National Taipei University of Nursing and Health Sciences

College of Nursing

Department of Nurse-Midwifery and Women Health

Graduate Institute of Nurse-Midwifery

Master Thesis

Factors Associated with Six Months of Exclusive Breastfeeding

among Employed Mothers After Returning to Work in

Karanganyar Regency of Central Java, Indonesia

Siska Ningtyas Prabasari

Advisor : Meei-Ling Gau, CNM, PhD

June 2020

Acknowledgements

First of all, I would like to thank Allah SWT, the almighty God who has given me the favors

of guidance, the favors of faith, the favors of health and the blessings of opportunity so that I

can complete this Master program.

Mr. Sarwoto and Mrs. Jalimah thank you for your motivation, support, guidance, and

prayers that you will never stop giving to your child. I am grateful to have you both.

My husband Rizal, My siblings Iwan, Bayu and Indra who always provide support,

understanding to solve difficulties in the preparation of this thesis.

Professor Meei-Ling Gau as the supervisor of my thesis, Professor Chieh-Yu Liu as the

supervisor of statistical analysis and Stephanie as a medical English editor, thanks for

providing guidance and direction in the preparation of this thesis.

Friends of National Taipei University of Nursing and Health Science especially for

international class of 2018-2020, thank you for all our moments together, hopefully we can

all achieve our goals according to each other's expectations.

i

Abstract

Background: The short- and long-term benefits of breastfeeding for babies and

mothers are widely recognized. Breastfeeding is associated with decreased incidence and

severity of infectious diseases, such as diarrhea, respiratory tract infections and otitis media.

In Indonesia, the rate of exclusive breastfeeding until six months was 42% in 2012, according

to the Indonesian Demographic and Health Survey. Over a three-year period the rate of

exclusive breastfeeding increased dramatically, rising to 55.7% by 2015. In 2017, the rate of

exclusive breastfeeding in the province of Central Java was close to the national average, but

it rose by only 0.2% that year. This study will be done in Karanganyar Regency, which

ranked 30th out of 35 regencies in Central Java, with about 23% of women breastfeeding

exclusively for the first six months of their infant’s life. This figure is far from the target rate

of 80% set out by the national government. Indonesia’s government has recognized the

importance of breastfeeding and breast milk, and has enacted policies aimed at improving

breastfeeding rates. Indonesian Health Law No. 36 was enacted in 2009, calling for every

baby to be breastfed for the first six months of life, unless impossible due to a medical

condition. Though this law aims to increase breastfeeding, workplaces are not well regulated,

and employersre not held accountable for providing support to new mothers who must

breastfeed or pump breast milk at work.

Purpose of the study: to explore factors related to exclusive breastfeeding among

employed mothers returning to work, in particular, assessing whether breastfeeding-friendly

workplace practices are actually succeeding.

Methodology: A descriptive correlational design was used to collect data using

written questionaire. The adapted questionnaire, which included the Multidimensional scale

of perceived social support, Breastfeeding and employment study, Iowa infant feeding

attitude scale, and demographic characteristics, was administered to 208 employed mothers

ii

who consented to participate in Karanganyar Regency from July to November 2019. A binary

logistic regression was used to calculate adjusted odds ratios (AdjORs) and 95% confidence

intervals (CIs) for exclusive breastfeeding practice.

Results: The analysis used seven demographic variables, including age, education,

monthly family income, parity, mode of delivery, and previous breastfeeding experience,

along with different dimensions of social support for breastfeeding, which included family

support, support from friends and significant others (husbands and health workers), and

workplace organizational and management support. Only support from workplace support

(BESt) (p-value = .002 ,odds ratio of 1.034) showed a significant association with successful

exclusive breastfeeding among working women. Social support was not significantly

associated with exclusive breastfeeding in this study.

Conclusion: Lack of workplace support was the dominant factor that predicted failure

to breastfeed exclusively among employed mothers. Breastfeeding-friendly workplace

policies must be implemented and carried out with regular evaluations. Health workers

should do outreach to companies to educate management and co-workers about the

importance of breastfeeding and ways to integrate it with work.

Keywords : exclusive breastfeeding, employed mothers, breastfeeding-friendly

workplace, social support

iii

Contents

Abstract .......................................................................................................................... i

Contents ........................................................................................................................ ii

List of Tables .............................................................................................................. vi

List of Figures ............................................................................................................ vii

List of Abbreviations ................................................................................................. viii

Chapter One Introduction ............................................................................................. 1

1.1 Research Background ...................................................................................... 1

1.2 Significance of the Study ................................................................................. 3

1.3 Research Purpose ............................................................................................. 3

1.4 Research questions ........................................................................................... 3

1.5 Definition of Major Concepts ........................................................................... 4

Chapter Two Literature Review .................................................................................... 6

2.1 Geography of Karanganyar Regency ............................................................... 6

2.2 Maternal and Infant Statistics ........................................................................... 8

2.3 Breastfeeding ................................................................................................... 9

2.4 Exclusive Breastfeeding ................................................................................... 9

2.4.1 Definition .................................................................................................. 9

iv

2.4.2 The Type of Infant Feeding .................................................................... 10

2.4.2 Benefits of Breastfeeding .......................................................................... 10

2.4.3 Factors Related to Exclusive Breastfeeding ............................................... 11

2.5 Conclusion ..................................................................................................... 18

Chapter Three Methodology ....................................................................................... 20

3.1 Research Design ............................................................................................ 20

3.2 Research Setting ............................................................................................ 20

3.3 The Inclusion Criteria and Exclusion Criteria ................................................. 21

3.4 Sample Size .................................................................................................. 21

3.5 Instruments .................................................................................................... 23

3.6 Translation and Pilot Study ............................................................................ 25

3.7 Data Collection ............................................................................................... 29

3.8 Data Analysis ................................................................................................ 32

3.9 Ethical Consideration ..................................................................................... 35

Chapter Four Results ................................................................................................. 36

4.1 Characteristics of Research Subjects ............................................................. 36

4.2 Descriptive statistics of the outcomes variables .............................................. 37

4.3 Relationship between personal factors, breastfeeding and employment study and

social support towards breastfeeding types .................................................... 43

4.4 Factors associated with adherence to six months exclusive breastfeeding ....... 46

v

Chapter Five Discussion ............................................................................................ 48

5.1 Finding of this study .................................................................................... 48

5.1.1 Personal Factors ...................................................................................... 48

5.1.2 Breastfeeding Workplace Friendly Factors ............................................. 52

5.1.3 Social Support Factors ............................................................................ 54

Chapter Six Conclusion, Limitation and Recommendation ......................................... 56

6.1 Conclusion ..................................................................................................... 56

6.2 Limitations ................................................................................................... 56

6.3 Recommendations ......................................................................................... 57

References

Appendix

vi

List of Tables

Table 3.1 Table Data of Analysis ................................................................................ 33

Table 4. 1 Demographic Characteristics of the study participants................................. 37

Table 4. 2.1 Descriptive Statistics of Breastfeeding and Employment Study ................ 39

Table 4. 2.2 Descriptive Statistics of MSPSS ............................................................... 42

Table 4. 2.3 Descriptive Statistics of Iowa Infant Feeding Attitude Scale ..................... 43

Table 4. 3.1 Relationship between personal factors and breastfeeding types ................. 43

Table 4. 3.2 Relationship between BEsT and breastfeeding types ................................ 45

Table 4. 3.3 Relationship between social support and breastfeeding types.................... 46

Table 4. 4 Factors associated with adherence to six months exclusive breastfeeding .... 47

vii

List of Figures

Figure 2.1 Geography of Karanganyar Regency .......................................... 7

Figure 2.2 Conceptual Framework .............................................................. 19

Figure 3.2 Data Collection .......................................................................... 31

viii

List of Abbreviations

WHO

UNICEF

World Health Organization

United Nations International Children’s Emergency Fund

IMR Infant Mortality Rate

BFW Breastfeedingf Friendly Workplace

ASI Air Susu Ibu (Mother’s Breastmilk)

IIFAS Iowa Infant Feeding Attitude Scale

BESt Breastfeeding and Employment Study

MSPSS

IRB

Multidimensional Scale of Perceived Social Support

Institutional Review Board

1

Chapter One

Introduction

1.1 Research Background

Breastfeeding is widely known for short-term and long-term health benefits for babies

and the mothers. Breastfeeding is associated with decreasing incidence and severity of

infectious diseases, such as diarrhea, respiratory tract infections and otitis media (Tang, Lee,

& Binns, 2014).

The World Health Organization (WHO, 2019) recommends that new born babies

breastfeed until the age of six months without providing other food or fluids, except vitamins,

minerals, and drugs that have been allowed for medical reasons. According to the United

Nations International Children's Emergency Fund (UNICEF, 2012), every three years, 30,000

infant deaths in Indonesia and 10 million under-five deaths around the world can be

prevented by exclusive breastfeeding for six months after the birth of the baby without

providing additional food and drink.

The Indonesian Demographic and Health Survey in 2012 showed the rate of exclusive

breastfeeding until six months was 42%. Nationally, there was a rather dramatic increase over

a three-year period, with the rate of exclusive breastfeeding for infants 0-6 months rising to

55.7% by 2015. Although in the province of Central Java the rate of exclusive breastfeeding

in 2017 was close to the national average, it rose by only 0.2% that year. The lowest

exclusive breastfeeding rate in the province was in Temanggung Regency at 8.4% (451

babies) and the highest was in the town of Magelang City at 87.2% (458 babies). This study

will be done in Karanganyar Regency (a regency is an administrative unit similar to a large

city), which, at 22.82 is ranked 30th out of 35 regencies (Central Java Health Profile, 2018).

This figure is far from the target rate of 80% set out in the national government’s Minimum

Service Standards.

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The infant mortality rate in Karanganyar Regency fluctuated over the five years from

2012 to 2017, with the lowest rate in 2013 at 9.9/1000 and the highest at 14.2/1000 in 2016

(In 2012 it was 10.1/1000, 9.9/1000 in 2013, 10.5/1000 in 2014, 12.8/1000 in 2015,

14.2/1000 in 2016 and 12.7/1000 in 2017). In 2017, there were 134 cases of infant mortality,

the most in the Karanganyar Primary Health Center at 17 cases and the least in the

Ngargoyoso Community Health Center with 2 cases (Central Java Health Profile, 2018).

Indonesia Governments have recognized the importance of breastfeeding and breast

milk, and they have enacted policies with the intention of improving breastfeeding rates. In

2009, Indonesian Health Law No. 36 was enacted, calling for every baby to be breastfed for

the first six months of life, unless impossible due to a medical condition (Indonesia Health

Profil, 2012). Though this law aims to increase breastfeeding. Workplaces are not well

regulated, and employers are not held accountable for providing aid to new mothers who

must breastfeed or pump breast milk at work.

Since a woman’s breast milk supply responds to demand, when she is unable to

release milk regularly, milk production decreases. Although employers are not being actively

regulated, the law states that women can face fines and/or jail time for not providing their

child with breast milk for the required amount of time (Alves, Dowling, & Mahan, 2017). In

urban areas where more mothers are working to make a living, it’s harder to breastfeed their

babies properly and regularly. Workplaces do not yet support the practice of breastfeeding,

for example, private space for pumping breast milk and proper means to store it are often

lacking. Also, most workplaces do not provide on-site child care facilities so that working

mothers could breastfeed their babies at certain times (Central Java Health Profile, 2018). In

addition, there are many other factors that influence working mothers’ ability to breastfeed

exclusively. Mothers who are employed postpartum are less likely to continue breastfeeding

than mothers who are not formally employed. However, as employment is increasingly

3

necessary for the majority of new mothers, it is important to investigate factors that influence

the continuation of breastfeeding among employed mothers (Bai, Wunderlich, & Weinstok,

2015).

1.2 Significance of the Study

The results of this study should help us understand the relationship between exclusive

breastfeeding and personal factors, social support for breastfeeding among employed

mothers, and breastfeeding-friendly workplace practices. The information provided should

offer a basis for designing practical guidelines for midwives to educate society and to

improve the implementation of exclusive breastfeeding among employed mothers returning

to work, which may further increase the exclusive breastfeeding rate.

1.3 Research Purpose

The purpose of this study is to explore factors related to exclusive breastfeeding among

employed mothers returning to work especially the breastfeeding-friendly workplace

practices. The research objectives were:

1.3.1 To examine breastfeeding-friendly workplace practices including workplace

organizational support, manager support, co-worker support, time support and physical

environment support for exclusive breastfeeding among employed mothers returning to work.

1.3.2 To examine personal factors related to exclusive breastfeeding among employed

mothers returning to work, including demographic and obstetrical data and personal attitudes

about breastfeeding.

1.3.3 To examine factors relating to social support among family, friends and others for

employed mothers to exclusively breastfeed after returning to work.

1.4 Research questions

1.4.1 What is the relationship between exclusive breastfeeding rates among employed

mothers returning to work and breastfeeding-friendly workplace practices, such as

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organizational support, manager support, co-worker support, time support and physical

environment support for breastfeeding?

1.4.2 What are the relationships between personal factors, including demographic and

obstetrical factors, and attitudes towards exclusive breastfeeding among employed mothers

returning to work?

1.4.3 What is the relationship between social support and exclusive breastfeeding among

employed mothers returning to work?

1.4.4 Which factors—personal, workplace, and social support—are the most important

for predicting exclusive breastfeeding among employed mothers returning to work?

1.5 Definition of Major Concepts

1.5.1 Exclusive Breastfeeding

Concept definition:

Exclusive breastfeeding refers to infants receiving only breast milk during the first six

months of life, and not food or even water, including other liquids like tea and herbal

preparations, except for doctor-recommended vitamins, mineral supplements, or medicines

(WHO, 2009).

