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Original Article OutcOme Of RespiRatORy DistRess synDROme in nepalOriginal Article

DOI: 103126/JNPS.V4113

Pitaloka ADA1, Nurhayati E2, Hadi H1, Lee K3, *Paramashanti BA1

1Department of Nutrition, Faculty of Health Sciences, Universitas Alma Ata, Yogyakarta 55183, Indonesia 
2Department of Midwifery, Faculty of Health Sciences, Universitas Alma Ata, Yogyakarta 55183, Indonesia
3Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Maryland 21205-2179, USA. 

Is Maternal Breastfeeding Motivation and Exclusive Breastfeeding 
Influenced by early Marriage age?

Introduction: Exclusive breastfeeding is beneficial for mother and 
child health. However, exclusive breastfeeding rate is low among 
young mothers. Thus, our study aimed to examine the relationship 
between maternal breastfeeding motivation and exclusive breastfeeding 
and determine whether the early marriage age influences both 
variables in Gunung Kidul District, Yogyakarta Special Region, 
Indonesia. 

Methods: A cross-sectional design was conducted among young 
adolescent mothers. A total of 144 married women who had young 
children aged six to 12 months were selected using simple random 
sampling. Exclusive breastfeeding was the dependent variable, while 
maternal breastfeeding motivation was the independent variable. 
Descriptive statistics, chi-square test, multiple logistic regression, and 
mantel haenzel tests were performed to analyse the relationship 
between variables using STATA 14.2.

Results: Maternal age at marriage < 20 years (OR = 2.98; 95%CI: 
1.15-7.74) and good maternal breastfeeding motivation (OR = 22.02; 
95%CI: 7.55-64.2) were associated with exclusive breastfeeding 
practice. In the stratification analysis, a larger association was found 
between maternal breastfeeding motivation and exclusive breastfeeding 
among younger mothers (OR=3.96; 95%CI: 2.25-6.97) compared to 
older mothers (OR = 1.79; 95%CI: 1.29-2.48).

Conclusions: Maternal breastfeeding motivation positively influences 
exclusive breastfeeding practice. Notably, young mothers are more 
likely to be motivated to breastfeed their children exclusively than older 
mothers. The results suggest a need to improve maternal breastfeeding 
motivation through quality prenatal and postnatal care services that 
involve other family members.

Abstract

*Corresponding Author
Bunga Astria Paramashanti
Universitas Alma Ata Jalan Brawijaya No. 99, 
Kasihan, Bantul, 
Daerah Istimewa 
Yogyakarta55183, 
Indonesia. 
Email: bunga@almaata.ac.id. 

Introduction
Exclusive breastfeeding for the first six months of life, with the introduction 
of complementary food and continued breastfeeding thereafter, has been 
recommended since 2001 by the World Health Organization (WHO).1 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article 
distributed under Creative Commons Attribution License (CC BY NC )

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i1.38053 

Article History 
Received On : 25 June, 2021
Accepted On : 05 Apr, 2022

Funding Sources: None

Conflicts of Interest: None

Keywords: Adolescent mothers; Exclusive breast-
feeding; Indonesia; Motivation; Young mothers



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 47

Original ArticleBreastfeeding Motivation and exclusive Breastfeeding

Also, breastfeeding is linked with Sustainable Development 
Goals by improving nutrition, health, economics, education, 
equity, and environmental aspects.2 Non-exclusive breastfeeding 
is responsible for high mortality and disease burden, especially 
among children under the age of five.3 In addition, breastfeeding 
promotion has the potential to decrease the disease burden of 
mothers.4 It is estimated that scaling up breastfeeding could 
save up to 823,000 child deaths and 20,000 deaths due to 
breast cancer annually.5 Globally, the improvement of exclusive 
breastfeeding is still very modest in the past few decades.6 In low 
and middle income countries, exclusive breastfeeding coverage is 
only 37% among children less than six months of age.5 Based on 
the nationally representative survey in Indonesia, the proportion 
of exclusive breastfeeding decreased slightly from 38.0% in 
2013 to 37.3% in 2018.7 Further analysis showed that exclusive 
breastfeeding was even lower among employed mothers, mothers 
who lived in the Eastern part of Indonesia, and those in urban 
areas.8 

Maternal breastfeeding behaviour is complex and is affected by 
socio-cultural and physiological factors.9 A systematic review in 
Brazil showed that exclusive breastfeeding was associated with 
living residence, maternal age, maternal education, maternal 
employment, child’s age, the use of a pacifier, and financing 
primary health care.10 Similarly, a review conducted in the 
Middle-East suggested that exclusive breastfeeding was linked 
to delivery factors, maternal employment, maternal age, and 
maternal education.11 

