The World Health Organization recommends exclusive breastfeeding for at least 6 months (Sudargo et al, 2018). Lack of exclusive breastfeeding in this period can have long-term effects on a baby's growth and development that are difficult to resolve. In addition to providing nutrition, breastfeeding also increases bonding between mother and baby (Nasution, 2017). Breast milk also has benefits for the health of the baby. Breast milk contains colostrum, a protein that functions as an antibody to protect against infection, thereby preventing infant death. Breast milk also contains enzymes that function as absorbent substances that do not interfere with other enzymes in the intestine (Ministry of Health, 2022).
In I ndonesia, rates of exclusive breastfeeding are lower among working mothers, likely as a result of difficulties having time to express breast milk (Rosida and Putri, 2020). Many Indonesian workplaces require mothers to return to work after 3 months of maternity leave. Although support programmes for breastfeeding mothers and exclusive breastfeeding have been implemented in some countries, including Indonesia, not all countries guarantee breastfeeding rights for working mothers (Bettinelli, 2012).
To support exclusive breastfeeding, the World Health Organization recommends that working mothers express breast milk between feedings during maternity leave (Horta and Victora, 2013). This allows those caring for a baby while the mother is at work to give expressed breast milk through indirect methods, such as spoons, cups or cup feeders (Nilam Sari, 2017).
Strategies are needed to support working mothers to exclusively breastfeed their babies, including the provision of adequate workplace conditions that allow mothers to pump breast milk (Mills, 2009). Some factors associated with reduced exclusive breastfeeding are the perception of inadequate breast milk, lack of knowledge about expressing breast milk, limited time to express and lack of support from workplace leaders (Basrowi, 2012; Rosida and Putri, 2020). However, factors that promote exclusive breastfeeding include strong intention to breastfeed, lactation management skills and a lack of environmental barriers (Rosida and Putri, 2020).
One lactation management strategy that working mothers can be educated on is expressed breast milk management. Dewi and Kurniawan (2016) examined the impact of training on mothers’ knowledge and skills in breast milk management. Before the training, several mothers reported that their milk production was low, so pumping was ineffective. They also did not know how to pump properly, store the breast milk or feed it to their babies. Some were afraid that stored breast milk would become stale and therefore unsafe for babies. The study reported that mothers’ knowledge and skills in breast milk management increased after training. Educational videos can thus be specifically designed to promote and support exclusive breastfeeding through expressed breast milk for working mothers.
Technology's development and the digital world have influenced all areas of life, including the health sector. Health applications are now easily accessed on smartphones or tablets (Kamisutara, 2017). Multimedia technology, including smartphones, has been widely used to promote health in the community, with practitioners and academics developing android-based applications. Smartphones can therefore be a useful tool to distribute health education information (Dinengsih and Hakim, 2020).
Breastfeeding mothers should be given education on how expressing breast milk works, and discussion forums should be created to develop understanding and commitment to exclusive breastfeeding. At the time of the study, the COVID-19 pandemic necessitated the use of virtual platforms for mentoring. This study's aim was to examine the effectiveness of an educational video and mentoring group on working mothers’ exclusive breastfeeding management by assessing pregnant women's knowledge, attitudes and self-efficacy in breast milk expression.
Methods
This study used a quasi-experimental design in the form of a randomised controlled pre-/post-test trial. Two randomly selected sample groups were selected using a cluster randomised trial. The research protocol is outlined in Figure 1.
Participants
The participants were working women who had been pregnant for <4 months, selected from each sub-district of Tomohon and Manado, two cities in Indonesia. After gathering the data, clustering for each sub-district was determined by defining the respondent quota for the intervention and control group. Computerised randomisation ensured that each participant from each sub-district had the same opportunity to join the intervention group as the control group. Using the Slovin formula (Ryan, 2013), the sample size was calculated as 50 participants for each group; participants were selected using simple random sampling based on their home city. Women were invited to participate in the study when attending health services.
