British Journal Of Midwifery - How do modern parents deal with cultural beliefs about breastfeeding? A qualitative study

The majority of infant morbidity and mortality occurs in developing countries (UNICEF, 2018). Indonesia is one of the countries with high infant morbidity and mortality rates (Indonesian Ministry of Health, 2015). The primary cause of infant death is contraction of an infectious disease, which may be prevented by providing an appropriate infant feeding regimen (UNICEF, 2018). Breastfeeding is a cheap and easy way to reduce infant morbidity and mortality rates (UNICEF, 2018).

Breastfeeding is known to be the best nutrition for infants. The World Health Organization (WHO) recommends that every mother breastfeeds exclusively for 6 months and then to continue breastfeeding for up to 2 years (WHO, 2017); however, the exclusive breastfeeding rate in Indonesia is only 45% (Indonesian Ministry of Health, 2015). Previous studies have highlighted the effects of cultural beliefs on breastfeeding practice (Osman et al, 2009; Sharma et al, 2016), and have shown that exclusive breastfeeding practices among Indonesian mothers are affected by cultural beliefs related to breastfeeding (Rejeki, 2010).

Cultural beliefs related to breastfeeding have been identified as a possible explanation for the differences in breastfeeding practices (Gibson et al, 2005). Different ethnic groups may have different beliefs, attitudes, and practices regarding nutrition and breastfeeding, even though they may live in the same region. The majority of Indonesians are of Javanese ethnicity (40.2%) and most live in Central Java Province, which is the third most populous province in Indonesia (Nuraini et al, 2016). Javanese cultural beliefs strongly influence breastfeeding practices among Javanese mothers (Choiriyah et al, 2015); however, there is little data on the cultural beliefs about breastfeeding among young and modern mothers in Java.

Identifying sensitive cultural beliefs directly helps health professionals to collect data regarding cultural beliefs that may affect community behaviour (Abramson, 1992). In Java there are many myths, taboos, rituals and customs related to the breastfeeding period (Choiriyah et al, 2015). Some cultural beliefs are safe and provide benefits for mothers and infants, but others are harmful (Ergenekon-Ozelci et al, 2006). Identifying cultural beliefs about breastfeeding is therefore important in order to promote maternal and infant health.

Cultural beliefs have been shown to affect health practice (Leininger, 2002). Health professionals should have the abillity to provide culturally congruent care (Garneau and Pepin, 2015). Exclusive breastfeeding promotion strategies should fit with the population and its characteristics (WHO, 2018). Therefore, having an understanding of cultural beliefs is important for healthcare providers in providing culturally sensitive care, better support and appropriate counselling to breastfeeding mothers (Osman et al, 2009). Little is known about the cultural beliefs around breastfeeding in the modern Javanese community, so a qualitative study was conducted to explore the cultural beliefs about breastfeeding. The results of this study are expected to lead to the development of a culturally sensitive educational programme for the young Javanese mothers in Indonesia.

Purpose

The purpose of this study was to explore cultural beliefs on breastfeeding and modern parents' perceptions of these cultural beliefs in Central Java Province, Indonesia. This study will help healthcare providers to improve their knowledge and provide culturally sensitive care in Central Java Province, Indonesia.

Method

Study design

This study was conducted using an ethnographic approach. Ethnography is a research method that provides a chance to understand the social constructs of customs, behaviour, language and interactions (Creswell, 2012). Cultural beliefs on breastfeeding were explored from the perspective of young Javanese mothers, their family members, health professionals and traditional birth attendants (TBAs). These cultural beliefs included beliefs on food, behaviour, myths, taboos and customs. All of the researchers were Javanese, lived in Central Java Province, and spoke the same language as the participants, which may have helped the researchers to understand, describe and interpret the meanings, situations and events.

Study participants

The researchers used both purposive and snowball sampling methods to select both key and general participants. Researchers contacted community health volunteers, who then recommended women for inclusion in the study. The researchers met potential participants at their homes, provided information about the study and asked women if they woud be interested in participating.

