Mal J Nutr 25(1): 117-128, 2019 Breastfeeding knowledge among indigenous Temiar women: a qualitative study

Sharifah Zahhura Syed Abdullah1* & Rozieyati Mohamed Saleh2

1Centre for Research on Women and Gender (KANITA), Universiti Sains , Pulau Pinang, Malaysia; 2Biomedical Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

ABSTRACT

Introduction: The benefits of breastfeeding for both mothers and infants are widely recognised. Breastfeeding confirms a woman’s unique ability to care for her infant in the best way possible and promotes optimum infant and maternal health. Methods: A qualitative research method involving five focus group discussions (n=33) was chosen in this study to compare and contrast the breastfeeding practice in two different locations: the communities of Pos Pulat and the regroupment scheme settlement at Rancangan Pengumpulan Semula (RPS) Kuala Betis in Kelantan, Malaysia which represents different lifestyle experiences of indigenous Temiar population. Results: The benefits of breastfeeding to the infants reported by some Temiar women (42.4%) were for the infant’s health and growth. Responses from urban RPS Kuala Betis women include breast milk contains antibodies (3.0%), delays in the return of regular ovulation (6.1%), thus lengthening birth intervals and bonding between maternal-baby (6.1%). In general, respondents from Pos Pulat seemed to have little knowledge regarding this issue, except for a woman who mentioned that maternal milk contains vitamins. Based on the narrative analysis, knowledge gap was observed between these two communities. Conclusion: Although all the women interviewed had the experience of breastfeeding their infants, most of them lacked the knowledge regarding the benefits of the breastfeeding either to the infants or to the mothers. The findings from this study are crucial for the preservation of breastfeeding culture among the Temiar women and can be used to improve promotion of breastfeeding to other groups in Malaysia.

Keywords: Breastfeeding, knowledge, health, indigenous, qualitative

INTRODUCTION (Habibah, Hamzah & Mushrifah 2010) because they exist on the fringes of The Malay term Orang Asli that highly developed areas. The Orang Asli translates as “original people” or “first is generally classified under three main people” is the term given to indigenous groups: Negrito, and Proto Malay, people (Masron, Masami & Ismail, with each group comprising six sub- 2013). Anthropologists, economists groups with ethno-linguistic differences. and planners describe the livelihoods The Temiar is one of the sub-ethnic of these as “poor groups of the Senoi people that can be and marginalised minority groups” found in the highest interior mountains ______*Corresponding author: Dr Sharifah Zahhura Syed Abdullah Centre for Research on Women and Gender (KANITA), Universiti Sains Malaysia, Pulau Pinang, Malaysia Tel: +6019-2322355; Fax: +604-6566379; E-mail: [email protected] doi: https://doi.org/10.31246/mjn-2018-0103 118 Sharifah Zahhura SA, Rozieyati MS and at the headwaters of various rivers to be dropping among the former while with limited access to civilisation remaining stable in rich mothers. (Domhoff, 2003). Nowadays, although The protection of breastfeeding in the most still live a traditional life, others world’s poorest populations is therefore have moved out of the forest to settle a major priority. They also emphasised in more accessible locales. Some live in the importance of breastfeeding for all villages while others have migrated to women and children, irrespective of their towns and cities. They live by various economic background. combinations of swidden farming (‘slash As most mothers are able to and burn’ agriculture and crop rotation), breastfeed, they should be provided hunting, gathering, fishing, and trading with accurate information and support forest products. More recently, some from their families, communities, men have started to undertake waged and healthcare providers. Currently, employment as day labourers. A few have only limited data is available on the successfully become lawyers, teachers, breastfeeding practices among the doctors or government employees. Orang Asli Senoi, and particularly for The World Health Organization the Temiar sub-group. An earlier study (WHO) recommends that all infants be conducted among 189 Semai women exclusively breastfed from birth until six (other sub-ethnics of Senoi) found that months of age and it be continued until the mean breastfeeding duration was up two years of age or longer along with to 23 months (Khor, 1985). A study done complementary foods (WHO, 2001). In a decade later found that although 95% the first six months of life breast milk of Semai women had breastfed their should be an infant’s sole and optimal infants, the average duration was found source of nutrition as it is superior