Few earlier studies examined the relationship between mothers’ 
motivation and exclusive breastfeeding practices in Indonesia.12,13 
In this study, we aimed to analyse the relationship between maternal 
breastfeeding motivation and exclusive breastfeeding in Gunung 
Kidul District, Yogyakarta, Indonesia. Gunung Kidul District was 
selected since it is a district with lower exclusive breastfeeding 
coverage and a high prevalence of young maternal age.14 The 
district consists of coastal, noncoastal, slope, and valley areas. 
The condition could be one of the reasons, in addition to the 
inequality in distribution of health professionals and limited health 
budget, that may lead to poor health care service in the district.15 
Gunung Kidul, as in other districts / municipalities in Yogyakarta, 
has strong cultural factors that may contribute to the population 
feeding practices.16 

Methods
A cross sectional observational design was used for this study. 
The population included all married women in Tepus Subdistrict, 
Gunung Kidul District, Yogyakarta Special Region, Indonesia. 
From the list of mothers registered at the Tepus II PHC, 72 married 
women were selected using a simple random sampling with a 
lottery method. We then added another 72 women from the list by 
matching their age at marriage with a ratio of 1:1. Thus, for every 
woman who married at an age < 20 years, one woman whose 
marriage age was < 20 years, was added resulting in a total of 
144 participants. The inclusion criteria were mothers of children 
aged six to 12 months and those who were agreed to participate 
in this study, evidenced by signing an informed consent form. If 
mothers had two children under-fives, then we only took data from 
the youngest child.

We collected data on women’s characteristics, history of exclusive 
breastfeeding, and breastfeeding motivation by a home-visit 
interview for all women. We also derived data on marriage 
information (e.g., identity, marriage age) from the Tepus Office of 
Religion Affairs Report in 2016. Data on mothers who had young 
children aged six to 12 months was obtained from Tepus II PHC. 
We then created a list of subjects based on data from the Tepus 
Office of Religious Affairs and Tepus II PHC and randomised it to 
select participants. All participants were asked for their willingness 
to join the study by signing an informed consent form. 

The dependent variable of this study was a history of exclusive 
breastfeeding as recommended by the WHO.1 The independent 
variable was the maternal motivation for breastfeeding. Maternal 
motivation for breastfeeding was categorised into favourable or 
unfavourable factoring in the maternal decision process related to 
breastfeeding. It covered intrinsic motivation related to maternal 
and child health and extrinsic motivation covering self-control, 
support, and social aspects.17 We categorised the motivation 
variable into two categories: good (50 - 100%) and poor (< 50%). 
Other variables that were analysed in this study included child’s 
sex, child’s birth rank, parity, mother’s age at marriage, mother’s 
level of education, mother’s employment status, spouse’s age, and 
spouse’s educational level. We used a structured questionnaire 
on maternal characteristics, breastfeeding practices, and a 
motivation checklist. This checklist has been translated to Bahasa 
Indonesia and validated in a previous study.18

Characteristics of mothers, children, their household, and the 
distribution of main variables were described with descriptive 
statistics. A chi-square test was used for bivariate analysis. 
Variables that showed an association with the history of exclusive 
breastfeeding with a p-value of < 0.25 were entered into multiple 
logistic regression. In the multivariate analysis, the p-value < 0.05 
was considered to be significant and the confidence interval for 
odds ratios was set at 95%. To examine confounding factors and 
the effect of the modification, we used the mantel haenzel test for 
stratification analysis. All of the analyses were performed using 
STATA 14.2 (Stata Corporation, College Station, TX).

Results
Almost half of women were married at a young age, less than 20 
years, whereas most spouses married < 20 years (90.3%). Our 
study participants had children who were primarily male (53.47%) 
and the first child (77.78%), with an average age of 8.7 months. 
Most of our study participants and their spouses completed junior 
high school as their highest educational attainment, 57.6% and 
47.9%, respectively. Most women were unemployed (81.25%).  
Sixty-one per cent of the sample reported exclusive breastfeeding 
at six months. 45.1% of mothers’ motivation for breastfeeding 
was scored as good. Table 1 shows the characteristics and the 
distribution of the main variables in this study.    
        
