AMJ Vol 7 No 1 2020Edit2.indd


Althea Medical Journal. 2020;7(1)

20     AMJ March 2020

The Characteristics, Knowledge, and Attitude of Pregnant Women 
Regarding Early Breastfeeding Initiation 

on the Fourth Antenatal Care Visit

Elsa Pudji Setiawati,1 Cindy Regina Putri,2 Tisnasari Hafsah3
1Department of Public Health Faculty of Medicine Universitas Padjadjaran, Indonesia,  

2Faculty of Medicine Universitas Padjadjaran, Indonesia, 3Department of Child Health Faculty of 
Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, Indonesia

Correspondence: Elsa Pudji Setiawati, Department of Public Health Faculty of Medicine Universitas Padjadjaran, Jalan 
Raya Bandung Sumedang Km. 21, Jatinangor, Sumedang, West Java- Indonesia, E-mail: elsapudji@gmail.com

Introduction

Early breastfeeding initiation within one 
hour after birth has a specific role to reduce 
the infant mortality rate.1,2 Furthermore, 
early skin-to-skin contact between mother 
and infant may give benefit to infant health.3,4 
The World Health Organization (WHO) has 
recommended the breastfeeding within one 
hour after childbirth to ensure that the infant 
receives the colostrums that contain many 
antibodies to increase the immunity of the 
newborn.5

The implementation of breastfeeding 
initiation within one hour after giving birth 
in Indonesia was very low, which is only 
29.3%.6 Implementation of early breastfeeding 
initiation is influenced by the mother’s 
knowledge and attitude about its benefits 

and risk associated with not breastfeeding.7 
Information regarding early breastfeeding 
initiation has given to pregnant women 
through the third (K3) and fourth (K4) 
antenatal care (ANC) visit.8 However, there is 
a considerable gap between the coverage of 
the fourth antenatal care (ANC) visit (K4) with 
the implementation of early breastfeeding 
initiation.6

Behavior is influenced by knowledge and 
attitude.9 It shows that successful breastfeeding 
was determined by the knowledge and attitude 
of the pregnant women.10,11 Knowledge and 
attitude are influenced by various factors, 
including age, education, environment, 
experience, facilities, and socio-cultural.9,12 
The aim of this study was to analyze the 
relationship among characteristics of a 
pregnant women during the fourth ANC visit 

AMJ. 2020;7(1):20–4

Abstract

Background: Early breastfeeding initiation within one hour after birth can reduce maternal and 
neonatal mortality. One of the interventions given on the fourth antenatal care (ANC) visit is providing 
information regarding breastfeeding initiation, however, the implementation is low. Many factors may 
influence breastfeeding initiation, including knowledge and attitude. The aim of this study was to 
analyze the relationship among the characteristics, knowledge, and attitude of the pregnant women 
on the fourth ANC visit regarding early breastfeeding initiation in Jatinangor.
Methods: An analytic cross-sectional study was conducted in September 2013. A total of 61 pregnant 
women registered for the fourth ANC visit (K4) in Jatinangor Public Health Center were involved 
in this study. Data were collected from questionnaires. Data on the number of gestation, level of 
education, source of information regarding breastfeeding initiation, knowledge and attitude about 
early breastfeeding initiation were collected and analyzed using chi-square.
Results: There was a significant relationship between a number of gestation, level of education, source 
of information and knowledge also attitude, as well as between age and attitude (p<0.05). However, 
there was no significant association between age and knowledge (p>0.05).
Conclusions: Number of gestation, level of education, and source of information have a significant 
relationship with both knowledge and attitudes about early breastfeeding initiation.
 
Keywords: Antenatal care visit, attitude, breastfeeding initiation, knowledge

https://doi.org/10.15850/amj.v7n1.1710



Althea Medical Journal. 2020;7(1)

21

(K4) with knowledge and attitudes regarding 
early breastfeeding initiation 

Methods

An analytical cross-sectional study was 
conducted in September 2013. The sample data 
was obtained from the Public Health Center 
(Pusat Kesehatan Masyarakat, Puskesmas) 
Jatinangor, Sumedang District, West Java. All 
pregnant women who registered for the fourth 
antenatal care (ANC) visit (K4) at Puskesmas 
Jatinangor during September 2013 and had 
consented to participate by filling the informed 
consent form were selected to be a participant. 
From these criteria, 61 pregnant women were 
participated and selected by consecutive 
sampling. This study was approved by the 
Health Research Ethics Committee, Faculty of 
Medicine Universitas Padjadjaran, with Ethical 
clearance no. 34/UN6.C2.1.2/KEPK/2013.

