Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11209 Mother’s knowledge as a dominant factor for the success of exclusive breastfeeding in Indonesia Rinik Eko Kapti1,3 Yuni Sufyanti Arief,2 Nurona Azizah3 1Doctoral Degree Programs, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 3Faculty of Health Sciences, University of Brawijaya, Malang, Indonesia Abstract Introduction: Exclusive breastfeeding is one of the important indicators in achieving nutritional problems in children. Unfortunately, only 1 in 2 babies are exclusively breastfed in Indonesia. Therefore, this study aims to examine the factors asso- ciated with exclusive breastfeeding in the country. Design and Methods: Data were obtained from the Indonesian Family Life Survey (IFLS), by using a cross-sectional design involving a total of 2,217 mothers. The independent variables include weaning food, knowledge, labor difficulties, postpartum visits, number of children, marital status, sex of children, and low birth weight (LBW), while the dependent variable include exclu- sive breastfeeding. Subsequently, chi-square test and logistic regression were used to examine the relationship between exclu- sive breastfeeding and the related factors. Results: The prevalence of exclusive breastfeeding in Indonesia was 36.5%. Bivariate analysis showed that the variables associated with exclusive breastfeeding were weaning feeding, knowledge, low birth weight, and difficulty in labor with p-values of 0.005, 0.000, 0.040, and 0.005, respectively. The most domi- nant variable for exclusive breastfeeding behavior is knowledge with a value of OR = 1.85. Conclusions: There is a significant relationship between knowledge of mothers, weaning food, and low birth weight with exclusive breastfeeding behavior. Meanwhile, the main determi- nant among the variables is mother’s knowledge. Therefore, health workers and community service cadres need to provide counseling about health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. Introduction Globally, only 36% of infants under six months of age are exclusively breastfed.1 In Indonesia, only 1 in 2 infants under the age of 6 months are exclusively breastfed, meaning that almost half of all the country’s children do not get the food they need dur- ing the first two years of their life. Another study showed that over 40% of infants are introduced to weaning foods before reaching 6 months, which often do not meet their nutritional needs.2 The per- centage of infants aged less than 6 months who received exclusive breastfeeding in 2018 was 44.36%.3 In the first crucial months, breastfed children were six times more likely to survive than non-breastfed children. Failure to exclusively breastfeed by six months of age and to initiate breast- feeding within the first hour contributed to the deaths of 800,000 children under the age of five.1 The risk of mortality from all caus- es was lower in infants who were exclusively breastfed for 0–5 months, than in those who were not. Children aged 6–11 and 12– 23 months who were not breastfed had a 1.8 and 2.0-fold increased risk of death, respectively. The risk of dying from an infection is higher in non-breastfed infants aged 0–5 months than in breastfed ones and the risk is twice as high.4 Exclusive breast- feeding reduces the prevalence of respiratory and digestive prob- lems in infancy.2,5 Also, it is associated with the incidence of pneu- monia in toddlers (Hidayah Nurul 2017; Wulandari 2018). For example, it has an effect of 34.70% on the incidence of pneumonia under the age of five.6,7 Infants who are not exclusively breastfed have a higher risk of dying from diarrhea than those who are exclusively breastfed for 0-5 months.8 Increasing breastfeeding rates globally were able to save the lives of over 820,000 children under 5 years of age each year and also prevent an additional 20,000 cases of breast cancer in women yearly.2 WHO recommends mothers around the world to exclu- sively breastfeed their babies for the first six months to achieve optimal growth, development, and health. Exclusive breastfeeding provides benefits in the form of faster maternal weight loss after delivery, and delays in the return of menstrual periods. Currently, no adverse effects on growth have been documented with exclu- sive breastfeeding for six months.9,10 Exclusive breastfeeding is one of the indicators for achieving child nutrition problems which is part of the