know the relationship between mother’s
knowledge, attitudes, and behavior about exclusive breastfeeding with the level of success. Methods: Analytic
observational study with a cross-sectional design conducted for 2 months in Karangmulyo Village, Kendal Regency,
Central Java. The research subjects consisted of 66 mothers who had children aged 6-24 months. Assessment is carried
out on the level of knowledge, attitudes, and behavior of mothers regarding exclusive breastfeeding, as well as the success
rate of exclusive breastfeeding. Data analysis used the Mann-Whitney test, Chi-square, and Fischer exact. Significant
p<0.05. Results: Most mothers have a good level of knowledge (n=57), attitude (n=45), and a sufficient level of behavior
(n=64) regarding exclusive breastfeeding. There was no significant result in the level of knowledge (p=0.528; 0.820),
attitude (p=0.339; 1.000), behaviour (p=0.342; 0.515) with the success of exclusive breastfeeding. Conclusion: There is
no relationship between the level of knowledge, attitudes, and behavior on the success of exclusive breastfeeding.
Keywords: Exclusive breastfeeding, knowledge, attitude, behavior
INTRODUCTION
Exclusive breastfeeding (ASI) is a condition
when the baby only receives breast milk from his
mother or foster mother for the first 6 months and no
solid food or other liquids.1 In the worldwide, only
37% of babies are exclusively breastfed. Rates of
exclusive breastfeeding range from 41% in North
Africa, 44% in Asia, and the lowest in Latin America
at 30%.2,3 The prevalence rate of exclusive
breastfeeding in Jakarta is 54.1%, which is higher
than the total value of exclusive breastfeeding in the
worldwide.4
Exclusive breastfeeding is known to have many
health benefits, both in the short and long term for
babies and their mothers. An increasing number of
studies report the relationship between exclusive
breastfeeding and long-term protection. Children's
cognitive development will increase with exclusive
breastfeeding.5
Based on the 2018 Basic Health Research
(Riskesdas) data, it is known that there has been a
decrease in exclusive breastfeeding as the baby ages,
namely at 0 months of age as much as 81.0%, 78.4%
at 1 month, 79.7% at 2 months, 79.7% at 1 month. 3
months 74.4%, 4 months 72.4%, and at 5 months only
62.2%.6 According to health profile data for the
province of Central Java in 2020, the average
exclusive breastfeeding (without complementary
food) is only up to 4.5 months of age, then
breastfeeding with additional food is carried out on
average for babies aged 5.7 months.7
Infants not being breastfed are associated with an
increased incidence of infectious morbidity, as well
as an increased risk of childhood obesity, type 1 and
type 2 diabetes, leukemia, and sudden infant death
syndrome. For mothers, failure to breastfeed is
associated with an increased incidence of
premenopausal breast cancer, ovarian cancer, type 2
diabetes, myocardial infarction, and metabolic
syndrome.8
Knowledge is one of the basic factors that
determine a person's reaction and decision-making
when faced with a situation, one of which is the
decision to give exclusive breastfeeding to children.
JURNAL KEDOKTERAN DIPONEGORO
(DIPONEGORO MEDICAL JOURNAL)
Online : http://ejournal3.undip.ac.id/index.php/medico
E-ISSN : 2540-8844
DOI : 10.14710/dmj.v12i6.38163
JKD (DMJ), Volume 12, Number 6, November 2023 : 343-349
Alnaora Tanjinna Zulfihda, Nurul Setiyorini, Ari Budi Himawan, Nahwa Arkhaesi
344
Knowledge will bring up a person's attitude which
also determines the behavior or action to be taken.
LITERATURE REVIEW
Optimal exclusive breastfeeding practices
will reduce child mortality, contribute significantly to
children's long-term health, reduce the length of stay
in children with diarrhea, respiratory infections, and
otitis media, and support optimal brain
development.9,10 In 2016, the Lancet estimated that
823,000 under-five deaths could be prevented each
year through optimal exclusive breastfeeding
practices.
Mother's knowledge and attitudes are
significantly related to exclusive breastfeeding
behaviour. Mothers with good knowledge are 14.8
times more likely to give exclusive breastfeeding than
mothers with good knowledge.11 These results are
similar to the findings of studies from Ethiopia,
Nepal, and Tanzania.12,13,14 This impact can be partly
explained by increased knowledge of mothers about
the benefits of breastfeeding for themselves and their
babies and the risks of not breastfeeding thereby
increasing the likelihood that mothers will breastfeed.