        
        
        
        
       
 



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202248

Original Article Breastfeeding Motivation and exclusive Breastfeeding

Table 1. Characteristics of children and parents and the 
distribution of main variables (n = 144 households)

Characteristics % / mean + SD

Child characteristics

Child’s age (Months) 8.7 + 2.1

Child’s sex

 Male 53.5

Female 46.5

Birth rank

 1st 77.8

 2nd 22.2

Parity

 1 81.9

<2 18.1

Parental characteristics

Mother’s age at marriage

< 20 years 48.6

< 20 years 51.4

Mother’s education

Not completed primary school 1.4

 Completed elementary school 18.1

 Completed junior high school 57.6

Completed senior high school 20.1

Completed tertiary education 2.8

Maternal working status

Not working 81.3

 Working 18.7

Spouse’s age at marriage

< 20 years 9.7

< 20 years 90.3

Spouse’s education

Not completed primary school 3.5

 Completed elementary school 28.5

 Completed junior high school 47.9

Completed senior high school 18.0

Completed tertiary education 2.1

Main variables

Exclusive breastfeeding

No 38.9

Yes 61.1

Maternal breastfeeding motivation

 Poor 54.9

Good 45.1

Being a later-born child (OR = 2.78; 95%CI: 1.13-6.79), parity more 
than one (OR = 3.20; 95%CI: 1.16-8.73), older maternal age at 
marriage (OR = 3.69; 95% CI: 1.83 - 7.47), and good maternal 
motivation for breastfeeding (OR = 21.86; 95% CI: 8.06 - 58.79) 
were significantly associated with exclusive breastfeeding at six 
months. Variables such as the child’s sex, mother’s educational 
level, mother’s employment status, and spouse’s age at marriage 
were not related to exclusive breastfeeding. 

In the multivariate results, factors associated with breastfeeding 
exclusively included maternal age at marriage <20 years (OR 
= 2.98; 95% CI: 1.15 - 7.74).  Having good motivation for 
breastfeeding was associated with a 22 times greater likelihood 
for exclusive breastfeeding for at least six months.

Table 3. Stratification analysis between maternal breastfeeding 
motivation and exclusive breastfeeding by maternal age at 
marriage

Strata Maternal 
breastfeeding 

motivation

OR (95%CI)

 Mother’s age at
marriage

< 20 years Poor (ref)

Good 3.96* (2.25 - 6.97)

< 20 years Poor (ref)

Good 1.79*(1.29 - 2.48)

COR 2.60* (1.91 - 3.54)

M-H OR 2.38* (1.79 - 3.16)

*Level of significance at < 0.05

COR = crude odds ratio; M-H OR = mantel-haenzel odds ratio

        
      



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 49

Original ArticleBreastfeeding Motivation and exclusive Breastfeeding

Table 2. Bivariate and multivariate analysis of exclusive breastfeeding determinants

 Characteristics Exclusive breastfeeding

 COR (95% CI) p AOR (95% CI) p

Child’s sex

Male (ref)

Female 0.89 (0.46 - 1.75) 0.75

Birth rank

1st (ref)

 2nd 2.78 (1.13 - 6.79) *0.03 1.87 (0.21 - 16.31) 0.57

Parity

1 (ref)

< 2 3.20 (1.16 - 8.73) *0.02 1.18 (0.09 - 14.14) 0.89

Mother’s age at marriage

< 20 years (ref)

< 20 years 3.69 (1.83 - 7.47) *0.00 2.98 (1.15 - 7.74) *0.02

Mother’s education

Primary school or below (ref)

Secondary school or above 0.85 (0.36 - 1.97) 0.70

Maternal breastfeeding motivation

Poor (ref)

Good 21.86 (8.06 - 58.79) *0.00 22.02 (7.55 - 64.2) *0.00
Maternal working status

Not working (ref)

 Working 1.10  (0.47 - 2.57) 0.83

Spouse’s age at marriage

< 20 years (ref)

< 20 years 0.86 (0.28 - 2.60) 0.79

Spouse’s education

Primary school or below (ref)

Secondary school or above 1.97 (0.97 - 4.00) *0.06 2.00 (0.78 - 5.14) 0.15

*Level of significance at < 0.05

COR = Crude Odds Ratio; AOR = Adjusted Odds Ratio

We analysed the relationship between maternal motivation and 
exclusive breastfeeding by maternal age at marriage (Table 
3). The association between maternal motivation and exclusive 
breastfeeding was not confounded by maternal age at marriage 
because there was only a small difference between crude odds 
ratio (OR = 2.60; 95% CI: 1.91 - 3.54) and adjusted odds ratio 
(OR = 2.38; 95% CI: 1.79 - 3.16). There was a larger effect of 
maternal motivation on exclusive breastfeeding among younger 
mothers (OR = 3.96; 95% CI: 2.25 - 6.97) compared to older 
mothers (OR = 1.79; 95% CI: 1.29 - 2.48).