Sustainable Development Goals (SDGs).11 The WHO has also set global tar- gets to improve maternal, infant, and young child nutrition as well as monitoring the progress. One of the targets is to increase the rate of exclusive breastfeeding to at least 50% during the first 6 months.12 The findings revealed that the baby’s age, birth order, mother’s education, income, place of residence, and antenatal treatment frequently significantly impact the practice of exclusive breastfeeding. We identified similarities and differences in the components related to exclusive breastfeeding and demonstrated the significance of these factors in exclusive breastfeeding.13,14 Article Significance for public health Mother's knowledge, weaning food, and low birth weight have a relationship with exclusive breastfeeding behavior in Indonesia. Among the listed variables, the main determinant is mother's knowledge. Therefore, it is important for health workers to provide information that will motivate mothers to exclusively breastfeed. This paper describes the relationship between mother's knowledge, weaning food, low birth weight, and exclusive breastfeeding behavior in the country. [Healthcare in Low-resource Settings 2023; 11(s1):11209] [page 129] No n- co mm er cia l u se on ly Meanwhile, research on exclusive breastfeeding in Indonesia has been limited. Policymakers must consider the findings to discover the reasons for the rise in exclusive breastfeeding. Meanwhile, research on exclusive breastfeeding in Indonesia is lacking. Policymakers must study the results to find the causes linked to the growth in exclusive breastfeeding in Indonesia. Design and Methods The design used was cross sectional and the data was obtained from the fifth Indonesian Family Life Survey (IFLS) in 2014 which is open access on rand.org. IFLS is a longitudinal survey conducted by Research And Development (RAND) Corporation in collaboration with research institutions such as Survey Meter, the Demographic Institute of Universitas Indonesia, and Center for Population and Policy Studies at Gadjah Mada University. The population were mothers who participated in IFLS 5 in 2014 with a total of 50,148 respondents covering 13 provinces in Indonesia, namely North Sumatra, West Sumatra, South Sumatra, Lampung, Jakarta, West Java, Central Java, Special Region of Yogyakarta, East Java, Bali, West Nusa Tenggara, South Kalimantan, and South Sulawesi as well as West Sulawesi, con- ducted from 2014 to 2015. The total population of children aged 0- 60 months known as toddlers was 5,095 living in the country in 2014. After the number of samples was processed, only 2,217 chil- dren met the requirements. The dependent variable was exclusive breastfeeding which is based on the length of time the baby is breastfed, while the inde- pendent entails 8 variables, as follows: i) Weaning food given for less than six months or more than six months; ii) Knowledge, namely good and poor categories; iii) Postpartum visits, which are divided into receiving postnatal visits or not; iv) Infant birth weight, with categories of less than 2.7 or more than 2.7; v) Difficulty in labor, namely categories of experiencing difficulties or not; vi) Gender, which is divided into male or female; vii) The number of children with total of below 3 and above, or equal to 3; viii) The marital status of the mother, namely married or unmar- ried. The data obtained from IFLS 5 were checked for complete- ness for each variable by using the STATA 16 program, and data were cleaned up by analyzing the frequency of all variables. When missing data are found, they will be treated according to the inclu- sion criteria. Women aged 15–49 years with newborns under one- year-old and a history of having a baby with Low Birth Weight (LBW) were included as inclusion criteria. When all data has been collected and the missing ones has been processed and cleaned, data coding is carried out according to the operational definition and objective criteria. For data collection, we used survey methods and documented observation. Data analysis was performed using Chi-square for univariate and bivariate, while logistic regression was used for multivariate analysis to see differences in each group of variables and assess the strength of the relationship (POR and 95% CI). In order to see the effect of each covariate variable on the relationship between the independent and dependent variables, a stratification