Exclusive breastfeeding behavior of adolescent mothers: A qualitative study

Exclusive breastfeeding behavior of


INTRODUCTION
Exclusive breastfeeding refers to the practice of feeding infants only breast milk from birth to the first 6 months, without providing other supplementary food and water. Currently, the overall rate of exclusive breastfeeding for infants under six months of age is only 41%. 1 This figure is projected to constantly rise in order to meet the World Health Assembly's global target of at least 50% exclusive breastfeeding. 2 Many factors can lead to unsuccessful exclusive breastfeeding, including maternal age at childbirth, lack of education, economic factors, lack of antenatal care (ANC) visits, lack of family support, working mothers, late early initiation of breastfeeding, caesarian section, and lack of knowledge and counseling about exclusive breastfeeding. [3][4] Younger maternal age at delivery is often highly related with low rates of breastfeeding among adolescent mothers. 5 In this line, adolescent mothers who have had children in their younger age are associated with the incidence of early marriage, which is deemed as form of violence and violation of children's rights. 6 Countries worldwide define early marriage as the marriage or union between two people in which one or both parties are under 18 years. 7 Currently, there has been an estimated number of early marriages of around 650 million in the world. This figure is taken from the number of teenage girls who were married before the age of 18 years and the number of adult women who were married or in union in their childhood or adolescents. 8 It was reported that in 2015, the prevalence of early marriage in Indonesia amounted to 23%.
In other words, 1 in 5 ever married women aged 20-24 years had their first marriage before the age of 18. 9 Adolescent brides are prone to experience a greater risk of negative health care experiences. 7 Mothers who have children at their teenage age generally have insufficient knowledge about child health and development. Hence, they may be less sensitive to the nutritional needs of infants. 10 This fact is attributed to the pain and feelings of fear they have. Adolescents also feel that their babies refuse the direct breastfeeding and are unable to suckle, and thus need to be given other supplementary foods, which results in the failure of exclusive breastfeeding. 11 Therefore, this study aims to explore the exclusive breastfeeding behavior among adolescent mothers. characteristics as the research subjects. The results of the pilot interview show that the list of questions from the interview guide was well understood by the participants, and the answers provided were adequate to answer the questions.

Trustworthiness and Data Analysis
To maintain the trustworthiness of this research, the interviews were recorded using an audio recorder, then transcribed using a verbatim technique, and checked by participants trough member checking. An audit trail was carried out by creating a clear and transparent description of the research process and by presenting evidence and quotes by participants. The researchers also used field notes, and the researchers also regularly discussed the research progress with the external reviewers/peer examinations. The data were analyzed by means of thematic analysis, by adopting the Milles, Huberman and Saldana model, which consisted of data condensation, data display, and drawing conclusions or verification. 12 To analyze the data, the researcher used the NVivo 12 trial version software.

RESULTS
The Data analysis revealed 5 themes that could explain and describe the behavior of adolescent mothers in exclusive breastfeeding. These themes are explained comprehensively, as follows:

Perspectives and Attitudes about Exclusive Breastfeeding
This study indicates that most participants share a positive perspective and attitude about exclusive breastfeeding. This fact is observable from their expression of support on breastfeeding, believing that breastfeeding alone can meet the baby's nutritional needs and their regrets for failing to provide exclusive breastfeeding, as stated by the participants in the followings: "I greatly support it (breastfeeding), rather than providing various kinds of milk. No matter how expensive the formula milk is, (yes), breastfeeding is still the best" (P4 In general, the participants shared their support and positive perspective and attitude towards exclusive breastfeeding. In contrast, some participants still indicated a permissive attitude towards formula feeding and did not really believe that breastfeeding alone would be enough for the nutritional needs of babies until they are 6 months old as revealed through the following statements: "

