Father’s Role on the Exclusive Breastfeeding

Background: Breastfeeding is a difficult time for a mother. A mother hopes that she can fully breastfeed in the first 6 months of her baby's life. But unfortunately, breastfeeding mothers often face various problems in baby care which result in disruption of breastfeeding such as stress due to not being adapted to being a mother, or due to pressure from the surrounding environment. The role of a partner is very important in helping mothers deal with problems that may arise. Father's support can help mothers, especially in their coping, in dealing with stress that may arise when breastfeeding. Purpose: The purpose of this study was to determine the father's role during the breastfeeding period to achieve the success of exclusive breastfeeding. Methods: This research method used a cross-sectional design which was carried out in Bangka Belitung Islands Province. The study was conducted on 35 married couples who have babies between 6 months to 1 year old. The aspects of the father's support that were assessed were financial, emotional, and physical. Quantitative data were analyzed using an independent t-test, while qualitative data were analyzed using chi-square. Results: The results of statistical analysis showed that there was no significant relationship between financial support (p = 0.372), emotional support (p = 0.166), and physical support (p = 0.227) on the success of exclusive breastfeeding. Although there is a close relationship if the three aspects are given together without reducing one aspect of support (p = 0.009). Conclusion: This shows that the father's support must include all three aspects, both financial, emotional, and physical to determine the success of exclusive breastfeeding.


BACKGROUND
To reduce child morbidity and mortality, the United Nations Children Fund (UNICEF) and the World Health Organization (WHO) recommend giving only breast milk (ASI) to children for at least 6 months. Starting in 2003, the Indonesian government changed the recommendation for exclusive breastfeeding from 4 months to 6 months (Kementerian Kesehatan RI, 2014) Bangka Tengah is a district in the Kepulauan Bangka Belitung Province which has the lowest exclusive breastfeeding coverage (41.9%) (Dinas Kesehatan Provinsi Kepulauan Bangka Belitung, 2019). Although overall Bangka Belitung has quite high exclusive breastfeeding coverage (80.48%), exclusive breastfeeding coverage in Central Bangka has not yet reached the 2019 Rentra target of 50% (Kementerian Kesehatan Republik Indonesia, 2020). This is of course a special concern to find any possible causes that may cause breastfeeding mothers in Central Bangka to stop breastfeeding before the baby is 6 months old. One of the factors that can influence the success of exclusive breastfeeding is the existence of social support around the mother. The person who is considered the most instrumental in providing support is the partner, in this case, the mother's husband (Rempel, Rempel, & Moore, 2017). Breastfeeding is a mother's job, but research has shown that the father of the baby has a significant influence on a mother's decision in the breastfeeding process. Mothers who have husbands who support them positively to breastfeed have higher success in breastfeeding (Vaaler, Castrucci, Parks, Clark, Stagg, & Erickson, 2011). The influence of the husband which is considered to influence the success of breastfeeding can be in the form of financial, emotional and physical support

OBJECTIVE
The purpose of this study was to determine the father's role during the breastfeeding period to achieve the success of exclusive breastfeeding

METHODS
This study used a cross-sectional research design located in Bangka Belitung Islands Province. The population in this study were all mothers who had babies between 6 months and 1 year of age. The sampling technique used was purposive sampling and obtained a total of 35 married couples with the inclusion criteria: full-term babies and no congenital abnormalities found with a history of vaginal delivery. The questionnaire contains questions about mother and father characteristics, parity, father's support (financial, emotional, and physical), and exclusive breastfeeding. This research has been declared ethical by the health research ethics committee of the Poltekkes Kemenkes Pangkalpinang with number 14a/EC/KEPK-PKP/VII/2019. All mothers agreed to participate in this research by signing an informed consent sheet. Independent variables in the form of partner characteristics (age and education) and maternal parity were then analyzed statistically using the SPSS program for their relationship with the dependent variable, exclusive breastfeeding. Quantitative data were analyzed using an independent t-test, while qualitative data were analyzed using chi-square. Based on table 1, it is known that the average age of mothers who became respondents was 27.4 years, father's age was 29.4 years, most mothers and fathers had basic education (82.9%) and slightly more mothers with primiparous (51.4 %) than multiparous mothers (48.5%).