to to be reduced to 17.9 months (Osman & all supplementations. The International Zaleha, 1995). Similar study conducted Convention on the Rights of the Child on another Senoi sub-ethnic (the Mah 1990 endorsed by the United Nations, in Meri group) revealed that the mean Article 24, has recognised breastfeeding period of breastfeeding was calculated as one of the child’s right (United Nation, to be around 11 months, although all 1990). Breastfeeding within the first one the mothers in the study had started hour of life has been shown to reduce lactation within one hour of delivery neonatal mortality by almost 22% (Wan Norlida et al., 2007). (Edmond et al., 2006; Debes et al., 2013; Many studies have utilised NEOVITA Study Group, 2016). quantitative methods such as A systematic review by Victora et knowledge, attitude and perception al. (2016) indicates that there are no questionnaires to gain information on differences between rich and poor breastfeeding. However, in recent years, mothers in exclusive breastfeeding rates, the use of qualitative methods such as in low and middle-income countries. interviews and focus group discussions They suggested that this was because has gained recognition in providing a rich mothers are adopting exclusive better understanding of the feelings breastfeeding at a much faster rate of individuals, their perceptions and than are poor mothers, although only misconceptions regarding breastfeeding 20 years ago, the poorer mothers had information and issues (Tengku Alina substantially higher rates of exclusive et al., 2012). Furthermore, underlying breastfeeding. Continued breastfeeding beliefs are better captured through this is still more common in poor than in type of qualitative studies (Rashidian, wealthy mothers, but the rates seem Eccles & Russell, 2008). In view of Breastfeeding knowledge among indigenous Temiar women 119 this, this study aimed to investigate potential participants. Each contact the knowledge among Temiar mothers person was a local person who was active regarding the breastfeeding practices in within or had connections to the Temiar their cultural context. community in that location. They knew of the best means to approach the target MATERIALS AND METHODS population and of any possible obstacles that might occur. The inclusion criteria This was an exploratory investigation were women of any age group who had conducted in 2015, using qualitative breastfed a child in each location. Those methods via five focus group discussions. who willingly consented to the study The two different locations chosen for this were enrolled and the times for focus project represented the different lifestyle group discussions were arranged. experiences and practices of the Temiar. Focus group discussion was selected The communities of Pos Pulat in Kelantan as a suitable method for this project in (a state that is located in the north-east order to gain in-depth understanding on of ) represent the a specific topic of interest (Nyumba et experiences of Temiar who live in the al., 2018). In this instance, focus group forest or close to it, approximately 2 km discussions helped to reveal the benefits away. On the contrary, the communities of breastfeeding through active and live in the Rancangan Pengumpulan Semula discussion between the participants and (RPS) regroupment settlement scheme, a trained facilitator. An “ice-breaker” located in Kuala Betis in Gua Musang, or introduction was conducted before Kelantan, represented those in transition commencing each discussion session to from forest to urban living. create a friendly environment. Firstly, The participants in the project the facilitator introduced herself and were women in the various households broadly outlined the aims of the research who were responsible for feeding the and the protocols. The participants then infants. An appropriate sample size for a introduced themselves and were asked qualitative study is one that adequately to respond to the first question from answers the research question. In the focus group schedule. According to practice, the number of required Peterson & Barron (2007), encouraging subjects usually becomes obvious as participants to become involved in an the study progresses, as new categories, interactive, open discussion is one of themes or explanations stop emerging the major challenges for the focus group from the data (i.e. having achieved data facilitator. saturation) (Marshall 1996). Focus group discussions in Pos Pulat In each location, participants were took place on a veranda of the home of identified using a snowball approach. one of the participants, while in RPS This sampling technique was chosen by Kuala Betis it was conducted in the taking into consideration the shyness childcare centre (Taska) during weekend. and sensitivity of indigenous people. The All focus group