Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13017 Maternal self-efficacy: perspectives on formula milk and insufficient breast milk in Koja District Health Center, Indonesia Sri Djuwitaningsih,1 Deswani Deswani,1 Alvina Dwi Lestari,1 Titi Sulastri,1 Made Riasmini,2 Tri Endah Pangastuti1 1Department of Nursing, Politeknik Kesehatan Kemenkes Jakarta III; 2Department of Nursing, Politeknik Kesehatan Kemenkes Bandung, West Java, Indonesia Abstract Breastfeeding self-efficacy substantially impacts mothers’ perceptions of formula milk and their beliefs regarding breast milk inadequacy, thereby directly influencing breastfeeding behaviors. Despite the considerable health advantages of breastfeeding for both infants and mothers, diminishing breastfeeding rates and a growing dependence on formula milk underscore the necessity for interventions aimed at enhancing mothers’ confidence in brea- stfeeding. This study’s objective is to determine the relationship among breastfeeding self-efficacy, perception of formula milk, and perceived breast milk insufficiency among breastfeeding mothers. A quantitative analytical approach using a cross-sectio- nal design was employed, involving 103 breastfeeding mothers with infants under six months. Data were collected using a self- developed questionnaire on formula milk perceptions, an adapted Perceived Insufficient Milk (PIM) questionnaire, and the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). A significant relationship was identified between perceptions of bre- ast milk inadequacy and breastfeeding self-efficacy (p=0.001). Factors such as exclusive breastfeeding experience and current infant nutrition positively correlated with self-efficacy. Addressing the perceptions of breast milk inadequacy is essential for promoting breastfeeding self-efficacy and improving brea- stfeeding practices. Future research should explore how these fac- tors evolve over time and how they affect breastfeeding success. Introduction Breastfeeding is universally recognized for its substantial health benefits to infants and mothers. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life to ensure optimal growth and development. Despite these recommendations, breastfeeding practices have remained suboptimal in several regions. According to the 2023 Indonesian Health Survey, exclusive breastfeeding rates in Jakarta Province increased from 52% in 2017 to 68% by 2023.1 However, only 27% of newborns received breast milk within the first hour of birth, and approximately 79.32% of infants aged 0-5 months were fed formula milk, as reported in the 2018 Jakarta Provincial Health Survey.2One of the critical factors influencing breastfee- ding practices is mothers’ perception of breast milk insufficiency. For instance, 81% of mothers reported dissatisfaction with their milk supply, which was often associated with physical challenges, such as nipple abrasion.3 A previous study noted that the percep- tion of insufficient breast milk is the primary reason for the global failure of exclusive breastfeeding.4,5 Additionally, marketing stra- tegies for formula milk contribute to a decline in breastfeeding rates by promoting products that are nutritionally equivalent to breast milk.6 Despite these insights, few studies have examined the impact of breastfeeding self-efficacy on mothers’ perceptions of formula and breast milk adequacy in Indonesia. Studies have shown that mothers with higher breastfeeding self-efficacy are more likely to initiate and maintain exclusive breastfeeding.7-9 This study focuses on how mothers’ confidence in breastfeeding interacts with their attitudes toward formula milk and perceived milk insufficiency in a specific population. It aimed to fill this research gap by explo- ring the relationship between breastfeeding self-efficacy, percep- tions of formula milk, and perceived breast milk inadequacy Correspondence: Deswani Deswani, Department of Nursing, Politeknik Kesehatan Kemenkes Jakarta III, Indonesia. E-mail: desika_64@yahoo.co.id Key words: breastfeeding self-efficacy; breast milk insufficiency percep- tion; exclusive breastfeeding; formula milk perception. Contributions: SD, conceptualization, investigation, methodology, vali- dation, and writing – original draft, review, and editing; DD, conceptual- ization, data curation, formal analysis, methodology, valida-tion, visual- ization, writing–original draft, review, and editing; ADL, conceptualiza- tion, methodology, formal analysis, validation, and writing – original draft, review, and editing; TS, MR, TEP, formal analysis, validation, and writing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the research received ethical approval from the Jakarta Ministry of Health Polytechnic III research ethics committee, with number LB.02.02/F.XIX.21/3828/2024. During the study, the researcher adhered to ethical principles, inclu-ding informed consent, respect for human rights, beneficence, and non-malef- icence. Consent for publication: written informed consent was obtained from the patient for the publication of anonymized information. