What Mother, Midwives, and Traditional Birth Helper Said About Early Initiation of Breastfeeding in Buginese-Bajo Culture.

INTRODUCTION: The aim of this study is to investigate how mothers, families, midwives, and traditional birth attendants in the Buginese-Bajo culture understanding breastfeeding and early initiation of breastfeeding (EIBF). Also to assess what support mothers receive from families, midwives, and traditional birth attendants during pregnancy, birth, and EIBF.
METHODS: This qualitative study included 21 subjects (11 pregnant women, three midwives, and seven traditional birth attendants). Recorded interviews with the three groups of participants were transcribed verbatim and analyzed separately, using latent content analysis. The study started in December 2014 and ended in July 2015.
RESULTS: Some mothers understood the meaning of EIBF, but engaged in it for different reasons. The midwives interpreted the principle of EIBF differently from a duration perspective. Traditional birth attendants explained it as a way to strengthen the relationship between mothers, and babies; they believed that prolonging breastfeeding until 2 years would change babies into caring children. According to them, this skin-to-skin contact has been practice for a century by traditional birth helpers. The philosophy of breastfeeding, according to the Buginese-Bajo, is creating "peru" relationships for mothers and babies each other for their whole lives.
CONCLUSION: These findings show a connection between established science and cultural beliefs. The concept of peru is the central philosophy to be achieved in EIBF. Breast-feeding's psychological value is known and passed from generation to generation; this essential fact needs to be preserved as local capital for changing breastfeeding behavior. The government should pay more attention to this opportunity to increase awareness and promote breastfeeding behavior changes.

Introduction

In traditional culture, gender roles in family life are clearly defined. Women's vital contributions are childbearing (pregnancy, birth, and breastfeeding), while men are breadwinners. Almost all traditional customs in Indonesia tie women to motherhood and men to fatherhood functions (Lamb, 2010; Meuwissen & Carlson, 2015; Parkinson et al., 2010). The transition to parenthood is defined by the cultural context of role limitation, in which fathers should provide for the family by working outside the house, and mothers should be responsible for raising a child at home. Transitions to parenthood also change two individuals and their social relationships, yet involve dynamic tasks that challenge their previous familial context (Feeney & Collins, 2015; Neyer et al., 2014; Parkinson et al., 2010).

Breastfeeding culture is a human existence. In the Egyptian, Greek, and Roman empires, women usually fed their children; later it became something too mundane to be done by royalty. Wet nurses were employed to breastfeed the children of royal families. In the 1900s, breastfeeding became seen as lower social class practice with the appearance of infant formula in the mid-19th century (which was improved after World War II). Breast milk substitutes were heavily marketed as a marker of a high-class social lifestyle. Infant formula became more widespread starting in 1988 when the formula industry began advertising directly to the public, creating tension between the medical profession and the formula manufacturers (Greer et al., 2008). The production, marketing, and power of the manufacturers influenced policymakers to change regulations, threatening the exclusive breastfeeding campaign. Scientific research discovered negative effects of the formula, including increased risk of atopy, diabetes, and obesity. The Lancet reported an estimated 820.000 under-five deaths could be prevented globally with breastfeeding (Victora et al., 2016). Efforts to make breastfeeding campaigns a priority have been pursued through varied programs, including making breastfeeding a key to attaining Sustainable Development Goals. By 2025, the World Health Organization (WHO) aims to increase global exclusive breastfeeding rates to 50% (WHO & UNICEF, 2018). Currently, only 38% of infants around the world are exclusively breastfed. Policymakers need to consider cultural diversity in any breastfeeding promotion program.

To achieve a breastfeeding duration of 6 months to 2 years, it must be ensured that every baby receives early initiation of breastfeeding (EIBF) in the first hour after birth. First-hour EIBF is crucial to determining the success of future breastfeeding. Developing countries with successful EIBF records, such as China, India, Pakistan, Malaysia, and other low-income countries, have shown positive breastfeeding coverage rates (Abdul Hamid et al., 2017; Ahmed et al., 2019; Lyellu et al., 2020; Muldiasman et al., 2018; Patel et al., 2015; Senanayake et al., 2019; Wang et al., 2020). In Indonesia particularly, EIBF practice remains unsettled. Many efforts and interventions address breastfeeding through educational and social support (Januraga et al., 2020; Wijaya-Erhardt et al., 2014). Culture-centered programs are on the rise, which engage with specific traditional communities.