RESULTS
More respondents gave exclusive breastfeeding to their babies (68.6%) than those who did not (31.4%). The mean age of mothers who exclusively breastfed was slightly higher (27.83 ± 4.22 years) than those who did not (26.45 ± 4.41 years). The mean age of the father was also slightly higher in infants who were exclusively breastfed (29.96 ± 4.10 years) than those who were not (28.18 ± 4.24 years).
Judging from the mother's education, both those who provide exclusive breastfeeding and those who do not, are dominated by basic education. The same is seen in the father's education. The majority of mothers and fathers who either received primary or advanced education still provide exclusive breastfeeding for their babies. From the perspective of maternal parity, it can also be seen that both mothers who have one or more children, the majority give breast milk exclusively to their babies. From the statistical assessment, it can be seen that none of the characteristics have a significant relationship with exclusive breastfeeding (all variables have p> 0.05) so that it can be concluded that statistically, the partners who are respondents in this study are homogeneous. Based on table 2 it can be seen that quantitatively, the majority of fathers provide support from a financial (88.6%), emotional (85.7%), and physical (91.4%) perspective. The majority of fathers also provide support for the three of them at the same time, be it financial, emotional, or physical (68.6%).
The results of the statistical analysis show that there is no relationship between financial support (p=0,372), emotional support (p=0,166), and physical support (p=0,227) to the success of exclusive breastfeeding. Although when these supports are given at once without compromising a single aspect of support it can affect the success of exclusive breastfeeding (p=0,009). On the financial aspect, most of the mothers who became respondents received support from their partners. However, when compared to exclusive breastfeeding, even though most mothers who received this support provided exclusive breastfeeding, the number of mothers who were not supported was not much different. The same incident also occurred in the aspects of emotional and physical support. This is supported by the results of statistical analysis which show that p>0.05 in these three aspects, which means that they do not have a significant relationship to the success of exclusive breastfeeding. A different incident occurred when the assessment was carried out where it was required that a mother had all three supports without missing any aspect to be called a recipient of support. Out of 35 couples, only 24 meet these requirements. It can be seen that there was a reduction in the number of mothers who received support compared to the three aspects of support when assessed separately previously. However, when the statistical test was carried out, this support had a significant relationship with the success of exclusive breastfeeding. This shows that these three aspects must be given simultaneously to be able to influence the success of exclusive breastfeeding

