The decision of breastfeeding practices among parents attending primary health care facilities in suburban Malaysia.

OBJECTIVES: This study aimed to determine the association between decision making for breastfeeding practices and associated factors for exclusive breastfeeding practices among parents attending primary health care facilities.
METHODS: This cross-sectional study involved 196 parents who attended primary health care facilities in suburban Malaysia. A self-administered questionnaire was given to assess decision-making styles and factors associated with exclusive breastfeeding practices. Systematic random sampling was used for the non-exclusive breastfeeding group, and convenience sampling was used for the exclusive breastfeeding group. Multiple logistic regression analysis was conducted to determine the associated factors for exclusive breastfeeding practices.
RESULTS: We found an association between the mutual decision of parents on exclusive breastfeeding and exclusive breastfeeding practices. Previous exclusive breastfeeding experience, fathers' ages, mothers' occupations and mutual decisions had significant impact on exclusive breastfeeding practices.
CONCLUSION: The important determinant for practising exclusive breastfeeding is parents' mutual decisions. Therefore, practitioners need to continuously educate and emphasize the fathers' role in the breastfeeding process.

Introduction

Over the past decade, the Malaysian government has recognized the importance of breastfeeding and infant nutrition. Exclusive breastfeeding has since been highly recommended and encouraged for infants in the first six months of life. However, current breastfeeding practices in Malaysia are still inadequate compared to other South-East Asian countries; only 14.5% of infants below six months were exclusively breastfed in 2006.2, 3

There are multiple issues that affect the decision to initiate breastfeeding, as well as the duration of breastfeeding itself. Psychological, emotional, social and environmental factors all play a part in determining if a child is bottle-fed or breastfed. Stress over not producing enough milk, uncertainty about whether the infant is getting enough milk, mother/infant discomfort with breastfeeding, nipple or breast problems, embarrassment to breastfeed in public, maternal fatigue, returning to work, non-supportive employers, previous breastfeeding history and concern about weight loss were the reported barriers to initiate breastfeeding and the factors associated with breastfeeding duration.5, 6, 7, 8, 9 Other reported barriers towards breastfeeding include negative attitudes of the women themselves, their partners and family members as well as health care professionals.

Previous research also found that demographic factors are associated with breastfeeding duration. Younger women with lower incomes, ethnic minorities and full-time employees were more likely to stop breastfeeding within the first month of a baby's life.9, 10 However, in terms of educational level of the mother, other research found that the breastfeeding duration is longer in better educated mothers.11, 12

Evidence suggests that the decision of a mother to breastfeed is significantly influenced by various factors. A study performed by Odom EC et al. found that the prenatal opinions of health care providers or family members, including the maternal grandmother and the infant's father, play an important role in women's breastfeeding decisions after infant birth. In this study, they found that mothers who had never breastfed were significantly associated with the perceptions of the maternal grandmother, infant's father or health care providers who prefer only formula feeding, who prefer both formula and breastfeeding or who do not have specific preferences. On the other hand, mothers who believed their family members and health care providers preferred breastfeeding only were least likely not to initiate breastfeeding.

The literature on breastfeeding initiation and duration provides evidence that mothers who start weaning before the recommended period of 6 months postpartum do so because the decision to breastfeed was made during or late into the pregnancy and that the mothers have low confidence in their ability to breastfeed.

Thus, the decision making of parents and associated factors for exclusive breastfeeding practices are the most important factors that determine whether the child was exclusively breastfed in the first 6 months.14, 15, 16 Therefore, this study was conducted to evaluate the association between the decision-making style of the parents and breastfeeding practices and to determine the associated factors for exclusive breastfeeding practices among parents attending primary health care facilities in suburban Malaysia. The results from this study may be used by policy makers to improve strategies related to the promotion of breastfeeding, directly targeting fathers as supporters of breastfeeding with a focus on exclusive breastfeeding practice for 6 months.

Materials and Methods

This study is a cross-sectional study that was conducted in all Machang district health centres of Kelantan. Reference populations were parents from Machang, Kelantan, and the source population was parents whose children were having follow-up meetings at a health or community clinic in Machang, Kelantan. Study populations were divided into two groups: the case group and control group. The case group comprised parents who have had an exclusive breastfeeding practice with children, while the control group comprised parents without an exclusive breastfeeding practice with children.

A list of exclusive breastfeeding (case group) and non-exclusive breastfeeding (control group) parents was identified earlier by a staff nurse in charge from each health clinic. From the list, one hundred parents from exclusive breastfeeding (case group) and two hundred parents from non-exclusive breastfeeding (control group) groups were selected from all five health clinics available in the district of Machang, Kelantan. The total number of parents in the exclusive breastfeeding group (case) versus the non-exclusive breastfeeding group (control) were distributed equally among these health clinics. In the exclusive breastfeeding group (case) the convenient sampling method was used, while systematic randomized sampling with a ratio of 1:2 was used to select subjects in the non-exclusive breastfeeding group (controls).