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Received: 5 September 2024. Accepted: 20 March 2025. Early access: 24 April 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13017 doi:10.4081/hls.2025.13017 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 2025;13(s1):13017] [page 127] among mothers attending public health centers. Understanding these dynamics is crucial for developing targeted interventions to enhance breastfeeding practices and to support maternal confiden- ce in breastfeeding. Materials and Methods Study design This study employed a quantitative analytical design with a cross-sectional approach to assess the relationship between brea- stfeeding self-efficacy and mothers’ perceptions of formula milk and breast milk adequacy. Study participants The research was conducted from February to May 2024, tar- geting mothers with infants under six months old within the wor- king area of the Koja Health Center, Indonesia. Purposive sam- pling was used to select 103 breastfeeding mothers for the study. Inclusion criteria consisted of breastfeeding mothers with infants under six months of age, and exclusion criteria were mothers with infants older than six months or those with comorbidities (such as HIV/AIDS). Variable, instrument, and data collection The independent variables included demographic factors (age, education, occupation, and number of children), perceptions of for- mula milk consumption, and perceptions of breast milk insuffi- ciency. The dependent variable was breastfeeding self-efficacy. Data were collected using three validated instruments: a self-deve- loped questionnaire for assessing perceptions of formula milk, the Perceived Insufficient Milk (PIM) Questionnaire10 modified for this study, and the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF).11 All instruments were validated for reliability using a 4-point Likert scale (1=strongly disagree to 4=strongly agree). Respondents completed questionnaires during their visits to the health center. Trained enumerators delivered instructions to gua- rantee comprehension and accurate execution of the instruments. Data analysis The data analysis included univariate analysis to describe the respondents’ characteristics and to provide a detailed overview of the sample demographics and study variables. Bivariate analysis was conducted using the chi-square test to examine the relation- ships between the independent and dependent variables and to identify significant associations within the data. Ethical clearance Ethical approval was obtained from the Jakarta Ministry of Health Polytechnic III Research Ethics Committee (no. LB.02.02/F.XIX.21/3828/2024). The study followed ethical princi- ples such as informed consent, respect for human rights, benefi- cence, and nonmaleficence. Results This study aimed to investigate the impact of breastfeeding self-efficacy on mothers’ perceptions of formula and breast milk adequacy. The results provide valuable insights into these relation- ships and how they may influence breastfeeding practice. As shown in Table 1, among the 103 participants, most (78.6%) were within the reproductive age range of 20-35 years. A significant proportion of the sample (79.6%) had a higher level of education, whereas 81.6% identified themselves as housewives. Additionally, 61.2% had more than one child. Notably, 40.8% had exclusive breastfeeding experience, and 61.2% relied exclusively on breast milk for their infants’ nutrition. Table 2 shows that 59.1% of mothers of non-reproductive age had low breastfeeding self-efficacy, whereas 60.5% of reproducti- ve-age mothers had high self-efficacy. The p-value for the associa- tion between maternal age and breastfeeding self-efficacy was 0.162, indicating no significant relationship. Regarding education, 61.9% of mothers with low educational levels displayed high breastfeeding self-efficacy, compared to 54.9% of those with higher education. The p-value for education was 0.739, suggesting no significant correlation between the mother’s level of education and confidence in breastfeeding. Among the working mothers surveyed, 12 (63.2%) expressed low breastfeeding self-efficacy, whereas 51 (60.7%) reported high self- efficacy (p=0.101), indicating no meaningful relationship between work status and self-efficacy. Mothers with only one child demonstrated a high level of