Operational definition:

A measure of exclusive breastfeeding among mothers will use the definition from WHO

including the types of infant feeding practice, which include exclusive breastfeeding, mix

breastfeeding and replacement feeding (formula) (Bai et al., 2009; Thurman & Allen, 2008;

WHO, 2009;)

1.5.2 Breastfeeding-friendly Workplace

Concept definition:

Workplace support for breastfeeding powerfully influences whether or not mothers

succeed at exclusive breastfeeding. Examples include places for pumping breast milk, proper

5

storage for breast milk, and childcare. In addition, work hours also affect the success of

breastfeeding, including the type and duration of work (Novayelinda, 2012).

Operational definition:

A measure of how breastfeeding-friendly workplaces support mothers to breastfed their

children exclusively. The measurement in this study uses Breastfeeding Employment Study

(BEESt) (Greene, Wolfe & Olson, 2008).

1.5.3 Social support

Concept definition:

Nursalam (2009) states that people involved in providing social support for breastfeeding

include spouses, parents, children, relatives, friends, health teams, and counselors.

Operational definition:

Using the Multidimensional Scale of Perceived Social Support (MSPSS). This instrument

is used to measure the social support factors which contains of three subscales: The

Significant Other Subscale, the Family Subscale and the Friends Subscale (Zimet, Dahlem,

Zimet & Farley, 1988).

1.5.4 Attitude

Concept definition:

Attitude is a reaction or response that is still closed from someone to stimulus or

object, attitude is not yet an action or activity, but it is a predisposition of an act of behavior

(Notoadmodjo, 2012).

Operational definition:

Using the Iowa Infant Feeding Attitude Scale (IIFAS) whch consist of 17 attitude questions,

half of which are favorable to breastfeeding and the remaining favorable to artificial feeding

(De la Mora, Russell, Dungy, Losch, & Dusdieker, 1999).

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Chapter Two

Literature Review

2.1 Geography of Karanganyar Regency

Karanganyar Regency is one of 35 Regencies / Cities in Central Java Province located

110°40°-100°70° east longitude and 7°28° - 7°46° south latitude (Figure 1). The average

height is 511 meters above sea level, has a tropical climate with temperatures of 22° C - 31°

C Surakarta dan Kabupaten Boyolali. North is bordered by Sragen Regency; East side

borders with East Java Province; The South is bordered by Sukoharjo and Wonogiri

Regencies; The west is bordered by Surakarta City and Boyolali Regency.

Topographically, Karanganyar Regency is a land and mountains with a very varied

altitude. The height of the region up to 100 meters above sea level, covering the District of

Jaten and Kebakkramat (8.11%). The height of 101-500 meters above sea level covers

Jumantono, Karanganyar, Tasikmadu, Colomadu, Gondangrejo, Mojogedang and Kerjo

(45.32%), 501-1,000 meters above sea level, covering Jatiyoso, Jatipuro, Matesih,

Tawangmangu (partly), Ngargoyoso (partly), Karangpandan and some of Jenawi Subdistrict

(36.59%). And the altitude of 1,000 meters above sea level, covers part of the District of

Tawangmangu, Ngargoyoso and Jenawi (9.98%). While the total area is 773.8 km2 or 2.73%

of the total area of Central Java Province.

Based on data from the Population and Civil Registry Service (Disdukcapil), Karanganyar

Regency in 2017 has a population of 896,991 people. the largest population in Karanganyar

Subdistrict is 82,381 and the lowest population is in Jenawi Subdistrict District Health Profile

Karanganyar 2017 6 as many as 27,221 people.

7

Figure 1: Karanganyar Geography

8

2.2 Maternal and Infant Statistics

The maternal mortality rate is the number of mothers who die from pregnancy, childbirth

and childbirth in a particular area per 100,000 birth live within one year. Maternal mortality

rates can describe nutritional status and maternal health, environmental health conditions and

the level of health services, especially for pregnant women, mothers of childbirth and

postpartum mothers. According to Karanganyar Regency Health Profile (2017) the maternal

mortality rate in Karanganyar in 2017 was 72.6 / 100,000 birth live, down compared to 2016

of 30.79 / 100,000 birth live, while in 2015 amounted to 123.3 /100,000 birth live, in 2014

amounted to 138.5 /100,000 birth live, in 2013 amounted to 68.3 /100,000 birth live, and in

2012 amounted to 127.1 /100,000 birth live. The number of cases of maternal deaths in 2017

was 9 cases spread in the Jumantono, Tawangmangu, Karangpandan, Colomadu II,

Gondangrejo, Kebakkramat I and Jenawi health centers as many as 1 case of maternal death,

while in Karanganyar Health Center there were 2 cases of maternal deaths.

Infant Mortality Rate (IMR) is the number of infant deaths (0-11 months) per 1,000 birth

live in one year. AKB describes the level of public health problems related to the factors that

cause infant mortality, the level of antenatal care, the nutritional status of pregnant women,

the success rate of the MCH and family planning programs, and environmental conditions

and economic issues. The infant mortality rate in Karanganyar Regency in 2017 was 12.7 /

1,000 birth live, a decrease compared to 2016 of 14.2 /1,000 birth live, while in 2015 it was

12.8 /1,000 birth live, 2014 was 10.5 /1,000 birth live, while in 2013 it was 9, 9 /1,000 birth

live, and in 2012 amounted to 10.1 /1,000 birth live. In 2017 there were 134 cases of infant

mortality, the most in the Karanganyar health center, which were 17 cases and the lowest in

the Ngargoyoso community health center in 2 cases.

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2.3 Breastfeeding Policy

The Exclusive ASI Policy in Indonesia is regulated in Decree of the Minister of Health

No. 450 / MENKES / SK / IV / 2004 concerning Giving Breast Milk Exclusively to Infants in

Indonesia, PP No. 33 of 2012 concerning Exclusive Breastfeeding. In addition, the

government also supports it with Law No. 36 of 2009 concerning 29 Health Article 129

paragraph (2), PERMENKES No. 15 of 2013 concerning Procedures for Provision of

Breastfeeding Facilities and Minister of Women's Empowerment and Child Protection

Regulation No. 3 of 2010 concerning Application of Ten Steps to the Success of

Breastfeeding (Indonesia’s data and information center of Ministry of Health, 2017).

Article 35 of Government Regulation no. 33/2012 on Granting Exclusive Breastfeeding

obliges the workplace manager and the administrator of public facilities to introduce internal

regulations that support and aid successful breastfeeding programs. Such internal regulations

demonstrate enterprise support of breastfeeding and allow the enterprise to implement an

effective BFW policy through the following means: Establish decent workplace facilities for

working mothers to breastfeed/ breast-pump (nursing room), give working mothers the

opportunity to breastfeed/ express breast milk during working hours, ensure that the policy on

3 month maternity leave is more flexible. It will not always be necessary to have a 1.5 (one-

and-a half) month’s period of rest before giving birth and a 1.5 month’s period of rest after

giving birth, but it is advisable that the maternity leave is adjusted closer to the date of birth,

based on a reference letter from the doctor. This will allow a mother to have more time to

breastfeed after the birth and to prepare for her to return to work (Better Work Indonesia,

2013).

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2.4 Exclusive Breastfeeding

2.4.1 Definition

According to the World Health Organization (2009), exclusive breastfeeding means that

the infant receives only breast milk. No other liquids, such as tea or herbal preparations, or

food are given – not even water – with the exception of oral dehydration solution, or

vitamins, minerals, or medicines in liquid form. If this practice is not continued for at least

six months, it does not meet the definition of exclusive breastfeeding. The WHO

recommends six months of exclusive breastfeeding for all newborns (Kumala, 2017; WHO,

2009).

2.4.2 The types of infant feeding

Two types of infant feeding, exclusive breastfeeding and complementary feeding.

Exclusive breastfeeding as receiving only breast milk and no other liquids or solids except

drops syrups consisting of vitamins, minerals, or medicines and complementary feeding as

the term which used for giving other foods and drinks in addition to breastfeeding after the

completion of the 6 months exclusive breastfeeding period. Including of replacement feeding

(formula) and mix feeding (breast milk and replacement feeding). According to WHO, this

process covers the period of growth during which infants are at high risk of nutrient

deficiencies and illnesses (Bai et al., 2009; Thurman & Allen, 2008; WHO, 2009).

2.4.3 Benefits of Breastfeeding

Breastfeeding has an extraordinary range of benefits. It has profound impact on a child’s

survival, health, nutrition and development. Breast milk provides all of the nutrients, vitamins

and minerals for infant needs for growth for the first six months, and no other liquids or food

are needed. Breastfeeding for the first six months decreases the infant’s risk of immune-

related diseases in the future. One reason is that breast milk carries antibodies from the

mother that help combat disease (Hirani, Karmaliani, Christie, Parpio & Rafique, 2013).

11

Breastfeeding also encourages mothers to pay closer attention to their infants’ mental and

physical health (Alves, Dowling, & Mahan, 2017).

Babies who get breast milk should develop good vision because breast milk contains

omega 3 fatty acids. Breastfeeding can also help babies learn to speak more quickly because

when breastfeeding the baby makes strong sucking movements that strengthen the cheek

muscles. In addition to being beneficial for babies, exclusive breastfeeding is also beneficial

for the mother. Breastfeeding the baby immediately after birth not only produces the

hormones that stimulate milk secretion, it can stimulate contractions of the muscles of the

uterus and prevent postpartum bleeding. In this way, it may also prevent iron deficiency

anemia and blood deficiency. Exclusive breastfeeding will also reduce maternal weight, as

the number of calories burned may be 200 to 500 calories (Roesli, 2009).

2.4.4 Factors Related to Exclusive Breastfeeding

A characteristic of personal factors, including demographic such as maternal age, marital

status, mother’s education, monthly family income, parity, mode of delivery, breastfeeding

experience and attitude so does breastfeeding-friendly workplace factors and social support

factors have been associated with exclusive breastfeeding.

2.4.4.1 Personal factors

More mature age will increase maturity in attitude and action (Arisdiani & Livana, 2016).

Mother who was young at first becoming a mother is also less to start breastfeeding

(Griffiths, Tate & Dezateux, 2005). Based on Silva et al. (2018) in their findings, maternal

age was statistically associated (p < .003) with exclusive breastfeeding, it is very likely that

older mothers have accumulated a more substantial prior experience, either because of

previous pregnancies or because of their receptiveness to the formal contacts with health

services where they were assisted during prenatal care, delivery and puerperium. As for

adolescents or young mothers, almost always with low or no parity, they face the demands of

12

pregnancy with greater insecurity, including the willingness to breastfeed. Dewi (2016) also

found that respondents aged between 18-35 years were more likely to breastfeed than

respondents who were <18 years old and the results of statistical tests proved there was an

influence between maternal age and breastfeeding status.

Previous studies have shown that marital status affects breastfeeding and showed that

married mothers are more likely to practice exclusive breastfeeding compared to unmarried

or widowed mothers (Jones, Kogan, Singh, Dee & Gummer-Strawn, 2011). This might be

related to greater family support for exclusive breastfeeding practices among married

mothers. For example, family members may help a new mother perform other household

tasks allowing her more time and energy for breastfeeding (Dhakal, Lee, & Nam, 2017).

According to Ferreira, Oliveira, Bernando, Almeida, Aquino, & Pinheiro (2018), women who

are not married but have significant others also are more likely to practice breastfeeding

exclusively than those without a life partner, suggesting that the key factor in studies linking

marital status and breastfeeding is social support. Because Ferreira included “significant

other” as a category, marital status did not show a significant statistical association with

exclusive breastfeeding (p=.90). Hunegnaw, Gezie and Teferra (2017) likewise found no

statistically significant relationship between exclusive breastfeeding and marital status

(p=.20).

Mothers’ education has been found to be related to exclusive breastfeeding. Ambarwati

and Wulandari (2010) found that, in Indonesia, a mother’s level of knowledge and education

has a positive effect on the frequency and pattern of breastfeeding. Another study conducted

in Indonesia likewise found that higher education was positively associated with exclusive

breastfeeding (Ratnasari, Paramashanti, Hadi, Yusistyowati, & Nurhayati, 2017). To explain

this finding, Ratnasari et al. proposed that highly educated people respond more rationally to

information they receive and use reason to weigh the benefits they might get from an idea.

13

For some mothers, Ratnasari et al. observed, breastfeeding is a natural and instinctive action.

Therefore, they assume that breastfeeding does not need to be studied. However, most

mothers in the study were less aware of the importance of breast milk as the baby's main

food. They only knew that breast milk was food that babies need, without being aware of the

specific benefits it confers (Ratnasari et al., 2017). But results of different studies may vary

regarding the effect of education on breastfeeding. For example, Hunegnaw et al. (2017)

found that mothers’ education had no statistically significant association with exclusive

breastfeeding. An Indonesian study by Kumala (2017) also found no significant relationship

between mother’s education and exclusive breastfeeding, with a p value of .202.

Family income is income from all family members living in one home that is used for

family shopping (Wendirati, Subagio, & Wijayanti, 2017). Some studies group family

income into two categories, high and low income (Wendirati et al., 2017).

A study conducted on 10,519 mothers in the US revealed that women with a higher

family income were more likely to exclusively breastfeed their infants than their lower

income counterparts (US Department of Health and Human Services, 2011). This might be

explained by an association between higher education and higher income, with higher income

mothers more aware of the benefits of breastfeeding. Conversely, studies from Saudi Arabia,

Peru and the Philippines all found that higher family income was associated with a reduced

initiation and duration of breastfeeding (UNICEF, 2011). This finding might be explained by

the fact that formula feeding is associated with higher status or higher income in some

countries. Many studies have shown that parity has an effect on the health of mothers and

children and directly affects breastfeeding (Mursyida & Wadud, 2013). A study conducted to

Ferreira et al. (2018) found that mothers who had experienced pregnancy and childbirth

before were more open to breastfeeding compared to mothers who had not. In a study by

Kaneko et al., 2006), the prevalence of exclusive breastfeeding increased with the number of

14

children a mother had. Mothers were more likely to breastfeed exclusively if they had three

or more children. They were more likely to use exclusive breastfeeding for the third child

compared to the second and first, so there was a significant relationship between parity and

exclusive breastfeeding. The study conducted by Kitano et al. (2016) also found that parity

was significantly associated with exclusive breastfeeding initiation.