discussions took place in Temiar were best approached by people a familiar comfortable environments in that they already knew or familiar with order to motivate participants, with the rather than by outsiders or strangers. hope that the best possible responses First, the local staff of the Department could be obtained. of Orang Asli Development (JAKOA) and The questions for focus groups were Tok Batin were contacted. The researcher developed to ensure consistency in explained the research project to the responses according to project themes contact person and asked to identify while allowing for flexibility of later 120 Sharifah Zahhura SA, Rozieyati MS interpretations. They were also designed decision of mothers to breastfeed their to be culturally compatible and general babies and the expectation of Temiar rather than personally probing in nature. women pertaining to breastfeeding issue. Research was conducted in ways that Below are summaries of responses from were appropriate for Orang Asli Temiar. It women in both locations for each of these is important that participants felt at ease themes. Where relevant, some excerpts and not threatened by the researcher are provided to illustrate the responses or the data-collection instruments. and reflect the way of thinking of these The focus group discussions started women. with a general discussion about the demographic profiling, followed by a Perception of the benefits of discussion on benefits of breastfeeding breastfeeding to the infants to both baby and mother, their decision The perceived benefits of breastfeeding to breastfeed the baby and the women’s to the infants reported by some of the expectation regarding breastfeeding Temiar women in Pos Pulat and RPS practices. Kuala Betis included the protection There were five focus group against a variety of infections as well discussions, of which two groups were as for infant health and growth. Below conducted in Pos Pulat (n=12) and three are some excerpts of the responses from (n=21) groups took place in RPS Kuala women in both locations: Betis. Each focus group discussions “For example the infection of disease took about 45 minutes to one hour to was lesser... sometimes if the baby complete. All participants were given false suck on breastmilk (sic), the occurrence names for anonymity. Narrative analysis of diarrhoea is less...” (Along, 36 was done after every recording. All focus years old, RPS Kuala Betis). group discussions were audio-taped “Healthy… for baby’s health” and video recorded (with permission) to (Saadiah, 32 years old, RPS Kuala allow the facilitator to focus on the group Betis). responses and non-verbal behaviour and “If we give milk such as formula milk these were then transcribed from oral there will be problem of diarrhoea... recordings to written text. The aim was but if we give breastmilk, if we for participants to ignore the recording so really do that, the baby will be fine” the interaction would be natural. All the (Halimah, 45 years old, RPS Kuala transcripts were coded and categorised Betis). as either a main or sub category and “For the baby’s health... he will grow then ‘thematised’ using the software healthily. He will become clever” package for handling qualitative data, (Anum, 25 years old, Pos Pulat). NVivo 10. The protocol of this study has One woman from RPS Kuala Betis been approved by the Human Research even mentioned that breast milk contains Ethics Committee of the Universiti Sains antibodies to fight diseases. Another Malaysia (approval code FWA Reg. No.: woman from Pos Pulat also stated that 00007718; IRB Reg. No.: IRB00004494). mother’s milk was the best food for the baby as it contained vitamins. She RESULTS further added that she obtained the information from a pamphlet found at Four key themes emerged from the the hospital. analyses of this study. These were the The practice of discarding colostrum perception of benefits of breastfeeding was also discussed. The women from to the infants and to the mothers, the both locations were also asked whether Breastfeeding knowledge among indigenous Temiar women 121 they provide the first milk or colostrum babies when they realised that they were to the baby. Most women from RPS Kuala pregnant. Kinah from Pos Pulat said Betis mentioned that they had given that “for example myself… aahhh… for colostrum to their babies. In contrast, me if someone… for example myself… if mothers from Pos Pulat agreed that I am pregnant, when I deliver the baby… colostrum needed to be discarded and of course I will give breast milk... my own thus revealed their limited knowledge milk…. and no formula…”. about its nutritious and anti-infective A woman from RPS Kuala Betis said properties. They believed that it was dirty “I feel that when breast milk is given, and contained bacteria. Nevertheless, the affection between us and the baby some