Table 1. Interview Questions

We analysed the data using a thematic analysis approach by reading and re-reading the reflective writings, selecting relevant ideas, coding and grouping them according to their similarities, and organising them into themes and subthemes based on the results of interviews and participants’ reflections. Atlas.ti version 24 was used to manage the data. Data triangulation was conducted between researchers by discussing themes and differences until a consensus was reached.

III. RESULTS

Fifty-six participants agreed to participate in the study and completed the interviews. Forty-five of them were from medicine, eight from pharmacy, and three from midwifery. There were variations in participants’ reflective writing, and the following four themes emerged:

A. Differences in Knowledge and Beliefs about Breastfeeding among Mothers and Their Families

Participants reflected that mothers’ knowledge and beliefs about breastfeeding varied depending on the information they received from their surroundings. Family members were their main sources of information on ways to overcome breastfeeding challenges.

‘The mother tried to commit to breastfeeding for six months. But when she fell ill and was weak, she had to give formula milk to the child on the advice of her mother-in-law, but after that, the child did not want to drink breast milk.’ (P24)

B. Breastfeeding Challenges that can be a Threat to Breastfeeding

Participants indicated that mothers faced various obstacles in breastfeeding, such as the pain experienced by them during breastfeeding, which may force them to switch to formula milk. Problems that triggered pain included low milk production, swelling of the breasts, and sore nipples. Mother’s health was also a reason for the people around her to support breastfeeding cessation. Another challenge in breastfeeding was mother’s readiness to breastfeed, particularly for working mothers to manage their time for breastfeeding. Therefore, healthcare professionals should explore the challenges of breastfeeding before providing appropriate advice.

‘In the Integrated Services Post (Posyandu), midwives or health workers can open a special session on questions about breastfeeding.’ (P28)

C. Healthcare Professionals’ Central Role in Providing Education and Advocating for Breastfeeding

Healthcare professionals should have adequate knowledge of breastfeeding management, good communication skills, ability to demonstrate breastfeeding techniques, and educational strategies to the public. They should also involve community leaders and use social media platforms to promote breastfeeding.

‘It is essential for healthcare workers to provide proper education, not endorse and recommend products such as breast milk supplements, whose ingredients and side effects are unknown. Instead, they must teach and provide education on benefits of breastmilk, breast massages which can facilitate mother’s breast milk production, and on managing stress which can impact breast milk production.’ (P48)

D. Involvement of the Family and Community in Breastfeeding Education

Participants reflected that breastfeeding is influenced by cultural aspects; if the mother does not have prior breastfeeding experience, she is likely to believe information provided by the people around her. Hence, apart from the mothers, breastfeeding education must also be extended to companions and families. Such education must include factors to support breastfeeding such as preparation and methods for giving breast milk, and appropriate information about lactation.

‘We as healthcare workers must pick up the ball by providing mass education to the community, especially to family members who are “always” supposed to be listened to. Breastfeeding education will be in vain if we do not educate the public. We are also responsible for the health and quality of the nation’s future generations.’ (P25)

IV. DISCUSSION

Healthcare professionals must possess mother-centred advocacy skills to promote breastfeeding. Increasing their understanding through educational measures is a commitment to achieving better breastfeeding coverage and improving maternal and child health (Mulcahy et al., 2022). In line with the principles of Kolb’s Experiential Learning Theory, the interviews provided authentic exposure to the participants where they could practice skills to explore mothers’ beliefs and knowledge, and develop an empathetic attitude towards mothers’ challenges. The reflection process also enabled them to strengthen their understanding and conceptualise their interpersonal skills and professional development (Yardley et al., 2012).  

Participants reflected that knowledge and beliefs of mothers are essential factors in sustaining breastfeeding. Mothers’ lack of independence from family influence and low self-confidence in overcoming challenges are considered to be related to short duration of breastfeeding (Balogun et al., 2015). The communal culture often affects mothers’ decision-making regarding breastfeeding as they are dependent on informal information from the surrounding people. Though this information may help them overcome breastfeeding-related problems, it may not necessarily be evidence-based (Susilo et al., 2019).