It is essential to use culturally appropriate methods to implement health programs among culturally diverse populations. Indonesia is incredibly diverse, with a hundred tribes and wide variations in language, tradition, clothing, dialects, and local leadership systems. The government has to consider whether the national program is suitable for each community and how it would take the program to achieve its goals. The government needs to include local customs and values as capital to collaborate with the national policy in achieving breastfeeding targets. Moreover, it must allow local wisdom to sustain loving care for mothers and newborns.

Further research is needed to explore cultural values regarding breastfeeding and in order to increase knowledge of the culture-related EIBF in the Middle and East Indonesia. The aim of this study is to investigate how mothers, families, midwives, and traditional birth attendants (TBAs) in the Buginese-Bajo culture understanding breastfeeding and EIBF. Also to assess what support mothers receive from families, midwives, and TBAs during pregnancy, birth, and EIBF.

Methods

Design

This study used a qualitative design with content analysis. Content analysis is a step-wise process of categorization based on the expression of thoughts, feelings, and actions described throughout the text (Graneheim & Lundman, 2004). The purpose of the analysis is to grasp the meaning and explore information on the implication of long-standing rituals of pregnancy, birth, and breastfeeding for the decision to initiate early and exclusive breastfeeding. In-depth interviews were performed to identify the opinions of mothers, TBAs, and midwives regarding breastfeeding practice, and a decision to breastfeed early.

Participants

This study was undertaken from December 2014 to July 2015 in the coastal region of South Sulawesi, which is home to the Buginese-Bajo maritime tribe. This culture has a specific ritual regarding newborns which has been practiced for a century. This region consists of eight sub-districts that use Bahasa Indonesia, and their local languages Bugis-Bajo dialogue. A local interpreter was used to complete semi-structured, guide-trained interviewers which were audio recorded for transcription and analysis. The study included 21 participants: 11 pregnant women, three midwives, and seven TBAs.

Inclusion Criteria

Pregnant mothers were selected from antenatal care visits. Subjects varied in parity, age, and education. All of them required vaginal births. The midwives who participated ranged from 30 to 37 years old, all with at least 10 years work experience. TBAs were selected by their local expertise; traditionally, this role is handed down from mother to daughter. They had been working on the site for 25 years or more, so were older than the midwives—between 43 and 70 years old. They had also lived in the area since they were born.

Institutional Review Board Approval

Ethical approval was received from the Ethics Commission of Medicine Faculty, Hasanuddin University, Makassar.

Data Collection and Analysis

Recorded interviews with the three groups of participants were transcribed verbatim and analyzed separately using latent content analysis. The in-depth sequencing interview results from mothers, midwives, and TBAs were scrutinized, discussed, compared, and validated. Familiarity with the text was achieved by repeated readings. Words and sentences containing relevant information were identified as meaning units, which were condensed and coded. The codes were grouped into subcategories, then categories. Data were further analyzed by reading across the categories, searching for new associations and meanings in the data. In the final step, findings were discussed and reflected upon, taking the research issues into account, and an overall theme emerged.

Interviews With Mothers

Interviews with 11 mothers started from the third trimesters of pregnancy. They began by exploring women's attitudes toward and understanding of EIBF, and exclusive breastfeeding; and how motivated they were to nurse their babies. The interview session lasted 3–5 h.

Interviews With Midwives

The interviews with the three midwives focused on their awareness of EIBF, patient communication, barriers to implementing this approach, and collaboration with TBAs, as well as their commitment to supporting breastfeeding initiatives.

Interviews With TBAs

The interviews with seven TBAs focused on the pattern and form of their collaboration with midwives in assisting with childbirth and understanding of early breastfeeding initiation from the perspective of traditional Bugis-Bajo culture.