Previous studies have shown that mothers with good
knowledge are 2.6 and 2.7 times more likely to give
exclusive breastfeeding compared to those with good
knowledge and negative attitudes towards exclusive
breastfeeding.12
Mother's good knowledge and positive attitude
play an important role in the breastfeeding process.15
A previous study reported that mothers with high
knowledge of exclusive breastfeeding were 5.9 times
more likely to practice exclusive breastfeeding than
mothers with low knowledge of exclusive
breastfeeding (OR 5.9; 95% CI 2.6, 13.3; p<0.001 ).16
Scores of higher breastfeeding knowledge (OR 1.09;
95% CI 1.04-1.14), attitude (OR 1.04; 95% CI 1.00,
1.09), and practice control (OR 1, 11; 95% CI 1.02,
1.20) was associated with a higher prevalence of
exclusive breastfeeding.17
A positive mother's attitude towards
breastfeeding is associated with longer breastfeeding
and a greater chance of successful breastfeeding.
Mothers with a positive attitude towards
breastfeeding tend to exclusively breastfeed their
babies. The results of this study indicate that some
mothers have a positive attitude towards exclusive
breastfeeding such as starting complementary foods
after six months and the belief that exclusive
breastfeeding is beneficial for children and better than
artificial feeding. This turned out to also be a
difference of opinion by the majority of mothers who
disagreed with the fact that giving colostrum to
newborns right away and within one hour is
important, exclusive breastfeeding is enough for
children up to six months, to feed their babies for the
first six months, breastfeeding increases the bond
between mother and baby, breastfed babies are
healthier than breastfed babies, and formula feeding
is more of a hassle than breastfeeding. The results of
this study indicate that mothers have the lowest level
of attitudes about exclusive breastfeeding.18
Based on these theories, it can be concluded that
knowledge, attitudes, and behaviour are entities that
in this study are related to the success of exclusive
breastfeeding.
METHODS
Analytic observational study with a cross-
sectional design conducted for 2 months in
Karangmulyo Village, Kendal Regency, Central Java.
The research subjects consisted of 66 mothers who
had children aged 6-24 months. The study exclusion
criteria included mothers or children with special
conditions that prevented exclusive breastfeeding.
Assessment is carried out on the level of knowledge,
attitudes, and behaviour of mothers regarding
exclusive breastfeeding by using a questionnaire from
previous research that is similar and has been
validated, as well as the success rate of exclusive
breastfeeding namely when the baby is only given
breast milk during the age of 0-6 months without any
additional food or support on a daily basis. Level of
knowledge, less (score 19-75), sufficient (score 76-
132), and good (score 133-190). Attitude level, less
(score 9-35), enough (score 36-62), and good (score
63-90). Behaviour level, less (score 18-71), moderate
(score 72-125), and good (score 126-180). Data
analysis used the Mann-Whitney test, Chi-square, and
Fischer exact. Significant p<0.05
RESULTS
Based on the assessment conducted on 66
research subjects, it was found that 26 subjects
(39.4%) underwent exclusive breastfeeding, while 40
subjects (60.6%) did not undergo exclusive
breastfeeding.
JURNAL KEDOKTERAN DIPONEGORO
(DIPONEGORO MEDICAL JOURNAL)
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E-ISSN : 2540-8844
DOI : 10.14710/dmj.v12i6.38163
JKD (DMJ), Volume 12, Number 6, November 2023 : 343-349
Alnaora Tanjinna Zulfihda, Nurul Setiyorini, Ari Budi Himawan, Nahwa Arkhaesi
345
Table 1. Knowledge score
Variable
Exclusive Breastfeeding
(n=26)
Non-Exclusive
Breastfeeding (n=40)
P
n
Mean ±
SD
Median
(min-
max)
n
Mean ±
SD
Median
(min-
max)
Knowledge
Score
147.15 ±
14.51
153
(103-
160)
147.43 ±
20.96
151 (42-
160)
0.528‡
Knowledge
level
• Less
• Enough
• Good
0
4
22
1
4
35
0.820†
‡Mann Whitney U; †Fischer Exact; *significant p<0.05
The level of knowledge in the Exclusive
Breastfeeding group obtained an average of 147.15
with a standard deviation of 14.51, the median value
was 153 with the smallest value being 103 and the
largest value being 160. There were 4 subjects with a
sufficient level of knowledge and 22 subjects with a
good level of knowledge. The level of knowledge in
the non-exclusive breastfeeding group obtained an
average of 147.43 with a standard deviation of 20.96,
a median value of 151 with the smallest value of 42,
and the largest value of 160. There was 1 subject with
less knowledge, 4 subjects with a sufficient level of
knowledge, and 35 subjects with a good knowledge
level. There was no significant relationship or
significant difference (p=0.528; 0.820) in the level of
knowledge for the exclusive breastfeeding and non-
exclusive breastfeeding groups.
