Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12089 Effectiveness of the SETIA (Self Empowering Woman, Empathy, Trust, Intimate and Affection) program in enhancing exclusive breastfeeding in Indonesia Ernani Setyawati, Endah Wijayanti, Ita Kusumayanti, Damai Noviasari, Sekar Handayani, Novi Pasiriani, Eli Rahmawati Diploma III of Balikpapan Midwifery Program, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia Abstract The sustainability of breastfeeding remains a challenge for primiparous mothers. Empowering women through home visits by midwives needs to be enhanced to ensure the continuity of breast- feeding. This research aimed to compare the effectiveness of the SETIA (Self-Empowering Women, Empathy, Trust, Intimacy, and Affection) program with a standard program in assisting primi- parous mothers to breastfeed their babies after one month. A total of 50 primiparous participants were divided into two groups through simple random sampling. The standard group received four home visits, while the SETIA group received five home visits within one month postpartum. The breastfeeding competency variable was evaluated after one month using the World Health Organization (WHO) instruments and interviews about exclusive breastfeeding. The variables were analyzed using comparative statistics. The results showed no significant difference between the standard and SETIA groups, with Mann-Whitney U values of 253.5 and Wilcoxon values of 578.5 (p-value=0.086, α<0.05). However, there is evidence that the intervention group managed breastfeeding problems better, and more mothers continued breastfeeding after one month. Therefore, the authors suggest more frequent home visits to help new mothers adapt to their breastfeeding roles, especially in the first week after birth. Further research is needed to assess exclusive breastfeeding after six months in both groups. Introduction Breastfeeding is an excellent beginning for both the mother and her newborn baby. Breast milk is tailored to the newborn’s needs and digestion, promoting maximum growth and develop- ment while helping prevent stunting.1 The beneficial effects of breastfeeding for mothers include protection against metabolic pathologies, obesity, gynecological disorders, and female cancers, particularly breast, ovarian, and endometrial cancer.2,3 It also plays a crucial role in providing psychological support to postpartum women, especially in combating depression and anxiety.4 Despite its well-established benefits, exclusive breastfeeding remains a global challenge, including in Indonesia.5,6 Women who undergo their first pregnancy typically acquire knowledge about pregnancy and breastfeeding through perinatal classes and seek information via mass media or healthcare providers. However, challenges arise when new mothers attempt to breastfeed their babies, as breastfeeding is a continued activity.7 Common problems include sore nipples, breast swelling, per- ceived insufficiency of breast milk, and limited communication with healthcare providers during breastfeeding. The lack of sup- port in addressing breastfeeding difficulties can hinder mothers’ ability to breastfeed successfully.8 The success of breastfeeding in infants can be influenced by both infant and maternal factors. Infant factors are affected by the development of oral-motor func- tion, which is greatly dependent on gestational age. Maternal fac- tors, on the other hand, encompass physical and psychological aspects.9,10 The mother’s psychological state emerges as a significant fac- Correspondence: Ernani Setyawati, Diploma III of Balikpapan Midwifery Program, Politeknik Kesehatan Kemenkes Kalimantan Timur, Samarinda, Indonesia. Tel.: +6281346398980 E-mail: esetyawati80@gmail.com Key words: breastfeeding; home visit; standard; SETIA. Contributions: ES, conceptualization, methodology, original draft, review, and editing; EW and IK, recruitment of field research assistants and prospective respondents, and also supervision during data collection; DN, SH, NP, and ER collecting data and project administration. All research members jointly ensured the research protocol was carried out properly and approved the final version to be published. Conflict of interest: the authors declare no potential conflict of interest. Funding: this research was supported by a research grant from Ministry of Health Polytechnic Kalimantan Timur. Ethics approval and consent to participate: this research was approved by the Health Research Ethics Committee of Health Polytechnic of East Kalimantan with an ethical clearance statement letter DL.02.03/4.3/ 10426/2022. Patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: we would like to thank all participants and all civi- tas academics from the Ministry of Health Polytechnic Kalimantan Timur for their valuable insights and contribution to this study. Received: 15 November 2023. Accepted: 21 May 2024. Early access: 3 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12089 doi:10.4081/hls.2024.12089 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. [Healthcare in Low-resource Settings 2024;12:12089] [page 595] tor that can deter her from breastfeeding her baby, even in the absence of any breast disorder. Emotional distress has the potential to inhibit the let-down reflex, impacting breastfeeding self-effica- cy, and may compound physical discomfort.11 Psychological fac- tors can also interfere with the process of milk production, affect- ing both the prolactin reflex and the oxytocin-driven milk ejection reflex, thereby compromising