Women in the key participant group were primiparous and multiparous, had undergone vaginal and caesarian births, and had delivered both term and preterm babies. All participants were Javanese-born, residing in Central Java Province, able to communicate verbally and willing to participate. They all signed an informed consent form. General participants in this study included family members, midwives and traditional birth attendants. According to Morse (1994), a qualitative study requires about 30-50 participants including key and general participants; however, if the study has reached saturation, the number of participants can be fewer (Morse, 2000). The number of participants in this study was 23 because saturation was reached with the 23rd participant.

Study setting

This study was conducted in a community setting on Java Island, which is the most populous island in Indonesia. Central Java Province is the third most populous province in Indonesia, and Javanese is the largest ethnic group (40.2%) in the country (Nuraini et al, 2016).

Ethical considerations

This study received ethical approval from an institutional review board, and the researcher received permission to conduct this study from the Government Office. All participants were asked to sign the informed consent form after being provided with information about the study, its purpose, benefits, potential risks, anonymity, confidentiality, the rights of study participants and the researchers' contact details. The researchers approached the study with empathy, allowing the interviews to be interrupted when babies became fussy or needed feeding, or when mothers needed to cook for another child.

Data collection

Data were collected from March to September 2017. The researchers used multiple data collection methods until data saturation was reached. This included focus group discussions, in-depth interviews, observations and document-related sources. Data were collected and analysed using thematic analysis (Braun and Clarke, 2012). The natural setting is important in an ethnographic study (Creswell, 2013), and so after receiving study approval and permission, the researchers approached the proposed participants to build rapport, provide study-related information and ask for their willingness to participate in this study. All participants then signed the informed consent form to show that they understood and wanted to participate in this study.

The focus group discussions and interview guides were based on previous knowledge related to the phenomena. They were peer-reviewed and pilot-tested before being used to collect the data. The focus group discussion guide included mothers' perceptions of breastfeeding and exclusive breastfeeding, cultural beliefs related to breastfeeding, suggestions given during breastfeeding, and myths, taboos and customs. The interview guide for the grandmothers, TBAs and healthcare providers focused on the cultural beliefs related to breastfeeding and their experiences on caring for breastfeeding mothers.

This study sought to examine what influenced modern Indonesian mothers to breastfeed

The researchers conducted two focus group discussions involving 18 breastfeeding mothers. This method was chosen since it allows for spontaneous and informal discussions of the participants' everyday lives and allows for participants to add further information to others' statements. The participants were selected by the diversity of their individual characteristics, and included both primiparous and multiparous women, vaginal and caesarean births, working and stay-at-home mothers, nuclear and extended family, and women living in both urban and rural areas. The researchers approached 11 mothers to be interviewed in-depth and observed in their homes, since they were more knowledgeable, had richer experiences or particular issues that could not be expressed in front of the other participants. In addition, grandmothers, TBAs and healthcare providers were interviewed and observed in order to explore their cultural beliefs on breastfeeding and their experiences caring for breastfeeding mothers. Each participant was interviewed three to four times.

The researchers collected data from the participants until no new information emerged, and no new category was raised when the researchers added more participants to the study. According to Creswell (2013), sufficient data in a qualitative study is acquired when saturation is reached. In this study, saturation was reached with the 23rd participant.

The researchers started the focus group discussions and interviews, moving from general questions to more specific questions regarding cultural beliefs on breastfeeding. The researchers conducted focus group discussions and interviews based on the participants' available time. The researchers also observed and took note of the participants' activities and home situations while taking in-depth interviews. All focus group discussions and interviews were recorded with the participants' permission. They were transcribed verbatim for data analysis and will be erased after publication.

Data analysis

The researchers analysed the data gained from the focus group discussions and in-depth interviews. After the data were transcribed verbatim, the researchers analysed them using qualitative thematic analysis (Braun and Clarke, 2012). According to Braun and Clark (2012), qualitative thematic analysis includes reading the data repeatedly, giving initial codes, finding the themes, reviewing themes, defining and naming themes and writing the report. Becoming familiar with the data provides an opportunity for the researchers to gain knowledge regarding cultural beliefs on breastfeeding among young Javanese women. The researchers then grouped the data based on the research questions. The codes guided the researchers to develop themes and sub-themes connected with the research questions.