of the women from Pos Pulat is more”. Another woman added “this did mention that they will discard the is how our mother did for us... their colostrum when they gave birth at home, sacrifices… how a mother scarifies... but gave it to the baby if the delivery was now we feel it”. This was supported by at a hospital. another woman from RPS Kuala Betis who mentioned that she herself decided Perception of the benefits of to give breast milk “when the baby was breastfeeding to the mothers born, immediately start to breastfeed, it The women in the two locations responded is compulsory, to give breast milk”. differently when asked regarding benefits of breastfeeding to mothers. The women Expectations regarding breastfeeding in RPS Kuala Betis spoke of the various The majority of the mothers in Pos advantages. One woman mentioned the Pulat revealed that information about delay in the return of regular ovulation, breastfeeding and infant formula was thus lengthening birth intervals as one rarely provided by their obstetricians of the benefits. Another woman said that during prenatal visits. One respondent “it was much easier to breastfeed the expressed the hope that health baby compared to bottle feeding since practitioners would give them some it was not necessary to boil the water, information regarding breastfeeding because cleanliness was guaranteed besides conducting vaccinations or with mother’s milk”. This view was also routine check-ups: supported by another woman who stated “If it is okay we want the health people that “moreover, we think why we need to to come to give talk, talk regarding pay for something that is already there? breastfeeding… because we only No need to buy bottle (formula) milk, no know how to give breast milk but we need to think. God has given everything have no idea what the milk is good complete in our body”. for… we know it is to cease hunger, to On the contrary, most of the women make the baby feels full and to make in Pos Pulat had no idea when asked them healthy... and that’s all… other about the benefits of breastfeeding to than that we do not know…” (Kinah, mothers. Only one woman responded 33 years old, Pos Pulat). that breastfeeding is to strengthen the bond between the mother and baby. DISCUSSION It has been well documented that the Decision to breastfeed general health of the indigenous people When the women were asked regarding is disproportionately lower than that of their decision to breastfeed the baby, all other communities. Although Orang Asli of the women from both locations stated in Malaysia comprise only 0.6% of the that they choose to breastfeed their 122 Sharifah Zahhura SA, Rozieyati MS total Malaysian population (Tan, 2016), negative impact. Since it is far-fetched they lag behind in almost all socio- to expect this rural community to gain economic indicators (Nicholas, 2007). online information, they are dependent Numerous studies in Malaysia have on support programmes such as health reported these health inequalities. The talks, discussions, pamphlets and Orang Asli, inter alia, have high infant hardcopy materials. Indigenous people mortality rates and lower life expectancy are known to have low self-esteem and compared to the national standards. are shy and timid (Louth, 2012). As Compared with other communities, such, it is very unlikely that they will they are more malnourished and have a initiate any discussion and enquiries, higher prevalence of persistent infectious despite their curiosity and eagerness to diseases such as malaria, tuberculosis learn. Gaps in breastfeeding knowledge and skin diseases (Nicholas, 2007; Khor will thus remain unfilled among them. & Zalilah, 2008). Studies have suggested that mothers Breastfeeding is a natural practice who are knowledgeable about the health that has been shown to have numerous benefits of breastfeeding are more likely benefits not only to babies, but also to breastfeed (DiGirolamo et al., 2005; to the mothers, society, economy and McCann, Baydar & Williams, 2007). environment (Binns, Lee & Low, 2016; Research has shown that mothers still U.S. Department of Health and Human believed that breastfeeding is the best Services, 2011). In this study, the Temiar practice for their babies, despite knowing women in RPS Kuala Betis, a semi-urban less about the specific reductions setting, seemed to have more knowledge in health risks that occur through regarding the benefits of breastfeeding breastfeeding and the consumption of compared to the mothers from the more breast milk (McCann et al., 2007). This rural setting of Pos Pulat due to their study found that despite having limited amenities and location. There was one or almost no knowledge of the benefits of Mothers and Child Clinic that can be breastfeeding, most women, particularly found in RPS Kuala Betis, while there those in Pos Pulat still nursed