A study by Fischer and colleagues (2013) found that both mode of conception and mode

of delivery affected the likelihood that a mother would breastfeed her baby exclusively.

Despite having a clear intention to do so, women who became pregnant through assisted

reproductive technologies such as IVF and those who had cesarean sections were more likely

to introduce infant formula before discharge from hospital. They were also more likely to

stop breastfeeding in the first four months after birth (Fisher et al., 2013). A study by

DiFrisco and colleagues found similar results, explaining that one of the consequences of

caesarean section is separating the mother and baby after delivery. This may disrupt the

relationship between them, as the first contact between mother and baby is not optimal, so the

mother is less likely to breastfeed the baby exclusively (DiFrisco et al., 2011).

Atindanbila, Mwini, Abasimi, Benneh & Avane (2014) likewise found that the mode of

birth impacted breastfeeding. Participants who had caesarian sections reported having

initiated breastfeeding a day after delivery, because nurses scheduled feeding times for babies

of mothers who had undergone caesarean section. By contrast, mothers who had spontaneous

vaginal deliveries initiated breastfeeding hours after delivery. DiFrisco and colleagues (2011)

found that mothers who breastfed within the first hour of birth were significantly more likely

to be exclusively breastfeeding at two-to-four weeks after discharge, than mothers who did

not breastfeed within the first hour of birth (DiFrisco et al., 2011).These results are similar

those of a study conducted in Western Australia which found that mothers who had a vaginal

delivery were almost twice as likely to breastfeed exclusively at hospital discharge compared

15

to mothers who had caesarean deliveries. This could be because the mothers who had

caesarean section deliveries were less comfortable and felt fatigue after the caesarean

procedure (Weber, Janson, Nolan, Wen, & Rissel (2011).

Mothers who have experienced lactation before tend to be better at breastfeeding than

mothers who have not, according to a study done in Indonesia. This prior experience made it

easier for such mothers to breastfeed exclusively (Purwanti, 2004). Similarly, Roig et al.

(2010) observed that not having breastfed a child previously was the variable with the highest

independent risk factor for abandoning exclusive breastfeeding within four months or less.

Mothers who successfully breastfed a previous child were more likely to succeed at

breastfeeding a second one.

Attitude is a reaction or response that is still closed from someone to stimulus or object,

attitude is not yet an action or activity, but it is a predisposition of an act of behavior

(Notoadmodjo 2012). According to Eagly and Chaiken (1993) in Leone (1995) review,

attitudes can be positioned as a result of evaluations of attitude objects, which are expressed

in cognitive, affective, and behavioral processes. So that the outline of the attitude consists of

cognitive components (ideas that are generally related to conversation and learning), behavior

(tends to affect the appropriate and inappropriate responses), and emotions (causing

consistent responses) (Wawan & Dewi, 2010). Attitudes towards and practices of exclusive

breastfeeding may differ among individuals, ethnic groups, countries, and even across

continents (Atindanbila et al., 2014).). In a study on attitudes and practices associated with

exclusive breastfeeding, Atindabila et al. (2014) found that most participants had a negative

attitude toward breastfeeding and did not practice exclusive breastfeeding effectively. These

findings were similar to a study conducted in Indonesia by Pertamasari et al. (2018) which

found that negative attitudes towards breastfeeding were significantly associated with weaker

or no intention to breastfeed exclusively.

16

2.4.4.2 Workplace friendly factors

Many studies have found that returning to work after childbirth affects breastfeeding.

Mothers who work full time generally worry about their babies and children at home. As

breastfeeding is the optimal nutrition for newborns and infants; with sufficient support in the

workplace, such as breastfeeding rooms and provision of childcare services on site, mothers

can both work and breastfeed their children at the same time (Ufamily, 2013). However, few

employers provide such facilities. A study conducted by Elyas, Mekasha, Admasie & Assefa

(2017) found that employed mothers had less opportunity to stay at home, compromising

their ability to breastfeed exclusively. Working mothers may have to leave their babies. Elyas

et al. (2017) found that only 43% of employed mothers breastfed their child for six months,

whereas mothers who were not working outside the home were 13% more likely to breastfeed

than working mothers. In addition, type of work and working hours also affect women’s

success at breastfeeding, in particular, length of the work day (Novayelinda, 2012).

Breastfeeding-friendly workplace policies can greatly influence women’s success at

exclusively breastfeeding their infants (Novayelinda, 2012). For example, some employers

provide a lactation room for pumping breast milk, equipment to store breast milk, and

babysitting services.

A recent study in Taiwan by Tsai (2013) supports the importance of a breastfeeding-

friendly workplace, finding that such policies figured into a complicated decision-making

process among employed mothers regarding whether and when to return to work. Women

employed in a labor-intensive work environment by a large electronics company who had

recently taken maternity leave completed questionnaires about their perceptions of

breastfeeding support at their workplace. They reported that they had access to a lactation

room and support for breastfeeding when raising their most recently born child. However, the

policies’ effectiveness was undermined by other aspects of the work environment including

17

pressure on the job; even though 85% of the mothers had access to a dedicated lactation

room, a substantial majority (63.8%) did not use pumping breaks, and more than half did not

continue to breastfeed after returning to work (Tsai, 2013).

Arranging physical facilities for breastfeeding in the workplace is one of the most

powerful interventions to promote breastfeeding among working mothers according to a

literature review by Hirani, Karmaliani, Christie, Parpio and Rafique (2013) that used only

studies with peer reviewed databases. Corroborating these findings, Yimyam and Hanpa

(2014) found that implementing a workplace breastfeeding support program significantly

raised the rate of exclusive breastfeeding and any breastfeeding at six months. The key to

success at exclusive breastfeeding for working mothers lies in the methods of expressing and

storing breast milk (breastfeeding management), according to a study on obstacles to

breastfeeding among working women (Better Work Indonesia, 2013). They found that the

difficulty of pumping and the risk of breast milk spoiling are the most common reasons why

working mothers stop breastfeeding. Therefore, it is important that workplaces have a

suitable nursing room and allow enough time for working mothers to express their breast

milk for the sake of children’s health (Better Work Indonesia, 2013). These studies

recommend that a breastfeeding room should offer privacy, accommodate breast pumps

(sufficient electrical outlets), and refrigerated storage facilities for breast milk, as well as

childcare facilities on site (Better Work Indonesia, 2013; Hirani et al., 2013).

2.4.4.3 Social support factors

Nursalam (2009) states that individuals included in providing social support include

spouses, parents, children, relatives, friends, health teams or counselors. According to

Ratnasari et al. (2017), support from the family will improve exclusive breastfeeding

compliance if health workers explain to the family the benefits of breast milk for babies after

returning to work, so that they will encourage the woman. Families can help out by providing

18

childcare, buying or making food, and also feeding the child expressed breast milk. Ratnasari

and colleagues concluded that adequate family support was significantly associated with

practicing exclusive breastfeeding. This finding is consistent with results from other studies

that also found family support can increase the rate of exclusive breastfeeding (Permatasari et

al., 2018; Sari, Yosi, & Nella, 2015).

A study conducted by Palupi and Devi (2016) in Indonesia showed that social support

tended to be positive but low. Low support led the mothers to give up on breastfeeding when

they encountered obstacles that were relatively hard for them to overcome, even though the

situations would have been surmountable if the mothers had received adequate information

and been highly motivated to breastfeed.

2.5 Conclusion and Conceptual Framework

Exclusive breastfeeding is influenced by a range of factors, including personal factors

such as demographic characteristics, social support, and workplace breastfeeding policies.

However, information about exclusive breastfeeding among employed mothers has received

limited attention so far. Of all these factors, having a breastfeeding friendly workplace is one

of the most impactful. Hence, understanding the factors related to exclusive breastfeeding

may help employed mothers continue to breastfeed their children after returning to work.

19

Figure 2.2 Conceptual framework

Personal factors:

1. Age

2. Marital Status

3. Mothers Education

4. Monthly Family Income

5. Parities

6. Attitude

7. Mode of Delivery

8. Breastfeeding Experience

Social support factors:

1. Family support

2. Friends

3. Significant others

Workplace friendly factors:

1. Workplace organization

support

2. Manager support

3. Co-worker support

4. Time support

5. Physical Environment

Support

6-month Exclusive

Breastfeeding types

1. Exclusive

breastfeeding

2. Not Exclusive

breastfeeding

20

Chapter Three

Methodology

This study was carried out among employed mothers in Karanganyar Regency who have

returned to work after having a child. A descriptive correlational design was used to identify

factors that influence exclusive breastfeeding. These included personal factors such as age,

marital status, mother’s education, monthly family income, parity, mode of delivery,

breastfeeding experience and attitude. The study also explored breastfeeding-friendly

workplace factors, such as workplace organization support, manager support, co-workers’

support, time provided for breastfeeding, and the physical environment for breastfeeding at

work. The study also investigated social support factors related to exclusive breastfeeding,

which included support from family, friends, and significant others. The instruments

(Appendix 1) used to explore our research questions were a demographic questionnaire for

the personal factors, the lowa Infant Feeding Attitude Scale (IIFAS), the Breastfeeding and

Employment Study (BESt) for assessing workplace-related factors, and the Multidimensional

Scale of Perceived Social Support (MSPSS).

3.1 Research Design

A descriptive correlational design was used among the employed mothers who were

willing to take part in this study. A convenience sampling was made to choose research

subjects and to ensure that they agreed to participate in the study by signing a consent inform

(Appendix 2).

3.2 Research Setting

Karanganyar Regency, one of the cities in Central Java, is a land and mountains with a

very varied altitude. The height of the region up to 100 meters above sea level, covering the

District of Jaten and Kebakkramat (8.11%). The height of 101-500 meters above sea level

covers Jumantono, Karanganyar, Tasikmadu, Colomadu, Gondangrejo, Mojogedang and

21

Kerjo (45,32%), 501-1,000 meters above sea level, covering Jatiyoso, Jatipuro, Matesih,

Tawangmangu (partly), Ngargoyoso (partly), Karangpandan and some of Jenawi Subdistrict

(36.59%). And the altitude of 1000 meters above sea level, covers part of the District of

Tawangmangu, Ngargoyoso and Jenawi (9.98%). While the total area is 773.8 km2 or 2.73%

of the total area of Central Java Province.

This study was carried out on Primary Health Center in Karanganyar. Based on data from

the Population and Civil Registry Service (Disdukcapil), Karanganyar Regency in 2017 has

21 Primary Health Cares they are primary health care of Jatipuro, Jatiyoso, Jumapolo,

Jumantono, Matesih, Tawangmangu, Ngargoyoso, Karangpandan, Karanganyar, Tasikmadu,

Jaten I, Jaten II, Colomadu I, Colomadu II, Gondangrejo, Kebakkramat I, Kebakkramat II,

Mojogedang I, Mojogedang II, Kerjo and Jenawi.

3.3 The Inclusion Criteria and Exclusion Criteria

3.3.1 Inclusion Criteria

The target population for the study was comprised all an employed mothers after

returning to work and who met the following criteria : Mothers whose infants aged 6-12

months (even though WHO recommendation for breastfeeding is up to 2 years, the researcher

only limited the sample aged only 6-12 months due to memory recall issues), mothers who:

work outside home, gave birth by vaginal or cesarean section delivery, were 18 years and

older, were able to read and write Indonesia language, agreed to participate in the study.

3.3.2 Exclusion Criteria

Infants who were adopted, severely ill (hospitalized in intensive care units), infants who

had medical indications to receive breast milk substitutes mothers.

3.4 Sample Size

22

The sample size was determined based on the calculation validated by G-Power software

version 3.1.2 (Faul, Erdfelder, Buchner, & Lang, 2009). Based on logistic regression where

Power = .8, alpha (α) = .05, assuming the probability of a mother giving breastfeeding is

50% and the mother with better workplace one more likely to have higher probability

assuming 60 % so the calculation of the odd ratio is with 1.5 thus suggesting a sample size of

208 subjects (Figure 3). Sample was collected from 21 primary health cares. Each primary

health care was drawn 13 or more respondents and data was collected in 4 months (July -

November 2019).

23

3.5 Instruments

Three instruments were used in this study including demographic data sheet. In order to

collect the data related factors which associated with exclusive breastfeeding among

employed mothers were used three kind instruments, they are Iowa Infant Feeding Attitude

Scale (IIFAS) for the Attitude, breastfeeding and employment study (BESt) for the workplace

friendly factors and the multidimensional scale of perceived social support (MSPSS) for

social support factors. Permission to use these questionnaires was obtained via email contact

with the authors, who provide a copy of the questionnaire to the researcher (Appendix 3, 4

and 5).

3.5.1 Exclusive Breastfeeding

Exclusive breastfeeding refers to infants receiving only breast milk during the first six

months of life, and not food or even water, including other liquids like tea and herbal

preparations, except for doctor-recommended vitamins, mineral supplements, or medicines

(WHO, 2009).

The dependent variable of this study is Exclusive breastfeeding and a measurement was

used of Exclusive breastfeeding in this study is the types of infant feeding practice, which

included exclusive breastfeeding, mix breastfeeding and formula feeding, for the exclusive

breastfeeding was coded as “1”, mix breastfeeding and formula feeding were coded as “0”.

