Epidemiology and Society Health Review| ESHR Vol. 7, No. 1, 2025, pp. 25-33 ISSN 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v7i1.12565 25 Review Article Exclusive Breastfeeding as a Risk Factor for Stunting Among Under-Fives in Urban and Rural Indonesia: A Systematic Review Rena Anjeli Wibowo1, Asep Rustiawan1* 1 Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia * Correspondence: asep.rustiawan@ikm.uad.ac.id. Phone: +6285743847969 Received 12 January 2025; Accepted 27 January 2025; Published 2 February 2025 ABSTRACT Background: Previous research found that children in rural areas have a 1.3 times greater risk of stunting than children in urban areas. Exclusive breastfeeding is one of the risk factors for stunting. The 2017 Indonesian Demographic and Health Survey (IDHS) showed that the percentage of exclusive breastfeeding in urban areas was 37.8%, while in rural areas, it was 46.9%. The purpose of this study was to determine the magnitude of the risk of stunting in toddlers who are not exclusively breastfed in rural and urban areas. Method: This research used a Meta-Analysis Systematic Review by searching articles in PubMed, Google Scholar, and Garuda that were in Indonesian or English and published between 2019 and 2024. Keywords included stunting, risk factors, exclusive breastfeeding, children under five, rural, and urban. The article search used the PICO framework, while the article quality assessment used the Joanna Bright Institute (JBI) Critical Appraisal Instrument. The data collected was presented in a PRISMA diagram and analyzed based on Forest Plot graphs using RevMan 5.4.1. Results: A total of 3,269 articles were identified, and 11 met the criteria. The analysis showed that toddlers not exclusively breastfed had a 3.84 times greater risk of stunting in rural areas and 2.38 times greater for urban regions than exclusively breastfed toddlers. Conclusion: Children who are not exclusively breastfed in rural areas are at greater risk of stunting than those in urban areas. Keywords: Stunting; Risk Factors; Exclusive Breastfeeding INTRODUCTION Toddlers have a double burden of nutritional problems, including obesity, stunting, anemia, thinness, and malnutrition.1 Stunting is a chronic nutritional problem with a lower height or length than the established standard. A child is said to be stunted if the height or length according to age has a Z-score value <-2SD.2 The prevalence of stunting in children under http://journal2.uad.ac.id/index.php/eshr/index mailto:eshr@ikm.uad.ac.id https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 26 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 the age of five globally in 2022 is estimated to reach 22.3%. This means that around 148.1 million children worldwide are stunted.3 The 2023 Indonesian Health Survey (HIS) results found that 1 out of 5 toddlers in Indonesia, or 21.5%, experienced stunting.4 This figure shows a decrease of 0.1% compared to the prevalence in 2022 at 21.6%. Despite the decrease, this progress has not been able to meet the target of the 2020-2024 National Medium-Term Development Plan (NMTDP), which targets the stunting of 14% in 2024. Rural and urban areas show different patterns in stunting incidence. Globally, the prevalence of stunting in rural areas is almost twice as high as in urban areas. Based on data from the Food Agriculture Organization, the prevalence of stunting is 1.6 times higher in rural areas than in urban areas.5 The 2018 Basic Health Research (BHS) results in Indonesia showed that the prevalence of stunting in rural areas reached 21.5%, while in urban areas, it was 17.4%.6 The 2023 SKI report showed the same results, that the prevalence of stunting in rural areas was higher at 13.9% and in urban areas at 12.3%.7 Stunting resulted from a complex interaction between direct causal and contextual factors. The WHO conceptual framework on stunting in children illustrates that a country and its society play a role in stunting children in that country. External factors include culture, education, health services, economic conditions, politics, agricultural conditions and food systems, water conditions, sanitation, and the environment. Meanwhile, internal factors in the child's home also influential such as adequate childcare, exclusive breastfeeding (EB) and optimal complementary foods (CF), maternal conditions, home conditions, food quality, food and water safety, and infection factors.8 This reflects that stunting is caused by household, environmental, socio-economic, and cultural factors.9 Exclusive breastfeeding is one of the risk factors for stunting. Exclusive breastfeeding is the best source of nutrients for infants, which can reduce the prevalence of child morbidity and mortality.10 Despite the fact that breast milk is the best food for infants, not all infants receive exclusive breastfeeding.11 Based on the Indonesian Nutritional Status Study (INSS) results, as many as 48.2% of infants in Indonesia received exclusive breastfeeding in 2021, which decreased to 14.6% in 2022. This shows that the coverage of exclusive breastfeeding in Indonesia is still low.12 Various studies in both rural and urban areas have shown that the inconsistency of exclusive breastfeeding can be a significant risk factor for stunting. Studies located in rural areas have shown that non-exclusive breastfeeding has an impact on the incidence of stunting.13 Several studies located in urban areas have also shown a relationship between exclusive breastfeeding and the incidence of stunting.14,15,16,17 In this case, it is interesting to know whether the risk of stunting in toddlers who do not receive exclusive breastfeeding in rural areas is the same as in urban areas. This information is essential to formulate a more effective strategy to reduce stunting rates in Indonesia. Based on this