their was none in Pos Pulat. The nurses in this babies. For them, breastfeeding was clinic had a routine weekly or monthly a cultural norm which had been talk on various topics that involved entrenched in their society. It also mothers and child health issues. Thus revealed that the Orang Asli women women in RPS Kuala Betis had better still held on firmly to their values and opportunities to gain more information trusted the knowledge that was passed and knowledge compared to their on to them from family members and counterparts in Pos Pulat. In contrast women within their community, which to this, the health practitioners visited included the practice of breastfeeding. Pos Pulat only once a month and only In addition, the desire to give the best performed routine check-ups. According for their babies was the key driving to the participants of this study, there force for these women throughout their were no talks or information given on decision-making process. Even though breastfeeding and its benefits or on breastfeeding is often described as any other general health topics. In this natural, it is actually an art that has particular case at least, the healthcare to be learned by both the mother and provider had overlooked the need for the newborn. Skills on how to hold disseminating such basic but vital and position a baby at the breast, how information to this community. The lack to achieve an effective latch, and other of physical support such as this had a breastfeeding techniques may need to Breastfeeding knowledge among indigenous Temiar women 123 be taught (U.S. Department of Health growth factor (Castellote et al., 2011). and Human Services, 2011) in order to There are various cultural practices with achieve effective lactation. Women and regard to discarding or feeding colostrum their families need to be informed fully to the newborn. In our study, all women on the health benefits of breastfeeding in Pos Pulat agreed that they needed for infants and their mothers (Sridhar to discard the colostrum because they & Salcedo, 2017). Furthermore, it is believed that it is dirty and contaminated essential to impart additional knowledge with bacteria. Other studies have also about the need for patience, the reported on the avoidance of giving difficulties associated with beginning this substance to the infants due to of breastfeeding and the acceptance of the cultural beliefs and taboos. A study these difficulties as a normal part of in Chandigarh found that majority of the process (Giugliani, 2004). This will the mothers considered colostrum as ensure that the practice is sustainable ‘dirty, yellow, smelly, stagnant milk’ for optimal periods. Maternal knowledge, which should not be given to the infant understanding, confidence, self-efficacy because of its impurity as it is produced and being proactive in seeking support during the antenatal period (Walia, and education have a positive correlation Kalia & Chopra, 2009). The reasons for with the longer duration and exclusivity discarding colostrum vary with different of breastfeeding (Brown, 2014). cultures, but most societies believe It is also known that breastfeeding that colostrum is dirty, poisonous and provides a sense of bonding, wellbeing, contaminated (Liamputtong, 2007). and improved self-esteem for many Domestic data have shown that more women (Labbok, 2001). Breastfeeding too than 60% of Mah Meri women discarded is associated with increased child spacing their colostrum because of tradition, the in women who practised breastfeeding perception that it was filthy and could compared to those who did not. Fertility cause illness to the baby, discomfort and is not immediately recovered with the fullness of the breasts, advice by others return of regular menstrual cycles. The or for no reason at all. Some respondents length of postpartum amenorrhea varies also claimed that besides being told by greatly and depends on several factors, close families and friends to discard the including maternal age and parity as colostrum, they also received similar well as the duration and frequency of advice from some of the professional breastfeeding (Chao, 1987). However health workers (doctors and nurses) this alone cannot provide a means of (Wan Norlida et al., 2007). reliable and adequate contraception for In the present study, the women in most women. Pos Pulat who delivered at the hospital Breast milk is the perfect source gave colostrum to their babies following of nutrition for infants, both in its encouragement from the hospital nutritional composition and in the staff and the information that they non-nutritive bioactive factors that are had gained from reading the available needed for infant survival and healthy pamphlets. Knowledge pertaining to development (Ballard & Morrow, 2013). benefits of giving first milk to the babies The first fluid produced