Table 1. Demographic characteristics of participants (n=23)

Code	Age (years)	Parity	Educational level	Employment	Marital Status	Role
R1	30	Multiparous	Bachelor's degree	Housewife	Married	Key informant
R2	22	Primiparous	High school	Housewife	Married	Key informant
R3	31	Multiparous	High school	Housewife	Married	Key informant
R4	23	Primiparous	Middle school	Housewife	Married	Key informant
R5	29	Multiparous	High school	Housewife	Married	Key informant
R6	33	Multiparous	Middle school	Housewife	Married	Key informant
R7	21	Primiparous	High school	Housewife	Married	Key informant
R8	62	Multiparous	Elementary	Housewife	Married	General informant
R9	31	Multiparous	Bachelor's degree	Housewife	Married	Key informant
R10	28	Multiparous	High school	Privately employed	Married	Key informant
R11	54	Multiparous	Middle school	Housewife	Married	General informant
R12	32	Multiparous	Middle school	Housewife	Married	Key informant
R13	21	Primiparous	High school	Housewife	Married	Key informant
R14	22	Primiparous	High school	Housewife	Married	Key informant
R15	34	Multiparous	Middle school	Housewife	Married	Key informant
R16	30	Multiparous	High school	Housewife	Married	Key informant
R17	28	Multiparous	High school	Housewife	Married	Key informant
R18	32	Multiparous	Middle school	Housewife	Married	Key informant
R19	22	Primiparous	High school	Housewife	Married	Key informant
R20	37	Multiparous	Diploma	Midwife	Married	General informant
R21	64	Multiparous	Elementary	TBA	Widowed	General informant
R22	30	Multiparous	Diploma	Privately employed	Married	Key informant
R23	59	Multiparous	Elementary	Housewife	Widowed	General informant

TBA: traditional birth attendant

Trustworthiness

In a qualitative study there are four elements to trustworthiness: credibility, transferability, dependability and confirmability (Lincoln and Guba, 2007). To ensure credibility, the researchers should spend prolonged periods of time in the research field. All of the researchers in this study are Javanese and have been in Central Java Province for a long time. Research methods included participant observation, peer debriefing, member checking and triangulation. Triangulation methods were used in this study and data were collected through focus group discussions, in-depth interviews and observations (Carter et al, 2014). The researchers also used triangulation sources to collect data involving breastfeeding mothers, family members, traditional birth attendants and healthcare providers. To ensure transferability, the researchers provided a detailed description about the participant's characteristics and the research method. To ensure dependability, the researchers allowed the participants to read the verbatim text, preliminary themes, and final themes. The research team also discussed the verbatim text, codes, preliminary themes and final themes to find a similar conclusion, which ensured confirmability. The researchers also checked, discussed and analysed the data with local experts in breastfeeding who were all Javanese and had lived in Central Java Province for a long time.

Findings

Participant characteristics

There were 18 key participants. Two-thirds of the mothers were multiparous, and ages ranged from 21–34 years old (median=27.72 years old). Of these key participants, 6 of the mothers were primiparous and 12 multiparous. All were married. Two had completed a bachelor's degree; one had completed a diploma; ten had completed senior high school and five had completed junior high school. Two worked as employees in the private sector and the rest were housewives. There were five general participants with experience in taking care of mothers during the breastfeeding period. They included family members (n=3), one healthcare provider, who had been working in maternity for 16 years, and one TBA, who had been caring for breastfeeding mothers for 23 years.

In this study, the preliminary themes were ‘suggested food and behaviour during breastfeeding’, ‘food taboos during breastfeeding’, ‘taboo behaviour during breastfeeding’ and ‘the dynamic change within cultural beliefs’. The researchers read the data associated with each theme, discussed the distinctions of each theme, the other themes within the data and how the themes overlapped. The researchers felt that ‘food taboos during breastfeeding’ and ‘taboo behaviour during breastfeeding’ overlapped and that there was not enough data to make them different themes, so the researchers collapsed them into a new theme, namely ‘restricted food and behaviour during breastfeeding’. Under the themes ‘food taboos during breastfeeding’ and ‘taboo behaviour during breastfeeding’, there were many distinct data that did not support the themes. The researchers decided to develop a new theme, namely, ‘consequences of ignoring cultural beliefs’. This study revealed four final themes: ‘suggested food and behaviours’, ‘restricted food and behaviours’, ‘the consequences of avoiding the taboos’ and ‘the dynamic change within cultural beliefs’.