Intervention
The intervention group was given a video, made by the research team for the purposes of the study, that explained management of expressed breast milk, with pictures and simulations to demonstrate methods for expressing breast milk, storing it in the refrigerator, preparing it and giving it to babies. It also contained messages about exclusive breastfeeding, as well as testimonials from working mothers who had exclusively breastfed their babies. The video content was created based on a review of the literature, with pictures and voiceovers provided by the research team and complemented by testimonials from working mothers who exclusively breastfed their babies.
The information was provided in language easily understood by the respondents, with the video being sent to participants in the intervention group via a WhatsApp group. This group was also used to facilitate discussions and mentoring, by allowing the opportunity for the participants to consult the lead researcher, who was a certified breastfeeding counsellor, about breastfeeding and expressed breast milk.
The control group received regular education on both exclusive breastfeeding and expressing breast milk in the form of leaflets.
Data collection
Data were collected using three tools to assess the participants’ knowledge, attitudes and self-efficacy. The knowledge and attitude questionnaires were modified from a standard questionnaire used in previous research (Pasambo et al, 2022). Following modification, the knowledge and attitude questionnaires were assessed for validity and reliability.
The knowledge questionnaire consisted of 10 statements, which could be categorised as true or false, and assessed participants’ knowledge of how to express, prepare and give breast milk to babies. Scores were calculated by awarding 1 point for a correct answer, and 0 points for an incorrect answer, with a maximum score of 10. Higher scores indicated better knowledge of expressing breast milk. The questionnaire had a Cronbach's alpha coefficient of 0.981 and validity r-value of >0.879 for all questions.
The attitude questionnaire consisted of 10 closed questions designed to assess the participants’ attitudes to expressing, preparing and giving breast milk. For each question, participants rated their response on a Likert scale (strongly disagree, disagree, unsure, agree, strongly agree), with an associated score of 0—4 and a maximum total of 40 points. Higher scores indicated a more positive attitude to expressing breast milk. The questionnaire had a reliability Cronbach's alpha coefficient of 0.89 and validity r-value of >0.86.
Self-efficacy was assessed using the Indonesian variant of the breastfeeding self-efficacy scale, as used in Muaningsih's (2013). The scale consisted of 14 questions rated on a Likert scale, with results ranging from 14 to 70 total points, as modified for working mothers in urban areas.
A pre-test was conducted to determine any initial differences between the intervention and control groups. This was carried out when the participants first attended the healthcare facility, and agreed to participate. Following the intervention, or regular care for the control group, the post-test was then carried out, using the same three scales. This was sent to the participants through Google forms. The same questionnaire was sent for the pre- and post-tests, and took approximately 15 minutes to complete.
Data analysis
The statistical data were analysed using the Mann-Whitney non-parametric U-test, as data distribution was not normal. P<0.05 was used to indicate significance.
Ethical considerations
This research was approved by the research ethics commission of the Health Polytechnic of the Health Ministry of Manado (reference: KEPK.01/05/100/2022). A research permit recommendation was received from the governments of Manado Regency and Tomohon Regency, through the National Unity and Politics Agency of North Sulawesi, Indonesia.
After explaining the study to the participants, the researchers distributed informed consent forms. Those willing to participate were asked to sign the form.
Results
The participants sociodemographic characteristics are shown in Table 1. The majority of participants were 31—40 years old (53.0%), worked as civil servants (58.0%) and were multipara (55.0%). The largest proportion of participants were at 12 weeks’ gestation (40.0%).
Table 1. Sociodemographic characteristics
| Characteristic | Frequency, n=100 (%) | |
|---|---|---|
| Age (years) | <30 | 47 (47.0) |
| 31-40 | 53 (53.0) | |
| Occupation | Private employee | 42 (42.0) |
| Civil servant | 58 (58.0) | |
| Gestational age (weeks) | 8 | 30 (30.0) |
| 12 | 40 (40.0) | |
| 15 | 30 (30.0) | |
| Gravidity | Nulípara | 45 (45.0) |
| Multipara | 55 (55.0) |
As shown in Table 2, there were no significant differences between groups in the pre-test scores for knowledge, attitude or self-efficacy. The average post-test scores for knowledge, attitude and self-efficacy between the control and intervention groups were significantly different, with the intervention group having higher average post-test scores in all areas. These results are shown in Table 3.