Table 2. Attitude score
Variable
Exclusive Breastfeeding
(n=26)
Non-Exclusive
Breastfeeding (n=40)
p
n
Mean
± SD
Median
(min-
max)
n
Mean
± SD
Median
(min-
max)
Attitude Score
64.42
±
11.49
66 (42-
80)
66.63
±
12.46
66 (38-
80)
0.339‡
Attitude Level
• Less
• Enough
• Good
0
8
18
0
13
27
1.000¶
‡Mann Whitney U; ¶Chi Square; *significant p<0.05
The attitude level in the Exclusive Breastfeeding
group obtained an average of 64.42 with a standard
deviation of 11.49, the median value was 66 with the
smallest value being 42 and the largest value being
80. The Exclusive Breastfeeding group had 8 subjects
with a sufficient level of attitude and 18 subjects with
a good level of attitude. The attitude level in the non-
exclusive breastfeeding group obtained an average of
66.63 with a standard deviation of 12.46, a median
value of 66 with the smallest value of 38, and the
largest value of 80. There were 13 subjects with a fair
attitude level and 27 subjects with a good attitude
level. There is no significant relationship and
significant difference (p=0.339; 1.000) in the attitude
level for the exclusive breastfeeding and non-
exclusive breastfeeding groups.
Based on the assessment of the
obstacles/problems faced by mothers in providing
exclusive breastfeeding to their children, as many as
17 subjects complained that breast milk was not
smooth/small production, followed by 7 subjects
complaining about sore nipples and as many as 2
subjects complaining about work factors that
hindered breastfeeding time for children.
Table 3. Behavior score
Variable
Exclusive Breastfeeding
(n=26)
Non-Exclusive
Breastfeeding (n=40)
p
n
Mean
± SD
Median
(min-
max)
n
Mean
± SD
Median
(min-
max)
Behaviour
Score
105.96
± 8.15
104
(88-
116)
101.45
±
14.90
102
(53-
125)
0.342‡
Behaviour
levels
• Less
• Enough
• Good
0
26
0
2
38
0
0.515†
‡Mann Whitney U; †Fischer Exact; *significant p<0.05
The level of behaviour in the Exclusive
Breastfeeding group obtained an average of 105.96
with a standard deviation of 8.15, a median value of
104 with the smallest value of 88, and the largest
value of 116. There were 26 subjects with sufficient
behaviour levels. The level of behaviour in the non-
exclusive breastfeeding group obtained an average of
101.45 with a standard deviation of 14.90, a median
value of 102 with the smallest value of 53, and the
largest value of 125. There were 2 subjects with less
behaviour and 38 subjects with sufficient behaviour.
There was no significant relationship and significant
difference (p=0.342; 0.515) at the level of behaviour
for the exclusive breastfeeding and non-exclusive
breastfeeding groups.
DISCUSSION
The rate of exclusive breastfeeding in this study
was 39.4%. Based on the WHO classification, the
percentage of exclusive breastfeeding in this study
was at an adequate level (12%-49%).19 In the two
groups, most of the research subjects did not work
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(54.20% and 63.72%).20 There is a positive
relationship between mothers who do not work and
exclusive breastfeeding practices. This is associated
with mothers who don't work can stay longer with
their children, thus allowing more frequent practice
of exclusive breastfeeding. However, working
mothers face several challenges in maintaining
exclusive breastfeeding such as conflicting
commitments at work, limited support at work, and a
lack of breastfeeding facilities.21 Mothers from low
socio-economic groups are also more likely to
practice exclusive breastfeeding than mothers from
middle-income families. A possible explanation is
that people with low incomes have limited resources
to afford alternative baby foods, so breastfeeding is
the only option for them. The other factor is age that
known to be a factor associated with smooth
breastfeeding. Older age generally decreases
physiological functions, one of which is the
production of breast milk. This is supported by
interviews with mothers regarding the obstacles
during exclusive breastfeeding, stating that breast
milk that is not smooth/low production is the most
common obstacle that mothers complain about in
their efforts to breastfeed their children.