Suggested food and behaviours

All of the participants explained that breastfeeding was the norm. In general, the Javanese community supports every mother to do anything possible in order to breastfeed her infant. Breastfeeding mothers are advised to eat specific foods in order to maintain breastmilk quantity and quality.

Suggested food

Breastfeeding mothers are encouraged to consume foods that are believed to affect the breastmilk supply. They are encouraged to eat vegetables and herbs in liquid form every day, which are made and delivered by the TBA.

‘I am advised to eat vegetable soup [tegean] every day to stimulate and maintain breastmilk supply … my mother suggested it to me just after I gave birth.’

(R3, multiparous, 31 years old)

Suggested behaviour

The participants also explained that they had to adapt certain behaviours during the breastfeeding period. It is believed that such action will stimulate, increase and maintain the breastmilk supply.

‘The breast should be massaged by the traditional birth attendant immediately after birth and the mother should massage her breasts by herself before breastfeeding.’

(R9, multiparous, 31 years old)

The TBA explained that she cared for postpartum mothers by massaging both the mother and infant, providing herb liquid (jamu) and advising the breastfeeding mother to consume a lot of vegetables.

‘Drinking herbal liquid and massaging the breasts may increase breastmilk supply … I used to make the herbal liquid by myself from fresh herbs … new mothers should also eat vegetables daily to maintain the breastmilk supply … I come to the mothers' houses daily to massage the mother and infant.’

(R21, multiparous,64 years old)

Restricted food and behaviour

The Javanese community has a number of taboos, and members believe that ignoring taboos lead to adverse consequences. A number of participants explained that they should avoid certain foods and behaviours during the breastfeeding period.

Restricted food

The Javanese community believe that a breastfeeding mother should avoid certain kinds of food in order to maintain the breastmilk supply and to prevent the infant from vomiting or refusing to breastfeed.

‘A breastfeeding mother may not eat fishy smelling food, sticky rice, longbean leaves … they are not good because they can cause the breastmilk supply to decrease and the infant to vomit due to a fishy smell in the breastmilk.’

(R2, primiparous, 22 years old)

Restricted behaviours

Breastfeeding mothers also mentioned that they were advised to avoid certain behaviours. According to Javanese cultural beliefs, there are several taboos during the breastfeeding period, which include attending a funeral, taking a nap during the day, travelling in the first 40 days after giving birth, flexing the legs when sleeping, and taking the infant away or to the local market.

‘A breastfeeding mother may not bend her knees while sleeping … my mother says that it may cause the white blood cells to rise up to the eyes, potentially making the mother blind or killing her.’

(R14, primiparous, 22 years old)

Healthcare providers reported that breastfeeding mothers asked them about various myths and taboos:

‘Some breastfeeding mothers asked me whether it was okay to take a nap at noon. They told me that they felt tired because their infants were fussy at night, but they were forbidden to sleep at noon.’

(R20, multiparous, 37 years old)

The consequences of ignoring cultural beliefs

The Javanese community believe that there are several consequences of ignoring the cultural beliefs related to breastfeeding, which may affect the infant or mother. Some participants had experienced the consequences of breaking the taboos directly, while others had learned indirectly by hearing about the experiences of other breastfeeding mothers.

Consequences for the infant

The Javanese community believe that indulging in restricted food or behaviours may have an impact on the infant.

‘My baby became sick, fussy and developed a fever after I took her away within 40 days after her birth … I ate some spicy food and my baby got diarrhoea … my mother asked me to not ignore the taboos again.’

(R16, multiparous, 30 years old)

Consequences for the mother

It was believed that ignoring the taboos while breastfeeding also had consequences for the mother. Some participants explained that, based on their own experiences, ignoring cultural beliefs during the breastfeeding period resulted in the mothers becoming sick and suffering from a reduced supply of breastmilk.