Results

The experience of mothers, midwives, and birth attendants in birth, and breastfeeding during their birth interaction become the first central theme: “the understanding of the principle of EIBF.” This theme was divided into two subcategories: understanding the benefits and the principle methods; and understanding what support mothers gained from their environment. This theme is traced from the perspectives of mothers, midwives, and TBAs. Each category was presented using indirect quotations in a reductional conversation format. A code number for each respondent was included after the quote (mothers: Ms, Mr, As, Ag, Hm, Mw, Nv, Nr, Hs, Ht, En, midwives: Mw1 to Mw3, TBAs: TBA1 to TBA7).

The Principle of EIBF

EIBF was recognized as kangaroo care according to midwives’ information (Hm, Nr, Ht, Nr, Nv)). Others found information on the internet (Hs, Mr, En, As, Ag). One mother found it too long from her educational history in college (Ms). Mothers saw early breastfeeding initiation as a way to strengthen affection (Ms, Hm), stimulate milk production (As, Hs, En), prevent bleeding (Ms, Hs), protect babies from disease (En, Hs), and help babies grow into a smart and caring child (En, Ht). This knowledge is based on the understanding of midwives, one of the primary sources of information for pregnant women.

Some mothers understood the steps of putting the baby on the mother's abdomen immediately after birth and letting him/her seek the mother's nipple (Ms, Mw, Hs, Ht, En). However, the principle of EIBF was interpreted differently by the midwives, in terms of the ideal duration from when the baby started moving toward the nipple to suckle ranged from 30 to 60 min (Mw1, Mw2, Mw3). The absence of this practice at every birth signified their weak commitment and narrowed the time to skin-to-skin contact.

TBAs know about EIBF from watching midwives when they collaborate in the birth process (TBA1, 2, 4, 5, 7). They interpret it as a way to strengthen the relationship between mother and baby (TBA1, 2, 3, 4, 7) while prolonging breastfeeding until 2 years turns the baby into a caring child (TBA2, 3, 4, 5, 6). According to them, this skin-to-skin contact reminds them of the routines they witnessed a long time ago when they were teenagers (apprentice period before the TBA's role handed-over by their mother) (TBA3, 4, 5, 6, 7). Their elder TBA's always do the same practice put the baby first on top of the mother's abdomen after birth. This practice is intended for the baby and mother to feel each other presence, strengthen the maternal bond, and maturing their motherhood instinct (TBA6, 7). TBA's argued that babies are born with extraordinary levels of sensitivity, beyond the mother, so a mother should not abandon a baby. Failing to breastfeed a child for at least 2 years is seen as a reason child becomes careless and inclined to disobey later (TBA5, 6, 7).

Environmental Support for EIBF Practice

Husbands play a critical supporting role for mothers. For example, they accompany their wives to the doctor (Ms, Mr, As, Ag, Hm), fulfill all kinds of wishes (Nr, Hs, En), provide nutrition (Ms, Ht, hs, Nv, Mw), buy maternity clothes (Mw, Nv, Nr, Hs, Ht), and maintain happy feelings during pregnancy (Ag, Hm, Mw, Nr, En). Mothers also have support from other family members, especially parenting assistance from their parents (grandmothers) (As, Mw, Hm, Nv, Nr). This assistance is vital for working mothers, however, having grandmother care for the child often leads to formula feeding (Hs, Ms, Ht), this occurs when the mother leaves insufficient breast milk at home.

Information support was obtained from midwives for matters related to pregnancy, birth, and breastfeeding (Ms, Mr, Ag, En, Ht). However, emotional support and a sense of empathy were less perceived (all mothers). Midwives were only present at antenatal care, the birth, and postpartum sessions. Birth attendants played a role as spiritual companions for mothers and babies during birth (all mothers). They believed that traditional birth attendants have specific skills that midwives will never have. This is proven by the power of prayer and their decades of experience, helping them to save two or three generations in a row.

All midwives agree that skin-to-skin contact is essential in the birth routine and benefits successful breastfeeding. All showed a positive attitude towards it, but did not always implement it. The midwivess’ efforts to deliver information to patients on antenatal care were inadequate. They admitted that they did not have equal time for each patient, as they were weighed down by administrative responsibilities such as writing task reports each day (Mw1, Mw2, Mw3).

