The Preparation of Lactation on 3rd Trimester Pregnant Women
with the Approach of WHO Behavior Determinant
A Factor Analysis
Esti Yunitasari, Iqlima Dwi Kurnia, Nindhita Dyah S, Tsuwaibatul Islamiyah
Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia
Keywords: Lactation, Culture, Antenatal Visit, Exclusive Breast Milk.
Abstract: The level of breast milk coverage in Indonesia is still far from the target. The preparation of lactation during
pregnancy affects the mother's confidence, self-efficacy and breast milk production, which are the predictors
of breastfeeding and exclusive breastfeeding practices. Given the low level of preparation by mothers for
lactation, it needs to be studied further regarding what factors affect the preparation of lactation. This study
aims to analyze the preparation factors of lactation in 3rd trimester pregnant women with the approach of
WHO behaviour determinants. This research uses a quantitative method with a cross-sectional approach. The
population of this study were all 3rd trimester pregnant women with 88 respondents with a large sample
obtained by a total sampling technique of 62 respondents with drop out of 26 respondents due to childbirth.
Independent variables include thoughts and feelings, personal references, culture and resource (antenatal
visits). The dependent variable of this study is lactation preparation. The data was collected by using
questionnaires and lists of antenatal visits which were analyzed using the Rho Spearmen statistic test with a
0.05 level of significance. The results of this study indicate a significant relationship between thoughts and
feelings, culture and resource (antenatal visits) with lactation preparation. While the personal references factor
does not have a significant relationship with lactation preparation. The role of parents is needed because
parents are a reference character. Factors associated with lactation preparation are thoughts and feelings,
culture and resource (antenatal visits). The socialization on the importance of preparation of lactation needs
to be taken by health agencies and health workers to the entire community both community leaders, religious
leaders, families and also pregnant women.
1 INTRODUCTION
Breast milk (ASI) is the secretion result of the breast
glands that is fluid; it has many benefits for mothers
and babies. Breastfeeding is the most effective effort
in improving infant health and reducing mortality of
infants in their first week (Monika, 2014).
Breastfeeding practice still encounters many
obstacles (Robinson, 2016). The Indonesian
Demographic and Health Survey (SDKI) regarding
national breastfeeding shows an increase in
breastfeeding, although the coverage rate of national
breastfeeding is still too low, in 2013 the national
coverage rate was still around 54.3% (Ministry of
Health, 2014). A general survey stated that the main
reasons that inhibit breastfeeding are pain during
feeding, lack of milk production and job demands
(Helda, 2009). Most mothers encounter obstacles
after starting breastfeeding by not preparing for it
during pregnancy (Aisha, 2016). Preparation for
lactation is very important in the practice of
breastfeeding. The relationship with the feeling of
readiness for breastfeeding will increase maternal
comfort and confidence and improve self-efficacy of
mothers in breastfeeding (Mcmullen & Newburn,
2014).
Preparation for lactation during pregnancy affects
the self-confidence and self-efficacy of mothers,
which are the predictors of breastfeeding and
exclusive breastfeeding practices (Mcmullen &
Newburn, 2014). In addition to the effect on
breastfeeding, lactation preparation also affects breast
milk production (Maga et al., 2013). Psychological
disorders during pregnancy are one of the factors that
may influence maternal breastfeeding decisions and
practices (Figueiredo et al., 2014). Preparation of the
mother's psychology for breastfeeding during
pregnancy is very significant because a mother’s
516
Yunitasari, E., Kurnia, I., S, N. and Islamiyah, T.
The Preparation of Lactation on 3rd Trimester Pregnant Women with the Approach of WHO Behavior Determinant.
DOI: 10.5220/0008327805160520
In Proceedings of the 9th International Nursing Conference (INC 2018), pages 516-520
ISBN: 978-989-758-336-0
Copyright
c
 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

positive decisions and attitudes must be shown during
pregnancy or even long before pregnancy (Mcmullen
& Newburn, 2014).