The size of the sample was calculated based on a pilot study. The calculated minimum sample size was 83 but was then increased to 100 per group after an additional 20% was added to account for nonresponse rates.

The biological parents of a healthy singleton infant born at term between 6 months and 2 years of age were included in the study. However, those who were illiterate, had psychiatric disorders and malformation or had disordered children were excluded from the study.

Questionnaire

The self-administered questionnaire was used to determine the decision-making style and the associated factors for exclusive breastfeeding. Two sets of questionnaires were used in this study. Set 1 required response from the mother, such as the mother's socio-demographic data, parity, previous exclusive breastfeeding experience and decision making on exclusive breastfeeding practices. Set 2 required response from the father such as information on age, race, educational level, income and occupation of the father.

Data collection procedure

All parents who were involved in this study were briefed on this study by a trained community nurse during home visits. Informed consent was then obtained from the participants. The self-administered questionnaire was given to the parents for completion. The questionnaires were collected on the same day, and the answers were checked for their completeness.

Statistical analysis

Data were entered and analysed using Statistical Program for Social Sciences (PASW statistic) version 20. Data were checked and cleaned before conducting descriptive analysis to investigate the socio-demographic data. Chi-square test analysis was used to determine the association between the decision-making style and the breastfeeding practices. Simple logistic regression was used to screen for factors potentially associated with exclusive breastfeeding practices, and multiple logistic regression was used to determine the factors associated with exclusive breastfeeding practices while adjusting for other confounders in the model. The dependent variable was parents in the exclusive breastfeeding group. The independent variables were knowledge score, attitude score, social demographic for both mother and father, parity of mother, previous exclusive breastfeeding experience and mutual decision on exclusive breastfeeding.

Results

A total of 200 respondents were invited to participate in the study; however, only 196 responded, making the response rate 98%. Four respondents were excluded from this study due to 70% incompletion of the questionnaires.

The socio-demographic profile of the fathers is shown in Table 1. The age of the fathers ranged from 31 to 40 years old for both groups, with a mean age of 35.5 (7.3) years old for the exclusive breastfeeding (EBF) group and 36.7 (7.8) years old for the control group. The maximum age for the fathers was 61 years old, and the youngest was 21 years old. In both groups, the majority of the fathers had an education level of up to secondary level. One-third of them were self-employed.

Table 1

Socio-demographic characteristics of the fathers.

Variables	EBFn (%)	NEBFn (%)
Age	35.5 (7.3)a	36.7 (7.8)a
20–30 years old	26 (26%)	19 (19.8%)
31–40 years old	42 (42%)	47 (49.0%)
> than 40 years old	32 (32%)	30 (31.2%)
Education
Primary school	14 (14.0%)	8 (8.3%)
Secondary school	76 (76.0%)	75 (78.1%)
Tertiary educational	10 (10.0%)	13 (13.5%)
Occupation
Self employed	32 (32.0%)	38 (39.6%)
Government or private sector	26 (26.0%)	31 (32.3%)
Farmer/rubber tapper	8 (8.0%)	9 (9.4%)
Labourer	34 (34.0%)	18 (18.8%)
Income/month
<RM1000	75 (75.0%)	51 (53.1%)
>RM1000	25 (25.0%)	45 (46.9%)

Mean (SD).

The socio-demographic profile of the mothers is shown in Table 2. The age of the mothers ranged from 31 to 40 years old. The majority of the mothers' education in both groups was up to secondary level. Nearly half of the mothers in both groups were between parity 1 to 2. For the baby's age, almost half of the babies were between 6 and 12 months old during the data collection, with a mean (SD) age of 13.6 (5.96) months.

Table 2

Socio-demographic characteristics of the mother.

Variables	EBFn (%)	NEBFn (%)
Age
20–30 years old	45 (45.0%)	36 (37.5%)
31–40 years old	39 (39.0%)	48 (50.0%)
> than 40 years old	16 (16.0%)	12 (12.5%)
Education
Primary school	9 (9.0%)	4 (4.2%)
Secondary school	80 (80%)	74 (77.1%)
Tertiary educational	11 (11.0%)	18 (18.8%)
Occupation
Working	11 (11%)	46 (47.9%)
Not working	89 (89%)	50 (52.1%)
Income/month
<RM1000	94 (94%)	68 (70.8%)
>RM1000	6 (6%)	28 (29.2%)
Parity
1–2	42 (42.0%)	46 (47.9%)
3–4	26 (26.0%)	13 (13.5%)
5–6	20 (20.0%)	23 (24.0%)
>6	12 (12.0%)	14 (14.6%)
Previous experience given EBF
Yes	95 (95.0%)	44 (45.8%)
No	5 (5.0%)	52 (54.2%)
Baby age during interview
6–12 months	61 (61%)	57 (59.4%)
13–18 months	15 (15%)	20 (20.8%)
19–24 months	24 (24%)	19 (19.8%)