brea- stfeeding self-efficacy, with 21 (52.5%) reporting this, whereas those with more than one child exhibited a similar level, with 37 (58.7%) reporting high self-efficacy. Statistical analysis yielded a p-value of 0.676, indicating no significant correlation between the number of children (parity) and breastfeeding self-efficacy. Tables 3 and 4 demonstrates maternal self-efficacy in relation to perceptions of formula milk and breast milk insufficiency at the Public Health Center. Mothers with a positive perception of formu- la milk had a higher proportion of low breastfeeding self-efficacy (53.2%) than those with a negative perception of formula milk (35.7%). However, this association was not statistically significant (p=0.114, OR=2.045, 95% CI: 0.927-4.515). In contrast, the per- ception of breast milk inadequacy was significantly linked to brea- stfeeding self-efficacy (p=0.001). Among mothers who believed they had insufficient breast milk, 88.5% exhibited low breastfee- ding self-efficacy, compared to just 28.6% in the low-insufficiency group. The odds ratio (OR=19.167, 95% CI: 5.220-70.381) sugge- Special issue Pathways of Change Table 1. Characteristics of respondents based on general data. Characteristics Frequency Percentage Age Non-reproductive 22 21.40 Reproductive 81 78.60 Education Low education 21 20.40 Higher education 82 79.60 Job Working 19 18.40 Housewife 84 81.60 Number of children (parity) 1 child 40 38.80 >1 child 63 61.20 Exclusive breastfee-ding expe-rience Not breast-feeding 40 38.80 Not exclu-sive 21 20.40 Exclusive 42 40.80 Current baby nutrition Breastmilk with formula/formula only 40 38.80 Breastmilk only 63 61.20 Total each variable 103 100 [page 128] [Healthcare in Low-resource Settings 2025;13(s1):13017] sted that mothers who perceived a high level of breast milk insuf- ficiency were significantly more likely to have low breastfeeding self-efficacy. These findings indicate that while maternal percep- tion of formula milk may not strongly impact breastfeeding self- efficacy, concerns about breast milk insufficiency play a critical role in underscoring the need for targeted interventions to enhance maternal confidence in breastfeeding practices. Discussion This study aimed to examine the impact of mothers’ self-effi- cacy in breastfeeding on their perceptions of formula and breast milk inadequacy among mothers attending public health centers. The key findings indicated a significant relationship between the perception of breast milk inadequacy and breastfeeding self-effica- cy; however, the perception of formula milk did not significantly influence self-efficacy levels. Specifically, 88.5% of the mothers who perceived breast milk as inadequate exhibited low breastfee- ding self-efficacy, whereas 71.4% of those with a low perception of breast milk inadequacy demonstrated high self-efficacy. In con- trast, only 46.8% of the mothers with a positive perception of for- mula milk reported high self-efficacy, suggesting that breastfee- ding confidence is more strongly associated with perceptions of milk adequacy than external feeding options. These findings underscore the importance of addressing maternal perceptions of milk sufficiency to enhance breastfeeding self-efficacy. The findings highlight that mothers’ perceptions of breast milk inadequacy are positively correlated with breastfeeding self-effica- cy. These results align with previous studies indicating that percep- tions of breast milk adequacy significantly influence breastfeeding practices.12 For example, Gusriani et al. emphasized that maternal psychological factors, including confidence and perceived milk production, play a crucial role in successful breastfeeding.13 Additionally, several studies have identified a significant associa- tion between the perception of insufficient breast milk and exclu- sive breastfeeding, reinforcing the notion that mothers’ beliefs about their milk supply can substantially impact breastfeeding out- comes.4,14 Furthermore, breastfeeding experience is a key determi- nant of breastfeeding self-efficacy, as supported by this study, which found that past experience with exclusive breastfeeding was positively associated with higher self-efficacy.15,16 These findings highlight the importance of addressing maternal perceptions of milk adequacy through targeted education and support programs to enhance breastfeeding self-efficacy and to promote exclusive brea- stfeeding. Interestingly, this study found no significant relationship bet- ween mothers’ perception of formula milk and breastfeeding self- efficacy. This suggests that attitudes toward formula milk may not directly influence confidence in breastfeeding, while other factors can impact it, including