Improvement of Breastfeeding Efficacy Through Small Group Education of Cadres with Pregnant Women

WHO recommends that every infant should be exclusively breastfed, but until now the coverage of exclusive breastfeeding is still low due to factors such as knowledge, breastfeeding efficacy, family support, lactation problems

Epti Yorita et al., / Scientific Periodical of Public Health and Coastal 5(4),2023, page 1357-1368 Vol 5 production of enough milk to meet the baby's needs (WHO, 2017).Data show that exclusive breastfeeding is currently still low in various countries; in Japan, 44% of mothers give formula milk to their babies after 8 weeks of age, exclusive breastfeeding coverage in Brazil is 37%, while in Thailand it is only 14% (Monteiro et al., 2020;Otsuka et al., 2014;Topothai et al., 2022).
The success of exclusive breastfeeding is influenced by several factors including low knowledge, lack of family and social support, embarrassment, lactation problems, employment, number of children, distance between childbirth and childcare, social norms and barriers in the health system (Laksono et al., 2021;Nguyen et al., 2022;Nkoka et al., 2019;Wulandari et al., 2022).
Breastfeeding efficacy also plays an important role in the success and duration of breastfeeding, good breastfeeding contact will also increase good breastfeeding efficacy (Suartiningsih et al., 2023).Previous research has shown that receiving information about breastfeeding is the dominant factor influencing breastfeeding efficacy; the mean breastfeeding efficacy score of mothers who received information about breastfeeding during pregnancy was higher than that of mothers who did not (Topuz et al., 2021).
Therefore, interventions that aim to promote breastfeeding by increasing breastfeeding efficacy should always be implemented.Effective programmes to promote exclusive breastfeeding can be developed according to the needs of mothers through individualised approaches, lactation clinics or classes for mothers (Nguyen et al., 2022).Baby friendly hospital interventions that start during pregnancy have been shown to increase breastfeeding efficacy until 4 weeks postpartum and exclusive breastfeeding until 6 weeks postpartum (Otsuka et al., 2014).
Prenatal breastfeeding education has been shown to improve postpartum mothers' knowledge, attitudes and behaviour (Wulandari et al., 2022).The implementation of antenatal classes in Indonesia is currently done in large groups with midwives as facilitators, but has several weaknesses such as low human resources, demographic factors, low access to health facilities such as in remote areas on Enggano Island (Novira, 2019;Yorita et al., 2023).
The remote antenatal education intervention developed in previous studies is effective in remote areas, but is not suitable for Enggano Island because the electricity supply is only 12 hours per day, which causes interference with internet access and other services (Hui et al., 2021a;Novira, 2020).Teaching mothers in small groups using the social capital of cadres in remote communities can be an alternative for remote, underdeveloped islands and border areas such as Enggano Island (Hui et al., 2021;Koushede et al., 2017;Maleki et al., 2021;Yorita et al., 2023).This study aims to determine the effectiveness of small group education of cadre with pregnant women on breastfeeding efficacy in remote area of Enggano Island, Bengkulu Province.