‘I did break the traditional rules during breastfeeding … When I attended my brother's funeral, I became sick [kesambet] and my breastmilk supply decreased.’

(R5, multiparous, 29 years old)

One TBA explained that there were consequences when a mother broke the restricted food or behaviour rules. According to the TBA, this belief was based on the previous generation's life experiences, which have grown from traditional Javanese cultural beliefs that have been passed down.

‘Ignoring the cultural beliefs may affect the mother or infant … after ignoring the cultural beliefs, the mother or infant will become sick … my grandmother is a TBA and she told me about these beliefs.’

(R21, multiparous, 64 years old)

The dynamic changing of cultural beliefs

The participants mentioned that many breastfeeding mothers now break the cultural rules. Some participants claimed that some cultural beliefs could be negotiated by bringing a local herb known as sambetan as an antidote, or could be replaced by doing other actions to prevent the consequences of violation of the cultural beliefs.

‘I should bring sambetan when I go on a trip with my infant … it may prevent my infant from sawan [a supernatural disorder].’

(R5, multiparous, 29 years old).

Some participants explained that the cultural beliefs perceived among the Javanese community had changed. The digital era has allowed everyone to access health information easily, and some participants mentioned that they accessed breastfeeding information online.

‘We should not obey all of the culture beliefs. I use logical thinking … if it does not make sense, I do not have to do it … I got breastfeeding information from the internet. If the culture beliefs do not tally with health sciences, I ignore them.’

(R1, multiparous, 30 years old)

Discussion

These findings extend the qualitative literature on breastfeeding by exploring cultural beliefs related to breastfeeding among the young Javanese community. The study's findings support the theory of cultural care diversity and universality developed by Madeleine Leininger, which proposes a close link between culture and care, and wellbeing and health (Leininger, 2002). The findings of this study tell us that breastfeeding is accepted among the Javanese community as a natural way to provide nutrition for an infant, and that breastfeeding mothers are supported to breastfeed the infant up to 2 years old and beyond. This study also showed that the Javanese community has beliefs around the stimulation and maintenance of breastmilk in postpartum mothers, which, if ignored, could result in either the mother or infant experiencing health problems. Perhaps surprisingly, the adherence towards cultural beliefs among the modern generation has changed.

The findings from this qualitative study highlight the concern within the Javanese community about having sufficient breastmilk quantity and quality to meet an infant's need (Hamzah, 2000). The majority of Javanese people pay significant attention to what should and should not be avoided during the breastfeeding period (Hidayati, 2013). Previous research (Hamzah, 2000; Hidayati, 2013; Rejeki, 2010) revealed that Javanese mothers adhered to specific behaviours and ate certain kinds of food while breastfeeding in order to stimulate and maintain the breastmilk supply, particularly in the few first days after birth.

Research has shown that the major reason for non-exclusive breastfeeding among modern Indonesian mothers is a perceived insufficient breastmilk supply (Afiyanti and Juliastuti, 2012), and so in this setting, maintaining the breastmilk supply is very important. Previous study results support the findings that certain foods and behaviours are thought to help maintain sufficient breastmilk supply. A breastfeeding mother is advised to wash the hair (Wuwung) every morning, to make the body feel fresh so it stimulates the breastmilk supply. She is also advised to wash the breasts after taking a trip, to ward off evil spirits (Sawanen), and is advised to drink herbal liquid (Rejeki, 2010); breastfeed the infant as needed (Hamzah, 2000); keep scissors, nail cutter, and pins close, to ward off evil spirits; sleep with straight legs; indulge in body massage and massage the breast (Yulianti, 2014). The suggested foods for a breastfeeding mother include rice, kangkung (morning glory), spinach, cabbage, carrot, long bean, oyong (a cucumber-like vegetable), buncis (green beans), mustard, eggplant, cassava leaves, papaya leaves, melinjo leaves, genjer (an aquatic plant), sprouts, boiled vegetables, chicken, beef (Waryani, 2004), tofu, tempeh, gooseberry leaves (Waryani, 2004; Haryati 2015), bengkoang (a vegetable similar to a yam) and cow's milk (Haryati, 2015). Almost all ethnic groups have such cultural beliefs around maintaining breastmilk supply. Studies have shown that breastmilk quality and quantity is a concern among Pakistani, Bangladeshi, and Nepalese mothers, who consume certain foods and practise some rituals (Mull, 1992; Osman et al, 2009; Sharma et al, 2016).

