Online Mother Support Group: The New Way of Peer Support for Improving Breastfeeding Performance

Background: Data from Riskesdas in 2010 showed that family living in the urban area still had lower rate of exclusive breastfeeding, specifically 25.2% compare to those living in the rural area. In Jakarta, the proportion of children aged 0-23 months that still being breastfed was only 70.3%, this rate was below the national level of children age 0-23 months that still being breastfed which reach 80.1%. This study aimed to explore the experiences of mothers attending online Mother Support Group as their breastfeeding support. Methods: Qualitative approach was used to explore mothers’ breastfeeding performance and mothers’ experience attending the online group. Key findings show the mothers in the group exposure received support and knowledge from other mother or peers. Type of support given to the mother by both peers and experts (professionals) can be in the form of support group and given in online form. Results: There were also mothers experienced overwhelmed with the information that circulate. This kind of mothers considered that they better learning with individual setting to be more focus or conduct only virtual meeting Conclusion: Good performance on breastfeeding among mothers’ can be maintained by their experiences of group that allow mothers learn in conducive environment and/or solved mothers’ breastfeeding problem.

of people to do the learning process which is related to their best in performing the behavior. Among the people tested during the decades, 13% learn best alone, another 28% learn best with teacher, while more than a quarter learn best with peers in groups. Once the style of learning process were known, it can be matched with the intervention strategy or environment to which each style is most responsive (K. J. Dunn & Dunn, 1979;R. Dunn, 2001). Based on those learning styles differences, there is an intervention to promote breastfeeding practice by individual or one-on-one consultation with peer or professional that involving breastfeeding counselor or lactation consultant. Aside from individual consultation by peer counselor, it also can be conducted in the form of Mother Support Group (MSG) both online or offline group. This study aimed to explore the experiences of mothers attending online Mother Support Group as their breastfeeding support.

METHOD
The study was conducted in DKI Jakarta as a qualitative study after receiving an approval from the Ethical Committee Faculty of Medicine, University of Indonesia. The inclusion criteria for breastfeeding mothers were at the reproductive age (15-49 years old) who have children aged 6-23 months. This study explored breastfeeding support, i.e. Mother Support Group (KP Ibu) online group and mailing list called online group exposure. Online group exposure was the group which consists of mothers who receive breastfeeding support in the group model, such as peer support group (kelompok sebaya), mailing list or other support in the group basis. Data quality assurance was obtained by pursuing the variations on the type of exposure apart of the variation on demographic characteristics among mothers. The respondents were 10 breastfeeding mother and a lactation consultant as the key informant for triangulation. The variation on the type of demographic characteristics were also included in order to provide variation results. The data collected using in-depth interview and observation. The observations conducted at two mailing lists (asiforbaby and milist SEHAT). During the observation, the researcher observed the in-

BACKGROUND
The WHO recommendation for proper breastfeeding practice mention, to achieve optimal growth, development and health, infant should receive breastmilk immediately within one hour of birth and exclusively breastfed until six months of age. They need adequate, nutritious and safe complementary foods after they reach the age of six months and breastfeeding is continued until they are two years old. Data from Riskesdas 2010 showed that family living in the urban area still had lower rate of exclusive breastfeeding specifically 25.2% than those living in the rural area. In Jakarta, the proportion of children aged 0-23 months that still being breastfed was only 70.3%, this rate was below the national level of children age 0-23 months that still being breastfed, which reach 80.1%. The success in applying the recommendation is influenced by many factors. Hector et al. (2001) explained the categories of factors affecting breastfeeding practice which are individual level factor, group level factor and societal level factor.
Based on Hector's model, many interventions are established involving varied subject's characteristics and different scope of intervention. In the South Asia, the main intervention for mother is Information, Education and Communication (IEC) in the form of mass media campaign and one-to-one counseling (The World Breastfeeding Conference, 2012). Whereas in Indonesia, although limited, government interventions to educate mothers are integrated in the Mother and Child Health (MCH) program consisted of Mother Class (Kelas Ibu), Antenatal Care and Integrated Health Post (Posyandu) (Kemenkes, 2011). From the government programs, there are also some organizations which have concern on breastfeeding support by providing Breastfeeding Counselors to help mothers in individual consultation such as AIMI-ASI (Asosiasi Ibu Menyusui Indonesia), SELASI (Sentra Laktasi Indonesia), IKMI (Ikatan Konselor Menyusui Indonesia), etc.
One thing that should be remembered that breastfeeding is a learning process. A theory of learning styles by Dunn (2001) explained that there are differences in preference teraction among members and the environment during session. To minimize bias, the researcher conducted preliminary analysis after every the interview to get the variation of the next informant. After all the transcript of in-depth interview are coded, inductive content analysis was conducted by generated categories from the codes (Burnard, 1994). Another possibility of bias was social desirability bias (Nankunda, Tumwine, Nankabirwa, & Tylleskär, 2010). As the mothers in this study were exposed to the information on breastfeeding recommendation, some mothers might have felt required to provide 'right' or 'socially acceptable' answer. To reduce this bias, the interviewer allowed mother answer freely and not prompting them for any answers by provides neutral expression for every answer.