Study Design
This is a qualitative research with a phenomenological approach. This study aims to dive deep into the real life cases of exclusive breastfeeding among adolescent mothers as a way to provide better insight and understanding of the actual problems. The purposive sampling technique was used to explore the exclusive breastfeeding experiences of adolescent mothers. The research participants were selected based on the following inclusion criteria: breastfeeding mothers aged <20 years, who were married before the age of 18 years, having children aged 6-12 months, physically and mentally healthy, and willing to participate in the study. Participants were excluded from the study if they met the exclusion criteria, such as mothers with breast diseases (breast cancer, abnormalities in the nipples), mothers with infectious diseases, mothers with low birth weight (LBW) and twin babies, and mothers with babies with abnormalities (labioschisis, labiopalatoschisis). The criteria for this study were met by 7 participants. After interviewing 7 participants, the researchers reached data saturation, in which no new ideas or themes emerged, whereas Creswell recommends 3-10 participants in phenomenological studies.

Data Collection
Data were collected from January to March 2020, in two primary health centers with the working areas of Bantul Regency, Yogyakarta Province, Indonesia. Four midwives and several health cadres as gatekeeper were involved to assist the selection of research participants. Interviews were conducted at the homes of health cadres and participants' homes based on the participants' requirements. Semistructured interviews were conducted after participants agreed and signed the informed consent form. Interviews were conducted for approximately 40 minutes to 1 hour based on the interview guide, which had previously been tested with a pilot interview to maintain trustworthiness of the study. Pilot interviews were conducted in this study by administering a trial of interview guidelines to a breastfeeding mother who shared the same ORIGINAL ARTICLE confused since it was the first time for me" (P2). These expressions denoted the unpreparedness of the participants for exclusive breastfeeding. However, the feeling of happiness towards the birth of their baby is also undeniable. According to some participants, in the end their motherly instincts allowed them to: "Before the baby was born, I was very confused about what to do. However, after a while, the motherhood instinct took over…" (P1). "I think it is just okay... especially after seeing the baby is satisfied. It made me happy. Just for the sake of the baby, I ignored the pain... " (P5).
In addition, this happy feeling may arise given the fact that early marriages are often resulted from pregnancy out of wedlock or even unwanted pregnancy. Hence, childbirth is often considered an essential moment to improve adolescent mothers' relations with their parents, as revealed by the participants in the followings: "For instance, the moment of childbirth is an extremely painful experience. It was so painful that I cried to my parents, apologizing for everything I have done, oh…" (P7).

Knowledge
The knowledge on exclusive breastfeeding of adolescent mothers who were married in their teenage years is seen from their various answers on the interview question. These expression indicate the lack of knowledge and wrong understanding of some participants on the recommended duration of exclusive breastfeeding.
However, participants already have a fairly good knowledge of the benefits of exclusive breastfeeding, as denoted by the followings: "In terms of the benefits of breastfeeding, in my opinion, the babies will have better immune system than the babies having formula feeding. In addition, it is less costly. " (laughing) (P1). "Oh, I guess breastfeeding is just fine. The baby will not easily get sick. The midwife also told me that breastfeeding also prevented some diseases later when I grow older" (P3).
Interestingly, this study revealed that all participants know that complementary feeding (MPASI) is given after the baby is 6 months old, although some say that exclusive breastfeeding shall last for 2 year long, as denoted below: "Yes, those 6 months shall eat rice and milk. However, my baby refuses drinking milk, hehehe" (laughing)" (P4). "They shall start eating complementary feeding at the age of 6 months right? During the age of 6 to 7 month, they shall consume only rice flour, and afterwards, they can consume something like pumpkin" (P2). These excerpts imply the good level of knowledge of the participants about the appropriate provision of complementary feeding after 6 months of age. However, this does not mean that they know that exclusive breastfeeding shall only last for the first 6 months of a baby's life and during which the baby cannot be provided with anything else, including water. It is evident that some participants believed that they had exclusively breastfed, even though the reality was different, as revealed from the following confession: "Yes, I think I have had an exclusive breastfeeding" (P1 The statements from these participants also indicate that the unsuccessful exclusive breastfeeding is not only due to the mother's behavior, but also due to other factors that hinder the practice of exclusive breastfeeding, such as the practice of providing formula milk for babies by some hospitals when they leave the hospital, sales promotions in pharmacies, and the non-supportive circles among the mother and baby environment.