3.5.2 Demographic Information

The researcher created the demographic information for this study using factors from

previous studies found to be associated with exclusive breastfeeding. The demographic

information including 8 items, including maternal age, marital status, education level, parity,

family monthly income, modeof birth, breastfeeding experience, and attitude toward to

breastfeeding. Marital status was categorized into single which was coded “0” and married

which was coded as “1”. Mother education was categorized into juniro high school which

24

was coded ‘0” and senior high school or above was coded “1”. Parity was categorized into

primigravida which will was coded “0” and multigravida was coded as “1”. Monthly family

income, the District or City Minimum Wage of Karanganyar Regency is 1.833.000 IDR

based on Central Java Governor Decree No. 560/68/2018 so for monthly family income was

divided into low income (< 1,833,000 IDR) which was coded ‘0” and high income

(≧1,833,000 IDR) was coded as “1”. Mode of delivery was categorized into vaginal delivery

which was coded “0”, caesarean section was coded as “1”. Breastfeeding experience was

categorized into experienced which was coded “0” and not experienced which was coded as

“1”. Attitude which used The IIFAS (Iowa Infant Feeding Attitude Scale, the IIFAS appears

to be very reliable, with Cronbach's alpha ranging from .85 to .86 (De la Mora et al., 1999).

The IIFAS consist of 17 attitude questions, half of which are favorable to breastfeeding and

the remaining favorable to artificial feeding. Higher IIFAS score means more positive

attitude toward to breastfeeding. Items of favorable to artificial feeding were reverse

computing the score.

3.5.3 Breastfeeding and employment study (BESt)

It was used to collect data (Greeneet al., 2008). BESt contains 41 items that require either

categorical yes/no or Likert scale responses, the categorical yes has score 1 and no has score

0 and the Likert scale has 4 score for strongly agree, 3 for agree, 2 for disagree and 1 for

strongly disagree. The survey items are grouped together to evaluate five aspects of the work

climate : organization support (11 items), manager support ( 12 items), co-worker support

(six items), time support (three items) and physical environment support (nine items) and this

instrument has 5 items negative and it will be reverse in computer for scoring the result.

Internal consistency reliability coefficients of the BESt were high (.87 and .89) and the

correlation between the subscales was moderately strong (r =.68) in the pilot study (n=104)

(Greene et al., 2008). The item of organization support, the highest score is 44 (low support:

25

1- 14, moderate: 15 - 28 and high support: 29 - 44). The Management support is 48 (low

support: 1 - 16, moderate: 17 - 32 and high support: 33 - 48). Co-worker support is 24 (low

support: 1 - 8, moderate: 9 - 18 and high support: 19 - 24). Time is 12 (low support: 1 - 4,

moderate: 5 - 8 and high support: 9 - 12). Physical environment is 24 (low support: 1 - 8,

moderate: 9 - 16 and high support: 17 - 24).

3.5.4 Multidimensional scale of perceived social support (MSPSS)

This study measured social support using the MSPSS. The MSPSS was developed by

Zimet et al. in 1988. The MSPSS is a 12-item instrument. It measures social support on three

subscales: (1) the Significant Other Subscale (items 1, 2, 5, & 10); (2) the Family Subscale

(items 3, 4, 8, & 11), and (3) the Friends Subscale (items 6, 7, 9, & 12). For the Significant

Other, Family, and Friends subscales, the alpha values were .91, .87, and .85, respectively.

Reliability of the overall scale was .88 (Zimet et al., 1988). Each item is rated according to a

seven-point Likert-type response format, with 1 indicating very strongly disagree and 7

indicating very strongly agree. An overall any mean scale score ranging from 1 to 2.9 could

be considered low support; a score of 3 to 5 could be considered moderate support; a score

from 5.1 to 7 could be considered high support.

3.6 Translation and Pilot Study

This study was carried out among employed mothers in Indonesia especially in

Karanganyar Regency. Validation of cross-cultural research instruments is very important

because of the variety of the global population (Sousa & Rojjanasrirat, 2011).

To ensure the quality of the instrument, the researcher arranged for the translation and the

results was examined with a forward and backward translation. The questionnaire of this

study was translated by three translators (Appendix 6, 7 and 8) with the following steps.

26

3.6.1 Translating from the source to the target language

The first translator translated the original English version into the target language,

Indonesian.

3.6.2 Blindly translating back from the target to the source

Re-translation is translating from the newly translated version back to the original source

language (Brislin, 1970). The second translator re-translated the instrument from the first

translator’s new Indonesian version back into English.

3.6.3 Comparing the two versions in the original language

It is possible to evaluate the equivalence of the instrument in its original language and the

target language version of the instrument (Brislin, 1970). The results of the two previous

translations were examined by an English language medical editor with 18 years of

experience editing medical journal articles.

The researcher and the two translators together evaluated the original text of the

instrument and the two translations, one in Indonesian and the back-translation into English.

After reaching agreement, the researcher then had a discussion with an expert, the English

language medical editor mentioned above. There were several points of difference between

the translated English version and the original one.

On item no 2, “I will be able to get information about combining work and

breastfeeding,” thetranslated version was, “I will get information about the regulation at work

while breastfeeding.” The Indonesian version used the word “regulation” while the original

question did not. “Regulation” in Bahasa is peraturan, while the original version only

mentioned “information,” informasi in Bahasa. So the researcher and the medical editor

agreed to delete the terms “regulation” and “peraturan” in the English and Indonesian

translations. The new Indonesian version says roughlyi, “I will get information about

breastfeeding at work.”

27

On item no 6, the original version “My job sould be at risk”,the back-translated version

was, “becomes risky,” while the original version used “at risk.” The editor pointed out that

the phrase “becomes risky” sounds like the job becomes physically dangerous. Indonesian,

“becomes risky,” beresiko, has a meaning similar to the meaning of the original version,

while the original term, “my job is at risk” means “I could lose the job.” So the researcher

and the medical editor agreed to substitute the term “at risk” for “becomes risky.”

On item no 8, the original version “I would feel comfortable asking for accommodations

to help me breastfeed” uses the term “accommodations” which mean a place or facility, while

the back-translated version did not mention it. In Indonesian, the translator only used

membantu, which means “helping.The back-tranlsated English was, “I feel comfortable

asking the company to help me breastefeed or pump breastmilk at the workplace.” “in

Indonesian, in the phrase is “menyediakan sesuatu untuk memenuhi kebutuhan,” means

approximately, “to provide something to fulfill a need.” In the back-tranlsated English

version, it sounds as if the company might literally help by squeezing a breast. So the

researcher and the editor agreed to put the term “menyediakan sarana” into the Indonesian

version.

In item no 13, “My manager would help me combine breastfeeding and work” the

original item used the term, “combine,” while the back-translated version did not. The

original phrase, “the manager will help me combine breastfeeding and work,” which means

that the manager will help arrange the work schedule and workload, while the Indonesian

version did use the term “combine.” In Bahasa combine means “menggabungkan beberapa

hal”. So researcher and the editor agreed to put term “combine” into the sentence.

In item no 18, the original version “my manager would consider it part of his/her job to

help me combine breastfeeding and work” while the back-traslated mention “my manager

will assume that one of his/her duties is helping me to breastfeed while working”,.the back-

28

translated version mentioned “helping to breastfeed while working” while the original

version said “ helping combine breastfeeding and work”. The term of “while working” is

slightly different than “at work”. In Indonesian, “while working” means “selama bekerja”

and “at work” means “saat bekerja”. The editor pointed out that the back translated version

suggested the respondent would be simultaneously breastfeeding while working. So the

researcher and the editor agreed to make sure the Indonesian version carried the idea of

“enabling the employee to breastfeed while at work”.

Item no 19, the original version mentioned “my manager would think less of workers who

choose to breastfeed or pump breast milk at work”, while the back-translated version

mentioned “manager will think that a few employees”, meaning “a small number of the

employees” while the original version used the phrase “the manager will think less of

workers.” The meaning differed from the original. To think less of someone—the original

text—means to look down on that person, to respect them less than before. So the researcher

and the editor decided to put Indonesian term “meremehkan”. The new Indonesian version

says roughly “think less/ to look down on that person”.

Item no 20, the translated version mentioned “will assure my work is handled”, which

seems to say that the manager will be confident that the worker is handling it. While the

original version mentioned “the job will covered,” which means that the manager will assign

another employee to cover the responsibilities while the respondent is breastfeeding or

pumping breast milk. So the researcher and the medical editor decided to put “digantikan

sementara” meaning roughly “the job will covered”.

Item no 28, the translated version included the word “replace” which in Indonesian is

“menggantikan”. While in original version used the word “covered” which in Indonesian is

“ditutupi/ digantikan”. The back-translated term “replace” sounds like the respondent is

permanently losing the job. The English word “cover” means to temporarily fill in for

29

someone else. So researcher and the medical editor decided to put sentence “digantikan”

meaning roughly, “to temporarily play someone’s role.”

The Iowa Infant Feeding Attitude Scale. Item no 6, the original version mentioned

“Breasfed babies are more likely to be overfed than formula-fed babies”, while in the back-

translated instrument,”A breastfed baby will have greater appetite than baby with milk

formula” using the phrase, “have greater appetite,” while the original version used the phrase

“to be overfed”. Those two meanings differ. “Have greater appetite” means

“to desire more food,” while “overfed” means to ingest too many calories. So the researcher

and the medical editor decided not to put “have greater appetite” but put the term “resiko

kegemukan”, meaning approximately, “to be overfed”.

A pilot study was carried out with five participants to check whether the questionnaire

would be easy for participants to follow.

3.7 Data Collection

Sample of this study were employed mothers. Researcher got the data of employed

mothers from the midwife in primary health care. The researcher made a permission letter

which forwarded to the Health Department of Karanganyar Regency. After receiving the

permission, the researcher handed the permission letter (Appendix 9) from Health

Department to Primary Health Care at Karanganyar Regency. Researcher have two persons

who helped her to collect the data, they had been trained by following the researcher how to

collect it. Then the respondents were approached door to door in their homes.

In Primary Health Care, the researcher got the data about the participant then screening

the participant to see if they meet inclusion criteria. Researcher explained the purpose of the

study to the participants. Those participants were signed the consent form and were given a

self-administered questionnaire. Once the participant was through answering the

questionnaire, the researcher went over the data collection forms to ensure their

30

completeness. Then the questionnaire was collected by the researcher (Figure 3.2). The

instrument was used in this study included the Exclusive breastfeeding mode at six months,

the breastfeeding and employment sudy (BESt), the Multidimensional Scale ofPerceived

Support (MSPSS) and the demographic information.

31

Figure 3.2 Data Collection

Recruitment

Inclusion Criteria Met

Respondent Given Information

about the study

Consent obtained and signed

Questionnaire

Started

Cross check for errors / Missing

information

Questionnaire completed

Respondent thanked

Respondent not

consented

Data collection is stopped

32

3.8 Data analysis

Each participant was provided with a unique code. Data was entered into Microsoft excel

and then was analyzed using SPSS 22.0 software. Descriptive statistics including frequency

and percentage were used for the discontinuous variables. Mean and standard deviation were

used for continuous variables. The t-test was applied to compare the mean differences

between feeding types and workplace friendly, personal factors (age, monthly family income)

and social factors. Chi-Square was applied to determine the relationship between feeding

types and personal factors (education, marital status, parity, attitude, mode of delivery and

breastfeeding experience). Furthermore, the significant variables were entered into binary

logistic regression analysis to identify the predictors of dependent variables.

33

No Research Question Variable Variable Type

Analysis

Strategy

1

What is the

relationship between

exclusive

breastfeeding rates

among employed

mothers returning to

work and

breastfeeding-friendly

practice ?

DV : Types of

breastfeeding

practices

IV: Breastfeeding-

friendly workplace

practice

DV : Categorical

IV: Continuous

t-test

2

What are the

relationships between

personal factors

including

demographic,

obstetrical, attitudes

and exclusive

breastfeeding among

employed mothers

after returning to

work ?

DV : Types of

Breastfeeding

practices

IV : Personal Factor :

(1) Education,

Marital Status, Parity,

Mode of Delivery,

Monthly Family

Income and

Breastfeeding

Experience

(2) Age and Attitude

DV: Categorical

IV :

(1) Categorical

(2) Continuous

1. Chi-

Square

2. t-test

3

What is the

relationship between

social support and

DV : Types of

Breastfeeding

DV : Categorical

t-test

34

No Research Question Variable Variable Type

Analysis

Strategy

exclusive

breastfeeding among

employed mothers

returning to work ?

practices

IV : Social Support

IV : Continuous

4

Which factors-personal

(demographic,

obstetric and attitude),

workplace and social

support- are the most

important for

predicting exclusive

breastfeeding among

employed mothers

returning to work ?

DV : Types of

Breastfeeding

practices

IV : Personal factors,

breastfeeding

workplace-friendly

and social support

DV : Categorical

IV : Continuous

or categorical

Binary

Logistic

Regression

Table. 1: Table of Data Analysis

35

3.9 Ethical Consideration

The study was granted permission prior to its commencement during summer vacation.

Researcher was applied and obtained the permission to conduct this study from Institutional

Review Board (IRB) in Indonesia (Appendix 10). A letter of request was sent to Department

of Health in Karanganyar then was forwarded to the Primary Health Care. Participant who

agreed to fill in the questionnaire were informed about the importance of the study and its

main purpose. Those participants in this study were given the inform consent. For protecting

the data subjects, researcher provided guarantees in the use of research subjects by not giving

or including the name of the respondent on the measuring sheet and only writing the code for

the data collection sheet or the results of the research to be presented. All information that

were collected is guaranteed confidentiality by researcher; only certain data groups was

reported on the results of research.

36

Chapter Four

Results

In this chapter, the results from this research on factors associated with six months of

exclusive breastfeeding among employed mothers after returning to work are discussed under

the following headings: characteristics of demographic variables, workplace breastfeeding

friendly and social support.

4.1 Characteristics of Research Subjects

This study was conducted in August 2019 in Karanganyar, one of the cities in Central

Java. The researcher went door-to-door to talk with working women with children ages 6 to

12 months, as shown in Table 4.1. A total of 208 subjects completed the questionnaires.