description, this study intended to determine the magnitude of the risk of stunting in toddlers who do not receive exclusive breastfeeding in rural and urban areas. https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 27 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 METHOD This research used a Meta-Analysis Systematic Review based on article search results in the electronic databases PubMed, Google Scholar, and Garuda. Articles were collected from August 2024 to September 2024. Keywords included stunting, risk factors, exclusive breastfeeding, children under five, rural, and urban, combined using Boolean Operators (AND, OR). The article searches flow used the PICO framework (Population, Intervention, Comparison and Context). Population explains the characteristics of the population to be observed, in this case, children under 5 years old (toddlers); Intervention explains the intervention or exposure being studied, namely toddlers who do not receive exclusive breastfeeding; Comparison informs the comparison group, namely toddlers who receive exclusive breastfeeding; and Outcome explains the results of previous studies that are consistent with the research topic, namely the incidence of stunting—article quality assessment using the Joanna Bright Institute (JBI) Critical Appraisal instrument. The collected data were presented in a PRISMA diagram following the identification, screening, eligibility, and inclusion selection stages. Data analysis based on the results of the Forest Plot graph using RevMan 5.4.1. This study set the inclusion criteria of the article as follows: scientific articles published in 2019- 2024; the study population was children under five years old (toddlers); the study examines risk factors for stunting; the location of the study was conducted in rural and urban areas in Indonesia according to the criteria of the Central Statistics Agency (CSA); the analytical observational study design includes Cohort, Case-Control, and Cross-Sectional; provides Odds Ratio (OR), Risk Ratio (RR), and Prevalence Ratio (PR); and the article was available in full text. The exclusion criteria applied were articles that were not primary research and articles in languages other than Indonesian and English. This study examines the findings of previously existing research using a Meta-analysis design of secondary data that has been published and does not involve human subjects directly, so it does not require Ethical Approval. RESULTS Figure 1 shows the research process; in the initial search process on various databases, article results were sourced from Google Scholar (2,855 articles), PubMed (167 articles), and Garuda (247 articles), so a total of 3,269 articles were obtained. After removing duplicate articles, the results were 2,264 articles. From this number, a systematic analysis was then carried out so that the final number of articles that met the criteria was 11, as presented in Table 1. Among the 11 selected articles, there are 6 research articles in rural areas and 5 research articles in urban areas. Furthermore, the Forest Plot analysis results are presented in Figure 2. Forest Plot on Figure 2 shows that in rural areas, toddlers who do not receive exclusive breastfeeding are at 3.84 times greater risk of experiencing stunting compared to toddlers who receive exclusive breastfeeding (OR=3.84; 95% CI=2.47–5.97; p<0.00001). For urban areas, toddlers who do not receive exclusive breastfeeding are at 2.38 times greater risk of experiencing stunting compared to toddlers who receive exclusive breastfeeding (OR=2.38; 95% CI=1.03–5.51; p=0.04). The significance value also shows that exclusive breastfeeding https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 28 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 is associated with the risk of stunting in toddlers both in rural (p<0.00001) and urban (p<0.04) areas. RESULTS The results of the article search are presented according to the following systematic flow: Figure 1. The flowchart of the paper selected in this study Table 1. List of Articles with Exclusive Breastfeeding Variables to be Analyzed No Author (Year) Research Design Setting Area p- value OR (CI) 1. Safitri, et al (2023) Case Control Rural 0.03 2.09 (0.98-4.61) 2. Agussalim, et al (2024) Case Control Rural 0.03 2.44 (1.24-4.29) 3. Fithria, et al (2024) Case- Control Rural 0.00 4.56 (2.25-9.23) 4. Wicaksono, et. al (2021) Case- Control Rural <0.01 3.64 (2.01-6.61) 5. Wahyuni, et al (2019) Case Control Rural 0.00 5.67 (1.97- 15.51) https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 29 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 No Author (Year) Research Design Setting Area p- value OR (CI) 6. Modjo, et al (2023) Case- Control Rural 0.00 14.06 (4.27-46.23) 7. Widayati, et al (2021) Case Control Urban 0.36 1.56 (0.71-3.39) 8. Al-Ayubi, et al (2021) Case Control Urban 0.62 1.33 (0.59 – 3.01) 9. Yuniarti, et al (2019) Case Control Urban 0.00 19.5 (5.56 - 68.36) 10. Maulana, et al (2023) Case Control Urban 0.02 3.47 (1.17-10.32) 11. Wahyuningrum, et al (2023) Case Control Urban 0.50 1.02 (0.63- 1.65) Figure 2. Forest Plot of the Relationship between Exclusive Breastfeeding and Stunting in Rural and Urban Areas DISCUSSION This study is a systematic review and combines quantitative estimation results (Meta-analysis) from several previous studies that answer the same research problem and can be combined. The study was conducted on exclusive breastfeeding as a risk factor for stunting in toddlers in rural and urban areas in Indonesia. The results of the study showed that toddlers who did not receive exclusive breastfeeding in rural areas were at greater risk of suffering from stunting compared to toddlers who did not receive exclusive breastfeeding in urban areas. https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 