According to Javanese beliefs, breastfeeding mothers should avoid certain kinds of food and behaviours in order to maintain the breastmilk supply. Food restrictions among Indonesian breastfeeding mothers is a practice inherited through many generations (Khomsan, 2006; Budiyarti, 2010). Breastfeeding mothers in these communities are advised not to consume fish, shrimp, crab, spicy food or coconut milk as well as other foods including eggs, animal protein (Waryani, 2004; Haryati, 2015), fried food and sour food (Waryani, 2004). Prohibiting food is also common among mothers of other ethnicities. For example, Lebanese mothers are also concerned about to quantity and quality of their breastmilk, and are advised to avoid eating cabbage, cauliflower, and mloukhieh (green leafy vegetables) in order to prevent the infant becoming sick (Osman et al, 2009).

Cultural beliefs affect an individual's selection, preparation and presentation of food. These findings indicate that Javanese breastfeeding mothers adhered to cultural beliefs during breastfeeding because of a belief in gugon tuhon, which means people who ignore taboos will experience consequences (Endraswara, 2012). Nevertheless, beliefs among the younger generations have changed, as the digital era has lead to health information being available online (Aref-Adib et al, 2016).

Digital technology can modify a culture by bringing knowledge, connectivity, and new behaviours (Combi, 2016). Technology is used widely by all ages, including new parents, many of whom incorporate technology into their daily lives (Tomfohrde and Reinke, 2016) Osei Asibey et al (2017) found that young people used the internet for health information because there was a large amount of easy-to-find information, and because it was anonymous, private, confidential, cheap, convenient, easy to communicate with peers, and less embarrassing than talking to a professional (Osei Asibey et al, 2017). The participants in this study explained that they used breastfeeding information from the internet to support their willingness to exclusively breastfeed until 6 months and continue breastfeeding up to 2 years. Another study reported that low-income mothers used the internet as the primary source of information during the postpartum period, particularly to maintain breastfeeding and solve breastfeeding problems (Guerra-Reyes et al, 2016).

Understanding Javanese cultural beliefs about breastfeeding is crucial for supporting meaningful, beneficial and satisfying healthcare services for postpartum mothers. Assessing adherence to cultural beliefs is an important part of postpartum evaluations in order to get information about health information needs and risk factors. Midwives may suggest appropriate web links to mothers who access online health information. Family empowerment and TBA participation are needed to develop culturally sensitive programmes for the Javanese community.

Conclusions

This qualitative study has reported detailed findings about the universal acceptance of breastfeeding in the Javanese community. Javanese mothers are highly supported to breastfeed but are challenged with several myths and taboos. Cultural beliefs are now being re-evaluated by modern breastfeeding mothers due to the modernisation and ease of access to health information. It is highly recommended that effective, comprehensive and culturally sensitive programmes and strategies are developed in order to meet modern parents' needs.

Key points

Breastfeeding is the norm in Indonesia and cultural beliefs strongly affect breastfeeding practices in the Javanese community

Breastfeeding mothers are advised to eat vegetable soup, drink herbal drinks and massage the breasts to increase breastmilk supply

Consuming fishy-smelling food, attending funerals, sleeping during the day, and traveling are prohibited during the first 40 days after birth

It is believed that ignoring these taboos results in the infant becoming sick, fussy or having a fever, or mother experiencing fever and a reduced breastmilk supply

Cultural beliefs have changed in the younger generations as a result of getting information about breastfeeding on the internet

CPD reflective questions

What experience do you have of cultural beliefs affecting a breastfeeding mother's diet and behaviour?

How does might internet amend cultural beliefs among young people?

What is the best strategy that can be used by health professionals to provide a culturally sensitive breastfeeding education?