optimal milk production or leading the mother to perceive her milk production as inadequate.12 Key psychological conditions that play a pivotal role include sadness, fear, lack of confidence, and inadequate breastfeeding support.13,14 Assisting mothers in breastfeeding their babies is crucial for ensuring the healthy development of future generations.15 Despite recommendations from health workers and government authori- ties, not all mothers breastfeed their babies. In Indonesia, approxi- mately 66.69% of babies are exclusively breastfed, with rates slightly higher in specific regions such as East Kalimantan (71.08% in 2019) and Balikpapan (78.74%). However, despite these efforts, data from the Indonesian Nutritional Status survey indicate that stunting rates in East Kalimantan reached 23.9% in 2022, exceeding the national average of 21.6%. This underscores the ongoing need to focus on promoting exclusive and sustained breastfeeding, particularly to mitigate the risk of higher stunting rates in the future.16 Mothers need a support system that assists them in adapting to their roles as new mothers, whether through professional health- care services or other support networks.17 This can be achieved through programs that offer foster care, prioritizing female empowerment, empathy, trust, intimacy, and affection for breast- feeding mothers. Such programs aim to enhance mothers’ breast- feeding abilities and equip them with coping mechanisms for any breastfeeding-related challenges that may arise. One such program is the SETIA (Self-Empowering Women, Empathy, Trust, Intimacy, and Affection) program, which involves five home visits during the first week after labor. The aim of this research was to compare the effectiveness of the SETIA program with that of the standard program in promoting exclusive breastfeeding one month post-partum. Materials and Methods This research used a quasi-experiment study conducted from March 2022 to November 2022 among 50 primiparas in Balikpapan City, Indonesia, which was divided into two groups. The standard group was 25 primiparas who had received four times of home visits according to the standard from the Indonesian Ministry of Health.18 The intervention group with the SETIA (Self- Empowering Woman, Empathy, Trust, Intimacy, and Affection) method was 25 primiparas who had received home visits five times. In each home visit, SETIA group respondents receive indi- vidual counseling, breastfeeding practices, and advice on how to overcome breastfeeding problems that may arise during breast- feeding. The sample size used the sample size formula for comparative analysis and was determined with consecutive sampling.19 The magnitude of the standard deviation based on previous research journals is 6.5. The magnitude of the average difference in breast- feeding between the two groups, which is statistically significant, is 5. If Z(1-α)=90%, then Zα=1.28. and Z(1-β)=90%, then Zβ=1.28. Research also adds a 10% loss to follow-up in this study, which results in 25 subjects for one group. The population of this study was primiparous women who received maternity services at primary health care, Independent Practice Midwives, and hospitals in Balikpapan, Indonesia. The study sample was 50 primiparous women who were divided into two groups: the control group (the standard program) and the inter- vention group (the SETIA program). The sampling method is con- secutive sampling. Each primiparous woman who fits the inclusion criteria is entered into the Excel program and assigned a number. Then, even numbers become the control group, and odd numbers become the intervention group. The inclusion criteria were the same for both groups: a woman who had a delivery in the research location and had a healthy new- born baby at term and weighing >2500 gr. The woman was given written and verbal information about the aim of the study and the term of confidentiality. They subsequently signed a written consent Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 596] [Healthcare in Low-resource Settings 2024;12:12089] Table 1. Home visit procedure. Model Time Procedure Standard program 1 (6-48 hours after labor) - Ensuring uterine contraction and involution to prevent postpartum bleeding - Early breastfeeding - Bonding attachment - Prevent hypothermia 3-7 days Postpartum - Monitor the adaptation of mothers and families with new born - Assess for signs of fever. infection. or bleeding - Make sure you get enough food. fluids. and rest - Make sure the mother breastfeeds well and there are no infections - How is the daily care of the baby 8-28 days postpartum - The beginning of sexual intercourse - Family planning method - Abdominal muscle toning exercises - Digestive function. constipation. and how to handle it 29-42 days postpartum - The beginning of sexual intercourse - Family planning method SETIA program. form and could resign anytime. This research was approved by the Health Research Ethics Committee of Health Polytechnic of East Kalimantan with an ethical clearance statement letter DL.02.03/4.3/10426/2022. During the home visit, the midwife helps the mother to adapt to breastfeeding in the first week, teaches the new mother to breastfeed, and discusses how to deal with the problem when breastfeeding their babies. Home visit procedures can be seen in Table 1. Quantitative data were collected from both the intervention and control groups (Figure 1), focusing on factors such as age, edu- cation, labor experience, and breastfeeding challenges. The researcher formed a group of five midwives