Discussion
Our study demonstrated that the proportion of infants who were 
breastfed exclusively for six months was higher than the national 
proportion in Indonesia.7 However, it remained below national 
and global targets for 80% and 90% coverage respectively.19,20 
Thus, to design interventions aiming at improving the rate of 
exclusive breastfeeding, it is essential to identify its associated 
factors.  

In this study, the mother’s age at marriage and maternal 
motivation for breastfeeding were significantly associated with 
exclusive breastfeeding. Women who married at an age < 20 



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202250

Original Article Breastfeeding Motivation and exclusive Breastfeeding

years were more likely to breastfeed their infants exclusively. Our 
study in line with a previous study reporting that mother’s age 
at 20 years was linked with the higher exclusive breastfeeding 
proportion than mothers of younger age.21 Maternal experiences 
in infant management may increase as maternal age increases.22 
Conversely, younger mothers may think about the change of their 
physical appearance (e.g., breast size) if they breastfeed their 
infant for a longer time and thus stop providing breastmilk.23 In 
Yogyakarta, strong cultural factors such as giving sugar water 
or tajin water from boiled rice may also contribute to the early 
introduction of complementary food.16 Additionally, mother’s 
decision making on breastfeeding could be explained by cultural 
and family factors.24 Our finding indicates that young mothers are 
vulnerable to nonexclusive breastfeeding practices, especially in 
settings where culture and social norms are highly influential.

Mothers who had good motivation for breastfeeding were more 
likely to breastfeed their infants exclusively. When we stratified 
maternal motivation by maternal age at marriage, the result 
showed that mothers with good motivation tend to provide 
exclusive breastfeeding, especially among younger mothers. A 
previous study conducted among low-income women divided 
maternal motivation on breastfeeding into three categories: 1) 
Extrinsically motivated, if women hadn’t succeeded breastfeeding 
previously but chose to breastfeed based on others’ suggestions, 2) 
Intrinsically motivated, if women hadn’t succeeded breastfeeding 
previously but chose to breastfeed based on their or their infant’s 
health reasons, and 3) Successfully experienced, if women 
had successfully breastfed previously and had a family with 
breastfeeding history, then chose to breastfeed for their and their 
infant’s health.25 In our study, mothers who married at a younger 
age might have no breastfeeding experience success as they just 
had one child. Thus, intrinsic motivation arising from maternal self-
decision making and extrinsic motivation influenced by family and 
social factors may play essential roles in the success of exclusive 
breastfeeding. A qualitative study among adolescent mothers 
demonstrated that the decision to breastfeed was made prenatally. 
Therefore, during prenatal and early postpartum health service, 
counselling strategy may benefit adolescents with low levels of 
motivation to breastfeed their infant.26 

On the contrary to the earlier study, we found that maternal 
education was not related to exclusive breastfeeding.21 Based 
on Susiloretni et al,27 the only factor associated with a longer 
duration of exclusive breastfeeding was maternal breastfeeding 
knowledge in Central Java, Indonesia. Maternal knowledge on 
breastfeeding can have a significant impact on the success of 
exclusive breastfeeding.28 On the other hand, high educational 
attainment does not always mirror the favourable knowledge 
about breastfeeding.8 In this case, it is the responsibility of health 
care providers to deliver messages on breastfeeding and early 
child feeding practices to mothers since preconception and their 
husbands / spouses and other family members. Besides, supports 
from families and the workplace may benefit the practice of 
breastfeeding.29,30

To our knowledge, this is the first study to analyse the association 
between maternal motivation for breastfeeding and exclusive 
breastfeeding that considers maternal marriage age in Indonesia. 
Findings for this study can be generalised to other populations with 
a high prevalence of adolescent marriage, as in the Gunung Kidul 
District. However, the use of a cross-sectional design prevents us 

from concluding any cause-effect relationship between maternal 
motivation for breastfeeding and exclusive breastfeeding. Further 
research with larger sample sizes and advanced study designs 
(e.g., cohort and community trial) may be needed to examine the 
association between both variables.

Conclusions
Maternal breastfeeding motivation positively influences exclusive 
breastfeeding practice. Notably, young mothers are more likely 
to be motivated to breastfeed their children exclusively than 
older mothers. The results suggest a need to improve maternal 
breastfeeding motivation through quality prenatal and postnatal 
care services, which involve mothers and family members. Such 
programs should engage mothers of all ages in the community.

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