METHODS
Quasi-experimental research design with pre-and post-test and a control group.The third trimester group were pregnant women who received health promotion through the Small Group of Cadres with Pregnant Women.This is a modified class for pregnant women divided into small groups with cadres as facilitators, while the control group were pregnant women who received conventional health promotion.
The independent variable was the small group education class, the dependent variable was breastfeeding effectiveness, and the extraneous variables were age, parity, education, occupation, and gestational age.The research was conducted in the area of Enggano Health Centre, North Bengkulu Regency, which is a remote, outermost and island area and has been the locus of stunting (Hui et al., 2021;Yorita et al., 2023).The research was conducted from January to November 2023.
The research sample of pregnant women in the third trimester of pregnancy from 25-36 weeks of age, was 50 people divided into experiment and control groups.Sampel selected through purposive sampling with inclusion criteria were pregnant women willing to participate in the study until completion, while exclusion criteria were pregnant women with a history of poor obstetric care or with pregnancy complications and co-morbidities.
The small group education classroom intervention takes the form of education in pregnant women's classes, delivered by cadres as facilitators.The cadres were trained by researchers before delivering the education to pregnant women.small group education class materials included transition to parenthood, couple communication, childbirth, breastfeeding practices and newborn care.Pregnant women were given small exercises to prepare for each session, with each session lasting 2.5 hours.Each small group education class consisted of small groups of 5-6 pregnant women of the same gestational age.The module and leaflet for the small group education class were developed based on the needs assessment and included a guide to practicing correct breastfeeding techniques.The learning activities were conducted through short oral presentations by the group facilitators, individual exercises, short film presentations, discussions and reflections (Koushede et al., 2017).The Breastfeeding Self-efficacy Scale-Short Form (BSES-SF) questionnaire was used to measure breastfeeding efficacy.The pretest was administered before the education in the small group education class, while the posttest was administered at 36 weeks of gestation, considering that 37 weeks is the age of normal labour (Amini et al., 2019) .
Table 1 shows that the age at risk group in the experimental group was lower than the control group (28%:48%), where the total number of pregnant women with age at risk was 38%.Based on parity, primiparity was greater in the experimental group than the control group (44%:24%).The multipara group was less in the experimental group than the control group (52%:60%), but the grande multipara group was greater in the experimental group than the control group (25%:16%).
Based on gestational distance, primigravida was greater in the experimental group than the control group (44%:24%).Gestational age <2 years was greater in the experimental group than the control group (8%:5%), gestational age >5 years was greater in the experimental group than the control group (20%:8%), but gestational age 2-5 within the normal range was less in the experimental group than the control group (28%:48%).
Table 2 also shows that the level of primary education was smaller in the experimental group than the control group (40%:64%), while the level of secondary/higher education was larger in the experimental group than the control group (60%:36%).More respondents in the experimental group were not working compared to the control group (92%:36%).2. shows that the mean efficacy score before the small group education class was 36.72 with a minimum score of 27 and a difference in the mean score of knowledge before and maximum of 45.After the treathird trimesterent, there was an increase in the mean score to 56.28 with a maximum score of 41 and a maximum of 66.The statistical test results showed that there was an effect of small group education class education on breastfeeding efficacy with a p=0.00 mean difference of 19.56, which means that education in the small group education class can increase the efficacy score by 19.56 times.
Table 2 shows that the mean efficacy score before treathird trimesterent in the control group also increased from 37.12 to 38.24 with a minimum score of 28 and a maximum score of 47.The statistical test results show that there is an effect of conventional class intervention on breastfeeding efficacy in the control group with a value of p=0.46 with a mean difference of 1.12.This means that conventional class intervention can increase breastfeeding efficacy in pregnant women by 1.12.The Table 4. results of the multivariate analysis in Table 4 show that there is a relationship between small group education class and breastfeeding efficacy with a value of p=0.00, a coefficient of correlation of 0.83, which means that 83% of breastfeeding efficacy is influenced by the variable small group education class, the rest by other factors.The table above also shows that there is an effect of education on breastfeeding effectiveness with a value of p=0.01, a relation coefficient of 0.35, which means that 35% of breastfeeding effectiveness is influenced by education, the rest by other factors.
Age was not associated with breastfeeding efficacy p=0.21, parity was not associated with breastfeeding efficacy p=0.15, distance was not associated with breastfeeding efficacy p=0.92, employment was not associated with breastfeeding efficacy p=0.83.Multivariate analysis concluded that small group education and education level were the dominant factors influencing breastfeeding efficacy.