Participant’s characteristics in this study 
were age, categorized into age above the 
median and below the median. The number 
of gestation was categorized into primigravid 
(first pregnancy) and multigravid (number 
of gestation ≥2). Level of education was 
categorized into high and low. High education 
including senior high school or college, low 
education primary high school, junior high 
school, or did not attend school. Source 
of information about early breastfeeding 
initiation was categorized into information 
from health care service and not from health 
care service.

This study used primary data. The 
participants were asked to fill the informed 
consent form and questionnaire. The 

questionnaires were explored about knowledge 
and attitude about early breastfeeding 
initiation. The scoring of good knowledge was 
more than 75, moderate was 50–<75 and low 
was less than 50. The attitude was categorized 
positive when the score is ≥the median and 
negative attitude when the score <median. 
The data collected were analyzed through 
Statistical Product and Service Solutions 
(SPSS). Bivariate analysis was conducted 
to assess the relationship of characteristics 
with knowledge and attitude regarding early 
breastfeeding initiation. The Chi-square test 
and Kolmogorov-Smirnov test were used to 
measure the bivariate relationship of two 
categorical data. If the p-value <0.05, it showed 
that there was a significant relationship 
between those variables tested.

Results

The median age in this study was 28.  Most of the 
respondent had age above the median (59%), 
multigravid (56%), high level of education 
(62%), and health care service as a source of 
information regarding early breastfeeding 
initiation (72%) (Table 1). Most of the 
respondents received information regarding 
breastfeeding initiation from primary health 
care and midwives. A total of 34 respondents 
(56%) graduate from senior high school.

Most the respondents had a moderate 
level of knowledge. Most of the respondents 
who had a good knowledge were within age 
group above the median, a multiple numbers 
of gestation (G≥2), high level of education, 
and health service as a source of information 
(Table 2).

Table 1 Characteristics of Pregnant Women during the Fourth Antenatal Care Visit.

Variables Category
Participants (n=61)

n %

Age (years old) Above the median 36 59

Below the median 25 41

Number of gestation Primigravida (G1) 27 44

Multigravida (G ≥ 2) 34 56

Level of education High 38 62

Low 23 38

Source of information From health care service 44 72

Not from health care service 17 28
Note: G1= the first gestation; G≥2= the second gestation or more

Elsa Pudji Setiawati et al.: The Characteristics, Knowledge, and Attitude of Pregnant Women Regarding Early 
Breastfeeding Initiation on the Fourth Antenatal Care Visit



Althea Medical Journal. 2020;7(1)

22     AMJ March 2020

Most of the respondents (44 respondents 
or 72%) had a positive attitude regarding 
early breastfeeding initiation. All respondent’s 
characteristics had a significant relationship 
(p<0.005) with the attitude of early 
breastfeeding initiation as shown in Table 3.

Discussions

Our study result has shown that pregnant 
women (K4) mostly had good knowledge 
regarding early breastfeeding initiation, 
including 34.4% with good knowledge and 

Table 2 Relationship between Characteristics of Pregnant Women and Knowledge Regarding 
  Early Breastfeeding Initiation

Variable
Knowledge 

Total 
(n=61) p-valueGood 

(n=21)
Moderate 

(n=23)
Low 

(n=17)
Age (years old)
     Above the median 16 13 7 36

0.088
     Below the median 5 10 10 25
Number of gestation
     G1 5 10 12 27

0.015*
     ≥G2 16 13 5 34
Level of education
     Low 3 9 11 23

0.006*
     High 18 14 6 38
Source of information
     From health care service 20 17 7 44

0.022*
     Not from health care service 1 6 10 17

Note: median of age= 28 years old; G1= the first gestation; G2= the second gestation or more, *significant p<0.05

Table 3 Relationship between Characteristics of Pregnant Women and Attitude regarding 
  Early Breastfeeding Initiation

Variable
Attitude Total 

(n=61) p-valuePositive (n =44) Negative (n=17)
Age (years old)
     Above the median 30 11 36