to administer the inter- vention. Prior to the start of the research, thorough preparation ensured that the procedure of home visits and the tools used to examine respondents during the intervention were well-known. During the intervention implementation, the research subjects in the intervention group underwent an assessment of breastfeed- ing latch using tools designed to observe both the mother’s and the baby’s ability to breastfeed, including the latch-on technique and breastfeeding difficulties experienced immediately after discharge from the hospital/clinic/private practice. These assessments occurred at three days, one week, two weeks, and four weeks after labor, totaling five visits during the postpartum period.20 In con- trast, the control group received standard home visits twice during the first week and twice again during the second and fourth weeks, totaling four visits during the postpartum period. Exclusive breastfeeding was assessed after one month through interviews with mothers regarding the feeding practices for their babies. Exclusive breastfeeding, defined as the sole provision of breast milk to infants, was the dependent variable measured one month after labor. The research was carried out as in Figure 1. Results Demographics The study included 50 primiparas divided into two groups: a control group (n=25) and an intervention group (n=25), with ages ranging from 18 to 35 years. The mean age for the entire sample for both groups was 25 years. Educational levels among partici- pants varied from elementary school to university education. The study results showed no significant relationship between age and education level in relation to exclusive breastfeeding after 1 month (Table 2). Breastfeeding problems During the home visit process, several breastfeeding problems were identified in both groups, including insufficient milk supply, improper breastfeeding positioning, and sore nipples. The control group likely experienced more breastfeeding problems than the intervention group. Most of these problems persisted even one month after the postpartum period (Figure 2). Most breastfeeding problems in the control group are incorrect positions because of a lack of knowledge of the new mother. The first-time mother can acquire this breastfeeding problem. The Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:12089] [page 597] Table 2. Subjects’ characteristics. Characteristics Group Group Standard Program SETIA Program n=25 n=25 Breastfeeding Breastfeeding & Formula Breastfeeding Breastfeeding & Formula Age <20 Year 1 3 2 1 >20 Year 17 4 21 1 Education Junior High School 1 2 2 1 Senior High School 14 4 10 1 College 3 1 11 0 Work Unemployed 14 6 15 2 Employed 4 1 8 0 SETIA, Self Empowering Woman, Empathy, Trust, Intimate and Affection. Figure 1. Research flowchart. study shows no significant difference before and after home visits in group control (0.022). Incorrect positions were even more fre- quent in the intervention group. But after one month, only a few mothers still experienced it, and so a lack of milk and nipple prob- lems. The study shows a significant difference in the intervention group before and after home visits (0.311). One month after labor, breastfeeding behavior is collected and analyzed. Table 3 shows the comparison between the standard pro- gram and the SETIA program. Statistic result on comparing Group A and Group B using Mann-Whitney and Wilcoxon test for variable breastfeeding after one month shows that there is no significant difference in breast- feeding after one month between the two groups (Mann-Whitney 253.5 and Wilcoxon 578.5 with a p-value is 0.086). Even though. mean rank intervention group likely better at breastfeeding after one month. Discussion In general, the majority of research subjects were aged between 20 and 35 years, with a high school education level. There was no significant relationship observed between age and breast- feeding practices after one month. The similarity in age among subjects in both groups suggests comparable levels of emotional maturity, experience, and information possessed by the subjects. Mothers of older age are often expected to possess greater knowledge and emotional maturity in fulfilling their role as moth- ers. Age is typically associated with increased life experience and access to information, which can contribute to building a strong self-concept and fostering confidence in various activities, includ- ing breastfeeding21. In the research, all respondents were new mothers giving birth to their first child and had not previously breastfed. However, some mothers may have observed or experi- enced indirect forms of breastfeeding through family members. Additionally, the educational level of the research subjects did not differ between the two groups, suggesting that both groups should have similar abilities to receive and analyze new information. The ability to read is particularly crucial for acquiring new information, such as breastfeeding techniques, and retaining it in memory. Attending classes on breastfeeding at primary health centers can significantly increase breastfeeding rates. However, most respondents in this study have not attended such classes, indicating a lack of clear understanding and sufficient knowledge about breastfeeding. This finding aligns with previous research empha- sizing the importance of antenatal classes in enhancing knowledge about pregnancy and childbirth. The lack of knowledge and expe- rience in breastfeeding may impact self-efficacy in breastfeeding