Characteristics of Online Group Exposure
The online group exposure that included in this study conducted with virtual meeting. Groups with virtual meeting were included mailing list (The Urban Mama, asiforbaby and milist SEHAT) and internet based messenger group (WhatsApp messenger and Blackberry Messenger). Those group can also be categorized based on the structure inside group whether the groups were had regular scheduled meeting or not, had a leader or administrator that may also had strict regulation or not and has a specific discussion in each meeting or forum

Characteristics of informant
There were 10 mothers participated in this study from the two exposures. Characteristics of the respondents are presented in table 1. The proportion of mothers' age were similar, more than half of mothers were in the age of 21-30 years. The proportion of mothers with primary education and high education were equal.
For family type, more than half of the mothers lived with other relatives as extended family. All mothers in are mostly having their first child.
Income of the family may vary, but half of mothers had family income less than 5,000,000 IDR. For mothers' occupation, more than half of mothers were non-working mother. 8 out of 10 Family Income < 5,000,000 IDR 5 out of 10 5,000,000 -10,000,000 IDR 2 out of 10 10,000,000 -15,000,000 IDR 1 out of 10 > 15,000,000 IDR 2 out of 10 Mother Occupation Working 4 out of 10 Non-working 6 out of 10

Mothers' experiences
Four themes related to the experience of mothers during following online group support. Those three themes are (1) What mothers do; (2) Why mothers come; (3) Added value; and (4) Unfavorable experiences Theme 1: What mothers do?
There were two types of mother support group that commonly found in DKI Jakarta, the first type is direct meeting groups which usually have routine direct meeting and the second is virtual meeting through media mailing list or through internet based messenger such as WhatsApp messenger group or Blackberry Messenger group. Both in the direct group and virtual group, mothers were gathering in the group they joined and talking each other during meeting.
"…we all gathered at the post every week talking about many things especially breastfeeding issues…" (Mother joined group, aged 35) Theme 2: Why mother come?
In online group, mother intended to join because they need the information about mother's health and child care. There were also mothers that willing to know others' experiences on breastfeeding or child caring.
"…after I knew that I was pregnant, I started to looking for the information about spotting and delivery preparation, then I met with The Urban Mama mailing list…" (Mother of one son, aged 26) There were also mothers that joined benefited by other mothers' experiences about breastfeeding. "…there is other mother who give tips on expressed breastmilk and share her experiences when having same problem…" (Working mother that join mailing list, aged 32) One mother joined mailing list explain that she in addition of breastfeeding and health information, she also got information about household living.
"…there were a lot of information too, there were financial planner, cooking recipe, and household tips such as children school choices, health and life insurances, how to manage family finance etc…" (Mother with one son, aged 26)

Theme 3: Added values for mothers
Mothers that joining groups felt they gain much of information from it.
"…I learned a lot from it, all of my knowledge were from those mailing list, valid information from doctors and also useful information from other smart parents…" (Mother with two children, aged 31) Besides the useful information, mothers also felt that they were getting socialized with others and it helped them because they can encouraging each other emotionally.
"…I usually shared what I felt and worry, and then the other members of the groups sometimes gave me compliments and it encourage me…" One mothers noted after joining group, she start to give more understanding to other mothers and stop judging. Those mothers were try to understand the reason behind the decision on feeding practice of other mothers.
"…sometimes when other mom giving formula-feeding, I can understand that she had reason, I stop judging her and start respecting her instead…" (Mother of 1 children joined mailing list, aged 32) Some mothers joined group felt that it easy to access the group exposures because it available anytime especially the virtual meeting groups. It accessible through mailing list, What-sApp messenger or BlackBerry messenger.
"…joining group were easier for me, because if I do individual consultation, I have to pay while the group was available freely for me, besides the groups place to gather were near from my home, so it's comfortable for me to take my child with me during meeting…" (Mother joined groups, aged 37)