Table 2. Assessment of pre-test differences in knowledge, attitudes and self-efficacy
| Group | n | Mean | Confidence interval | Z | P value |
|---|---|---|---|---|---|
| Knowledge | |||||
| Intervention | 50 | 3.48 | 3.45-3.70 | -0.245 | 0.806 |
| Control | 50 | 3.85 | 3.46-3.78 | ||
| Attitude | |||||
| Intervention | 50 | 17.45 | 15.89-17.03 | -0.614 | 0.416 |
| Control | 50 | 17.51 | 15.96-16.60 | ||
| Self-efficacy | |||||
| Intervention | 50 | 18.00 | 22.98-24.06 | -0.242 | 0.809 |
| Control | 50 | 18.00 | 23.2724.04 | ||
Table 3. Assessment of post-test differences in knowledge, attitudes and self-efficacy
| Group | n | Mean | Confidence interval | Z | P value |
|---|---|---|---|---|---|
| Knowledge | |||||
| Intervention | 50 | 8.46 | 8.27-8.65 | -8.998 | 0.001 |
| Control | 50 | 5.16 | 5.04-5.28 | ||
| Attitude | |||||
| Intervention | 50 | 35.20 | 34.81-35.59 | -8.674 | 0.001 |
| Control | 50 | 19.10 | 18.70-19.50 | ||
| Self-efficacy | |||||
| Intervention | 50 | 50.56 | 50.05-51.07 | -8.652 | 0.001 |
| Control | 50 | 25.00 | 24.48-25.52 | ||
The average post-test knowledge score of the control group was 5.16, compared to 8.46 in the intervention group (P=0.001). The average post-test attitude score was 19.10 in the control group, compared to 35.20 in the intervention group (P=0.001). The average post-test self-efficacy score was 25.00 in the control group, compared to 50.56 in the intervention group (P=0.001).
Discussion
This study aimed to assess the impact of an educational intervention intended to promote knowledge, attitude and self-efficacy in working mothers for expressing breast milk. The intervention consisted of both an educational video and mentoring conducted via a group WhatsApp chat.
Knowledge of expressed breast milk management
The post-test knowledge scores for the intervention and control group were significantly different, with the intervention group having a higher score. Similarly, Tindaon and Hanum (2019) found that counselling through group discussion had a significant effect on working mothers’ knowledge of milk storage techniques. Additionally, various studies have reported that education through videos effectively improves pregnant and lactating mothers’ knowledge (Aeni andYuhandini, 2018; Idris and Enggar, 2019; Febriyani and Rizka, 2020; Sayuti, 2020; Safitri et al, 2021).
Health education videos can help people make decisions and change their behaviour (Notoatmodjo, 2012). Videos create a dynamic, rather than monotonous, educational process (Afriyani and Salafas, 2019). Afriyani and Safalas (2019) examined the effectiveness of health promotion media (reciprocal leaflets and videos) in increasing mothers’ knowledge about expressed breast milk, and found that video media more effectively increased knowledge than leaflets. Consequently, changes in knowledge, attitude and behaviour arose more rapidly (Febriyani and Rizka, 2020). Video media can deliver information in a more interesting manner, because the material is presented briefly in the form of sound and images, allowing viewers to understand the information more easily (Batjo et al, 2021).
Lestari et al (2012) argued that to achieve results according to set goals and objectives, health education should be provided using interesting and acceptable media for the target audience. Audio-visual media is a demonstrably effective choice to increase mothers’ understanding of breastfeeding. One of the advantages of audio-visual media is that it can be accessed anytime and anywhere (Wawan and Dewi, 2010; Lestari et al, 2012). Videos facilitate easy access to information, and it has been shown that more frequent viewing of an educational video leads to greater understanding (Supliyani and Djamilus, 2021). Additionally, compared to listening or reading about particular actions, demonstrations significantly reduce error in carrying out a particular task (Syah, 2017).