In an effort to prepare mothers for breastfeeding
the government held an ANC (antenatal care)
program. This includes a program that prepares for
breastfeeding and breast care for pregnant women
scheduled for K1 and K3 (Maternal and Child Health
Nutrition, 2014). East Java Provincial Health Office
in 2014 stated that the coverage of pregnant women
of East Java Province for K1 reached 96.20% and K4
88.6%. The city with the highest coverage rate is
Surabaya and one of the districts with the lowest
number is Sampang Regency with 76% coverage
(Health Office of East Java Province, 2015).
Preliminary study conducted with the Midwife
Coordinator of Sreseh Sampang Community Health
Centre shows that pregnant mother visits are still low.
At K1 it is targeted that all pregnant women should
attend but only 65% came and the number of visits
always reduced in the next pregnancy visit. The
procurement of the ANC program in Sreseh
Community Health Centre itself is in accordance with
the guidelines and SOP set by the Ministry of Health
of the Republic of Indonesia. The distance of the
housing from the services is far enough to be one of
the obstacles; in addition social support from
community leaders is still considered deficient
concerning the promotion of breastfeeding. People
still believe in myths about avoiding eating food that
comes from the sea and assume that when the mother
is outside the home the baby does not have to receive
breast milk. Giving mashed bananas (lothek) has
become an alternative food that is given while the
mother is doing activities so that the baby is full and
not crying. Most of the knowledge of pregnant
women is deficient regarding breastfeeding
techniques and handling problems surrounding
breastfeeding is still poor.
2 METHODS
The design of this study used a cross-sectional study
design with the population of all 3rd trimester
pregnant women in Purwida Sreseh working areas of
Sampang Regency. The sampling used total sampling
and amounted to 88 people with a drop out of 26
people. The variables studied were lactation
preparation of pregnant women and the WHO
determinant factors include thoughts and feelings,
personal references, culture and resource (antenatal
visit). The research instrument used were
questionnaires and determinants of WHO factors with
modification. This study was conducted from 12th
November 2017 to 30th November 2017. This
research has passed an ethical test which is proved by
ethical certificate No. 559-KEP K by Health Research
Ethic Commission of Nursing Faculty, Airlangga
University.
3 RESULTS
Table 1 on the relation of thoughts and feelings as
well as lactation preparation by 3
rd
trimester pregnant
women showed that the majority of respondents had
negative thoughts and feelings. The results of
statistical tests show that there is a significant relation
between thoughts and feelings as well as lactation
preparation, which is a strong and positive relation.
The results of the study in Table 2 on the relation of
personal reference and lactation preparation by 3
rd
trimester pregnant women showed that the majority
of respondents had positive personal references. The
results of this study indicate that there is no relation
between personal references and lactation preparation
performed by 3
rd
trimester pregnant women.
The results of the study in Table 3 on the relation
of culture and lactation preparation by 3
rd
trimester
pregnant women showed that the majority of
respondents have negative culture. Culture is related
to lactation preparation including avoiding seafood
which is a protein needed by pregnant women, not
giving colostrum during less than one hour of birth,
not exclusively breastfeeding because of the habit of
feeding babies with bananas or lontong and not giving
breast milk if the mother's nipple is inverted.
The results of this study indicate that there is a
significant relation between culture and lactation
preparation.
The results of the study in Table 4 on the relation
of antenatal visits and lactation preparation by 3
rd
Table 1: The relation of thoughts and feelings as well as
lactation preparation in Sreseh Community Health
Centre, Sampang Regency, November 2017.
Thought
and
feelings
Lactation Preparation
Total
Not
Ready
Ready
f
%
f
%
f
%
Deficient
27
43
6
9,65
33
53.2
Good
6
11
23
35
29
46.8
Total
33
55
29
44
62
100
Spearmen’s Test Rho = 0,00
correlation coefficient (r) =0,611
The Preparation of Lactation on 3rd Trimester Pregnant Women with the Approach of WHO Behavior Determinant
517

trimester pregnant women showed that the majority
of respondents were irregular in following the
antenatal visits. The results of this study indicate that
there is a relation between antenatal visits and
lactation preparation.
4 DISCUSSION
Thoughts and feelings in this research combined four
factors, knowledge, perception, attitude and belief.
Critical factors of thoughts and feelings are based on
the total score of the four factors. The merger of these
four factors is rarely used, as most studies only look
at a few factors such as knowledge and attitude.