practices. Therefore, promoting the acceptance of early breastfeed- ing initiation materials in antenatal classes is essential for fostering a positive attitude towards early breastfeeding initiation and exclu- sive breastfeeding22. The studies show that mothers with higher education tend to have higher confidence in breastfeeding their babies. A mother’s education will influence the mother in receiving and analyzing the new information received. Intellectual capacities such as reading will affect the retention stage of a new behavior being observed. Meanwhile. the new behavior that is formed is very dependent on physical abilities. communication. and learning abilities to behave the same as the model that is exemplified23. Breastfeeding self-efficacy plays a critical role in the success of mothers in overcoming breastfeeding challenges. Home visits offer health workers the opportunity to provide tailored education to mothers experiencing breastfeeding difficulties24. By directly interacting with these mothers, health workers can offer verbal per- suasion and advice, thereby boosting their self-confidence25. This increased confidence positively impacts mothers’ efforts, attention to the breastfeeding process, and their response to breastfeeding problems. In essence, breastfeeding self-efficacy significantly influences mothers’ ability to address breastfeeding challenges effectively26. The research results show that home visiting by the SETIA group is effective in providing mothers with a positive experience and enhancing breastfeeding for babies aged one month compared to the standard group. The frequency of home visits by the SETIA group enables midwives to enhance mothers’ breastfeeding skills through exercises and evaluations. Breastfeeding problems encountered are addressed, assisting mothers in adapting during the first week. Breastfeeding self-efficacy tends to be high during home visits, as scheduling visits at the beginning of the postpartum period allows midwives to identify breastfeeding issues early on. The ability of both the mother and baby to adapt significantly influences breastfeeding success. With three consecutive home vis- its in the first week, mothers receive assistance in resolving breast- feeding issues27. The first week postpartum can significantly impact breastfeed- ing experiences, either positively or negatively. Increasing the fre- quency and customization of home visits for mothers after child- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 3. Comparison of control group and intervention group with breastfeeding. Home visit Breastfeeding after 1 month Mann-Whitney Wilcoxon p Breastfeeding only % Breastfeeding and formula % Mean rank Standard Program 18 72 7 28 23.14 253.5 578.5 0.086 SETIA Program 32 92 2 8 27.86 SETIA, Self Empowering Woman, Empathy, Trust, Intimate and Affection. Figure 2. Breastfeeding problems. [page 598] [Healthcare in Low-resource Settings 2024;12:12089] birth can enhance the health of both the baby and the mother, lead- ing to greater satisfaction26. Tailoring care to meet the unique needs of each mother can also contribute to improved maternal health. The timing, frequency, duration, and intensity of home visits after labor should be personalized according to individual requirements. Further research is needed, particularly to promote exclusive breastfeeding for the first six months of life28. The results indicated that both groups experienced breastfeed- ing challenges at the onset of the postpartum period, as it was their first experience with breastfeeding. Midwife visits allowed for the detection of these problems through direct observation while mothers breastfed their babies. This facilitated the identification of difficulties faced by breastfeeding mothers, enabling discussions on how to overcome them. Midwives provided direct advice to breastfeeding mothers through verbal persuasion, aiming to boost their confidence and ultimately enhance breastfeeding success4. Home visits conducted by midwives provided an opportunity for respondents to discuss various topics, including problems encountered during the delivery process, the role of new parents, and the breastfeeding process. First-time breastfeeding mothers often experience feelings of vulnerability and require support as they navigate their new role and initiate the breastfeeding process7. The continuous care model plays a crucial role in assisting mothers with emotional challenges during the postpartum period. Postpartum mothers often seek opportunities to discuss their birth experiences with the midwives who assisted them during deliv- ery27. Moreover, the brief duration of postpartum care at hospitals may not adequately address mothers’ needs for understanding breastfeeding and the postpartum period. Therefore, home visits by midwives are invaluable in helping postpartum mothers adapt to their new roles and overcome challenges they may encounter29. The brief hospitalization period, ranging from 6-24 hours for women who gave birth normally and 3-4 days for those who under- went surgery, may lead new mothers to lack understanding of the breastfeeding process and how to address potential challenges that may arise during breastfeeding. Negative breastfeeding experiences during the first week post- partum can significantly impact a mother’s breastfeeding self-effi- cacy4. Therefore, it is crucial to identify and support mothers who are at risk of such negative experiences during this critical period. Addressing factors that may contribute to unsuccessful breastfeed- ing