individual perspectives, family, education, and knowledge.17-20 This result was unexpected, as previous studies have suggested that negative perceptions of formula milk may con- tribute to increased confidence in breastfeeding.21 Instead, our stu- dy’s findings indicate that breastfeeding confidence is more stron- gly associated with perceptions of milk adequacy than with attitu- des toward formula feeding.14,22 Moreover, this study suggests that mothers exhibit varying levels of self-efficacy regardless of their opinions about formula milk. These nuances may reflect the com- plexity of maternal attitudes, where personal experiences and social support systems play a more significant role than external perceptions of formula feeding.23,24 These findings suggest a clear relationship between mothers’ perceptions of both formula milk and breast milk adequacy and their confidence in breastfeeding. This aligns with existing literature, which indicates that percep- tions of milk sufficiency significantly influence breastfeeding practices.10,11 Understanding these dynamics is essential for deve- loping interventions aimed at improving breastfeeding rates and enhancing maternal confidence. For further insights into the influence of maternal perceptions on breastfeeding, refer to rele- vant studies.25 Several limitations of this study should be acknowledged when interpreting the results. The cross-sectional design limits the ability to establish causal relationships, as data are collected at a single point in time. Additionally, the sample size of 103 participants, although sufficient for preliminary insights, may restrict the gene- ralizability of the findings to broader populations and diverse set- tings. The reliance on self-reported measures may also introduce bias, as participants may provide socially desirable responses. Furthermore, key factors, such as maternal mental health, social Special issue Pathways of Change Table 2. Relationship between respondent characteristics and breastfeeding self-efficacy (n=103). Variables Breastfeeding self-efficacy Total P OR Low High value (95% CI) n % n % n % Age 0.162 2,212 Non-reproductive 13 59.1 9 40.9 22 100 0.847-5.774 Repro-ductive 32 39.5 49 60.5 81 100 Total 45 43.7 58 56.3 103 100 Education 0.739 0.748 Low education 8 38.1 13 61.9 21 100 0.280-1.999 Higher education 37 45.1 45 54.9 82 100 Total 45 43.7 58 56.3 103 100 Job 0.101 2,649 Wor-king 12 63.2 7 36.8 19 100 0.946-7.420 Hou-sewife 33 39.3 51 60.7 84 100 Total 45 43.7 58 56.3 103 100 Number of children 0.676 1.288 1 child 19 47.5 21 52.5 40 100 0,580-2,860 >1 child 26 41.3 37 58.7 63 100 Total 45 43.7 58 56.3 103 100 [Healthcare in Low-resource Settings 2025;13(s1):13017] [page 129] support, and socioeconomic status, which could influence brea- stfeeding self-efficacy, have not been comprehensively examined. The subjective nature of the measures related to perceptions and self-efficacy may affect the reliability of the data, and the study’s focus on breastfeeding mothers may have excluded the perspecti- ves of those who rely on formula feeding. Given these considerations, future research should explore the dynamics of breastfeeding self-efficacy in larger and more diverse populations. Investigating the impact of social support networks and mental health on breastfeeding confidence could provide dee- per insights into factors that facilitate successful breastfeeding. Longitudinal studies could also be valuable for establishing causal relationships between maternal perceptions and breastfeeding practices over time. Conclusions Mothers who perceived their breast milk as inadequate were more likely to have low self-efficacy regarding breastfeeding. These findings highlight the need for interventions that enhance mothers’ confidence in their breastfeeding capabilities, such as educational programs that dispel myths about breast milk insuffi- ciency and provide evidence-based breastfeeding information. Future interventions should prioritize educational outreach, com- munity support networks, and resources that empower mothers, thereby contributing to improved breastfeeding practices and bet- ter health outcomes for families in the district and beyond. References 1. BPS Indonesia SI. Statistical Yearbook of Indonesia 2023. Catalog Number: 1101001. Available from: https://www.bps. go.id/en/publication/2023/02/28/18018f9896f09f03580a614b/ statistik-indonesia-2023.html 2. Kementerian Kesehatan Republik Indonesia. Laporan Riskesdas 2018 Nasional.pdf. Available from: https://reposito- ry.badankebijakan.kemkes.go.id/id/eprint/3514/1/Laporan%2 0Riskesdas%202018%20Nasional.pdf 3. Widita Muharyani P, Nadra Maulida M, Adhisty K, et al. Tantangan yang Dihadapi Ibu Menyusui dalam Pemenuhan Hak Anak: Asi Eksklusif. Jurnal Keperawatan 2022;14:893- 906. 