0.019
     Below the median 14 11 25
Number of gestation
     G1 13 14 27

0.000*
     ≥G2 31 3 34
Level of education
     Low 12 11 23

0.007*
     High 32 6 38
Source of information
     From health care service 38 6 44

0.003*
     Not from health care service 6 11 17

Note: median of age= 28 years old; G1= the first gestation; G2= the second gestation or more, *significant p<0.05



Althea Medical Journal. 2020;7(1)

23Elsa Pudji Setiawati et al.: The Characteristics, Knowledge, and Attitude of Pregnant Women Regarding Early 
Breastfeeding Initiation on the Fourth Antenatal Care Visit

37.7% with a moderate knowledge. One of 
intervention given in the fourth antenatal 
care visit (K4) was providing information 
regarding early breastfeeding.8 Thus, the 
knowledge of pregnant women K4 can be 
obtained from counseling on antenatal care. 
However, there were 17 subjects (27.8%) who 
had  low knowledge. The results suggest that 
information regarding early breastfeeding 
initiation through antenatal care was not 
optimal, proven by a total of 11 respondents 
(27.9%) who did not get the information from 
the health caregiver.

A significant relationship has been found 
between the number of gestation, level 
of education, source of information and 
knowledge regarding early breastfeeding 
initiation. The relationship between age and 
knowledge regarding early breastfeeding 
initiation was not significant.

The number of gestations has a significant 
association with knowledge. Knowledge 
is influenced by sensing and intensity of 
attention.9 Number of gestation related to 
childbirth experience. This experience affects 
knowledge regarding early breastfeeding 
initiation. A study by Narayan et al.13 
showed that primigravida adversely affects 
breastfeeding.

Education is one of the factors that affect 
knowledge. Education is needed to get 
information. The higher level of education, the 
easier to receive the information,12 therefore, 
the level of education of pregnant women 
determines knowledge regarding early 
breastfeeding initiation.

The source of information had a significant 
association with knowledge regarding early 
breastfeeding initiation. It was related to the 
counseling given by health care to pregnant 
women who visit antenatal care. Some studies 
discovered that knowledge and awareness 
related to breastfeeding was better after 
counseling.14,15

The age of the pregnant women did not 
have a significant relationship with their 
knowledge. The older person’s age, the better 
able to work and think, the experience was 
one of the factors.12 However, older age does 
not always create  better knowledge. Younger 
mothers are less likely to do breastfeeding 
initiation compared with older mothers. This 
is due to the lack of social support and mother 
misperception about breastfeed.16 It shows 
that age does not become an absolute factor 
that determines the knowledge level of a 
pregnant women.

Most of the respondents (72.1%) have a 

positive attitude regarding early breastfeeding 
initiation, confirming the theory by Newcomn 
that attitude is a readiness to take action.9 That 
means the subjects mostly ready and agreed to 
do early breastfeeding initiation.

Based on the analysis of each characteristics 
with attitude, all of characteristic of pregnant 
women, that is age, a number of gestation, 
level of education, and source of information 
regarding early breastfeeding initiation have a 
significant association with attitude.9 Factors 
that influence attitude is experience, facilities, 
and socio-cultural. Experience related to age 
and number of gestation, facility related to 
promote and support breastfeeding provided 
by health care service and one of socio-cultural 
factors is the level of education.17 Through 
one of the questions about attitudes on the 
questionnaire, most of the respondents (92%) 
agreed to do early breastfeeding initiation 
after childbirth. The result contradicts the fact 
that there was the low implementation of early 
breastfeeding initiation.  It may relate to other 
factors, including health care service factors. 17

This study had some limitations. Not all the 
questionnaires were administered directly by 
the author and the sampling used in this study 
was consecutive sampling, therefore this study 
tends to less reflecting the Jatinangor sub-
district.

In conclusion, Most of the characteristics of 
pregnant women have a significant association 
with knowledge and attitude. Age did not have 
a significant association with knowledge. 
The suggestion for health care services is to 
improve antenatal care service, particularly 
in providing information regarding early 
initiation of breastfeeding and further research 
is needed to follow up on the implementation 
of early breastfeeding initiation among 
respondents

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3. Debes AK, Kohli A, Walker N, Edmond 
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