Attitudes to expressed breast milk management
Increased knowledge of expressed breast milk management is expected to change working women's attitudes and behaviour, as well as improve their confidence in exclusive breastfeeding. These benefits are likely to affect their decision making regarding expressing breast milk and are intended to improve exclusive breastfeeding rates. Hidayah and Setyaningrum (2018) demonstrated that the majority of working mothers had positive attitudes to expressed breast milk, when their knowledge improved. In the present study, the average post-test attitude scores between the control and intervention groups were significantly different, as were the knowledge scores.
Education is also related to attitude, with higher education being linked with a more positive attitude. Education enables people to more easily understand new information, while a low level of education can hinder the development of a positive attitude to receiving information and new values (Mubarak et al, 2009).
Previous research has found that a positive attitude to exclusive breastfeeding is linked to its practice in working mothers (Mutuli et al, 2012; Anggraeni et al, 2016). A positive attitude encompasses the belief that breastfeeding offers benefits, such as cost-effectiveness, practicality and promotion of children's health, which encourages mothers to exclusively breastfeed. This belief can be encouraged through provision of knowledge from health workers, books, the internet or experience. Increasing positive attitudes and decreasing negative attitudes can improve rates of exclusive breastfeeding (Mutuli et al, 2012; Anggraeni et al, 2016).
A good understanding of and positive attitude to expressing breast milk are important for working mothers because they are not always home to exclusively breastfeed their babies. The provision of education about the benefits of breastfeeding is crucial to increasing positive attitudes. Interventions should be designed to increase mothers’ self-confidence and dispel misconceptions about expressing and storing breast milk. These interventions are beneficial for working mothers who can work while exclusively breastfeeding their babies (Mogre et al, 2016).
Afriyanii and Nuryanti (2018) found that working mothers had negative attitudes to expressed breast milk management. They felt that working mothers should not express breast milk because it reduced resting time, was difficult and was a financial burden. Rejeki (2010) reported that working mothers who expressed breast milk faced obstacles such as an uncomfortable environment, breast milk spilling on their clothes, the frequent need to express which took up working time and constant hunger. Workplaces should provide facilities for breastfeeding or expressing breast milk, and mothers should have opportunities to breastfeed their babies. Consequently, mothers are more likely to develop positive attitudes to breastfeeding and expressing breast milk while working (Afriyanii and Nuryanti, 2018).
Self-efficacy in exclusive breastfeeding
The control and intervention groups had significantly different average self-efficacy scores following the intervention. This is consistent with Mohamad Pilus et al (2022), who reported significantly increased self-efficacy in breastfeeding in their intervention group, who participated in both face-to-face and WhatsApp-based groups designed to improve self-efficacy using social cognitive theory.
Increasing self-efficacy in early pregnancy is pivotal. Sarimin et al (2020) reported that mothers with high self-efficacy can produce milk for longer periods than those with low self-efficacy. Working women in the antenatal period should receive education that increases their knowledge of how to express breast milk. This will lead to a more positive attitude and higher self-efficacy in exclusive breastfeeding when their child is born.
Conclusions
This study's intervention group, who received education through videos and mentoring via WhatsApp groups, had higher knowledge of expressed breast milk management, a more positive attitude to the practice and greater self-efficacy than the control group, who only received regular education for pregnant women working in urban areas. Health workers can use video recommendations and mentoring to educate and monitor breastfeeding mothers, and promote exclusive breastfeeding and breast milk expression.
Key points
- The exclusive breastfeeding rate among working mothers is low, and can be attributed to the perception of inadequate breast milk, lack of knowledge about expression, limited time to express and lack of support from workplace leaders.
- Pregnant women should be educated on how to express breast milk, and discussion forums should be created to develop self efficacy, understanding and commitment to exclusive breastfeeding.
- This study assessed the effect of an expressed breastmilk management video and assistance through WhatsApp groups on pregnant women's knowledge, attitudes and self-efficacy in expressing breast milk.
- Knowledge, attitude and self-efficacy were significantly higher in the intervention group, both compared to control and pre-test results. It is expected that these participants will exclusively breastfeed when returning to work.