Support of a skin-to-skin routine was not explicitly mentioned by traditional birth attendants. However, their values are highly positive toward breastfeeding, even considering it a mother's responsibility to her baby (TBA1, 2, 4, 6). They believe that breasts were created by God and it is a mother's duty to nurture and give life to her children (TBA2, 5, 6, 7).

Barriers to EIBF Implementation

Early initiation of breastfeeding still faces many obstacles. Several mothers felt a little embarrassed at being seen by people topless for a protracted period of time (Ms, Mw, Ag, Hm, Nv). Some said they were afraid the baby would crawl and fall (As, Hm, Nr, Hs). Other's decisions were influenced by grandmothers who knew nothing about the benefits of the practice (Ht, En). While midwives recognize the long suckling period of this practice is the reason they are reluctant to follow the procedures (Mw1, Mw3). One admitted that EIBF is based on national policy, but its implementation is weakly supervised, so they feel it is not mandatory (Mw2).

All the mothers understood the benefit of breastfeeding but found it difficult to maintain breastfeeding duration. Some had problems with the nipple and positioning (Mw, En, Ht), some had to go back to work (Ag, Nv, Nr, En), others had problems with milk production (Nr, Hm, As, Ms, Mr), Midwives thought mothers ceased breastfeeding to return to work, due to lack of knowledge, difficulty in lactation technique, and exhaustion (Mw1, Mw2, Mw3). Traditional birth attendants assume, that mothers should never stop breastfeeding, or they make excuses because they are less patient and caring (TBA1, 3, 4, 5, 7).

Discussion

Based on the subjects’ responses to the central theme, it was concluded there are three characteristics of maternal understanding of EIBF related to birthplace factors. First, mothers at home are generally not aware of EIBF planning; during birth, they accept whatever the midwives do. It may happen because a home birth situation is usually handled only by midwives, without a prediction of time. Midwive’s actions are accepted by the family to save the baby and the mother. There is no discussion about the birth plan, and what families want or midwives suggested. New methods are needed to explain, using evidence-based practices, which the patient will be willing to hear, especially after experiencing the benefits. Second, births take place in hospitals that fail to practice EIBF. Maternal routine care absence implemented the Baby-Friendly Hospital Initiative. Activities such as cleaning, measuring, and weighing newborns, giving vitamins drops or vaccines, and all other routines are delayed until EIBF is completed. This situation occurs from lack of supervision, and obligation to do this practice persistently. Many EIBF failures occur in hospitals, mostly due to the demands of midwives’ jobs (Majra & Silan, 2016). Some senior midwives are poor role models, being part of habitual cultures not aligned with maternal and infant health.

Third, some mothers understand and insist on EIBF, but it is not done as expected. Midwives not committed to patient-centered care interrupted the process before 60 min. Optimally, EIBF least 60 min after the baby reaches the mother's nipple (Gangal et al., 2007). Indonesia has not fully initiated BFHI standards; there are no exact figures for how many BFHI accredited hospitals it has. IBFAN's report for the Indonesian commission indicates that obstacles to EIBF implementation are numerous, especially the persuasion of EIBF policies and the lack of protection for breastfeeding women working in the informal sector. There are no penalties for violations of the WHO's International Code of Marketing of Breast-Milk Substitutes, and no planning program that protects breast milk administration in emergencies such as natural disasters and HIV/AIDS (IBFAN, 2014). As well as maternal knowledge and understanding of EIBF, the pressure of birth attendants and hospital childbirth can override the intention and determination of the mother. Postpartum fatigue can make mothers vulnerable, passive, and accepting of any treatment by midwives. Also, EIBF may not be done properly for reasons such as the baby being weighed, measured, and vaccinated.

These circumstances contrast with Nepal (Adhikari et al., 2014). Two-and-a-half babies born in the hospital take advantage of EIBF, with 1.67 times more success than in home births. This maintains behavior support by positive routine practice. Almost all hospitals certified as BFHI practice Ten Step to Successful Breastfeeding. They have EIBF and breastfeeding programs based on community support. These provide guidelines and help the patient so they are able to adapt and increase a supportive behavior before being discharged from hospitals (Schmied et al., 2014). If all the government hospitals in Indonesia were capable of adopting and implementing the BFHI standard, at least two-and-a-half birth would receive EIBF and continue to breastfeed for 2 years.

