Relationship of Self-Efficacy with Breastfeeding Practices among Primiparous Mothers

Provision of breast milk is the most effective way to ensure baby's health and safety. Breast milk has nutritional and non-nutritional benefits both for the health of the child and the mother. WHO recommends exclusive breastfeeding for up to six months, continued for up to two years. Breastfeeding Self-Efficacy is the most powerful factor that can influence the process of breastfeeding and the success of breastfeeding. The purpose of this study was to identify the relationship between self-efficacy and breastfeeding practices among primiparous mothers. The research was a cross-sectional study. The population in this study was mothers who had given birth to a first live baby at the Widuri Primary Clinic. The sample size in this study was 40 primiparous mothers recruited with the total sampling method. Data were collected using the Breastfeeding Self Efficacy (BSES) questionnaire which contains 25 questions about the breastfeeding self-efficacy of the mothers and observation of breastfeeding practices that refer to 16 breastfeeding practice items. Data analysis was used univariate and bivariate analysis. The results showed that there was no relationship between self-efficacy and breastfeeding practice (p-value = 0.215). There is no relationship between self-efficacy and breastfeeding practice.


INTRODUCTION
The SDGs target is to reduce child mortality with an indicator that is to reduce IMR to 12/1000 live births in 2030. 1 Efforts that can be made to reduce the infant mortality rate include breastfeeding. Breast milk is the first food for newborns. Breastfeeding is an effort to fulfill nutrition in newborns. The content of breast milk includes protein, carbohydrates, fat, sodium, potassium, calcium, and phosphorus. These substances function in the development of the baby. 2 Exclusive breastfeeding is giving only breast milk without giving the baby food and drinks other than breast milk from the time the baby is born to the age of six months and is continued until the baby is two years old. 3 Worldwide coverage of exclusive breastfeeding for infants aged 0-6 months is 40%, and this percentage has not yet reached the target for coverage of exclusive breastfeeding in the world of 50%. Meanwhile, the coverage of breastfeeding in Indonesia in 2016 was 54%, this percentage has not reached the national target set by the government, which is 80%. 4 This illustrates that the practice of exclusive breastfeeding is still low, while the practice of non-exclusive breastfeeding is still high. 5 The failure of exclusive breastfeeding is one of the problems that occur in postpartum mothers. 6 One of the factors that determine the success of breastfeeding is the mother's emotional condition, such as the mother's confidence and self-efficacy in breastfeeding. 7 During the newborn period, most breastfeeding sessions take 20 -45 minutes. However, because newborns are often sleepy, this timeframe may require patience and persistence. 8 Self-efficacy affects breastfeeding. Selfefficacy describes a person's belief in his ability to take certain actions to achieve the expected results. 9 Breastfeeding Self Efficacy (BSE) is a mother's beliefs regarding her ability to breastfeed her baby and estimates whether the mother chooses to breastfeed or not, how much effort is spent on breastfeeding the baby, the ability to increase breastfeeding efforts, and how to respond to difficulties experienced while breastfeeding emotionally. 10 Low BSE scores and ineffective breastfeeding practices often occur in mothers who have never had previous breastfeeding experience. 9 Mothers with the first experience of breastfeeding are often very sensitive to everything related to the state of their babies. This makes it easy to be provoked by various negative assumptions, such as babies who will not be full enough if they only get breast milk. At the beginning of the postpartum period, the mother only produces colostrum, which amounts to a small amount or even not yet expresses milk. 11 Self-efficacy of breastfeeding refers to the mother's confidence in her ability to breastfeed her baby. 12 BSE affects the initiation of breastfeeding, the achievement of exclusive breastfeeding, and the duration of breastfeeding, the higher the success rate of exclusive breastfeeding in postpartum mothers. 12 BSE is the strongest factor that can influence the breastfeeding process and the success of exclusive breastfeeding in the future. 13 The various results of these studies open up a new discourse that the self-efficacy of breastfeeding is thought to be closely related to the success of breastfeeding practice. Based on a preliminary study using an observational method that was carried out in August 2019 at the Widuri Primary Clinic, Sleman Regency, the obstacles that are often found in exclusive breastfeeding include breast milk that comes out little, sore nipples, pulled inward nipples, lack of support from the parties. family, whether the husband or other family members who live in the same house, habits in society such as giving food to babies. The community gives food to babies when the baby is fussy, fussy babies are considered by the community as a condition where the baby feels hungry, so they give additional food other than breast milk (formula milk, baby porridge, honey, sugar solution, and bananas) to the baby, the community perceives that the baby is not full if only given breast milk. These things are caused by the lack of understanding of family and society about exclusive breastfeeding. Based on the findings from the preliminary study above, the researchers are interested in researching with the aim to identify the relationship between selfefficacy and breastfeeding practice in primiparous mothers.