Based on the results found in the field, researchers
argue that mothers who have good thoughts and
feelings about lactation preparation have a tendency
to make lactation preparations so that they are more
ready in breastfeeding the baby. While mothers with
negative thoughts and feelings are not likely to be
ready for breastfeeding.
We can see that for factors such as thoughts and
feelings, the first is knowledge. Based on the results
of research the majority of respondents have less
knowledge. Knowledge affects lactation preparation,
so respondents with less knowledge are not likely to
be ready for breastfeeding. Prior research on the
analysis of exclusive breastfeeding factors conducted
by Kharismawati (2014) using WHO theory where
one of the variables raised is knowledge, found that
knowledge has a positive relation with exclusive
breastfeeding.
The results of this study show the experience of
mothers who previously already had children in
relation with maternal knowledge level on lactation
preparation. This is supported by demographic data in
which the respondents have enough knowledge and a
high majority are respondents who have children,
either one or more. This is in line with research by
Saraswati (2014) where it was found that the higher
the parity the more mothers have the tendency to give
more health attention to the next child. The level of
parity has largely determined maternal concerns
about maternal and child health. According to the
theory proposed by Notoatmodjo (2012), experience
is a source of knowledge, a way of obtaining the truth
of knowledge by repeating the knowledge gained in
solving problems faced in the past.
Mothers’ perception about lactation preparation is
still in the negative category due to the deficiency of
knowledge of pregnant women. From the results of
research conducted, it was found that the majority of
respondents with negative perceptions have less
knowledge about lactation preparation. This is
according to the theory put forward by Thoha (2009)
where knowledge is an external factor that affects the
Table 2: The relation of personal references and
lactation.
Personal
references
Lactation Preparation
Total
Not
Ready
Ready
f
%
f
%
f
%
Negative
15
37,7
14
22,6
29
46,7
Positive
18
15,5
15
24,1
33
53,2
Total
33
53,2
29
46,7
63
100
Spearmen’s Test Rho p = 0,828 correlation
coefficient (r) = -0,028
Table 3: The relation of culture and lactation
preparation in Sreseh Community Health Centre,
Sampang Regency, November 2017.
Culture
Lactation Preparation
Total
Not
Ready
Ready
f
%
f
%
f
%
Negative
26
42
9
14,4
35
56,5
Positive
7
11,2
20
32,3
27
43,5
Total
33
53,2
29
46,7
58
100
Spearmen’s Test Rho p = 0,00 correlation
coefficient (r) = 0,481
Table 4: The relation of antenatal visits and lactation
preparation in Sreseh Community Health Centre,
Sampang Regency, November 2017.
Antenatal
visit
Lactation Preparation
Total
Not
Ready
Ready
f
%
f
%
f
%
Irregular
26
44,8
11
19
37
63,8
Regular
6
10,3
15
25,6
21
36,2
Total
32
55,2
26
44,8
58
100
Spearmen’s Test Rho p = 0,02 correlation
coefficient (r) = 0,403
Antenatal
visit
Lactation Preparation
Total
Not
Ready
Ready
f
%
F
%
F
%
Irregular
26
44,8
11
19
37
63,8
Regular
6
10,3
15
25,6
21
36,2
Total
32
55,2
26
44,8
58
100
Spearmen’s Test Rho p = 0,02 correlation
coefficient (r) = 0,403
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
518

perception of a person other than family background
and information obtained.
The next factor is attitude. The majority of
respondents still have negative attitudes towards
lactation preparation. This is supported by research
by Yulianah et al. (2013) showing that the attitudes of
mothers in breastfeeding tend to be negative hence
they cannot achieve exclusive breastfeeding.
Research by Rahmadani et al. (2012) mentions that a
mother’s positive attitude will lead to good behaviour
in pregnancy and breast examination which are parts
of lactation management. While the study by Amiel
et al. (2017) found that the attitude during pregnancy
is a key predictor and can increase 20-30% of
breastfeeding practices.
Based on data obtained the majority of
respondents have a positive belief about lactation
preparation. However, some respondents with
positive beliefs did not make lactation preparations so
they were considered not ready. Nevertheless, from
the results of the study, it can be seen that the
respondents with positive trust tend to be more ready
to breastfeed their baby.