Hence, participants were aware of the urgency with which healthcare professionals must act to provide appropriate breastfeeding counselling. This assignment helped them critically think about mothers’ perceptions of challenges in breastfeeding and their own future actions to support breastfeeding. This comprehensive understanding will help promote breastfeeding, by providing mother-centred advocacy and breastfeeding counselling with appropriate advice and anticipatory steps to overcome breastfeeding obstacles (Radzyminski & Callister, 2015).

Our study showed that the participants were motivated to play a central role in supporting breastfeeding mothers. This assignment served as a strong trigger to motivate participants to improve the knowledge about breastfeeding management they would obtain throughout the course.

This study has two limitations. First, the analysis of participants’ awareness was based on their reflective writing skills, which may be diverse as they have not been consistently introduced in academic institutions in Indonesia. This may have influenced how the participants expressed their understanding in their reflective writing. Oral reflections can yield different themes. Second, this study focused only on the interviews and reflective writing assignments of the course, as we believe that an intensive look at these would provide valuable lessons. Triangulation with other data is necessary to determine the effectiveness of the entire course.

V. CONCLUSION

An assignment based on experiential learning principles made participants aware of the diversity of knowledge and beliefs of breastfeeding mothers in a communal culture and the potential challenges for mothers deciding to stop breastfeeding. The reflection process motivated them to learn about mother-centred advocacy for breastfeeding mothers and their surroundings.

Notes on Contributors

Astrid Pratidina Susilo designed the study, conducted the data collection and analysis, and drafted the manuscript.

Lucia Pudyastuti Retnaningtyas designed the study, conducted the data collection and analysis, and reviewed the manuscript.

Lisa Aditama designed the study, conducted the data collection, and reviewed the manuscript.

Karunia Wijayanti designed the study, conducted the data analysis, and drafted the manuscript.

Ethical Approval

This study was approved by the institutional ethics committee of Universitas Surabaya (No. 179/KE/VII/2023). All the participants provided written informed consent.

Data Availability

We do not share the raw data as the reflective writing assignments were in Indonesian. Readers who are interested in accessing the data can contact the author.

Acknowledgement

We are grateful to the Ubaya Global Academy (UGA) management team for supporting the development and implementation of this online course. We also thank Santi Desi, Denny Herliana, and Laurentia Audi Agatha for their administrative support for this study. This study was presented at the International Conference of the AMEE 2024.

Funding

This research was supported by the Ministry of Education, Culture, Research, and Technology of Indonesia (Grant Number 109/E5/PG.02.00.PL/2024).

Declaration of Interest

No potential conflicts of interest are relevant to this article.

References

Balogun, O. O., Dagvadorj, A., Anigo, K. M., Ota, E., & Sasaki, S. (2015). Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: A quantitative and qualitative systematic review. Maternal & Child Nutrition, 11(4), 433-451. https://doi.org/10.1111/mcn.12180

Mulcahy, H., Philpott, L. F., O’Driscoll, M., Bradley, R., & Leahy-Warren, P. (2022). Breastfeeding skills training for health care professionals: A systematic review. Heliyon, 8(11). https://doi.org/10.1016/j.heliyon.2022.e11747

Radzyminski, S., & Callister, L. C. (2015). Health professionals’ attitudes and beliefs about breastfeeding. The Journal of Perinatal Education, 24(2), 102-109. https://doi.org/10.1891/1058-1243.24.2.102

Susilo, A. P., Marjadi, B., Dalen, J. V., & Scherpbier, A. (2019). Patients decision-making in the informed consent process in a hierarchical and communal culture. The Asia Pacific Scholar, 4(3), 57-66. https://doi.org/10.29060/TAPS.2019-4-3/OA2085

Yardley, S., Teunissen, P. W., & Dornan, T. (2012). Experiential learning: AMEE guide No. 63. Medical Teacher, 34(2), e102-e115. https://doi.org/10.3109/0142159X.2012.650741

*Lucia Pudyastuti Retnaningtyas
Faculty of Medicine, University Surabaya, Indonesia
Jl. Raya Kalirungkut, Surabaya 60293
+628113113338
Email: luciaretnaningtyas@staff.ubaya.ac.id