analysis was performed, which was also able to see the confounding variables and the modifying effect of the homo- geneity test results. Results and Discussions A total of 809, representing 36.5% of 2,217 children under 5 years, were exclusively breastfed. These children were divided into boys and girls with the respective percentages of 48.5% and 51.5%. Subsequently, 7.63% had a history of LBW and those who did not are 92.37%. Infants with inappropriate weaning food were 60.67%, while 39.33% were adequate. Of the mothers who took part in this survey, 30.99% had knowledge about exclusive breast- feeding and 69.01% had less knowledge. The majority of respon- dents who are married with more than 2 children represent 63.51%. 36.81% of mothers had a history of difficult delivery and 38.79% received postpartum visits. Further details on the descrip- tive characteristics of the respondents are presented in Table 1. In the bivariate analysis, most variables were significantly associated with exclusive breastfeeding. Variables that have a rela- tionship are weaning food, knowledge, LBW, and labor difficul- ties. While the other four including postpartum visits, gender, num- ber of children and maternal status, were not associated with exclu- sive breastfeeding. The details of the bivariate analysis are present- ed in Table 2. In the multivariate analysis, multiple logistic regression was used to analyze the dependent and independent variables as shown in Table 3. The most dominant variables for exclusive breastfeed- ing behavior were knowledge followed by weaning foods and birth weight with a p value of 0.015 and 0.013, respectively. Respondents with less knowledge had 1.8 times risk of exhibiting non-exclusive breastfeeding behavior after controlling through weaning food with a value of OR = 1.25 and birth weight with OR = 0.66. In the general population, 95% of people believe that knowledge is a factor that determines exclusive breastfeeding behavior with an interval ranging from 1.54 to 2.23. This study aims to analyze the determinants of exclusive breastfeeding in infants in Indonesia. Overall, only 36.49% of 2,217 respondents were exclusively breastfed. According to BPS data from 2018, exclusive breastfeeding coverage in the country Article Table 1. Socio-demographic characteristics of study participants (n = 2.217). Variables N % Breastfeeding Exclusive 809 36.49 Non exclusive 1408 3.51 Weaning food Appropritate 872 39.33 Not appropriate 1345 0.67 Knowledge Good 687 30.99 Poor 1530 69.01 Low birth weight Yes 169 7.62 No 2048 92.38 Difficulty of labor Yes 816 6.81 No 1401 63.19 Postpartum visit Yes 860 38.79 No 1357 1.21 Gender Female 1142 1.51 Male 1075 8.49 Number of children ≤2 612 27.60 >2 1605 2.40 Marital status Married 2176 98.15 Unmarried 41 1.85 [page 130] [Healthcare in Low-resource Settings 2023; 11(s1):11209] No n- co mm er cia l u se on ly has increased, but it is still low at 44.36%.3 This result is consistent with the one conducted in Ethiopia which showed that exclusive breastfeeding coverage was 44.2% and 56.1% in Nigeria.15,16 Although the WHO and Unicef have recommended exclusive breastfeeding for the first 6 months, the rate of exclusive breast- feeding is still low. Many factors influence exclusive breastfeed- ing, including a lack of knowledge, breastfeeding problems, poor families and social support, social norms, work, and health ser- vices.17 This study showed that mothers who have less knowledge about breastfeeding will have the opportunity to provide up to 1.85 to exclusive breastfeeding. UNICEF stated that every woman has the right to receive full information about breastfeeding to ensure the right decision is made for the babies (UNICEF, 2017). This helps to balance mothers’ perceptions of the benefits of breastfeed- ing with their practice.16 This is also supported by the results of previous studies which showed that knowledge is the most impor- tant determining factor in exclusive breastfeeding.18,19 Karcz’s study also explained that knowledge is the main determinant of breastfeeding duration, while Rapingah’s stated that knowledge and age are dominant factors in the practice of exclusive breast- feeding.20,21 Furthermore, Tambuanan’s 2021 survey of knowledge and exclusive breastfeeding in a hospital found that mothers with little knowledge were given the opportunity to exclusively breast- feed 2,556 times.18 Knowledge is an influential factor