Decision-making style on exclusive breastfeeding by parents

Association between mutual decisions of parents with exclusive breastfeeding practices was observed. The majority of parents (98%) in the exclusive breastfeeding group had a mutual decision on exclusive breastfeeding practices for their children. In the non-exclusive breastfeeding group, the percentage is slightly lower, with 86.5% of the parents making a mutual decision for exclusive breastfeeding practices (Table 3).

Table 3

Decision-making style on exclusive breastfeeding by parents.

Decision on exclusive breastfeeding by parents	EBFn (%)	NEBFn (%)	P value
Mutual decision	98 (98.0%)	83 (86.5%)	0.002
Non-mutual decision	2 (2.0%)	13 (13.5%)

Associated factors for exclusive breastfeeding practices

Simple Logistic regression analysis shows significant associated factors for exclusive breastfeeding practices: father's income, mother's income, mother's occupation, previous exclusive breastfeeding experience and mutual decision for exclusive breastfeeding (Table 4).

Table 4

Factors associated for exclusive breastfeeding practices using simple logistic regression analysis.

Variables	SLRa
	Crude OR (95% CI)	Wald stat	P value
Father's age	0.98 (0.94,1.01)	−1.08	0.282
Mother's age	0.97 (0.93,1.01)	−1.29	0.198
Father's education
Primary school	1.00
Secondary school	0.58 (0.23,1.46)	−1.16	0.247
Tertiary educational	0.44 (0.13,1.45)	−1.35	0.179
Mother's education
Primary school	1.00
Secondary school	0.48 (0.14,1.62)	−1.18	0.239
Tertiary educational	0.27 (0.06,1.09)	−1.83	0.067
Father's occupation
Self employed	1.00
Government or private sector	0.99 (0.49,2.00)	−0.01	0.991
Farmer/rubber tapper	1.06 (0.36,3.05)	0.10	0.921
Labourer	2.24 (1.07,4.70)	2.14	0.032
Mother's occupation
Working	1.00
Not working	0.13 (0.06,0.28)	−5.290	<0.001
Father's income
<RM1000	1.00
>RM1000	0.38 (0.21,0.69)	−3.16	0.002
Mother's income
<RM1000	1.00
>RM1000	0.16 (0.06,0.39)	−3.91	<0.001
Parity	0.98 (0.86,1.11)	−0.31	0.759
Previous EBF experience
No	1.00
Yes	22.45 (8.38,60.11)	6.19	<0.001
Mutual decision on EBF
No	1.00
Yes	7.67 (1.68,34.99)	2.63	0.008

Simple logistic regression.

Multiple logistic regression analysis shows that previous exclusive breastfeeding experience and mutual decision for exclusive breastfeeding were significant associated factors for exclusive breastfeeding practices. However, mothers who are working are less likely to practice exclusive breastfeeding. In addition to that, the older the father is, the higher the probability of the baby not receiving exclusive breastfeeding (Table 5).

Table 5

Factors associated for exclusive breastfeeding practices using multiple logistic regression analysis.

Variables	MLRa
	Adjusted OR (95% CI)	Wald stat (df)	P value
Father's age	0.94 (0.89,0.99)	−2.32	0.021
Previous exclusive breastfeeding experience
No	1.00
Yes	29.13 (9.63,88.12)	5.97	<0.001
Mother's occupation
Working	1.00
Not working	0.12 (0.05,0.28)	−4.80	<0.001
Mutual decision on EBF
No	1.00
Yes	6.68 (1.15,38.81)	2.12	0.034

There were no interaction between the variables and no multicollinearity problem. The Hosmer and Lemeshow goodness of fit was not significant (P value 0.12), indicating the model was fit. The model fitness was also supported by the classification table of 82%, and an area under the ROC curve of 0.87.

A backward LR multiple logistic regression model was applied.

Discussion

Mutual decision among parents in the current study was found to be associated with exclusive breastfeeding practice. In other words, those who made a joint decision to exclusively breastfeed were more likely to practice it. Comparable findings were also found in two other studies among fathers in the southern United States and Finland, where 68% and 69%, respectively, of fathers agreed that a decision to breastfeed should be made by both parties.17, 18 Another study conducted in England found that the mother should make the decision on breastfeeding and that the father's role is to endorse the mother's decision and provide emotional and practical support.