by mothers for women in RPS Kuala Betis had been after delivery (colostrum), is rich in communicated to them by nurses at the immunologic components such as clinic. Given that the knowledge and secretory of immunoglobulin A (IgA), benefits of breastfeeding are sub-optimal lactoferrin, leucocytes, as well as among the rural Orang Asli, there is a developmental factors such as epidermal pressing need for the health authorities 124 Sharifah Zahhura SA, Rozieyati MS to play an active role in promoting the professionals, they can easily be practice to help bridge the gap in the influenced and accept any advice health and social disparities between from promoters of formula-feeding rural and urban communities. Moreover (MacVicar et al., 2015). Furthermore, it is also imperative that healthcare it was also noted that mothers from workers are equipped with accurate low socioeconomic and education knowledge and appropriate standards, background may require substantial and provide equitable delivery of it, so input and support surrounding the that conflicting advice can be avoided. breastfeeding issues. As such, it is highly In our study, all women from both critical for health practitioners to possess locations were confident with their good interpersonal communication decision to breastfeed. Confidence in skills, as well as to master some breastfeeding is an indication that she basic fundamental knowledge on possesses the knowledge and skills to breastfeeding, while tackling some successfully breastfeed her infant. It is misconception of this practice in cultural based on information gained from prior context in order to ensure optimal experience, the observations of other breastfeeding practice. Inaccurate and women who had breastfed, support contradictory information can easily and encouragement from individuals cause early cessation of this practice in whose opinions are respected, and the this community (MacGregor & Hughes, physiological reaction to the prospect 2010). or act of breastfeeding (Dennis & Faux, The WHO International Code of 1999). Since confidence is enhanced Marketing Breastmilk Substitutes through knowledge, breastfeeding was adopted in 1981 by the World education, particularly when it is Health Assembly (WHA) to contribute skills-based or observational, may be to the provision of safe and adequate an important strategy for improving nutrition for infants, by the protection breastfeeding rates (Chezem, Friesen & and promotion of breastfeeding, and by Boettcher, 2003). Although the women ensuring the proper use of breast-milk in this study were confident enough substitutes, when these are necessary to breastfeed their babies, the lack of (WHO, 1981). In order to protect, support knowledge regarding the benefits of the and promote breastfeeding practices in breastfeeding may result in decreasing Malaysia, Ministry of Health (MOH) first rates of it in the future. Maternal formulated a Code of Ethics for Infant awareness can be compromised if Formula Products in 1979 based on important information is not received. 1975 International Council of Infant Moreover, many people, including Food Industries (ICIFI) Code. A revised some health professionals, believe that version of the Code was launched on because commercially prepared formula August 1, 2008 and was renamed Code has improved in recent years, this form of Ethics for the Marketing of Infant of sustenance is equivalent to breast Foods and Related Products (MOH, milk in terms of its quality and health 2019). The goal of the Code of Ethics’ benefits (U.S. Department of Health and is to contribute to the promotion of safe Human Services, 2011; Martin, Ling & and optimal nutrition for infants by Blackburn, 2016). protecting and promoting breastfeeding This can be quite alarming since and by ensuring the use of correct this disadvantaged group would breast milk replacement products where never question the actions of health this is necessary, by providing adequate Breastfeeding knowledge among indigenous Temiar women 125 information using a controlled marketing The old tradition of breastfeeding and distribution method. among Temiar women can easily be Although Malaysia has some of eroded if marketing that favours bottle- the strictest regulations that protect feeding reaches them. This, together with the practice of breastfeeding, some their limited knowledge of the benefits companies which market formula milk of breast milk can result in a decrease continue to circumvent the Code. This or even cessation of their breastfeeding has resulted in numerous violations of practices. This would be unfortunate the International Code of Marketing of since Orang Asli groups have more to Breast-milk Substitutes and subsequent gain from extended breastfeeding and resolutions by IBFAN (2014) that have where breast milk is the most secure been documented