The ages of the subjects participating in this study ranged from 18 to 40 years with

mean age of 28.80 (SD 5.46). All of the respondents in this study (100 %, n=208) were

married. The mean age of their babies was 8.95 months (SD 1.89).

The women’s level of education is expressed as a binary category: elementary school

and junior high school on the one hand, and senior high school, diploma (one to three years

of college), or bachelor (completed four years) on the other hand. Less than half of the study

participants (39%, n=39) had completed junior high school, while the majority of them 81%

(n=169) were categorized as senior high school/diploma/bachelor.

More than two-thirds of the respondents 60% (n=125) had monthly family income

≥1,833,000 IDR. For the parity, 39% (n=81) were primigravidas. About 65% (n = 130) of the

respondents had experienced vaginal delivery. Most of the study participants (61%, n=127)

had experience breastfeeding.

37

Table 4.1 Demographic characteristics of the study participants (N=208)

Variables n % Mean SD

Age (yrs) 28.80 5.46

Age of Baby (months) 8.95 1.89

Marital Status

Married 208 100

Education

Junior High School 39 19

Senior High School/Above 169 81

Monthly Family Income (IND)

< 1.833.000 83 40

≥ 1.833.000 125 60

Parity

Primigravida 81 39

Multigravida 127 61

Mode of Delivery

Vaginal delivery 130 63

Cesarean Section 75 36

Forceps/Vacuum 3 1

Previous Breastfeeding experience

No

Yes

6 Months of Exclusive Breastfeeding

Not breastfeeding exclusively

Exclusive breastfeeding

81

127

55

153

39

61

26

74

4.2 Descriptive statistics of the outcomes variables

Descriptive statistics for this study consist of the total scores on three instruments: the

Breastfeeding and Employment Study (BESt) (which includes organization support, manager

support, co-worker support, time support and physical environment support); the

38

Multideminsional Subscales of Perceived Social Support (MSPSS) (which includes family,

friends, and significant others); and scores on the Iowa Infant Feeding Attitude Scale

(IIFAS).

4.2.1 Breastfeeding and Employment Study (BESt)

The categories of the breastfeeding and employment survey included organization

support, manager support, co-worker support, time support, and physical environment

support. The organization support consisted of 11 items, which were all continuous variables.

According to Table 4.2.1, the item with the highest mean score was “limited opportunities for

job advancement” with a score 3.01 (SD = 0.81) and the item with the lowest mean score was

“written policies for employees that are breastfeeding” with a score 2.14 (SD = 0.79).

Manager support consisted of 12 items and the item with the highest mean score was

“support for breastfeeding or pumping at work,” with a score of 2.78 (SD = 0.70) and the

item with the lowest mean score was “Suitable schedule to allow the employee to breastfeed

or pump breast milk,” with a score of 2.30 (SD = 0.62). Co-worker support consisted of six

items. The item with the highest mean score was “thought of supporting breastfeeding” with

a score of 2.93 (SD = 0.65) and the item with the lowest mean score was “covered others’ job

duties to allow mothers to breastfeed or pump,” with a score of 2.53 (SD = 0.70). Time

support, meaning adequate time for breastfeeding or pumping milk, consisted of three items.

The item with the highest mean score was “Frequent enough breastfeeding or pumping breast

milk (at work),” with a score of 2.86 (SD = 0.80) and the item with the lowest mean score

was “time (at work) long enough for breastfeeding or pumping breast milk,” with a score of

2.63 (SD = 0.80). For physical environment support, which means having sufficient facilities,

space, tools and privacy, consisted of nine items. The item with the highest mean score was

“a designated place was available for breastfeeding or pumping when needed,” with a score

39

of 2.42 (SD = 1.08) and the item with the lowest mean score was “provided equipment for

pumping breastmilk at work,” with a score of 0.21 (SD = 0.40).

Table 4.2.1 Descriptive Statistics from the Breastfeeding and Employment Study

Items Mean ± SD

Organization Support

Enough maternity leave (paid and/or unpaid time off) 2.93 ± 0.67

Information about combining work and breastfeeding 2.72 ± 0.74

Written policies for employees that are breastfeeding* 2.14 ± 0.79

Place for breastfeeding or pumping 2.87 ± 0.81

Someone who would help make arrangements for

breastfeeding or pumping breast milk

2.42 ± 0.91

Job could be at risk if breastfed or pumped (losing job) * 2.90 ± 0.80

Able to talk about breastfeeding at work 2.85 ± 0.75

Accommodations to help breastfeed or pump 2.60 ± 0.73

Limited opportunities for job advancement* 3.01 ± 0.81

Breastfeeding experience of women in higher level positions 2.92 ± 0.70

Co-workers’ experience of breastfeeding/pumping at work 2.88 ± 0.70

Total of organization support 30.13 ± 4.10

Manager Support

Supports breastfeeding or pumping at work 2.78 ± 0.70

Supports combining breastfeeding and work 2.50 ± 0.77

Thinks it disturbs work if worker takes breaks for

breastfeeding*

2.55 ± 0.87

Feels comfortable talking about breastfeeding 2.48 ± 0.80

Considered supporting breastfeeding 2.50 ± 0.76

Manager views breastfeeding as an employee’s personal choice 2.75 ± 0.85

Considers that combining breastfeeding and work is part of the

job

2.56 ± 0.75

Thinks less of workers who choose to breastfeed* 2.52 ± 0.73

Makes sure that the job is covered for breastfeeding or

pumping breast milk

2.70 ± 0.67

40

Items Mean ± SD

Makes suitable schedule to allow the employee to breastfeed or

pump breast milk

2.30 ± 0.62

Helps dealing with the workload to allow for breastfeeding or

pumping

2.38 ± 0.74

Embarrassed to speak about breastfeeding* 2.66 ± 0.61

Total of Manager Support 30.21 ± 5.63

Co-Worker Support

Thinks less of workers who choose to breastfeed* 2.54 ± 0.66

Feels comfortable speaking about breastfeeding 2.85 ± 0.60

Considered supporting breastfeeding 2.93 ± 0.65

Willing to switch the break times to breastfeed 2.64 ± 0.71

Covered the job duties to allow mothers breastfed or pumped 2.53 ± 0.70

Embarrassed to speak about breastfeeding* 2.72 ± 0.75

Total of Co-Worker Support 15.71 ± 2.47

Time Support

Frequent enough opportunities for breastfeeding or pumping

breast milk at work

2.86 ± 0.80

Long enough time for breastfeeding or pumping breast milk 2.63 ± 0.80

Adjust the break schedule in order to breastfeed or pump 2.80 ± 0.92

Total of Time Support 8.28 ± 2.29

Environment Support

Considering buying or borrowing the equipment for

breastfeeding or pumping breast milk

0.73 ± 0.44

Company provides equipment for pumping breastmilk at work 0.21 ± 0.40

Company provides place to store expressed breast milk at work 0.41 ± 0.50

There is a company-designated place for women to breastfeed

or pump milk during the workday

0.67 ± 0.47

There is a designated place for breastfeeding or pumping

available when needed

2.42 ± 1.08

The designated place is close enough to the work area to use

during a break

2.31 ± 1.04

The designated place is comfortable for breastfeeding or

pumping

2.28 ± 1.13

41

Items Mean ± SD

The designated place for breastfeeding or pumping is

satisfactory

2.19 ± 1.08

The designated place for breastfeeding or pumping includes

everything needed

2.06 ± 1.04

Total of Environment Support 13.27 ± 6.30

* Reverse items have been recoded

4.2.2 Multidimensional Scale of Perceived Social Support Scores (MSPSS)

Multideminsional Subcales of Perceived Social Support (MSPSS) includes the

categories of family, friends, and significant others. The descriptive analysis is in

Table 4.2.2. The family support consisted of four items. The item with the highest

mean score was “my family is willing to help me make decisions” with a score of

6.04 (SD = 0.73) and the item with lowest mean score was “I can talk about my

problems with my family,” with a score of 5.88 (SD = 0.84).

Support from friends consisted of four items. The item with the highest mean

score was “I have friends with whom I can share my joys and sorrows” with a score

of 5.62 (SD = 1.03) and the item with the lowest mean score was of “I can count on

my friends when things go wrong” with a score of 5.33 (SD = 1.15).

Support from significant others, which in this study included husbands and

health workers, consisted of four items. The item with the highest mean score was

“There is a special person in my life who cares about my feelings” with a score of

6.08 (SD = 0.78) and the item with the lowest mean score “There is a special person

who is around when I am in need” with a score of 5.75 (SD = 1.02).

42

Table 4.2.2 Descriptive Statistics of Multidimensional Scale of Perceived Social Support

Items Mean ± SD

Family

My family really tries to help me 5.98 ± 0.79

I get the emotional help and support I need from my family 5.93 ± 0.89

I can talk about my problems with my family 5.88 ± 0.84

My family is willing to help me make decisions 6.04 ± 0.73

Total Family Support 23.82 ± 2.51

Friends

My friends really try to help me 5.60 ± 1.05

I can count on my friends when things go wrong 5.33 ± 1.15

I have friends with whom I can share my joys and sorrows 5.62 ± 1.03

I can talk about my problems with my friends 5.60 ± 1.05

Total Friends Support 22.14 ± 3.47

Significant Others

There is a special person who is around when I am in need 5.75 ± 1.02

There is a special person with whom I can share my joys and sorrows 5.76 ± 0.95

I have a special person who is a real source of comfort to me 5.94 ± 0.80

There is a special person in my life who cares about my feelings 6.08 ± 0.78

Total Significant Others Support 23.53 ± 2.72

4.2.3 Iowa Infant Feeding Attitude Scale (IIFAS)

The IIFAS consists of 17 items, half of which are favorable to breastfeeding and the

remaining are favorable to artificial feeding. The mean score obtained for the IIFAS was 58.9

(SD = 7.96).

43

Table 4.2.3 Descriptive Statistics of Iowa Infant Feeding Attitude Scale

Items Mean ± SD

The benefit of breastmilk lasts only as long as the baby is fed* 3.31 ± 1.19

Formula feeding is more convenient than breastfeeding* 3.12 ± 1.27

Breastmilk is lacking in iron* 2.51 ± 1.05

Formula feeding is the better choice if the mother plans to go out to work* 3.32 ± 1.11

Women should not breastfeed in public places* 3.70 ± 1.15

Breastfed babies are more likely to be overfed than formula-fed babies* 3.45 ± 0.90

Fathers feel left out if a mother breastfeeds* 2.28 ± 0.87

Formula is as healthy for an infant as breast milk* 2.80 ± 1.10

A mother who occasionally drinks alcohol should not breastfeed her baby* 3.68 ± 1.11

Breastfeeding increases mother-infant bonding 4.30 ± 0.70

Formula-fed babies are more likely to be overfed than breastfed babies 3.32 ± 0.96

Mothers who formula feed miss one of the great joys of motherhood 3.05 ± 1.10

Breastfed babies are healthier than formula fed babies 3.83 ± 1.03

Breastmilk is the ideal food for babies 4.36 ± 0.67

Breastmilk is more easily digested than formula 4.34 ± 0.69

Breastfeeding is more convenient than formula 4.40 ± 0.58

Breastfeeding is cheaper than formula 4.46 ± 0.60

Total Score 58.9 ± 7.96

* Reverse items have been recoded

4.3 Relationship between personal factors, breastfeeding and employment study scores,

and social support for different types of breastfeeding

To identify whether there is robust evidence about the relationship, univariate

analyses were performed using the independent samples t-test and Chi-Square. The

results are summarized in Tables 4.3.1, 4.3.2 and 4.3.3.

44

4.3.1 Relationship between personal factors and different breastfeeding types

A univariate analysis to identify associations between personal factors

(demographic characteristics) and exclusive breastfeeding was performed using the

independent sample t-test (continuous variables with breastfeeding types) and Chi-

square (categorical variables with breastfeeding types). None of the personal variables

and obstetrics variables were statistically significantly related to breastfeeding type (p

>.05).

Table 4.3.1 Relationships between personal factors and breastfeeding types (N=208)

Variables Total N (%)/

Mean ± (SD)

Exclusive

Breastfeeding

Not Exclusive

Breastfeeding

t/χ2 p

Age 28.80 ± 5.46 29.08 ± 5.32 28.07 ± 5.80 1.191a .235

Age of Baby 8.95 ± 1.89 9.11 ± 1.86 8.63 ± 1.92 1.643a .102

Marital Status

Married

151 (72.6)

57 (27.4)

Education

Junior High School

Senior High School/ Above

26 (17.2)

125 (82.8)

13 (22.8)

44 (77.2)

0.848b

.357

Monthly Family Income

< 1.833.000

≥ 1.833.000

59 (39)

92 (61)

24 (42.1)

33 (57.9)

0.1b

.690

Parity

Primigravida

Multigravida

58 (38.5)

93 (61.5)

23 (40.4)

34 (59.6)

0.066b

.798

Mode of Delivery

Vaginal delivery

Cesarean section

Vacuum/ Forceps’

95 (63)

54 (36)

2 (1)

35 (61)

21 (37)

1 (2)

0.082b

.960

Breastfeeding Experience

Yes

No

93 (62)

58 (38)

34 (60)

23 (40)

0.066b

.798

Attitude 58.9 ± 7.96 58.9 ± 7.86 58.8 ± 8.30 0.094 a .926

a Independent Samples t-Test

45

b Chi-Square Tests

4.3.2 Relationship between breastfeeding-friendly workplace factors and breastfeeding

types

Independent t test was used to analyze the relationship between breastfeeding friendly

factors and breastfeeding types. The results showed that higher organization support (t =

2.924, p = .004), manager support (t =2.062, p = .041), physical environment support (t =

2.000, p = .047), and time support (t = 2.974, p = .003) increased the likelihood of exclusive

breastfeeding. There was no significant association between the co-worker support score and

exclusive or non-exclusive breastfeeding type (t = 1.725, p = .086).