METHOD
The research was used a cross-sectional study. 14 The research design used was correlational.
14 Data collection begins with a preliminary study using the observation method in August 2019 at the Widuri Primary Clinic, Sleman Regency. The population in this study were mothers who had given birth to a live baby once at the Widuri Primary Clinic. The sample size in this study was 40 primiparous mothers. This study uses a total sampling technique, namely taking a sample of the same number as the population. 15 If the population is less than 100, the entire population is used as the research sample. For the characteristics of the sample not to deviate from the population, it is necessary to determine inclusion and exclusion criteria before taking the sample. The inclusion criteria were 1) Primiparous mothers who gave birth normally or cesarean section at Widuri Primary Clinic, 2) Primiparous mothers who gave birth without complications, 3) Mothers who gave birth to babies at 37 weeks of gestation or more, 4) Mothers who gave birth to single babies, and 5) Postpartum mothers who do postpartum control on the fifth day. While the exclusion criteria were 1) mothers who were not willing to be respondents, 2) mothers who gave birth to babies who died because of IUFD, and 3) mothers who gave birth to babies who died after birth. The instrument used in this study was a questionnaire containing 25 questions with closed questions to measure the self-efficacy of breastfeeding mothers. Meanwhile, to determine the practice of breastfeeding, researchers conducted direct observation techniques concerning 16 items of breastfeeding practice. Test the validity and reliability of 30 primiparous postpartum mothers at Sleman Public Health Center. There are 25 questions in the BSES that have been tested valid from a total of 33 questions tested. Whereas in the reliable test, the value of Cronbach's Alpha after being tested was 0.8 (alpha count> minimal alpha). In this study, statistical tests were carried out using the chi-square test to determine the relationship between self-efficacy and breastfeeding practice. The confidence level used was 95% and p-value <0.05.

RESULTS AND DISCUSSION
Research on the relationship between selfefficacy and breastfeeding practice in primiparous mothers at the Widuri Primary Clinic was conducted in December-January 2020. The sample that met the research requirements was 40 respondents. All respondents in this study were in the productive age range. All respondents in this study were married and there was no unwanted pregnancy. All respondents in the study had a minimum education level of Senior High School.

Characteristics of respondents by age and education level
Age of respondents in this study can be seen in Table 1. Out of a total of 40 respondents, respondents aged 29 years had the highest number of nine primiparous mothers (23%). In this study, primiparous mothers aged 23 and 27 were 1 person (3%) respectively.
The education level of the respondents in this study can be seen in Table 2. Table 2 shows that of the 40 respondents studied, the education level of the respondents was mostly educated at the end of a 3-year diploma of 15 primiparous mothers (38%). The lowest level of education is Senior High School with 11 primiparous mothers (28%). Total 40 100% Table 3 shows that of the 40 respondents, it shows that 20 respondents (50%) have a household income of between two and three million rupiah (IDR). Mothers' occupations in this study can be seen in Table 4. Table 4 explains that of the 40 respondents, 22 primiparous mothers worked (55%). Total 40 100%

Frequency distribution of breastfeeding practices
The practice of breastfeeding in this study can be seen in Table 6. Table 6 shows that the majority of primiparous mothers practiced appropriate breastfeeding by 28 respondents (70%).