In most European countries, EIBF attainment in hospitals is high. In Germany, it reaches 90%, but after the mother leaves the hospital, exclusive breastfeeding decreases. This situation is due to a lack of breastfeeding support programs off-hospital (Drago, 2011). In a scenario for strengthening breastfeeding programs from health care providers such as general hospitals, there would be funding problems. For example, the hospital needs to provide in-patient support such as certified counselors, patients would be charged counseling fees because insurance companies do not cover educational services. If the hospitals have to provide it themselves, the problem lies in financing the training of clinical personnel into certified counselors. If they have to pay for certificates, their commitment to support breastfeeding is still weak. Also, lactation counseling is considered a less-promising profession in Indonesia (Rouw et al., 2014).

The study also found that midwives’ misinterpreted the difference between EIBF principles, and benefits, leading to less systematic implementation of EIBF guidelines. The duration of implementation was less than 60 min because they considered EIBF too time consuming, though it was written in the standard of care delivery. These factors indicate a lack of confidence, commitment, and knowledge among midwives regarding the latest guidelines for breastfeeding babies. They may have a weak commitment to the implementation of EIBF because they are imitating senior midwives. Puskesmas (Primary Health Care Institutions) leaders also do not enforce this regulation in writing, as called for by Government Regulation No. 33/2012.

Other inhibitors include disturbances by family members during the EIBF. Counseling efforts to educate mothers are rare in prenatal times. This was also reported in a study of midwives and nurses on breastfeeding knowledge and practices. Poor knowledge becomes a determining factor in the effort to support lactation education. Inadequate understanding of EIBF is also a factor in non-exclusive breastfeeding, although the main reason is due to the workloads of housewives and working mothers (Dachew & Bifftu, 2014; Mcneill et al., 2012).

Only one of the seven TBA knew and had seen midwives perform EIBF, but they thought it was not something new. In the past, they witnessed the elder, who was also a TBA's, put the baby on the mother's stomach. This was so the baby could recognize, perceive and smell the mother, and look at her face. Whether the infant is on prone or supine position, the purpose of this action has the same philosophy as the goal of EIBF, which is to increase the bond between mother and baby (Gangal et al., 2007). Moreover, TBAs assume that childbirth at home is much more comfortable and safer than in hospitals, as they often find that their clients are afraid of having a baby in the hospital because of Cesarean sections. A meta-analysis of the risk of childbirth at home and in the hospital found no reliable evidence on maternity health care facilities regarding benefits and safety levels (Olsen & Clausen, 2012). However, planning a home birth with midwives needs integrated expertise with obstetric and neonatal emergency services, so patients feel safe and have options (Hutton et al., 2009). Midwives must be certified in basic obstetric emergency neonatal care.

Support required by the mother includes instrumental, emotional, informational, and appraisal. This support comes from people related to the mothers, especially families, midwives as care providers, and TBA's as spiritual guides. Midwives provide much-needed support in the form of information. They, as literate practitioners of obstetrics, should educate women on processes undertaken by the mother. Information on EIBF should be part of prenatal counseling to induce the mother's intention; the stronger the influence, the more likely this intention will turn into positive attitudes and behaviors. Although this role is essential, information on feeding behavior is rarely improved by health care providers. Also, some midwives who show a supportive attitude, have personal experience in breastfeeding and have been proven through years of practical experience (Creedy et al., 2008).

Specifically, the term EIBF is less well-known to TBAs, but the act of putting babies on the mother's abdomen has long been a part of the birth routine. The principle of implementation and purpose of this action is the same as EIBF. The wisdom of the mother and baby approach is typical of Sanro Ugi or Buginese TBA services. The positive attitude of a TBA when a mother gives breast milk aligns with the principle of mental closeness, goodness, patience, and the future success of the child. Buginese philosophy assumes breastfed babies will be caring and compassionate (maperu) to their parents someday; instead, they grow up to be mapettu-peru, disobedient, rebellious, and less concerned about their parents. The Buginese philosophy also sees breastfeeding as an obligation for the mother, and breasts as created by God for women to breastfeed. No reason whatsoever is justified when the mother stops breastfeeding. If there is a pain when breastfeeding, it is because the breast removes milk and it heals itself. Breastmilk is also known as a traditional remedy for babie’s health problems. In the future, breastfeeding problem occurs from mothers attitudes of ignoring their babies.