Theme 4: Perceived unfavorable experiences
Some mothers also felt overwhelmed with information especially from the mailing list, because there were a lot of information shared by other member of the groups.
"…well…I felt it was abundant information given, it's just overload for me…" (Mother with one son, aged 32) As observed in the SEHAT mailing list and Asiforbaby mailing list, the information were sent to their e-mail address more than once in a day and sometimes mothers had no time to read one by one. To manage it, some mothers just picked what information that they may needed.
There was also mother felt that one of the disadvantages in joining group was it tended to deviate from main objectives and time consuming.
"…the groups will only waste my time if it drifted away from its purpose, then it became less beneficial for me …" (Working mother, aged 41, joining groups and attending individual consultation)

Discussion
What mothers felt beneficial on attending the support were the information that being shared. In the online group exposure, information about mother's health and child care including breastfeeding practice was shared to mothers. This finding reflects that the educating mothers is one of the most effective intervention for increasing mothers' knowledge (Guise et al., 2003).
A systematic review by Shakya (2017) review highlighted four major findings on the effectiveness of communitybased peer support for mothers on their breastfeeding practices. First, community-based peer support for mothers can improve Exclusive Breastfeeding (EBF) duration. Moreover, mothers in Low Middle Income Countries (LMICs) continued EBF for a longer period than mothers in highincome countries. Second, such interventions can improve breastfeeding initiation within the first hour of life in LMICs. Finally, community based peer support can reduce prelacteal feeding in LMICs Aside information sharing, in the online group exposure, mothers also get benefit from knowing the other mothers' experiences because they get socialized with peer that may ever experience some breastfeeding problems or already managed the phase of child feeding. There was study explain that other mothers was being preferred resource for new mothers' concerns about child caring and gathering with peers can also decreased psychological distress, particularly symptoms of depression, anxiety and anger (Kumakech, Cantor-Graae, Maling, & Bajunirwe, 2009).
The group ambiance also let mothers to give encouragement to other mothers and not to being judgmental for other mothers feeding decision. This finding reveals that in the group, the leader, administrator (for mailing list) and the members should create a specific effort to make everyone feel comfortable in the group and encourage positive spirit. The group should deliver a reliable ambiance, sense of respect, distribute of information, obtainability of useful help and emotional circumstances. If the group failed to maintain the supportive ambiance, mothers or members would feel unfavorable because the main objectives of group was deviated and mothers felt they just wasted their time during session and less motivated.
Breastfeeding peer support can build social capital using a synergy of bonding, bridging and linking with community members. Horizontal and vertical relationships between individuals, communities and across public, private and statutory sectors can help to embed peer support into care pathways, may help to promote positive attitudes to breastfeeding and maximize reach for breastfeeding support across the community (Thomson, 2015) There were also mothers overwhelmed with the information that circulate. This kind of mothers considered that they better learning with individual setting to be more focus or conduct only virtual meeting. This result revealed that learning styles theory determined the way mothers comfort to receive information related to breastfeeding. There is conducive situation that needed for perform best in learning process as explained by Dunn (2001). Furthermore, they got helps for treating their breastfeeding problem from professional. In this study, most mothers met hospital-based counselor. As the literature mention that hospital based counselor is providing any counseling or behavioral interventions to improve breastfeeding outcomes, such as helping to manage lactation crisis (Riordan & Wambach, 1993). There were significant increases in breastfeeding knowledge after training; however, some areasshowed larger changes than others. Larger increas in knowledge levels were found in relation to knowledge of growth patterns, the use of glucose water and the management of sore nipples. The increased knowledge of growth patterns in the current study was reflected in an improvement in three separate items on infant growth. (Kempeenar, 2011). Breastfeeding peer supporters across the region; a strategy recognised as effective in the support of initiation and maintenance of breastfeeding (Johnson, 2017). Peer support was strongly associated with the postnatal period. The combination of professional support and peer support by trained and experienced peer supporters was effective in ensuring the continuation of breastfeeding. Only continuous breastfeeding support produces effective results. Diverse types of interventions are needed during different phases of motherhood. The role of peer support is most important during the postnatal period. If professional support is not available for mothers, peer support could provide an alternative worth considering (Kaunonen, 2012).
Online group exposure was easier to be access in term of affordability and availability. It can be reached with virtual meeting, and the membership of the exposure were commonly free especially for mailing list membership. This finding was also explored in a study that resulting that group exposure was relate to a costeffective, easy modified method and socially proficient way to promote and support breastfeeding for women especially where professional breastfeeding support is not widely available (Chapman, Damio, & Pérez-Escamilla, 2004).

CONCLUSION
Online group exposures are beneficial for mothers by educating mothers for recommended breastfeeding practice. Having proper group ambiance, mother can share experiences on breastfeeding and encouraging each other.