Table 4.3.2 Relationships between breastfeeding workplace friendly factors

and breastfeeding types

Variables Exclusive

Breastfeeding

Not Exclusive

Breastfeeding

t p

Organization Support 30.64 ± 3.93 28.81 ± 4.27 2.924 .004*

Manager Support 30.70 ± 5.60 28.91 ± 5.56 2.062 .041*

Co-Worker Support 15.89 ± 2.40 15.23 ± 2.60 1.725 .086

Time Support 8.56 ± 2.20 7.53 ± 2.35 2.974 .003*

Environment Support 13.80 ± 6.10 11.86 ± 6.61 2.000 .047*

Note : * p < .05

4.3.3 Relationships between social support factors and breastfeeding types

A univariate analysis to identify associations between social support and breastfeeding types

was run using the independent sample t-test. There were no statistically significant

associations between social support and breastfeeding types for all the support subscales (p

>.05).

46

Table 4.3.3 Relationships between social support factors and breastfeeding types

Variables Exclusive

Breastfeeding

Not Exclusive

Breastfeeding

t p

Family 23.86 ± 2.44 23.72 ± 2.70 0.362 .718

Friends 22.12 ± 3.502 22.21 ± 3.426 -0.169 .866

Significant others 23.72 ± 2.52 23.04 ± 3.17 1.612 .108

4.4 Factors associated with adherence to six months of exclusive breastfeeding

A binary logistic regression was used to understand the factors associated with

adherence to six months of exclusive breastfeeding. This analysis included the seven

demographic variables of age, education, marital status, monthly family income,

parity, mode of delivery, and previous breastfeeding experience together with family

support, friends support, significant other support and BESt support. Only BESt

support scores showed a significant association with adherence BESt support had a p-

value of .002, odds ratio of 1.034.This could be interpreted as one unit increase is

BESt, mother have the probability of exclusive breastfeeding increase of 3.4 %.

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Table 4.4 Factors associated with adherence to six months of exclusive breastfeeding

B S.E. p-value OR

95% CI for EXP(B)

Lower Upper

Age 0.045 .032 .169 1.046 0.981 1.114

Education (junior high school

vs senior high school or

above)

0.562 .418 .179 1.754 0.772 3.983

Monthly family income:

<1,833,000 vs ≥1,833,000 -0.071 .354 .841 0.932 0.465 1.866

Parity: primigravida vs

multigravida -0.122 .368 .740 0.885 0.431 1.819

Birth Mode: vaginal delivery

vs Cesarean section -0.027 .338 .936 1.034 1.012 1.057

Social Support -0.111 .023 .634 0.989 0.945 1.035

Attitude -0.007 .021 .745 .993 .954 1.035

BESt 0.027 .0338 .002 1.034 1.012 1.057

Constant -2.727 2.156 .206 .065

Note: BESt (Breastfeeding Employment study for breastfeeding friendly workplace)

48

Chapter Five

Discussion

This chapter discusses the findings of this study, which aimed to understand the

factors associated with six months of exclusive breastfeeding among employed mothers after

returning to work in Karanganyar Regency, Central Java, Indonesia. The following variables

were investigated: personal factors including demographic data and attitudes; social support

factors, and breastfeeding-friendly workplace factors.

5.1 Findings of this study

Four main variables were used to explore the factors associated with continued

exclusive breastfeeding among employed mothers after returning to work in Karanganyarar

Regency: demographic factors (include of age, education, monthly family income, parity,

birth mode and previous experience), attitude, social support factors (include of family

support, friend support and significant other support) and workplace breastfeeding friendly

factors.

5.1.1 Personal Factors

The personal factors investigated in this study included demographic characteristics

and also attitudes. Characteristics included age, marital status, education, monthly family

income, parity, mode of delivery and previous breastfeeding experience.

The result on demographic characteristics showed that 74% of employed mothers

practiced breastfeeding exclusively. This prevalence was high, almost reaching the target rate

of 80% set out by the Indonesian goverment’s target. By contras, studies conducted by Danso

(2014) and Chhetri, Rao, and Guddattu (2018) found that the prevalence of exclusive

breastfeeding practice among working mothers was found to be low. A study done in East

Java, Indonesia by Pujiani and Rahmawati (2014) found that mothers within the age range 18

to 35 were 3.188 times more likely to practice exclusive breastfeeding than than those under

49

age 18 or over age 35. Their study was consistent with previous studies (Cristiana, 2016;

Kassahun, 2019; Kingston, Heaman, Fell, & Chalmers, 2012; Tsai, 2013;). In contrast,

some studies, including this one, did not find a signficant relationship between the age of

mothers and the practice of exclusive breastfeeding (Lenggogeni, 2016; Setegn et al., 2012).

Highly educated mothers may have more control over their jobs and work schedules,

meaning they are able to enjoy a more breastfeeding-friendly work environment (Li Bay,

Tak Fong, & Tarrant, 2015). Ratnasari et al. (2017) as well as Ambarwati and Wulandari

(2010) found that the education of mothers had a positive effect on the frequency and pattern

of breastfeeding. This may be because highly educated people are better able to absorb

information they receive and weigh the benefits they might get from a recommendation, such

as exclusive breastfeeding. It is generally assumed that educational status would be

associated with having more in-depth information regarding the practice of exclusive

breastfeeding.

In contrast, in this study, education was not a significant factor in exclusive

breastfeeding, which indicates no significant association between education and the practice

of exclusive breastfeeding. In this study, education was a binary variable. Among the 208

respondents, 169 had obtained senior high school education or above and 125 of those

breastfed their children exclusively. Of the remaining women who had junior high school

education (n=39), only 13 breastfeed their children exclusively. However, the difference in

exclusive breastfeeding rates by education was not statistically significant in this study. The

companies that employed women in this study generally required workers to have senior high

school education or above. Because all the women in this study were employed, they tended

to have higher than average levels of education than Indonesian women in general. The fact

that all the women in this study were more highly educated than average meant there was not

sufficient difference between them to find a significant association between exclusive

50

breastfeeding and education. If the study had included women with less education, the result

might have been different. This result is consistent with another study on breastfeeding and

employment conducted in Indonesia by Khayati and Kusumaningrum (2019) which likewise

found that the education level of the mothers did not have a significant correlation to the

practice of exclusive breastfeeding.

Some studies have found that families with higher monthly incomes are more likely to

practice exclusive breastfeeding. This is partly explained by their ability to buy extra food,

such as milk formula, that could be given to infants in addition to breastmilk (Baale, 2014).

However, the results of this study found no significant relationship between monthly family

income and exclusive breastfeeding practice. This finding is similiar with studies conducted

by Rosita (2016) and Wendiranti et al. (2017) who found that monthly family income did not

have a significant relationship with the practice of exclusive breastfeeding. In this study, the

lack of clear relationship between income and exclusive breastfeeding could be because this

study gathered data only about the wife’s income rather than household income.

Previous studies found that parity has a significant correlation to the practice of

exclusive breastfeeding (Ferreira et al., 2016; Kassahun, 2019; Keneko, 2006; Kitano et al.,

2016; Kusumastuti, 2014). Mothers are more likely to breastfeed exclusively if they have

three or more children. Moreover, they are more likely to use exclusive breastfeeding for the

third child compared to the second and first. On the contrary, this and other studies found that

parity had no significant correlation to the practice of exclusive breastfeeding (Hunegnaw et

al., 2017; Kumala, 2017).

Studies have likewise shown that parity also has a relation to the prior exprience of

exclusive breastfeeding. Mothers with one or two children often have problems giving milk

to their babies because the nipple blisters due to lack of breastfeeding experience or because

the mother is psychologically unready to breastfeed (Aprizal, & Deniati, 2018). In this study,

51

prior experience of breastfeeding unexpectedly did not show a significant association to the

practice of exclusive breastfeeding. By contrast, a study by Maharloue et al. (2018) found

that prior history of breastfeeding did have a significant association with the practice of

exclusive breastfeeding. These different results might be due to the different characteristics of

the study participants. The participants in that study included both employed mothers and

unemployed mothers, whereas all the women in this study were employed. Because all the

women in this study were working, and working is often an obstacle to breastfeeding, prior

experience had no influence on exclusive breastfeeding practice. In other words, working

might mediate the relationship between prior breastfeeding experience and exclusive

breastfeeding practice.

Previous studies have found that mode of delivery was associated with the practice of

exclusive breastfeeding, with mothers who received cesarean sections less likely to breastfeed

exclusively (Alves et al., 2017; Chekol, Biks, Gelaw, & Melsew, 2017; Maharlouei et al.,

2018). This could be due to the condition mothers who have had cesarean section face in the

first hours after delivery as they may be experiencing pain and a lack of energy. Also, early

initiation of breastfeeding is an important factor in a woman’s success at exclusive

breastfeeding; women who initiate breastfeeding sooner are more likely to succeed at it. On

the contrary, women who give birth to their baby vaginally are readier to start breastfeeding

in the first hours after delivery because they are in good physical condition. However, in this

study, the results showed that there was no significant association between mode of delivery

and practicing exclusive breastfeeding. This might be possibly the sample size for this study

was too small to reveal the connection. Also, this study did not ask a question about early

initiation of breastfeeding, which may be a mediating factor between mode of delivery and

breastfeeding practice. This finding is consistent with a study conducted in South East

Ethiopia by Setegn et al. (2012).

52

Studies on how attitude affects the practice of exclusive breastfeeding show mixed

results. Septiani, Hanulan; Budi, Artha; Karbito.,(2017) found that attitude has a significant

correlation with practice of exclusive breastfeeding. They found that respondents who had a

positive attitude towards exclusive breastfeeding were 3.7 times more likely to practice

exclusive breastfeeding than those who had a negative attitude towards exclusive

breastfeeding. Lack of knowledge and inappropriate beliefs are the major obstacles to

exclusive breastfeeding (Hillowis, 2016). For example, a study conducted in Somalia showed

that attitude toward breastfeeding is strongly influenced by maternal grandmothers and other

elderly women in the community. Most children start breastfeeding two or three days after

birth and mothers do not feed the infant colostrum as it is considered dirty. But results of this

study showed that the attitude did not have a significant correlation with exclusive

breastfeeding. One reason for this finding may be that all the women in this study were

employed. Even if they had a positive attitude about breastfeeding, practical obstacles might

prevent them from doing it.

5.1.2 Breastfeeding Workplace Friendly Factors

The breastfeeding workplace friendly factors investigated in this study included

organization support, manager support, coworker support, time support and environment

support.

The number of working women in Indonesia has begun to increase due to the demand

to improve family welfare (Ratnasari, Paramashanti, Hadi, Yugistyowati & Nurhayati, 2017).

A study conducted by Li Bay, Tak Fong, and Tarrant (2015) found that breastfeeding

workplace friendly has significant assosiated with the practice of exclusive breastfeeding for

employment mothers. According to the result showed that four of the breastfeeding

workplace friendly factors variables has a significant association with the practice of

53

exclusive breastfeeding on employment mothers, there are organization support, manager

support, time support and environment support.

A mother's dual role between caring for her child including giving breastfeeding and

working to help the family economy often makes it difficult for a mother to cope. Some

barriers to the success of exclusive breastfeeding programs in the workplace included the

unavailability of private lactation areas to express the breastmilk, the absence of a flexible

schedule or time, bad relation with the other employers or the supervisor. The result of the

multiple logistic regression showed that mothers with the support from organization,

manager, time also environment are more likely to have exclusive breastfeeding practices

1.034 times than those who doesn’t have support. Also this result showed the p-value .002

which mean that breastfeeding workplace friendly support has a significant correlation with

the practice of exclusive breastfeeding. Similiar finding by Septiani et al. (2017) showed

that manager support has significant relationship toward practice of exclusive breastfeeding.

Support that comes from manager will influence the success of exclusive breastfeeding in the

workplace included support in combining breastfeeding and work aslo giving suitable time to

allow the employee for breastfeeding or pumping breast milk.

Previous studies mentioned that working hours was associated with the practice of

exclusive breastfeeding (Novayelinda, 2012; Wendiranti, Subagio, & Wijayanti, 2017).

Some workplaces provide lactation space but limition time is given to express the breast

milk, it can also be the barrier of success exclusive breastfeeding practice in the workplace.

Despite the place to express the breast milk and place for storing the breast milk (Wendiranti

et al., 2017).

Although the organization or the employee already understood about the advantage of

breastfeeding, there were still no efforts made to support the exclusive breastfeeding

programs in the workplace (Sariet al., 2015). The possible reason might be employement

54

rules and regulations such as maternity leave and employed mohters have less opportunity to

stay at home, compromising exclusive breastfeeding and lack of child care facilities close to

the workplace (Elyas et al., 2017). Novayelinda (2012) as well as Yimyam and Hanpa (2014)

found that breastfeeding-friendly workplace policies can greatly influence women’s success

at exclusively breastfeeding their infants. In Indonesia the regulation has been set up by the

State Minister for Women Empowerment, the Minister of Manpower and Transmigration and

the Minister of Health in 2012 on increasing breastfeeding during working time in the

workplace. But the application and evaluation of this regulation is not yet known clearly and

in detail so it requires further study.

5.1.3 Social Support Factors

The social support factors investigated in this study included family support, support

from friends, and support from significant others. The results showed social support factor

variables had no significant association with the practice of exclusive breastfeeding among

employed mothers.

The finding that support from family did not increase the likelihood of exclusive

breastfeeding in this study was contrary to results of other studies. For example, in another

Indonesian study, family support significantly increased the likelihood of exclusive

breastfeeding (Ratnasari et al., 2017). The researchers observed that family can help out by

providing childcare, buying or making food, and also feeding the child expressed breast milk

(Ratbnasari et al, 2017). Other studies have come to similar conclusions, that family support

increases the likelihood of exclusive breastfeeding (Chekol et al,, 2017; Permatasari et al.,

2018; Rahmawati, 2016; Rosita, 2016; Sari, Yosi & Nella, 2015; Sephani et al., 2017; Umami

& Margawati, 2018).