4. Metasari D, Kando Sianipar B. Hubungan Persepsi Ibu Tentang Ketidakcukupan Asi (PKA) Terhadap Pemberian Asi Eksklusif Pada Bayi Di Wilayah Kelurahan Kuala Lempuing Kota Bengkulu. J Nurs Public Health 2019;7:41-5. 5. Pambudi W, Dewanto NEF, Yusra Y, et al. Perceptions, practi- ces, and associated factors towards expressed breastfeeding among mothers in Jakarta, Indonesia. Paediatr Indones 2024;64:168-75. 6. Fitriani K, Rahayuning P D, Nugraheni SA. Faktor-Faktor yang Melatarbelakangi Ibu dalam Pemberian Susu Formula pada Bayi Usia 0-6 Bulan Di Wilayah Kerja Puskesmas Rowosari Kecamatan Tembalang Semarang Tahun 2014. Jurnal Kesehatan Masyarakat 2015;3:118-26. 7. Ismawati, Abdurrachim R. Relationship Knowledge Level, Perception of Formula Milk and Family Support with Exclusive Breastfeeding. Jurnal Riset Pangan dan Gizi 2022;4:35-45. 8. Tsaras K, Sorokina T, Papathanasiou IV, et al. Breastfeeding self-efficacy and related socio-demographic, perinatal and psy- chological factors: a cross-sectional study among postpartum Greek women. Mater Sociomed 2021;33:206-12. 9. Oktarianita O, Wulandari RD, Supriyanto S. Exploring the determinants of exclusive breastfeeding practices among first- time mothers: A narrative review. Afr J Reprod Health 2024; 28:239-48. 10. McCarter-Spaulding DE, Kearney MH. Parenting self-efficacy and perception of insufficient breast milk. J Obstet Gynecol Neonatal Nurs 2001;30:515-22. 11. Dennis CL, McQueen K, Dol J, et al. Psychometrics of the breastfeeding self-efficacy scale and short form: a systematic review. BMC Public Health 2024;24:1-25. 12. Wahyuni SD, Santoso B, Triharini M, Susan N. Perceptions of working mothers toward breastfeeding self-efficacy. Jurnal Ners 2020;15:50-6. 13. Gusriani G, Wahida W, Noviyanti NI. Status gizi ibu dan per- sepsi ketidakcukupan asi (Air Susu Ibu). Jurnal Ilmu Kedokteran Kesehatan 2023;2:152-9. 14. Menekse D, Tiryaki Ö, Karakaya Suzan Ö, Cinar N. An inve- stigation of the relationship between mother’s personality traits, breastfeeding self-efficacy, and perception of insuffi- cient milk supply. Health Care Women Int 2021;42:925-41. 15. Mardiyaningsih E, Purwaningsih H, Widodo GG. Breastfeeding self-efficacy ibu post Seksio Sesarea. J Holist Nurs Sci 2021;8:54-60. 16. Ulfah HR, Nugroho NFS. Hubungan usia, pekerjaan, dan pen- didikan ibu dengan pemberian ASI eksklusif. Intan Husada: Jurnal Ilmiah Keperawatan 2020;8:9-18. 17. Fajar NA, Ananingsih ES, Sulaningsi K, et al. Social Determinant of Health on Exclusive Breastfeeding Practice in South Sumatra, Indonesia. Malays J Med Health Sci Special issue Pathways of Change [page 130] [Healthcare in Low-resource Settings 2025;13(s1):13017] Table 3. Relationship of Mothers’ perception with Breastfeeding Self-Efficacy (n=103). Mothers’ perception Breastfeeding self-efficacy Total P OR Low High value (95% CI) n % n % n % Perception of formula milk Positive 25 53.2 22 46.8 47 100 0.114 2.045 0.927-4.515 Negative 20 35.7 36 64.3 56 100 Total 45 43.7 58 56.3 103 100 Perception of breast milk inadequacy Perception of high breast milk insufficiency 23 88.5 3 11.5 26 100 0.001 19.167 5.220-70.381 Perception of low breast milk insufficiency 22 28.6 55 71.4 77 100 Total 45 43.7 58 56.3 103 100 2024;20:163-9. 18. Dwijayanti I, Sulistyowati M, Isaura ER, et al. Exploring fac- tors influencing complementary feeding practices of mothers with infants aged 6-23 months in Sidoarjo Regency, Indonesia: A qualitative study. Afr J Reprod Health 2024;28:25-33. 19. Tumaji T, Mahmudiono T, Laksono AD, et al. Exclusive Breastfeeding Among Adolescent Mothers in Indonesia: Does Maternal Education Level Matter? J Popul Soc Stud 2025;33:562-76. 20. Syam A, Musni M, Amin AN, Iskandar I. Potential Loss among Infant Feeding Options. Jurnal Ners 2021;16:74-80. 21. Yuliantie P, Kusvitasari H, Mariana F, et al. Identifikasi Keterpaparan Promosi Susu Formula Terhadap Pemberian Asi Eksklusif. Health Care: Jurnal Kesehatan 2023;12:206-2014. 22. Gatti L. Maternal perceptions of insufficient milk supply in breastfeeding. J Nurs Scholarsh 2008;40:355-63. 23. Yuen M, Hall OJ, Masters GA, et al. The Effects of Breastfeeding on Maternal Mental Health: A Systematic Review. J Womens Health 2022;31:787-807. 24. He J, Yimyam S, Namprom N. Breastfeeding self-efficacy, social support, and breastfeeding among Chinese mothers with late preterm infants. J Neonat Nurs 2022;28:21-5. 25. Akalpler Ö, Sarpkaya Güder D, Tekbaş S, Vural G. Examination of the Relationship Between Breastfeeding Self- Efficacy and Perceived Breastfeeding Sufficiency of Mothers. Cyprus J Med Sci 2023;7:731-7. Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13017] [page 131]