DISCUSSION
Surveys in previous studies have shown that the father of the baby or husband wants to be involved in the breastfeeding process. They want to be given advice that can help them how to help their partner who is breastfeeding even though it has not been researched to what extent the specific advice is intended (Brown & Davies, 2014). Several other studies that used a qualitative design have identified what is seen as ways fathers can support breastfeeding. Fathers can help wash the baby, change diapers and do some household chores (Ingram & Johnson, 2014). Fathers can also support the breastfeeding process by doing household chores, offering emotional support and suggesting and providing support for breastfeeding in public (Sherriff, Hall, & Pickin, 2009). Mothers in Australia also added that fathers can share the burden of being a new parent, investigate and learn about breastfeeding, provide advice on breastfeeding techniques, assist mothers in relaxation while breastfeeding, praise and encourage mothers for their efforts during breastfeeding and become a breastfeeding policymaker. in family and healthcare professionals (Tohotoa, Maycock, Hauck, Howat, Burns, & Binns, 2009). Other studies have also suggested further that fathers can support by sitting with the mother during the breastfeeding process and being aware of the amount of work the mother needs in breastfeeding (Nickerson, Sykes, & Fung, 2012) From these results, it can be seen that although it has been proven from previous research that the role of the father is important in the process of breastfeeding mothers, it is not known which role has the most important influence (Rempel, Rempel, & Moore, 2017). In this study, there was no significant relationship between financial support (p = 0.372), emotional support (p = 0.166) and physical support (p = 0.227) on the success of exclusive breastfeeding. Although there is a close relationship if the three aspects are given together without reducing one aspect of support (p = 0.009). From the results of this study, it can be seen that father's support must include financial, emotional and physical aspects to be able to support the success of exclusive breastfeeding. When support is only provided in one aspect, it is not sufficient to support exclusive breastfeeding. Basically, the financial, emotional and physical aspects should be given to a mother as a form of support during breastfeeding. Financial support although it is important to ensure the fulfillment of the mother's daily necessities is not entirely a factor in determining the success of breastfeeding. Mothers who receive financial support but are not physically assisted such as doing household chores can make the mother exhausted which affects breast milk production. Mothers need to rest and eat enough to be able to breastfeed smoothly. This of course becomes difficult when the mother's obligation to take care of the house is not helped by her partner. The same thing happens when the mother does not receive emotional support even though her needs are met financially and physically. Stress greatly affects milk production. Mothers who receive psychological support from their father will have better coping in dealing with stress than those who do not. This becomes even more important when it occurs in primiparous mothers, where all the things they face when they start breastfeeding are new things they have never experienced which of course make it easier for them to experience stress. Although father's support has been shown to have a positive influence from several previous studies as well as in this study, this is still a contradiction. Paradoxes in father's support for breastfeeding have been found in previous studies (Rempel, Rempel, & Moore, 2017;Holt-Lunstad & Layton, 2010;Uchino, Bowen, Carlisle, & Birmingham, 2012;and Ito, Fujiwara, & Barr, 2013). In Rempel, Rempel, & Moore's (2017) study, for example, a shorter period of breastfeeding was found in fathers who wanted their partners to breastfeed longer and express appreciation for breastfeeding, were very informed and invested in breastfeeding, and were present during the breastfeeding process. This may be due to fathers starting to improve their behavior to help when the mother has started to show problems and plans to stop breastfeeding. Of course, a sensitive father will become more actively involved when his partner starts having problems. Several other studies have also shown that not all failures of exclusive breastfeeding are a consequence of health conditions that lead to increased support. Instead, several studies have shown that social support provided may lead to reduced maternal confidence, autonomy and control which symbolizes the ability of mothers as mothers (Martire, Stephens, Druley, & Wojno, 2002). It is further stated that a mother shows a positive response to breastfeeding if it is given indirect rather than direct support. This may be because the support given keeps the mother able to maintain her confidence in breastfeeding her baby (Bolger, Zuckerman, & Kessler, 2000) (Bolger & Amarel, 2007) (Stewart, Jeanne, & Fisher, 2012) Breastfeeding mothers should of course be in a calm state and a happy mood. Stressed mothers will cause disturbances in their milk production which will affect the ongoing breastfeeding process. The husband's support is needed to make mothers happy and not stressed (Kementerian Kesehatan RI, 2014). When the mother only receives support both financially, emotionally and physically, this does not affect the mother in breastfeeding. This may be since all three forms of support must be given simultaneously to significantly influence the mother's breastfeeding process. When the mother does not get all three or only gets one of the three, this does not make a significant difference to the success of exclusive breastfeeding.

CONCLUSION
Based on the results of this study, it can be concluded that the father is proven to have a significant role in the success of exclusive breastfeeding, although statistically, it does not show any particular support that has the most influence on the process. Father's support must cover all three aspects, both financial, emotional and physical to determine the success of exclusive breastfeeding. When the mother does not get all three or only one aspect of support, it does not have a significant effect on the breastfeeding process.

ACKNOWLEDGMENTS
The author would like to thank the Poltekkes Kemenkes Pangkalpinang for facilitating the author in terms of administration and thanks to all residents of Tanjung Gunung village along with community leaders and health workers who work in the area.