However, this study did not find a significant relationship between family support and

practice of exclusive breastfeeding; there may be several explanations for this result. First,

55

women living with extended family may have more difficulty controlling what other people

feed their infants. In some families, a woman may not have the authority to ask her parents or

in-laws not to feed the baby anything but breast milk. Other family members may feed the

baby honey, juice, or porridge. This might explain why support from family was not

positively associated with exclusive breastfeeding practice in this study.

Another reason that family support was not associated with exclusive breastfeeding

among women in this study might be related to the fact that all participating women were

employed and employed women were more likely to live with only their husband and

children, rather than with an extended family. In this living situation, support from extended

family members for (or against) exclusive breastfeeding had less impact on their daily lives

and child feeding practices.

The statistical results showed that support from friends was not significantly associated

with exclusive breastfeeding.This finding was in agreement with results of studies conducted

by Septiani et al. (2017) and Ariani, Ariescha, & Vera (2019)) which likewise showed that

support from friends did not improve the mother’s ability to provide exclusive breastfeeding.

Other studies, however, showed that women who reported strong support from friends were

significantly more likely to practice exclusive breastfeeding Astutik (2018).The difference in

results might be due to the different characteristics of the respondents. Also, in this study,

friend support can be define as a friend who can be the listener when the respondent has any

problems but it was not clearly explained about the problems which they faced about.

In contrast with results of other studies, support from significant others was

significantly correlated with the practice of exclusive breastfeeding Rosita (2016); Umami

and Margawati (2018). In other words, women who reported more support from significant

others were more likely to breastfeed exclusively than those who did not. The stastitical result

of this study did not show this association.

56

Chapter VI

Conclusion

In this chapter contains the summary of the findings, conclusions, limitations

and recommendations:

6.1 Conclusion

A descriptive correlational design was adopted to collect data using

questionnaires to identify the factors associated with six-months of exclusive

breastfeeding among employed mothers after returning to work in Karanganyar

Regency Central Java, Indonesia.

Lack of workpace support was the dominant predictive factor that could

potentially derail exclusive breastfeeding. Breastfeeding friendly workplace factors

identified as key to a breastfeeding-friendly workplace were found to be significantly

associated with the practice of exclusive breastfeeding among employed mothers.

Support which comes from the company where they work, such us organizational

support, support from the manager, having time available for breastfeeding, and also a

breastfeeding-appropriate environment, are essential for employed mothers.

6.2 Limitations and Recommendations for Future Research

Even though this study has several strengths, including a reasonably large

sample size and use of well-established instruments, it also has several limitations.

First, the manner of recruiting participants introduces a high risk of selection bias,

because respondents worked in government offices, some of which already conform

to breastfeeding-friendly workplace guidelines, and the rest worked in well-known

big companies with many employees, rather than in small shops. Future research

could include a wider range of workplaces such as smaller businesses and schools.

Moreover, it would be informative to clearly identify the types of work the women

57

were engaged in. Second, this study relied on Likert-scale questionnaires that offer

pre-determined responses. Qualitative research that asks open-ended questions is

needed to know more deeply about barriers to practicing exclusive breastfeeding.

A live interview might establish better rapport and elicit more detailed and honest

responses.

6.3 Recommendations

6.3.1 Recommendations for Goverment

This research provides a basis for government agencies to conduct routine

evaluations of how well workplaces have implemented breastfeeding-friendly policies

to enable workers to perform exclusive breastfeeding for six months. In addition,

government should collaborate with health workers to design programs for outreach

aimed at educating both workers and management about the importance of exclusive

breastfeeding for working mothers. Government and health workers should help

employers comply with the government’s policy to promote exclusive breastfeeding,

Perbup Karanganyar No. 82 of 2015.

6.3.2 Recommendations for Health Providers

Currently, health workers counsel women in healthcare settings about

exclusive breastfeeding and its benefits, as well as addressing practical issues like

breastfeeding techniques, how to store breast milk, and how to combine exclusive

breastfeeding with work .

However, if working women are to succeed at breastfeeding, it is essential to

have breastfeeding-friendly workplaces, not just in name only, but as a reality. Some

mothers in this study were hesitant to claim the right to breastfeed or pump milk at

work out of concern that it would burden their co-workers or annoy their managers.

Women will not use their right to breastfeed if they are concerned that they could lose

58

their job or lose a promotion. Therefore, since most companies do not hire health

workers on site, health workers must conduct outreach into the workplace, in order to

provide counselling not only to employed mothers themselves, but also to their co-

workers and managers in the workplace. Government should pay health workers extra

for visiting companies to perform such outreach for this purpose.

6.3.3 Recommendations for Companies

Companies are expected to create a working environment that supports

exclusive breastfeeding through the provision of breastfeeding facilities in the

workplace and via work policies that enable female workers to practice exclusive

breastfeeding.

59

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Appendix

Appendix 1

QUESTIONNAIRE

ASSOCIATED FACTORS OF SIX MONTHS BREASTFEEDING AMONG

EMPLOYED MOTHERS AFTER RETURNING TO WORK

A. General Instructions

1. Fill in the identity completely and correctly

2. Give a check (√) to the answer column that you think is correct

3. Answer honestly according to your conscience

4. Choose one answer in each question

5. All questions must be read all nothing has been missed

B. Characteristics of Respondents

1 Age ……………… years

2 Marital Status

Married

Single

3 Education

Elementary School

Junior High School

Senior High School/ So

4 Monthly Family Income

< 1,833,000 IDR

≥ 1,833,000 IDR

5 Parity

Primigravida

Multigravida

6 Mode of Delivery

Vaginal Delivery

Cesarean Section

Vacuum

Forceps

7 Previous Breastfeeding Experienced:

Yes

70

No

8 How old is your baby now ? ….……... months

9 Whatt is your feeding mode currently 1. Exclusive breastfeeding

2. Partially breastfeeding

3. Formula

4. Solid foods

(If you choose exclusive breastfeeding, go to

number 10)

(If you choose partially breastfeeding or

formula or solid food go to number 11)

10. For how many months did you feed

your children only with breast milk

without any liquid or food (except for

medical condition)?

………… months

11. At what age did you stop giving

your baby only breastmilk ?

………… months

71

Organizational Support

This section asks about the overall support you feel would be provided by your

company if you wanted to combine breastfeeding and work.

Strongly

Agree Disagree

Strongly

agree disagree

1. I would have enough maternity leave (paid and/or

unpaid time off) to get breastfeeding started before

going back to work.

2. I would be able to get information about combining

work and breastfeeding from my company.

3. I’m certain my company has written policies for

employees that are breastfeeding or pumping breast

milk.

4. I’m certain there is a place I could go to breastfeed

or pump breast milk at work.

5. There is someone I could go to at work that would help

me make arrangements for breastfeeding or pumping

breast milk.

6. My job could be at risk (e.g. lose my job or get fewer

scheduled hours) if I breastfed or pumped breast milk at work.

7. I would be able to talk about breastfeeding at work.

8. I would feel comfortable asking for accommodations to help me breastfeed or pump breast milk at work.

9. My opportunities for job advancement would be limited

if I breastfed or pumped breast milk at work.

10. I’m certain that women in higher-level positions have

breastfed or pumped breast milk at my workplace.

11. I’m certain coworkers have breastfed or pumped

breast milk at my workplace.

72

Manager Support

This section asks about the overall support you feel would be provided by your direct

manager/supervisor if you wanted to combine breastfeeding and work.

Strongly

Agree Disagree

Strongly

agree disagree

12. My manager would support me breastfeeding or pumping breast milk at work.

13. My manager would help me combine breastfeeding and work. 14. My manager would think I couldn’t get all my work

done if I needed to take breaks for breastfeeding or pumping breast milk.

15. I would feel comfortable speaking with my manager about breastfeeding.

16. My manager says things that make me think he/she supports breastfeeding.

17. I feel my manager would view breastfeeding as an employee’s personal choice.

18. My manager would consider it part of his/her job to help me combine breastfeeding and work.

19. My manager would think less of workers who choose to breastfeed or pump breast milk at work.

20. My manager would make sure my job is covered if I

needed time for breastfeeding or pumping breast milk.

21. My manager would change my work schedule to allow

me time for breastfeeding or pumping breast milk.

22. My manager would help me deal with my workload so I could breastfeed or pump breast milk at work.

23. My manager would be embarrassed if I spoke with him/her about breastfeeding.

73

Co-worker Support

This section asks about the overall support you feel would be provided by your coworkers if you

wanted to combine breastfeeding and work.

Strongly

Agree Disagree

Strongly

agree disagree

24. My coworkers would think less of workers that choose to breastfeed or pump breast milk at work.

25. I would feel comfortable speaking with my coworkers about breastfeeding.

26. My coworkers say things that make me think they support breastfeeding.

27. My coworkers would change their break times with me so that I could breastfeed or pump breast milk.

28. My coworkers would cover my job duties if I needed

time for breastfeeding or pumping breast milk.

29. My coworkers would be embarrassed if I spoke with them about breastfeeding.

Time

This section asks about the pace of your job and available time you would have during your workday

to breastfeed or pump breast milk.

Strongly

Agree Disagree

Strongly

agree disagree

30. My breaks are frequent enough for breastfeeding or pumping breast milk.

31. My breaks are long enough for breastfeeding or pumping breast milk.

32. I could adjust my break schedule in order to breastfeed or pump breast milk.

74

Physical Environment

This section asks about the physical environment of your workplace for breastfeeding

or pumping breast milk after returning to work.

33. I could buy or borrow the equipment I would need for pumping breast milk.

No

Yes

34. My company would supply the equipment I would need for pumping breast milk at work.

No

Yes

35. I could find a place to store expressed breast milk at work.

No Yes

36. There is a company-designated place for women to breastfeed or pump milk during the

workday.

No

Yes

Strongly

Agree Disagree

Strongly

agree disagree

37. The designated place for breastfeeding or

pumping breast milk at work would be

available when I needed it.

38. The designated place for breastfeeding or pumping

breast milk is close enough to my work area to use during my breaks.

39. I would feel comfortable breastfeeding or pumping breast milk in the designated place.

40. The designated place for breastfeeding or pumping breast milk is satisfactory.

41. The designated place for breastfeeding or pumping breast milk includes everything I need.

75

Multidimensional Scale of Perceived Social Support

Instructions: We are interested in how you feel about the following statements. Read each

statement carefully. Indicate how you feel about each statement.

Give a check (√) in the column “1” if you Very Strongly Disagree Give a check (√) in the column “2” if you Strongly Disagree

Give a check (√) in the column “3” if you Mildly Disagree

Give a check (√) in the column “4” if you are Neutral

Give a check (√) in the column “5” if you Mildly Agree

Give a check (√) in the column “6” if you Strongly Agree

Give a check (√) in the column “7” if you Very Strongly Agree

No Questions 1 2 3 4 5 6 7

1. There is a special person who is around when I am in

need.

2. There is a special person with whom I can share my

joys and sorrows.

3. My family really tries to help me.

4. I get the emotional help and support I need from my

family.

5. I have a special person who is a real source of

comfort to me.

6. My friends really try to help me.

7. I can count on my friends when things go wrong.

8. I can talk about my problems with my family.

9. I have friends with whom I can share my joys and

sorrows.

10. There is a special person in my life who cares about

my feelings.

11. My family is willing to help me make decisions.

12. I can talk about my problems with my friends.

76

Iowa Infant Feeding Attitude Scale

Instructions: We are interested in how you feel about the following statements. Read each

statement carefully. Indicate and give a check (√) how you feel about each statement.

No Infant-Feeding Attitude Strongly

Agree Agree Moderate Disagree

Strongly

Disagree

1 The benefits of breastmilk last only as long as

the baby is fed

2 Formula feeding is more convenient than breastfeeding

3 Breastmilk is lacking in iron

4 Formula feeding is the better choice if the

mother plans to go out to work

5 Women should not breast-feed in public places

6 Breastfed babies are more likely to be overfed

than formula-fed babies

7 Fathers feel left out if a mother breast-fed

8 Formula is as healthy for an infant as breast

milk

9 A mother who occasionally drinks alcohol

should not breast-feed her baby

10 Breastfeeding increases mother-infant bonding

11 Formula-fed babies are more likely to be over

fed than breastfed babies

12 Mothers who formula feed miss one of the great joys of motherhood

13 Breastfed babies are healthier than formula fed

babies

14 Breastmilk is the ideal food for babies

15 Breastmilk is more easily digested than

formula

16 Breastfeeding is more convenient than formula

17 Breastmilk is cheaper than formula

77

KUESIONER

FAKTOR-FAKTOR YANG BERHUBUNGAN DENGAN 6 BULAN ASI EKSKLUSIF

PADA IBU SETELAH KEMBALI BEKERJA

A. Petunjuk Umum

1. Isilah identitas anda dengan lengkap dan benar

2. Berilah tanda centang(√) pada kolom jawaban yang menurut anda benar

3. Jawablah dengan jujur sesuai dengan hati nurani anda

4. Pilihlah satu pilihan jawaban disetiap pertanyaan

5. Semua pertanyaan harus terisi dan jangan sampai ada yang terlewatkan

B. Karakteristik Responden

1. Umur ……………… tahun

2. Status Pernikahan

Menikah

Belum menikah

3. Pendidikan

SD

SMP

SMA/ DIII/ SI/ SII

4. Pendapatan Keluarga

< 1,833,000

≥ 1,833,000

5. Kehamilah ke

Pertama

Kedua/ lebih

6. Tipe persalinan Pervaginam

CS/ Sesar

Vakum

Forcep

78

7. Pengalaman menyusui

Pernah

Tidak pernah

8. Berapa usia bayimu sekarang ….……... tahun

9. Tipe menyusui saat ini 1. Asi Eksklusif

2. Asi dan MPASI

3. Formula

4. Makanan padat

(Jika kamu memilih asi eksklusif, silahkan

langsung ke nomor 10)

(Jika kamu memilih asi/ MPASI, formula dan

makanan padat, silahkan langsung ke nomor 11)

10. Selama berapa bulan anda memberi

makan anak anda hanya dengan ASI

tanpa cairan atau makanan ? (kecuali

pada kondisi medis) ?