In both research groups, most of the research
subjects were dominated by a good level of
knowledge. In the non-exclusive breastfeeding group,
there was 1 subject with a low level of knowledge. A
good mother's knowledge and a mother's positive
attitude are known to play an important role in the
breastfeeding process. A study reported that mothers
with higher knowledge of exclusive breastfeeding
were 5.9 times more likely to practice exclusive
breastfeeding (OR 5.9; 95% CI 2.6, 13.3;
p < 0.001)16, and scores of knowledge of exclusive
breastfeeding were higher. higher (OR 1.09; 95% CI
1.04-1.14), attitude (OR 1.04; 95% CI 1.00, 1.09),
and practice control (OR 1.11; 95% CI 1.02, 1.20)
was associated with a higher prevalence of exclusive
breastfeeding.22 This is supported by Susilawati D in
her research which states that there is a relationship
between the level of knowledge and exclusive
breastfeeding.23
A person's education can influence a person's
mindset, whereas in general the higher a person's
education the easier it is to receive information.
Associated with exclusive breastfeeding at the
educational level is very closely related to the ability
to absorb or receive information about exclusive
breastfeeding. Wawan et al stated that education
means guidance given to others with certain
directions to achieve safety and happiness. Education
can affect a person including a person's behaviour,
especially lifestyle, motivated to participate in
development. In general, the higher a person's
education, the easier it is to receive information.24
In both research groups, most of the research
subjects were dominated by the level of a good
attitude. In the non-exclusive breastfeeding group,
there was 1 subject with a low level of knowledge. In
the exclusive breastfeeding group, the percentage of
good attitudes was higher than in the non-exclusive
breastfeeding group (69% versus 67%). Substandard
breastfeeding / low production is the most common
obstacle complained of by mothers in their efforts to
breastfeed their children.
Research conducted by Rana MDM, et al found
that maternal age ≥21 years 13.84 times (adjusted
odds ratio (AOR) = 13.84, 95% CI: 7.394–25.904;
p<0.001) more likely to have high knowledge about
exclusive breastfeeding and (AOR = 0.084, 95% CI:
0.050–0.143; p<0.05) are less likely to practice
exclusive breastfeeding compared to mothers aged
≤20 years. Working mothers were 9.99 times (AOR =
9.992, 95% CI: 4.485–22.260, p<0.05) more likely to
practice exclusive breastfeeding than housewives.
Mothers who gave birth at home (AOR = 0.208, 95%
CI: 0.111–0.389; p<0.05) were less likely to practice
exclusive breastfeeding than mothers who gave birth
in a hospital. High family monthly income (AOR =
0.092, 95% CI: 0.050–0.168, p<0.05) is less likely to
practice exclusive breastfeeding.25
Good exclusive breastfeeding practices can
prevent 13.8% of all deaths among infants aged less
than 2 years and 11.6% of deaths among children
under 5 years. Morris C, et al who conducted research
related to factors influencing attitudes towards
exclusive breastfeeding found that exclusive
breastfeeding was influenced by age, religion,
parental status, and breastfeeding status, but not by
household income.26 Nuampa S, et al also added
several personal factors related to exclusive
breastfeeding for six months, including being a
housewife (AOR 2.848; 95% CI 1.512, 5.367),
perception of the adequacy of family income (AOR
2.502; 95% CI 1.362, 4.594) ), work from
home/business (AOR 2.071; 95% CI 1.074, 3.995),
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intention to breastfeed (AOR 1.162; 95% CI 1.116,
1.210), and mother's age (AOR 0.932; 95% CI 0.882,
0.986). From the qualitative interviews, mothers who
can exclusively breastfeed explain four reasons
underlying exclusive breastfeeding: 1) having to save
money, 2) being able to spend all the time with the
baby and breastfeeding, 3) partner support is
invaluable, and 4) the opportunity to avoid beliefs
hindering exclusive breastfeeding. Mothers with
higher socioeconomic status and who are
unemployed or work from home are more likely to
breastfeed exclusively. Healthcare providers can
provide tailored programs for breastfeeding mothers,
based on socioeconomic status, employment status,
mother's age, and social network. Optimal exclusive
breastfeeding output can be increased through