The concept of peru, expressed by TBAs, is a logical in the context of breastfeeding. In the Buginese language, peru means empathetic compassion and a caring attitude; maperu is an inward manifestation, based on an inbreeding relationship. The bond of affection is entwined in mother and baby, physiologically, early in pregnancy. Mother and infant connect through physiological responses during the pregnancy. Mother can communicate with the baby intimately. Buginese-Bajo society views hope, prayers, and ethical behavior as inherited. Generally, every parent has high hopes and wishes for their children. The concept of peru is the central philosophy to be achieved in EIBF. Maternal-infant bonding through the EIBF, improves hormonal responses, including increased levels of oxytocin (Lawrence, 2008).

In the early postpartum phase, and throughout parenting, peru is an embodiment of the mother's love for her child, at that time the child is in a situation of full dependence. As the child bigger and becomes independent, the mother turns older and weaker, in return they need care and compassion from their grown-up child. Peru becomes an embodiment of the child's love for her parents. This reciprocal function according to the TBAs, is potentially dysfunctional if one of these roles is undertaken inappropriately by the mother. One manifestation of their role is giving affection through breastfeeding. They believe a child grows into a person who is bad-tempered, rude, and not empathetic as a result of parenting patterns. The worst outcome is if a child becomes mapettu peru (the opposite of peru) to his parents. TBAs in the Buginese-Bajo community are believed to guide mothers safely through pregnancy until the birth of the baby. This expertise rests on the prayers of salvation offered at births, and assistance to the mother. The value of salvation prayers is based on a belief in God.

This spiritual power is needed by the mother, especially during the birthing process. This knowledge is absent in midwife education, which prompts mothers and families to use TBA maternity services. The cultural value of the TBA is the promotion of EIBF and breast milk feeding. However, their role seems to be underestimated by midwives. Their positions are slowly being replaced due to government policies on prenatal care, increased antenatal coverage, and childbirth, all of which must be handled by midwives.

This study emphasizes the importance of EIBF in the Buginese-Bajo community as a basis for building relationships between mothers and babies. The basis of these relationships will determine how they evolve in the future. Many empirical studies have proven the benefits of breastfeeding initiation: temporal, long term, physical, intelligence, emotional, and psychological (Chowdhury et al., 2015; Eidelman & Schanler, 2012; Ip et al., 2007; Weimer, 2001), and it has been carried out from generation to generation in this community. The longer a child breastfeeds, the better its condition, psychologically, and physically. The bonding that is achieved between the two is a sacred relationship that extends beyond the biological roles of mother and child. Other findings are clarified, such as the need to increase correct and up-to-date knowledge for midwives and families to support EIBF.

Strengths and Limitations

This EIBF issue is culturally analyzed in depth, with philosophical concepts anchored in daily life. As current living stresses undermine breastfeeding values, this pure foundation might deepen their comprehension of their forefathers. The data findings are more powerful and convincing in answering the question of decreased breastfeeding achievement. This qualitative discussion, however, could have been impacted by the authors’ personal biases toward the private practice of EIBF, and it could also be significantly different from other cultural values in Indonesia. This difficulty, however, has been addressed with a translation procedure that allows participants to catch the full meaning.

Implication for Practice

Similar research can be useful in coming up with easier ways to adjust methods by emphasizing the noble qualities that have usually been identified in the past to improve breastfeeding programs.

Conclusion

The indigenous practice of placing babies on the mothers chests is similar to EIBF. Breastfeeding has a meaningful purpose of protecting and promoting care between mother and baby throughout their lives. Barriers raised by families and birth attendants should be addressed through upgrading information and skills on maternal needs. Traditional values should be conserved as a local capital for transforming breastfeeding behavior. The government should give more attention to this, to raise awareness and change behavior. Indonesia is one of the most diverse nations in the world, with a hundred different tribes with various languages, traditions, clothing, dialects, and local leadership systems. This diversity has brought breastfeeding culture promotion under consideration. The more the practice can be tied to local values, the easier it will be to support optimal breastfeeding behavior and attitudes.