…………bulan

11. Pada usia berapa anda berhenti

memberi bayi anda hanya ASI tanpa

cairan atau makanan lain ?

………… bulan

79

C. Dukungan Tempat Kerja

Bagian ini menanyakan tentang dukungan-dukungan yang menurut anda akan

diberikan oleh tempat kerja jika anda ingin menyusui.

No Pernyataaan Sangat

Setuju Setuju

Tidak

Setuju

Sangat

tidak

setuju

1 Saya akan mendapatkan cuti melahirkan yang

cukup untuk menyusui bayi saya baik digaji

maupun tidak digaji

2 Saya akan mendapatkan informasi tentang bekerja

sambil menyusui ditempat saya bekerja

3 Saya yakin bahwa tempat kerja saya memiliki

kebijakan tertulis bagi karyawan yang sedang

menyusui atau mempompa ASI

4 Saya yakin ada tempat yang bisa saya gunakan

untuk menyusui atau mempompa ASI ditempat

saya bekerja

5 Ada seseorang yang bisa membantu saya

mengatur persiapan menyusui atau mempompa

ASI ditempat kerja saya

6 Pekerjaan saya bisa beresiko jika saya menyusui

atau mempompa ASI ditempat saya bekerja,

misalnya kehilangan pekerjaan atau pengurangan

jam kerja

7 Saya dapat membicarakan perihal menyusui

ditempat kerja

8 Saya merasa nyaman meminta fasilitas dalam

membantu saya menyusui atau mempompa ASI

9 Kesempatan saya untuk naik jabatan akan dibatasi

jika saya menyusui atau mempompa ASI

80

D. Dukungan Atasan

Bagian ini menanyakan tentang dukungan-dukungan yang menurut anda akan

diberikan oleh atasan anda jika ingin menyusui.

10 Saya yakin bahwa wanita dengan jabatan tinggi

ditempat saya bekerja pernah menyusui atau

mempompa ASI ditempat kerja

11 Saya yakin rekan kerja saya juga pernah

menyusui atau mempompa ASI ditempat saya

bekerja

No Pernyataaan Sangat

Setuju Setuju

Tidak

Setuju

Sangat

tidak

setuju

12 Atasan saya akan mendukung saya untuk

menyusui atau mempompa ASI ditempat saya

bekerja

13 Atasan saya akan membantu saat saya menyusui

sambil bekerja

14 Atasan saya akan berpikir bahwa semua pekerjaan

saya tidak akan selesai jika saya butuh istirahat

untuk menyusui atau mempompa ASI

15 Saya akan merasa nyaman membicarakan perihal

menyusui dengan atasan saya

16 Atasan saya mengatakan sesuatu yang membuat

saya berpikir bahwa dia mendukung perihal

menyusui ditempat kerja

17 Saya merasa atasan saya akan memandang bahwa

menyusui adalah pilihan pribadi setiap karyawan

18 Atasan saya akan mempertimbangkan bahwa

membantu saya untuk menyusui sambil bekerja

81

E. Dukungan Rekan Kerja

Bagian ini menanyakan tentang dukungan-dukungan yang menurut anda akan

diberikan oleh rekan kerja anda jika anda ingin menyusui.

adalah salah satu tugasnya

19 Atasan saya akan berpikir bahwa sedikit

karyawan yang memilih menyusui dan

mempompa ASI ditempat kerja

20 Atasan saya akan memastikan pekerjaan saya

selesai meskipun saya membutuhkan waktu untuk

menyusui atau mempompa ASI

21 Atasan saya akan merubah jadwal bekerja saya

untuk memberikan saya waktu menyusui atau

mempompa ASI

22 Atasan saya akan membantu saya menangani

beban kerja saya, sehingga saya bisa menyusui

atau mempompa ASI ditempat saya bekerja

23 Atasan saya akan merasa sungkan jika saya

membicarakan periihal menyusui dengannya

No Pernyataaan Sangat

Setuju Setuju

Tidak

Setuju

Sangat

tidak

setuju

24 Rekan kerja saya akan berpikir bahwa sedikit

karyawan yang memilih untuk menyusui atau

mempompa ASInya ditempat kerja

25 Saya akan merasa nyaman membicarakan perihal

menyusui dengan rekan kerja saya

26 Rekan kerja saya mengatakan sesuatu yang

membuat saya berpikir mereka mendukung

perihal menyusui ditempat kerja

82

F. Waktu

Bagian ini menanyakan perihal waktu yang tersedia untuk menyusui atau

mempompa ASI pada jam kerja

G. Lingkungan Fisik

Bagian ini menayakan tentang lingkungan fisik dimana anda bekerja sambil

menyusui atau mempompa ASI

33. Saya dapat membeli atau meminjam peralatan yang saya butuhkan untuk

mempompa ASI saya.

Tidak

Ya

27 Rekar kerja saya akan menukar waktu

isitirahatnya dengan saya sehingga saya bisa

menyusui atau mempompa ASI

28 Rekan kerja saya akan menyelesaikan pekerjaan

saya jika saya membutuhkan waktu untuk

menyusui atau mempompa ASI

29 Rekan kerja saya akan merasa sungkan jika saya

membicarakan perihal menyusui dengannya

No Pernyataaan Sangat

Setuju Setuju

Tidak

Setuju

Sangat

tidak

setuju

30 Saya cukup sering mendapatkan waktu istirahat

untuk menyusui atau mempompa ASI

31 Waktu istirahat saya cukup lama untuk menyusui

atau mempompa ASI

32 Saya dapat menyesuaikan jadwal istirahat saya

untuk menyusui atau mempompa ASI

83

34. Tempat saya bekerja akan menyediakan peralatan yang saya butuhkan untuk

mempompa ASI saya ditempat kerja

Tidak

Ya

35. Saya dapat menemukan tempat untuk menyimpan ASI yang telah dipompa ditempat

kerja

Tidak

Ya

36. Ditemapat saya bekerja, tersedia ruangan menyusui/ mempompa ASI selama jam

kerja

Tidak

Ya

No Pernyataaan Sangat

Setuju Setuju

Tidak

Setuju

Sangat

tidak

setuju

37 Ruangan menyusui atau mempompa ASI ditempat

kerja saya kan dibuka ketika saya memerlukannya

38 Ruangan menyusui atau mempompa ASI cukup

dekat dengan lokasi saya bekerja untuk digunakan

saat waktu istirahat

39 Saya akan merasa nyaman menyusui atau

mempompa ASI diruang menyusui

40 Ruangan untuk menyusui atau mempompa ASI

memuaskan

41 Ruangan menyusuil atau mempompa ASI terdapat

segala sesuatu yang saya perlukan

84

H. Skala Multidimensional Dukungan Sosial I.

Intruksi : Kami tertarik pada bagaimana perasaan anda tentang pernyataan berikut dan

berilah tanda centang(√) pada kolom.

No Pernyataan

San

gat

tid

ak

set

uju

Tid

ak

setu

ju

Agak

tid

ak

setu

ju

Net

ral

Agak

set

uju

Set

uju

San

gat

setu

ju

1 Ada orang khusus yang ada disekitar ketika saya

membutuhkan

2 Ada orang khusus dengan siapa saya dapat berbagi

suka dan duka saya

3 Keluarga saya benar-benar mencoba untuk

membantu saya

4 Saya mendapatkan bantuan emosiaonal dan

dukungan yang saya butuhkan dari keluarga saya

5 Saya punya orang khusus yang merupakan sumber

nyata kenyamanan bagi saya

6 Teman-teman saya benar-benar mencoba untuk

membantu saya

7 Saya dapat mengandalkan teman-teman saya ketika

ada sesuatu yang salah

8 Saya dapat berbicara tentang masalah saya dengan

keluarga saya

9 Saya punya teman dengan siapa saya dapat berbagi

suka dan duka saya

10 Ada orang istemewa dalam hidup saya yang peduli

tentang perasaan saya

11 Keluarga saya bersedia untuk membantu saya

membuat keputusan

12 Saya dapat berbicara tentang masalah saya dengan

teman-teman saya

85

I. Iowa Skala Sikap Menyusui

Berilah tanda centang(√) pada kolom.

No Infant-Feeding Attitude

Str

on

gly

Agre

e

Agre

e

Mod

erate

Dis

agre

e

Str

on

gly

Dis

agre

e

1 Manfaat ASI hanya bertahan selama bayi menyusui

ibunya

2 Susu formula lebih memudahkan dari pada ASI

3 Kandungan zat besi pada ASI sangat kurang

4 Susu formula merupakan pilihan yang lebih baik jika ibu

berencana bekerja diluar rumah

5 Ibu seharusnya tidak menyusui di tempat umum

6 Bayi yang disusui ASI cenderung minum berlebih

dibandingkan bayi yang diberikan susu formula

7 Para ayah akan merasa diabaikan jika ibu menyusui

bayinya

8 Untuk bayi, susu formula sama sehatnya dengan ASI

9 Seorang ibu yang terkadang minum alkohol seharusnya

tidak menyusui bayinya

10 Menyusui dapat meningkatkan ikatan ibu dan bayi

11 Bayi yang diberi susu formula cenderung minum

berlebih dibandingkan bayi yang diberikan ASI

12 Ibu yang memberikan susu formula pada bayinya

kehilangan sebuah kebahagiaan menjadi seorang ibu

13 Bayi yang disusui ASI lebih sehat dari pada bayi yang

diberi susu formula

14 ASI merupakan makanan yang ideal untuk bayi

15 ASI lebih mudah dicerna dari pada susu formula

16 ASI lebih memudahkan dari pada susu formula

17 ASI lebih murah dari pada susu formula

86

Appendix 2

INFORM SHEET

Accosiated Factors of Six Months Breastfeeding among Employed Mothers after

Returning To Work

My name is Siska Ningtyas Prabasari, a Master Student at National Taipei University

of Nursing and Health Sciences. I am conducting study about factors related to exclusive

breastfeeding among employed mothers after returning to work. This study is intended to

fulfill an academic requirement.

I will ask you few questions relating to exclusive breastfeeding, breastfeeding

workplace-friendly and sosial support. There are four sections to this questionnaire. The first

is personal factors including demographic and attitude factors, second is breastfeeding

workplace-friendly factors and social support factors. This will take little bit your time

approximately 30 minutes. The information you will provide me will be made confidential

and will not be shared to a third party. After signing the consent form, a copy of

questionnaire will be given to you, kindly answer all question honestly and completely.

Thank you for giving me privilege of sharing your experiences and for taking your

time to participate in my research study.

Sincerely,

Siska Ningtyas Prabasari

Master Student

National Taipei University of Nursing and Health Sciences

87

LEMBAR INFORMASI

Faktror-faktor yang mempengaruhi ASI Eksklusif pada ibu pekerja setelah kembali bekerja

Nama saya Siska Ningtyas Prabasari, seorang Mahasiswa Magister Ilmu Kebidanan

dan Kesehatan Universitas Nasional Taipei. Saya sedang melakukan studi tentang faktor-

faktor yang berhubungan dengan pemberian ASI eksklusif di antara ibu yang bekerja setelah

kembali bekerja. Studi ini dimaksudkan untuk memenuhi persyaratan akademik.

Saya akan mengajukan beberapa pertanyaan kepada anda terkait pemberian ASI

eksklusif, lingkungan di tempat kerja dan dukungan sosial. Ada empat bagian untuk

kuesioner ini. Yang pertama adalah faktor pribadi termasuk faktor demografi dan sikap,

kedua adalah faktor ramah tempat kerja menyusui dan faktor dukungan sosial. Ini akan

menghabiskan sedikit waktu anda sekitar 30 menit. Informasi yang anda berikan kepada saya

akan dirahasiakan dan tidak akan dibagikan kepada pihak ketiga. Setelah menandatangani

formulir persetujuan, salinan kuesioner akan diberikan kepada anda, silakan jawab semua

pertanyaan dengan jujur dan lengkap.

Terima kasih telah memberi saya hak istimewa untuk berbagi pengalaman dan untuk

meluangkan waktu Anda untuk berpartisipasi dalam studi penelitian saya.

Hormat kami,

Siska Ningtyas Prabasari

Mahasiswa Master

Universitas Nasional Ilmu Keperawatan dan Kesehatan Taipei

88

CONSENT FORM

After been provided with clear explanation of the study, I know and understand purpose of

this study. I believe that researcher will acknowledge my rights as a respondents and this

study does not have a negative impact on me. I understand my participation will help

researcher and nurse to improve nursing services.

Hereby, I state willing to be a respondent in the study and my signature is evidence to

confirm my consent to participate in this study.

Date : / /2019

Respondent,

Signature or thumb print

( Name )

89

LEMBAR PERSETUJUAN

Setelah diberikan penjelasan yang jelas tentang penelitian ini, saya tahu dan mengerti tujuan

dari penelitian ini. Saya percaya bahwa peneliti akan mengakui hak-hak saya sebagai

responden dan penelitian ini tidak berdampak negatif pada saya. Saya mengerti partisipasi

saya akan membantu peneliti dan perawat untuk meningkatkan layanan keperawatan.

Dengan ini, saya menyatakan bersedia menjadi responden dalam penelitian ini dan tanda

tangan saya adalah bukti untuk mengkonfirmasi persetujuan saya untuk berpartisipasi dalam

penelitian ini.

Tanggal: / / 2019

Termohon,

Cetak tanda tangan atau ibu jari

(Nama)

90

Appendix 3

91

Appendix4

92

Appendix 5

96

Appendix 7

100

Appendix 9

101

102

103

104

Appendix 10