in the success of exclusive breastfeeding. Therefore, nurses need to develop and improve health promotion to increase mothers’ knowledge. The health pro- motion of exclusive breastfeeding behavior is very important and should be taught not only in the prenatal period but also in the post- natal period up to the second year of delivery.18 Health promotion is expected to include a maternal support system based on the results of the study which found that father’s knowledge of Exclusive Breastfeeding (EBF) enhances mother’s knowledge by sharing information and offering the support mothers need.22 In Indonesia, health workers need to develop and improve child health promotion facilities through discharge planning, to raise mothers’ awareness of exclusive breastfeeding and to develop infant program and cadres in Posyandu. Similarly, program activi- ties and cadres need to be optimized as an important support and media to identify mothers who are struggling to exclusively breast- feed at home. Mothers and babies need to be monitored through regular assessments by cadres and health workers during Posyandu activities, and provide mothers with proper health education to enable them provide exclusive breastfeed. In this study, LBW was associated with exclusive breastfeed- Article Table 2. Socio-demographic characteristics of study participants (n = 2.217). Variables Exclusive Breastfeeding X2 Yes No N % N % Weaning food - - - - 0.005 Appropritate 349 15.74 523 23.59 - Not appropritate 460 20.75 885 39.92 - Knowledge - - - - 0.000 Good 319 14.39 368 16.60 - Poor 490 22.10 1040 46.91 - Low birth weight - - - - 0.040 Yes 74 3.34 95 4.29 - No 735 33.15 1313 59.22 - Difficulty of labor - - - - 0.005 Yes 268 12.09 548 24.72 - No 541 24.40 860 38.79 - Postpartum visit - - - - 0.798 Yes 311 14.03 549 24.76 - No 498 22.46 859 38.75 - Gender - - - - 0.613 Female 411 18.54 731 32.97 - Male 398 17.95 677 30.54 - Number of children - - - - 0.189 ≤2 210 9.47 402 18.13 - >2 599 27.02 1006 45.38 - Marital status - - - - 0.718 Married 300 13.53 875 39.47 - Unmarried 509 22.96 533 24.04 - [Healthcare in Low-resource Settings 2023; 11(s1):11209] [page 131] Tabel 3. Multivariate analysis of factors associated with exclusive breastfeeding among children in Indonesia. Variables Odds Ratio P>|z| [95% Conf. Interval] Minimum Maximum Weaning food 1.25 0.015 1.04 1.49 Knowledge 1.85 0.000 1.54 2.23 Low Birth Weight 0.66 0.013 0.48 0.92 No n- co mm er cia l u se on ly ing. Additional findings from this study are that mothers with LBW babies have the option of exclusively breastfeeding up to 0.6. This result is not in line with the study of Pineda (2011), stating that the baby factors including birth weight and gestational age, were not related to the mother’s breastfeeding behavior.23 However, the results showed that only 52% of low birth weight infants were effectively breastfed after discharge from the hospital and four weeks after LBW infants were home, 40% were still exclusively breastfed but 19% were replaced with formula milk.24 Mothers who give early weaning food have an opportunity to give exclusive breastfeeding up to 1.25. Lessa et al. indicated that the early introduction of solid foods was likely to shorten breast- feeding duration thus suggesting to delay solid foods until 6 months of age because it is important to support breastfeeding.25 Based on Paramita and Purnomo (2015), one of the factors influ- encing exclusive breastfeeding is the introduction of weaning foods before the age of 6 months.26 Interestingly, exclusive breast- feeding is also the most powerful indicator to check for the early introduction of solid foods.27 The WHO and UNICEF recommend an early start of breastfeeding within 1 hour after birth, exclusive breastfeeding for the first 6 months of life, and the introduction of solid foods that are nutritionally adequate and safe at the age of 6 months along with continued breastfeeding up to age 2 years or older. However, many babies and children are not optimally nour- ished. For example, in 2015–2020, only about 44% of infants aged 0–6 months worldwide were exclusively breastfed.28 Exclusive breastfeeding has a positive effect on both mother and baby. Mothers who do not exclusively breastfeed are 7.58 times more likely to experience Postpartum Depression (PPD) than mothers who exclusively breastfeed. This PPD is significantly higher in mothers with impaired exclusive breastfeeding