experiences early on can increase the likelihood of a positive breastfeeding journey. One-to-one support interventions have been reported as particularly beneficial, as support persons typically have more time to sit, talk, and observe entire feeding sessions compared to general or standard support methods30,31. Despite breastfeeding being a natural process, many postpar- tum mothers require assistance to adapt to it successfully. Failure to adapt during this period may jeopardize the achievement of exclusive breastfeeding for six months and could potentially impact the future health of the baby. The intervention group was found to have detected more breastfeeding problems than the control group. This is because midwives conducting home visits identified a greater number of breastfeeding difficulties during the first week of the postpartum period. This increased detection of issues can be attributed to the more frequent contact that midwives had with respondents in the intervention group compared to the control group. After a home visit and evaluation after one month, the inter- vention group experienced a significant reduction in breastfeeding problems compared to the control group. This improvement was attributed to the educational assistance provided by midwives dur- ing the home visit. Respondents in the intervention group breastfed more exclu- sively for one month during the postpartum period than respon- dents in the control group, despite facing similar breastfeeding problems. The undermilk syndrome observed in both groups was mostly manageable, and there was no reported risk of supplemen- tary feeding other than breast milk. Home visits in the early postpartum period conducted by pro- fessional midwives have proven effective in promoting positive maternal behaviors, such as breastfeeding and contraceptive use.4 These visits offer breastfeeding mothers the opportunity and flexi- bility to learn and practice proper breastfeeding techniques in the comfort of their own homes, rather than in a public facility.11 This advantage is particularly beneficial in areas or cultures where pri- vacy is highly valued. Healthcare professionals play a significant role in promoting, protecting, and supporting exclusive breastfeed- ing. They can offer various forms of support tailored to sociocul- tural norms and individual backgrounds to assist mothers in breast- feeding effectively.31,32 The SETIA Program prioritizes privacy, intimacy, and affec- tion for postpartum mothers during home visits, addressing their individual problems with sensitivity and compassion. Midwives involved in this program refrain from judging or blaming mothers for any limitations or breastfeeding difficulties they may face. Instead, they empower mothers to develop the skills necessary to overcome these challenges. By fostering a belief in mothers’ abili- ties to address breastfeeding issues independently, midwives aim to ensure breastfeeding continuity and promote a positive breast- feeding experience for mothers. Scheduling and increasing the frequency of home visits for postpartum mothers can positively impact infant health and mater- nal satisfaction. Home visits offer the flexibility to assess the health condition of both mothers and babies and their breastfeed- ing skills in a comfortable environment. Midwives can provide individualized care tailored to the specific needs of postpartum mothers, offering invaluable support during breastfeeding. Additionally, home visits can contribute to the success and conti- nuity of exclusive breastfeeding beyond the first month. The home visit model has proven effective in promoting healthy weight gain in babies during their first year of life. Additionally, home visits can serve as a valuable tool in encourag- ing mothers to breastfeed their babies. Certain home visit models have been shown to decrease infant morbidity and mortality rates. During these visits, mothers receive both social and professional support, which act as protective factors for exclusive breastfeed- ing.12,33,34 Other studies have demonstrated that mothers who receive home visits during pregnancy are 4,5 times more likely to breast- feed their babies compared to those who do not receive such visits.35 Home visitation models have shown effectiveness in pro- moting breastfeeding. Increasing the frequency of individual home visits during the postpartum period can enhance both infant health and maternal satisfaction with health services.28,33 The frequency, timing, duration, and intensity of home visits during the postpar- tum period should be tailored to local and individual needs. Further research is necessary to assess the potential impact of SETIA home visits on achieving six months of exclusive breastfeeding. Conclusions There was no significant difference observed between the two Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:12089] [page 599] groups; however, evidence suggests that the intervention SETIA program is more effective in managing breastfeeding problems, with more mothers breastfeeding after one month. Therefore, the authors recommend more frequent home visits to assist new moth- ers in adapting to breastfeeding, particularly during the first week after birth. Further research is warranted to assess exclusive breast- feeding rates after six months in both groups. Limitations of this study include a limited number of respondents and a failure to identify other factors that may influence breastfeeding among par- ticipants. 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