Perspectives and Attitudes about Exclusive Breastfeeding
The results of this study are in line with the research conducted by Mundagowa et al. 4 which revealed that 84% of the 225 respondents in his study in Zimbabwe had a positive attitude towards the practice of exclusive breastfeeding. However, only 36% of the participants were successful in exclusive breastfeeding. During the first 6 months of exclusive breastfeeding, many things can happen. Challenges and difficulties often complicate the process and may lead to the failure of exclusive breastfeeding. Some of these problems include pain, less protruding nipples, insufficient milk production, and even the fear of breastfeeding. Thus, the mothers' positive perspective and attitude about exclusive breastfeeding does not guarantee the success of exclusive breastfeeding. 11, 13 The result will be even worse when the participants show tolerance for the provision of formula milk or feel that breast milk alone is not enough for the baby during his first 6 months. Some participants actually looked doubtful or did not have a strong view of exclusive breastfeeding. This Perception of insufficient breast milk is related to the knowledge that they have about exclusive breastfeeding. 14 It was notable that the family is one of the supporters for mothers in providing exclusive breastfeeding, but the family can also hinder the practice of exclusive breastfeeding. The research by Henry et al. 15 highlighted that social aspects can influence marriage decisions. This causes adolescent mothers to be very dependent on their families, including in child care. The research by Palupi and Devy 16 also denoted that mothers of early marriage who live with large families usually show an attitude of relying on their parents and tend to ask for advice from them. When parents are the only source of information, there is a tendency for mothers to get outdated information. In fact, the information from parents is still closely related to the old customs and culture, unless their parents actively seek updated information.

Initial Response of Breastfeeding
Breastfeeding pain fears among adolescent mothers have been documented in the literature. 11,17 Young women are frequently psychologically depressed and physically unable to begin breastfeeding for a few days after delivery. 17 Because of early marriage, mothers have a low level of education and knowledge, limiting their ability to provide exclusive breastfeeding. This is what leads to confusion in the face of breastfeeding for mothers having early marriage. Breastfeeding becomes more complicated than they anticipate or are capable of handling, and they can quickly feel overwhelmed and out of control. 3, 18 Early marriages often result from unplanned or even unwanted pregnancies. The transition from someone being cared for to someone in charge of taking care of the baby is certainly not an easy thing to deal with. In addition, the initial experience of breastfeeding that is physically unpleasant, painful, and unbearable will have an impact on stopping breastfeeding and failing to provide exclusive breastfeeding. 19 They may, however, be happy and proud of themselves, or relieved that the labor is over. In addition, adolescent mothers are generally pleased to have children and believe that their lives have improved since becoming mothers. 20 Furthermore, in the case of early marriage, the birth of a child can be an opportunity to improve relations with parents, particularly those who are at odds with their mothers because they share one trait: they are mothers. Resilience develops when they are able to critically assess the alignment of their environment and their own needs. This critical reflection takes place after the baby is born, when they realize their role has shifted from that of a child to that of a mother responsible for caring for her own child. 21

Knowledge
A mother's exclusive breastfeeding behavior is greatly influenced by her knowledge. 22 Lack of breastfeeding knowledge is a barrier from the beginning of breastfeeding to the decision to wean the baby. 18 Exclusive breastfeeding in adolescent mothers, especially given their age and lack of knowledge and experience, may result in a stressful phase in exclusive breastfeeding. 23 All participants in this study were aware that complementary foods could only be given to a baby after the age of six months. However, three of the seven participants in this study stated that exclusive breastfeeding is the practice of breastfeeding for two years. In addition, although the majority of participants said that exclusive breastfeeding was the practice of only giving breast milk, in fact only one participant was successful in giving exclusive breastfeeding. This shows that incomplete knowledge about the concept of exclusive breastfeeding affects the success of exclusive breastfeeding. The same thing was also expressed by Bhanderi et al. 3 , in their research in India which stated that lack of knowledge about exclusive breastfeeding is an obstacle to exclusive breastfeeding behavior.
Research conducted in Ontario showed