30 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 The United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) recommend that babies only be given breast milk for at least six months. Exclusive breastfeeding is recommended in the first six months of a baby's life because pure breast milk is not contaminated and contains many nutrients needed by babies at that age.18 In line with WHO, the Minister of Health, through the Regulation of the Minister of Health (RMH) No. 15 of 2014, also stipulates the provision of exclusive breastfeeding for 6 months, without adding and/or replacing it with other foods or drinks.19 Breast milk is a fat emulsion in a solution of protein, lactose, and inorganic salts released by the mother's breasts, which is useful as a nutritional intake for babies. Breast milk is a white liquid produced by the mother's mammary glands during breastfeeding. Breast milk is a food that has been prepared for babies since the mother is pregnant.20 Breast milk is the perfect food source with nutritional content that matches the body's needs and B12-binding protein, an essential amino acid that plays a vital role in increasing the number of baby brain cells and is related to the baby's intelligence.21 The results of the Meta-analysis conducted in this study strengthen the evidence that non- exclusive breastfeeding consistently increases the risk of stunting, both in rural and urban areas. In rural areas, toddlers who do not receive exclusive breastfeeding are at 3.84 times greater risk of stunting compared to toddlers who receive exclusive breastfeeding (OR=3.84; 95% CI=2.47–5.97; p<0.00001). For urban areas, toddlers who do not receive exclusive breastfeeding are at 2.38 times greater risk of stunting compared to toddlers who receive exclusive breastfeeding (OR=2.38; 95% CI=1.03–5.51; p=0.04). This means that toddlers who do not receive exclusive breastfeeding in rural areas have a greater risk of stunting compared to toddlers who do not receive exclusive breastfeeding in urban areas. The high risk of stunting in toddlers in rural areas is because rural areas have limited resources compared to urban areas, such as socio-economic levels, parental education and knowledge, and access to health services.22,23,24,24,26 The socio-economic level greatly influences families in meeting the nutritional needs of toddlers. The more excellent the opportunity to earn income, the healthier the choice of additional food and lifestyle habits. Low family income levels will cause stunting in children due to decreased purchasing power for quality food.27 If access to food in the family is disrupted due to poverty, stunting in toddlers will occur.28 Parents, especially mothers with low education, will find it difficult to absorb information, which can put their toddlers at risk of stunting. Mothers with higher education will find obtaining information about the nutrition their children need easier.29 Mothers must know how to meet nutritional needs to prepare for pregnancy, during pregnancy, and after birth to increase breast milk production. Efforts that can be made to overcome stunting include providing exclusive breastfeeding for 6 months, early breastfeeding when the baby is born, ensuring that food is available in reasonable quantity and quality, and receiving good and proper care.30 Access to health services that are too far and difficult to reach can be an obstacle for pregnant women to check their fetal health (antenatal). As a result, pregnant women lack information related to nutrition during pregnancy, even though stunting prevention can be done starting from the age of 0 days. Checking children's health through health services can help mothers monitor their children's growth and development to avoid malnutrition and disease infections.31 https://doi.org/10.26555/eshr.v3i1.3629 https://doi.org/10.26555/eshr.v3i1.3629 Wibowo et al. (Exclusive breastfeeding as a risk factor for stunting among under-fives in urban and rural Indonesia) 31 Vol. 7, no. 1, 2025, pp. 25-33 10.26555/eshr.v7i1.12565 CONCLUSION Based on the results of the study, it can be concluded that toddlers in rural and urban areas who do not receive exclusive breastfeeding have a greater risk of experiencing stunting than toddlers who receive exclusive breastfeeding. However, toddlers who do not receive exclusive breastfeeding in rural areas are at greater risk of suffering from stunting compared to toddlers who do not receive exclusive breastfeeding in urban areas. This situation is influenced by complex factors such as socio-demographics, economics, and health services. Policy recommendations to address this problem include poverty reduction, education, and quality of health services, including antenatal checks. A holistic solution involving all stakeholders is needed to reduce the disparity between rural and urban areas. Acknowledgement The researchers would like to thank the research database providers from PubMed, Google Scholar, and Garuda. Declarations Authors' contribution RAW was responsible for the research design and data collection; AR provided data analysis and reviewed the manuscript. Funding statement This research has not received external funding. Conflict of interest There is no conflict of interest in this research. REFERENCES 1. Agustina SA& Rahmadhena MP. Analysis of Determinants of Toddler Nutritional Problems. Journal of Health. 2020;7(2):353–60. https://doi.org/10.35730/jk.v11i1.685 / 2. WHO. World Health Organization (WHO). Nutrition Landscape Information System (NLIS).2021. 3. UNICEF, WHO, WORLD BANK. Levels and Trends in Child Malnutrition. 2023:4. 4. Ministry of Health of the Republic of Indonesia. Stunting in Indonesia and Determinant Factors. In: SKI Thematic Report 2023. 2023. 5. FAO, IFAD, UNICEF, WEP, WHO. 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