These findings highlight the importance of the father's role in influencing the decision on infant feeding. A survey conducted among Malaysian mothers showed that exclusive breastfeeding is more common among mothers with supportive husbands regarding breastfeeding compared to non-supportive husbands.20, 21 Thus, a husband's decision and encouragement about breastfeeding positively influences exclusive breastfeeding by the mother.

There were similar findings in a study conducted among post-delivery mothers at John Hopkins Hospital, Maryland. The opinion of fathers on breastfeeding was found to be one of the most influential factors in practising breastfeeding among mothers. Mothers were more likely to breastfed if their partners were favourable to breastfeeding. Another study which was conducted among post-partum women in Ohio also reflected similar findings to the current study where a father's strong approval was associated with a higher incidence of breastfeeding (98.1%), while only 26.9% were being breastfed if the fathers were indifferent to the feeding choice. Findings in a study conducted in Hong Kong ranked the husband's opinion as the second most important factor in influencing the mother's decision on breastfeeding. The study also noted that infant-feeding outcomes were found to correspond to the father's preference. The majority of mothers agreed that encouragement and support from their husbands was an important factor for them to decide to breastfeed.

Our study also observed that previous exclusive breastfeeding experience has a significant association with current exclusive breastfeeding practices. This finding is similar to a study conducted in Singapore: a mother who had previously breastfed was more likely to continue breastfeeding at 2 and 6 months compared to one who did not breastfeed her child previously. Another study in Glasgow found that there is an association between previous breastfeeding experience and longer breastfeeding duration. A probable explanation is that mothers who had previous experiences of exclusive breastfeeding are more confident in practising the same for their current children as they are familiar with issues that might arise from exclusive breastfeeding practices. Thus, education on breastfeeding should be emphasized among women in their first pregnancy since they will continue exclusive breastfeeding practices with the next child.

Mutual decisions on exclusive breastfeeding practice are also one of the important associated factors as shown in this study. Practices of exclusive breastfeeding increased seven-fold among parents when both husband and wife agreed to practice exclusive breastfeeding compared to those without a mutual decision. Similarly, Australian women who felt that their partners preferred breastfeeding were ten times more likely to start breast-feeding than those who perceived that their partners preferred either bottle-feeding or were ambivalent about feeding methods.16, 26 Therefore, education on exclusive breastfeeding should strongly involve fathers so that they are well-informed of the importance of breastfeeding and encourage their partners during its initiation and process. They should also be encouraged to sit through regular antenatal class or breastfeeding practical courses together with their partners. Effective collaboration among family agencies and support groups will also strengthen exclusive breastfeeding practices in the community.

In our study, we found that mothers who are working were less likely to practice exclusive breastfeeding. Our findings were similar to other surveys conducted in Singapore, Peninsular Malaysia and Jordan.11, 20, 27 Exclusive breastfeeding rates are significantly low, which eventually leads to the cessation of breastfeeding once a mother has to return to work after her maternity leave is over. Furthermore, support from the employer is almost non-existent. There is no flexible time to assist mothers who need to breastfeed and very rarely is there a child care centre within reasonable walking proximity to the workplace. Therefore, proper education for mothers during the antenatal period on how to express, store and feed the expressed breast milk to their babies is an important strategy to improve exclusive breastfeeding practices. In addition, awareness among the employers should be improved, especially awareness of having a breastfeeding-friendly workplace, such as providing a private area with the appropriate facilities where mothers can express and store their breast milk. This would largely contribute to the success of exclusive breastfeeding practices among working mothers.

In this current study, another finding is that older fathers are not associated with exclusive breastfeeding practices. This, however, contradicts findings by Giugliani et al., which shows that fathers of breast-fed babies were significantly older (i.e., more than 25 years old). Fathers in the breastfeeding group in their study were better educated and more supportive. However, the fathers in our study were educated up to only the secondary school level. The differences in terms of educational level between their and our study might be the factor determining why older fathers in our study did not support exclusive breastfeeding.

Conclusion

Mutual decision-making of parents on the practice of exclusive breastfeeding is an important determinant for successful practices of exclusive breastfeeding. Previous experience as well as making a mutual decision on exclusive breastfeeding practices are favourable factors. However, working mothers and increases in father's ages are unfavourable factors. These results warrant primary health care practitioners' attention to increase the awareness and emphasize the importance of exclusive breastfeeding to their clients, in every pregnancy and postpartum period, to every newly coupled as well as elderly couples, and encourage positive support from husbands.

Ethical approval

The study was approved by the Ethics Committee of Universiti Sains Malaysia on the 14th of June 2011 (USMKK/PP/JEPeM [237.4 (2.3)]).

Authors' contributions

All of the authors have contributed significantly to this article, including study design, data collection, data analysis and interpretation and preparation and approval of the final draft of the article.

Conflict of interest

The authors have no conflict of interest to declare.