increased support resources, intensive programs, and
partner involvement, especially for mothers who face
financial difficulties and work outside the home.27
In addition to the factors that make it possible to
carry out exclusive breastfeeding, several other
factors can hinder the implementation of exclusive
breastfeeding. Research has revealed that maternal
factors such as the mother's occupation, higher
education level, smoking during pregnancy, partner
violence or lack of partner support, health problems,
breast complications during breastfeeding, and use of
birthing aids have a negative impact on the duration
of exclusive breastfeeding. In addition, younger
mothers, especially teenage mothers, those who have
had a caesarean section, as well as those who
experience postpartum depression or feel they are
under-produced, report a shorter duration of exclusive
breastfeeding.28
In both research groups, most of the research
subjects were dominated by moderate behaviour
levels. In the non-exclusive breastfeeding group,
there were 2 subjects with less behaviour. The
percentage level of behaviour obtained higher values
in the exclusive breastfeeding group compared to the
non-exclusive breastfeeding group (100% versus
95%).
Although in general mothers had a positive
attitude towards exclusive breastfeeding, 42%
(n = 79), mothers did not practice exclusive
breastfeeding for their babies. These mothers do not
practice exclusive breastfeeding because they
misunderstand certain signs of a child wanting to eat
or drink water, think that breast milk is not sufficient
to meet the nutritional needs of children, and
misunderstand exclusive breastfeeding advice from
health professionals. Research in Pekanbaru found
that only 36.1% of mothers practiced exclusive
breastfeeding. Most of the respondents thought that
their milk was lacking and felt that their baby was still
hungry. Therefore they gave formula milk, namely
77.0%, and bananas, namely 61.6%, while 35.8% of
them gave 2 kinds of solids for their babies before the
age of six months. Mother's age, education level, and
family income are significantly correlated with
exclusive breastfeeding practices. Information,
values, and emotional support from the community
were also identified as important aspects for the
success of exclusive breastfeeding practices
(p<0.001).29
Qualitative research conducted by Afiyanti Y, et
al stated that the failure of the breastfeeding
experience was mostly caused by mothers who
believed that they were producing inadequate milk.
The belief that the mother's milk production was
insufficient was the starting point for the participants'
decision to wean their babies. All participants decided
to provide additional food to their babies because they
felt that the milk produced was not sufficient for the
baby's needs. Some mothers feel that their milk
production is less than usual, the baby is getting
bigger and needs more milk, and the baby is getting
hungry.30
CONCLUSION
Most mothers have a good level of knowledge
and attitude regarding exclusive breastfeeding as well
as a sufficient level of behaviour regarding exclusive
breastfeeding. There is no relationship between the
level of knowledge, attitudes, and behaviour on the
success of exclusive breastfeeding.
ETHICAL CLEARANCE
A research ethics permit was obtained from the
Health Research Ethics Commission (KEPK) Faculty
of Medicine UNDIP with no. 393/EC/KEPK/FK-
UNDIP/XI/2022.
CONFLICT OF INTEREST
The author declares that there is no conflict of
interest in this research.
JURNAL KEDOKTERAN DIPONEGORO
(DIPONEGORO MEDICAL JOURNAL)
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DOI : 10.14710/dmj.v12i6.38163
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Alnaora Tanjinna Zulfihda, Nurul Setiyorini, Ari Budi Himawan, Nahwa Arkhaesi
348
FUNDING
All research funding comes from the primary
author.
AUTHOR CONTRIBUTIONS
Conceptualization, Alnaora, Nurul; methodology,
Alnaora, Ari; data analysis, Alnaora, Ari; data
collection, Alnaora; source of funds, Alnaora; wrote
the original draft, Alnaora; review and edit, Alnaora,
Nurul, Ari, Nahwa; supervision, Alnaora, Nurul, Ari.
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DOI : 10.14710/dmj.v12i6.38163
JKD (DMJ), Volume 12, Number 6, November 2023 : 343-349
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