Based on the above description, it was found that
the thoughts and feelings factors have a relation with
lactation preparation. From the results of this study,
the majority of respondents have a deficiency in
knowledge, negative perceptions, negative attitudes
and positive beliefs. Based on the above explanation
it can be concluded that for lactation preparation,
thoughts and feelings are not only influenced by the
trust but also influenced by other factors such as
knowledge, perception and attitude.
The results of the study in Table 2 on the relation
of personal preferences and lactation preparation by
3
rd
trimester pregnant women showed that the
majority of respondents had positive personal
preferences. The results of this study indicate that
there is no relation between personal preferences in
lactation preparation performed by 3
rd
trimester
pregnant women.
In this study the people who are considered
important and influential in lactation preparation are
health workers, cadres, parents and religious leaders.
Negative preferences are encouragement and support
that can inhibit lactation preparation. Positive
preferences are suggestions that can support lactation
preparation of 3
rd
trimester pregnant women. The
majority of personal preference respondents are
positive, whose support and suggestions are good for
lactation preparation.
The results of this study indicate that although the
respondent has a positive personal preference the
majority of respondents are not considered ready for
breastfeeding. This study is not in line with the
research by Rahmadani et al. (2012), which shows
that factors that support the action of pregnant women
are still in the medium category so that the behavior
of pregnant women in lactation management is in the
medium category.
From the demographic data it is found that the
majority of respondents consider parents as the
figures they obey and they consider as an example.
Based on the results of the interviews, the
respondent's parents provided support for what the
respondents did. The respondents were given more
advice and information about lactation preparation
from health workers. Based on the results of research,
most respondents did not conduct regular antenatal
visits so that the information obtained is still minimal.
The results of this study are supported by the research
of Chang et al. (2015) showing that the provision of
information by health workers can be positive and
motivate the mother in extending the duration of
breastfeeding.
The results of the study in Table 3 on the relation
of culture and lactation preparation by 3
rd
trimester
pregnant women showed that the majority of
respondents have negative culture. Culture is related
to lactation preparation including avoiding seafood
which is a protein needed by pregnant women, not
giving colostrum during less than one hour of birth,
not exclusively breastfeeding because of the habit of
feeding babies with bananas or lontong and not
breastfeeding if the mother's nipple is inverted. The
results of this study indicate that there is a significant
relation between culture and lactation preparation.
The results of this study are not supported by
previous research on the analysis of exclusive
breastfeeding factors conducted by Kusumaningrum
et al. (2009), which found that there is no relation
between social culture and exclusive breastfeeding.
However, based on research in Palu, Central Sulawesi
conducted by Rahman et al, (2017) it was found that
socio-culture has a significant relationship with
exclusive breastfeeding in a positive direction.
According to Notoatmodjo (2012) the culture where
someone lives and breeds has a great influence on the
formation of one's attitudes.
The results of this study indicate that there is a
relation between antenatal visits and lactation
preparation. This is supported by Aisyah and
Fitriani's research (2013), in which the regularity of
ANC visits has a positive relationship with
breastfeeding skills. Respondents making regular
antenatal visits were better prepared to breastfeed
than respondents with irregular antenatal visits. The
results of this study are in line with McMullen and
The Preparation of Lactation on 3rd Trimester Pregnant Women with the Approach of WHO Behavior Determinant
519

Newburn (2014) where mothers taking antenatal
classes will be better prepared to breastfeed and the
Bonuck et al. (2015) study showed that giving
education about breastfeeding is better given during
pregnancy. Meanwhile, according to the WHO
behavioral theory (1984) resources are supporters for
the occurrence of behavior of people.
Low antenatal visits are due to socio-economics
i.e. education, employment and income. From the
data obtained, most respondents have a low
educational background and insufficient knowledge.
Most of the respondents are housewives who do not
have income independently so they depend on their
husband's income. The majority of respondents’
revenue is still below the minimum wage, hence it
might affect antenatal visits, which need money and
the distance to the health facility is quite far. From
demographic data it was also found that the majority
of respondents have children aged between 2 and 5
years old who live with the large family.
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