ORIGINAL ARTICLE
that knowledge is one way to empower oneself, but exchanging information with others in a breastfeeding support group (BSG), is an important two-way process in which participants give and receive support. 24 In addition, the challenges encountered during breastfeeding, the support received from the social environment, socio-economic conditions including housing conditions, opinions from husbands, mothers, and other family members are also related to the success of breastfeeding. 4-5

Challenges and Difficulties in Breastfeeding and the Strategies to Deal with These Challenges
The results of this study are in line with the research conducted by Schindler-Ruwisch et al. 25 which revealed that despite experiencing difficulties such as pain, sore nipples, swollen breasts, mastitis, etc., mothers still showed perseverance and commitment to continue breastfeeding. However, the research by Hawley et al. 26 also showed that some mothers who experienced sore nipples made them experience excruciating pain and frustration to the point of thinking about the need to use formula milk or a breast pump. Therefore, it is very important to provide education to mothers, especially young mothers, about the correct breastfeeding technique. Inadequate skills are what actually cause mothers to have painful breastfeeding experiences that they cannot manage properly. 19 Feelings of resignation and despair also often arise because of guilt towards parents, because their early marriage is the result of pregnancy out of wedlock. This sense of hopelessness may also arise because of the stigma they receive from the surrounding environment for being a mother at a very young age. 27 In addition, often young mothers of early marriages are unable to tell others when they are having problems in breastfeeding. Hence, they just surrender and undergo the practice of breastfeeding by letting the baby and their breasts control the practice of breastfeeding they live. 19

Failure of Exclusive Breastfeeding
The next theme revealed in this study was the failure of exclusive breastfeeding. This is in line with the results of the study by Mundagowa and his colleagues, which showed that 99.6% of participants in their study breastfed their babies, but only 36% of them had exclusive breastfeeding. The cohort study conducted in Connecticut by Spisma et al. also showed that 54.4% of respondents who had breastfed, had been given formula milk, water, juice, and even solid food before their baby was 6 months old. In fact, 21.3% of them gave higher amounts of formula milk, water, juice, and solid food than breast milk. [4][5] Water is the most common complementary drink given during breastfeeding and is the cause of the failure of exclusive breastfeeding. However, many mothers are often unaware and feel that they have been given exclusive breastfeeding. This fact has resulted from the ignorance of mothers. They assumed that giving water to babies does not damage or thwart the practice of exclusive breastfeeding. 4 Another factor that causes babies to receive drinks/foods other than breast milk before the age of 6 months is the circulating belief among the family and society. Family support is known as one of the factors associated with the practice of exclusive breastfeeding. 28 A cross-sectional study revealed that there is a relationship between grandmother's involvement with the introduction and administration of water to infants. 29 In particular, adolescent mothers are expected to be obedient and unable to resist the advice of family members. The inability to reject these conflicting suggestions ultimately led to failure in the plans for exclusive breastfeeding. 30 This study also found that some hospitals had contributed to providing and marketing formula milk. This fact is of concern because health care facilities that should have supported the practice of exclusive breastfeeding had provided formula milk to mothers. Therefore, it is necessary to strengthen regulations related to the promotion and marketing of formula milk as substitutes for breast milk. 16

CONCLUSION
Most of the participants in this study were breastfeeding mothers who had unsuccessful exclusive breastfeeding to their babies. The behavior of these adolescent mothers who were married at their teenage years in exclusive breastfeeding can be seen from the perceptions and attitudes of their support in exclusive breastfeeding, their response when breastfeeding for the first time, insufficient knowledge, and challenges and difficulties in exclusive breastfeeding and how they deal with those challenges, and failures of exclusive breastfeeding. Therefore, it is necessary to have a comprehensive and sustainable education and counseling program about exclusive breastfeeding for adolescent mothers who were married in their teenage years. In addition, families, especially parents and husbands of teenage mothers need to be involved in the education and counseling process of exclusive breastfeeding.