Relationship between Self-Efficacy and Breastfeeding Practices
The relationship between self-efficacy and breastfeeding practice can be seen in Table 7. Table 7 shows that of the 40 respondents who had high self-efficacy, 14 (35%) practiced breastfeeding. Chi-square test results obtained pvalue = 0.215, RP = 1.737 and 95% CI = 0.849-3.555. The results of the analysis indicated that there was no relationship between self-efficacy and breastfeeding.  Table 7. Relationship between Self-Efficacy and Breastfeeding Practices The results of the analysis with the chisquare test showed a p-value of 0.215 (> 0.05), there was no significant relationship between self-efficacy and breastfeeding practice. Epidemiologically, it shows a value of RP 1.737, that mothers with low self-efficacy have a chance to practice not-proper breastfeeding by 1.737 times greater than mothers with high selfefficacy. Based on the self-efficacy description, 21 respondents had high self-efficacy. Respondents with high self-efficacy who practiced proper breastfeeding were 14 mothers (35%). This probably happened because respondents with low self-efficacy felt insecure about breastfeeding. The mother's high selfconfidence will increase the mother's confidence in giving breast milk to her baby. Lack of support from families, cadres, and health workers may lead to low self-confidence in primiparous mothers. A previous study found that the women becoming pregnant four times or more got significantly higher average Breastfeeding Self-Efficacy Scale-Short Form and average LATCH scores, and the women married for 11 years or longer and the mothers starting to breastfeed their babies within 30 minutes of their birth got significantly higher average LATCH scores 20 .
From previous studies in Turkey, we conclude that primiparous mothers do tend to have low self-efficacy in breastfeeding due to their inexperience in caring for and breastfeeding their babies, compared to mothers who have given birth several times and have a long breastfeeding duration. his finding suggests that a mother's first breastfeeding experience is difficult in terms of confidence and breastfeeding initiation. First-time mothers in Turkey especially experience intense concern related to insufficient milk supply, which harms breastfeeding self-efficacy. 21 The results of statistical tests between selfefficacy and breastfeeding practice showed that there was no significant relationship. The statistical reason for this is that there are several respondents with a fairly high BSE scale but have not proper breastfeeding practice scores. Based on the concept, every person's actions are always influenced by self-efficacy, but high selfefficacy does not necessarily indicate the success of proper breastfeeding practice because breastfeeding is influenced by attachment, position, and milk transfer, which are closely related to anatomy and physiology of the breast. In addition, further research is needed on the relationship between breastfeeding selfefficacy and the practice of exclusive breastfeeding. Zhu et al. (2014) concluded that mothers who have previous breastfeeding experience, who watch other mothers breastfeed their babies, or who decide to breastfeed earlier have higher levels of breastfeeding self-efficacy. This previous study supports the idea that psychosocial elements are of great importance in influencing mothers breastfeeding self-efficacy and breastfeeding capabilities. 22,23,24 The self-efficacy of breastfeeding is influenced by four main things. The first is the experience of the success of breastfeeding itself, this experience will be able to increase selfconfidence, confidence, and a strong desire in breastfeeding mothers. The second factor is the experiences of other people. Based on the results of interviews with postpartum mothers, respondents had a lot of experience with breastfeeding from birth mothers, in-laws, and sisters who told them about breastfeeding techniques. The third factor is a verbal invitation, namely solicitation, and support from people around such as friends, family, health practitioners, and lactation consultants. 12 Reinforcement and advice are a source of strength for mothers to breastfeed their babies. This is in line with research conducted which states that there is a significant relationship between self-efficacy and social support. The fourth factor is the physiological response, for example, anxiety, stress, and fatigue. A mother will feel safe and comfortable if she is free from physical and emotional stress. This can be seen when after giving birth, the family accompanies the mother, provides support and affection. Although some respondents had complaints such as a little dizziness, anxiety, and worry that the supply would not come out much, this could be resolved after receiving support from their families and midwives.
In an effort to increase the self-efficacy of breastfeeding mothers, it is necessary to have a program since the antenatal period. 25 This program can be realized by providing a breastfeeding support package. In addition, there is a need for a discussion class on breastfeeding as a health promotion medium to improve breastfeeding practices in postpartum mothers. This ASI discussion class can be held by paying attention to the intensity and time of implementation and involving the entire family, both husbands and decision-makers in the family. This is in line with research that has been conducted which shows the effectiveness of breastfeeding discussion classes, that there are differences between mothers who attend breastfeeding discussion classes and those who do not. 3

CONCLUSION
This study concluded that there was no relationship between self-efficacy and breastfeeding practice in primiparous postpartum mothers (p = 0.215). Every person's actions are always influenced by self-efficacy, but high selfefficacy does not necessarily indicate the success of proper breastfeeding practice because breastfeeding is influenced by several factors, especially the mother's experiences. The mothers who have previous breastfeeding experience, who watch other mothers breastfeed their babies, or who decide to breastfeed earlier have higher levels of breastfeeding self-efficacy and breastfeeding capabilities.