and even get worse when there is increased stress and restricted social sup- port.29 Exclusive breastfeeding for 6 months is recommended for infants because it can protect against diarrhea and respiratory tract infections, reduce hospital admissions, and achieve growth.30 This study provides new information using secondary data from Indonesia’s Demographic Year 2017 and Health Survey (IDHS). It’s only that this study has limitations, such as still focusing on the mother’s understanding. Family center care must be prioritized to improve children’s health. It is necessary to study the mother’s information and knowledge from the father’s side. So, for future research, focusing on the father’s side of expertise will bring new and essential information on whether it influences the effective- ness of exclusive breastfeeding in Indonesia. Conclusions Mother’s knowledge, weaning food, and low birth weight has a significant relationship with exclusive breastfeeding behavior in Indonesia. Meanwhile, the most important determinant among the variables was the mother’s knowledge. Therefore health workers and community service cadres need to provide counseling about the health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. The result also motivates educational institutions and nursing students to further increase their creativity in the development of mother-friendly health promotion. Further study is needed to identify the optimal factors for exclusive breastfeeding behavior by adding aspects from husband support. References 1. Shetty P. Indonesia’s breastfeeding challenge is echoed the world over. Bull World Health Organ 2014;92:234–5. 2. WHO. World Breastfeeding Week: UNICEF and WHO call on the Government and employers to support breastfeeding moth- ers in Indonesia during COVID-19. 2020. Available from: https://www.who.int/indonesia/news/detail/03-08-2020- world-breastfeeding-week-unicef-and-who-call-on-the-gov- ernment-and-employers-to-support-breastfeeding-mothers-in- indonesia-during-covid-19 3. BPS. Persentase Bayi Usia Kurang Dari 6 Bulan Yang Mendapatkan Asi Eksklusif Menurut Provinsi (Persen), 2018- Article [page 132] [Healthcare in Low-resource Settings 2023; 11(s1):11209] Correspondence: Rinik Eko Kapti, Doctoral Degree Programs, Faculty of Nursing, Universitas Airlangga, Jl. Mulyorejo Campus C Unair, Surabaya Indonesia, 60115, E-mail: rinik.eko.kapti-2020@fkp.unair.ac.id Key words: Knowledge, exclusive breastfeeding, mother Acknowledgments: The authors are grateful for the data provided by the Indonesian Family Life Survey (IFLS) which helps to know about the important issues that occur regarding mother’s knowledge as a determi- nant of exclusive breastfeeding in Indonesia. Contributions: REK and YSA understand the ideas presented, and con- tributed to the study design, analysis of the results, and writing of the manuscript. All authors read and approved the final manuscript. Conflict of interest: The author declares no conflict of interest. Funding: This study did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sector. Clinical trials: The IFLS data used is publicly available, while the sur- veys and procedures were reviewed and approved by the Institutional Review Board (IRB) at RAND Corporation in the US and Universitas Gadjah Mada (UGM) in Indonesia. Written informed consent was obtained from all participants before data collection began. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legal- ly authorized representative(s) for anonymized patient information to be published in this article. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 5 December 2021. Accepted for publication: 18 May 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11(s1):11209 doi:10.4081/hls.2023.11209 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. No n- co mm er cia l u se on ly 2020. [Percentage of Infants Age Less Than 6 Months Getting Exclusive Breastfeeding by Province (Percent), 2018-2020.] 2021. Available from: https://www.bps.go.id/ indica- tor/30/1340/1/persentase-bayi-usia-kurang-dari-6-bulan-yang- mendapatkan-asi-eksklusif-menurut-provinsi.html 4. Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeed- ing practices and infant and child mortality: A systematic review and meta-analysis. Acta Paediatr Int J Paediatr 2015;104:3–13. 5. Fisk CM, Crozier SR, Inskip HM, et al. Breastfeeding and reported morbidity during infancy: Findings from the Southampton Women’s Survey. Matern Child Nutr 2011;7:61– 70. 