DISCUSSION
The results of this study found that almost half (38%) of pregnant women were in the risky age group.This finding is in accordance with past research that the average mother gave birth at the age of 17.8 years with the largest percentage (37.8%)at the age of 19 years (Putri et al., 2017).The same findings also found that 80% of pregnancies occurred at the age of 18 years.Young pregnancies have an impact on birth outcomes that are detrimental to the health of the mother and the child to be born because they are not physically and psychologically ready so they are at risk of sexually transmitted diseases, premature birth, miscarriage, physical violence and others (Kabir et al., 2019).
The results of this study also found that 34% of pregnant women were primiparous and 10% grande multiparous.Parity was significantly associated with breastfeeding intention and timing of breastfeeding immediately after delivery.Primiparous mothers need special attention because they have no experience related to pregnancy and newborn care including breastfeeding.Primiparous mothers are more likely to experience exclusive breastfeeding failure by giving early breasthird trimesterilk substitutes (Neves et al., 2020).Similar findings also found that exclusive breastfeeding decreased with age and the number of children born (Bilal Safdar et al., 2021).
This study found that only a small proportion 14% of pregnant women were less than 2 years apart, which is a risk factor for breastfeeding failure, consistent with previous findings that 64.9% of mothers with a birth spacing of less than 2 years experienced failure of exclusive breastfeeding (Nisa, 2023).This finding is supported by previous research showing that birth spacing is associated with exclusive breastfeeding (Fatiah et al., 2022).
The results of this study showed that some respondents had a basic level of education, which is in line with previous findings that people in Enggano Island have low motivation and perception of education due to the lack of human resources and supporting infrastructure (Novira, 2019).The same findings were also found in previous studies that only 10% of pregnant women have basic education (Prastyoningsih et al., 2021).Education level is related to exclusive breastfeeding, where 87.2% of mothers with secondary education are able to breastfeed exclusively.Education level is related to the ability to absorb knowledge and exposure to information about exclusive breastfeeding (Eugenie et al., 2018).
The results of this study found that there was an effect of breastfeeding education on breastfeeding efficacy.The results of this study are similar to previous research, which found that breastfeeding education increased mean breastfeeding efficacy scores.Health education Vol 5 during pregnancy and postpartum has been shown to increase breastfeeding efficacy to promote the success of exclusive breastfeeding (Prastyoningsih et al., 2021).
The results of this study are also consistent with previous findings that education during pregnancy can increase breastfeeding efficacy.Breastfeeding education in antenatal classes is an effective way to improve breastfeeding practice, which has a significant impact on the continuation of exclusive breastfeeding.Pregnant women who receive breastfeeding counselling have been shown to have better breastfeeding knowledge and higher breastfeeding efficacy (Piro et al., 2020).
Interventions to promote exclusive breastfeeding should therefore be emphasised, without ignoring social inequalities and the need to bridge the knowledge gap on breastfeeding practices.These aspects should be considered as integral components of any comprehensive strategy aimed at promoting and supporting breastfeeding practices through various interventions, educational programmes and services such as breastfeeding counselling, leading to substantial improvements in nutritional, immunological, psychosocial and economic conditions (Değer et al., 2023).
Breastfeeding self-efficacy is influenced by motivation, experience, subjective norms supporting breastfeeding, number of children and experience of exclusive breastfeeding with previous children.Therefore, antenatal education is an appropriate tool to improve breastfeeding efficacy in pregnant women (Jaya et al., 2022).
Health education and breastfeeding promotion by health professionals have been shown to improve breastfeeding success programmes.In addition, continuous support from healthcare providers and breastfeeding counsellors during the seven stages of breastfeeding contact, starting during pregnancy until after delivery, is needed to ensure that mothers receive sufficient and appropriate information about breastfeeding (Awaliyah et al., 2019).
In this study, the increase in the mean breastfeeding efficacy score was probably due to the small-group approach of the small group education class, which allowed sufficient time for discussion of pregnancy, labour and infant care.Pregnant women were also given the opportunity to share their breastfeeding experiences, both the successes and failures of exclusive breastfeeding with previous children.In this study, small group education was provided three times during the third trimester of pregnancy, which was shown to improve breastfeeding effectiveness.
The same approach has been used in previous studies, which have shown that efforts to improve antenatal care at 25-36 weeks of pregnancy can have positive effects on pregnancy care and preparation for parenthood (Swift et al., 2021).This finding supports previous research that found high breastfeeding efficacy among mothers who had 4 or more antenatal visits, possibly due to exposure to knowledge about pregnancy and childbirth care during contact with health services (Gizaw et al., 2022).
Parent education during pregnancy increases pregnant women's knowledge of antenatal care.Education in small groups of 8-12 people of similar gestational age allows providers and pregnant women to share knowledge and experience, and empowers women to take responsibility for health during pregnancy.Antenatal classes provide a platform to empower pregnant women with knowledge and informed decision-making, preparing them for healthy pregnancy, labour and newborn care (Ratzon et al., 2022).

CONCLUSIONS
The study concluded that small group education of cadre with pregnant women is effective in improving breastfeeding efficacy among third trimester pregnant women.Small group education of cadre with pregnant women and education level are the dominant factors influencing breastfeeding efficacy.It is recommended that health care providers should provide continuous small group and structured breastfeeding education to improve breastfeeding efficacy and exclusive breastfeeding.

Table . 1. Characteristics of Respondents Based on Age, Parity, Pregnancy Distance, Education and Occupation in Remote Areas Of Enggano Island in 2023 (n=50)
. Data analysis was carried out univariate to see the characteristics of the respondents, bivariate with wilcoxon test and multivariate with spearman rank with software SPPS version 23.This research has received an ethical review letter from the Ethics Commission of the Poltekkes Kemenkes Bengkulu, number No.KEPK.BKL/112/03/2023.

Table 4 . Influence of Small Group Education, Age, Parity, Gestational Age, Education And Occupation on Breastfeeding Efficacy in Remote Areas of Enggano Island
*Spearman Rank Test