6. Wulandari RA. The Influence of Exclusive Breastfeeding Toward The Occurrence of Childhood Pneumonia in East Java. J Berk Epidemiol 2018;6:236. 7. Hidayah Nurul. The Correlation Of Sex And Exclusive Breastfeeding Status With Acute Respiratory Infection (Ari) Incidence Among Under-Five Children At The Cempaka Public Health Center Banjarmasin. Din Kesehat 2017;8:330–5. 8. Mazumder S, Taneja S, Dube B, et al. Effect of community-ini- tiated kangaroo mother care on survival of infants with low birthweight: a randomised controlled trial. Lancet 2019;394:1724–36. 9. WHO. Exclusive breastfeeding for six months best for babies everywhere. 2011. Available from: https://apps.who.int/media- centre/news/statements/2011/breastfeeding_20110115/en/inde x.html 10. Ho C. Optimal duration of exclusive breastfeeding. Int J Evid Based Healthc 2013;11:140–1. 11. UNICEF, BAPPENAS. Achieving the SDGs for children in Indonesia: Emerging findings for reaching the targets. Indones Minist Natl Dev Plan United Nations Child Fund 2019;288. 12. WHO. Global Targets 2025. 2021. Available from: h t t p s : / / a p p s . w h o . i n t / n u t r i t i o n / g l o b a l - t a r g e t - 2025/en/index.html 13. Rahman MA, Khan MN, Akter S, et al. Determinants of exclu- sive breastfeeding practice in Bangladesh: Evidence from nationally representative survey data. PLoS One 2020;15:1– 14. 14. Um S, Chan YZC, Tol B, et al. Determinants of exclusive breastfeeding of infants under six months among Cambodian mothers. J Pregnancy 2020;2020. 15. Elyas L, Mekasha A, Admasie A, et al. Exclusive Breastfeeding Practice and Associated Factors among Mothers Attending Private Pediatric and Child Clinics, Addis Ababa, Ethiopia: A Cross-Sectional Study. Int J Pediatr 2017;2017:1– 9. 16. Sholeye OO, Abosede OA, Salako AA. Exclusive Breastfeeding and Its Associated Factors among Mothers in Sagamu, Southwest Nigeria. J Heal Sci 2015;5:25–31. 17. EL-Houfey AA, Saad K. Factors that Exclusive Breastfeeding. Int Nursing, Midwife Heal Related Cases 2018;4:16–28. 18. Tambunan AT, Tanggulungan F, Poppy R, et al. Relationship between Mothers’ Knowledge and Exclusive Breastfeeding Behavior in One Private Hospital in West Indonesia. Int J Nurs Heal Serv 2021;4:1–8. 19. Rosyid ZN, Sumarmi S. Hubungan Antara Pengetahuan Ibu dan IMD Dengan Praktik ASI Eksklusif. [The Relationship Between Mother’s Knowledge and IMD With Exclusive Breastfeeding Practices.] Amerta Nutr 2017;1:406. 20. Karcz K, Lehman I, Królak-olejnik B. The link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in Poland. Int Breastfeed J 2021;1–15. 21. Rapingah S, Muhani N, Besral, et al. Determinants of exclu- sive breastfeeding practices of female healthcare workers in Jakarta, Indonesia. Kesmas 2021;16:59–65. 22. Ouyang YQ, Nasrin L. Father’s knowledge, attitude and sup- port to mother’s exclusive breastfeeding practices in bangladesh: A multi-group structural equations model analysis. Healthcare 2021;9:276. 23. Pineda RG. Predictors of breastfeeding and breastmilk feeding among very low birth weight infants. Breastfeed Med 2011;6:15–9. 24. Hill PD, Ledbetter RJ, Kavanaugh KL. Breastfeeding patterns of low-birth-weight infants after hospital discharge. J Obstet Gynecol Neonatal Nurs 1997;26:189–97. 25. Lessa A, Garcia AL, Emmett P, et al. Does early introduction of solid feeding lead to early cessation of breastfeeding? Matern Child Nutr 2020;16:1–9. 26. Paramita A, Pramono MS. The Pattern and Factor Analysis of the Breastfeeding Duration in 2013. J Ekol Kesehat 2015;14:157–70. 27. Kronborg H, Foverskov E, Væth M. Predictors for early intro- duction of solid food among Danish mothers and infants: An observational study. BMC Pediatr 2014;14:1–10. 28. WHO. Infant and young child feeding [Internet]. 2021. Available from: https://www.who.int/news-room/fact- sheets/detail/infant-and-young-child-feeding 29. Islami MJ, Broidy L, Baird K, et al. Early exclusive breast- feeding cessation and postpartum depression: Assessing the mediating and moderating role of maternal stress and social support. PLoS One 2021;16:1–19. 30. Agrasada GV, Ewald U, Kylberg E, Gustafsson J. Exclusive breastfeeding of low birth weight infants for the first six months: Infant morbidity and maternal and infant anthropom- etry. Asia Pac J Clin Nutr 2011;20:62–8. Article [Healthcare in Low-resource Settings 2023; 11(s1):11209] [page 133] No n- co mm er cia l u se on ly