over the years. A and economically advantageous way to compilation of violations includes feed infants. direct promotion and selling of their formula milk products to parents at CONCLUSION Parenthood Expos. Other violations are This study analyses the descriptions of more subtle. These include attracting past events and provides insights into the parents with lucrative packages with thoughts, emotions, interpretations and every purchase of their formula milk lived experiences of the Temiar women products, encouraging parents to submit regarding breastfeeding. Our study has videos of their kids with product logos revealed that there is a knowledge gap and reviews. The promotion of formula between rural and semi-urban Temiar milk with includes comprehensive women despite originating from the same programmes that cover the entire period sub-ethnic background. Mothers from of pregnancy to the toddler stages with semi-urban setting of RPS Kuala Betis the recommended company’s products seem to have better awareness of the in every developmental stage, and vast array of the benefits of breastfeeding promotion in a form of goodie bags, compared to those from the rural Pos coupons and prizes. Events related to Pulat location. Besides these, inequalities bottle-feeding are heavily promoted in the healthcare services provided to through social media such as Facebook. both locations were also noted in this In clinics in Malaysia, particularly at study. There was inadequate support for private practices, formula names and those in Pos Pulat, where dissemination brand logos are promoted in the form of of breastfeeding knowledge or on any decorative accessories, toys and formula other health topics was neglected by the milk tester size. healthcare provider. Fortunately, due to Besides skilful marketing strategies the strong cultural norms within this to promote formula-milk feeding, some community, the practice of breastfeeding bottle-feeding accessories such as teats has continued despite having limited are sold without any indication that its awareness of the benefits of such a use will interfere with the breastfeeding tradition. It is vital to inculcate strong practices as required by the Malaysian fundamental knowledge and reinforce Code. Such items are often wrapped in beliefs of benefits of breastfeeding practice attractive packaging with claims and among the Temiar for preservation of comforting words that the products are their breastfeeding culture, in the face “ideal for babies”, are “anti-colic teats”, of subtle and direct pressures for bottle/ “natural breast-shaped teats”, “natural formula-feeding from outside. Policy latch”, etc. makers and healthcare providers should 126 Sharifah Zahhura SA, Rozieyati MS ensure that accurate information on Castellote C, Casillas R, Ramírez-Santana C, Pérez- breastfeeding is disseminated and made Cano FJ, Castell M, Moretones MG, López- Sabater MC & Franch A (2011). Premature accessible to Orang Asli women through delivery influences the immunological qualified health practitioners in order to composition of colostrum and transitional and make breastfeeding practice sustainable. mature human milk. J Nutr 141(6):1181-7. This study had a limited number of Chao S (1987). The effect of lactation on ovulation participants and was carried out only and fertility. Clin Perinatol 14(1):39-50. among the Temiar, a sub- of Chezem J, Friesen C & Boettcher J (2003). the Orang Asli. Therefore it is suggested Breastfeeding knowledge, breastfeeding that more research should be carried out confidence, and infant feeding plans: effects to explore the breastfeeding practices on actual feeding practices. J Obstet Gynecol Neonatal Nurs 32(1):40-7. among other 17 sub-ethnic groups of Orang Asli in Peninsular Malaysia. The Debes AK, Kohli A, Walker N, Edmond K & Mullany LC (2013). Time to initiation of breastfeeding findings from this study can be used to and neonatal mortality and morbidity: a improve promotion of breastfeeding to systematic review. BMC Public Health 13(Suppl mothers of other Orang Asli groups in 3):S19. Malaysia. Dennis CL & Faux S (1999). Development and psychometric testing of the Breastfeeding Self- Acknowledgement Efficacy Scale.Res Nurs Health 22(5):399-409. This study was made possible by the generous DiGirolamo A, Thompson N, Martorell R, Fein support of the Universiti Sains Malaysia Short S & Grummer-Strawn L (2005). Intention Term Grant (304/PKANITA/61313051). We would or experience? Predictors of continued also like to thank the Department of Orang Asli breastfeeding. Health Educ Behav 32(2):208- Development (JAKOA) Malaysia for their assistance 26. in this study. Domhoff GW (2003). In: Senoi dream theory: Authors’ contributions myth, scientific method, and the dreamwork movement. From http://dreamresearch.net/ SZSA, principal investigator who conceptualized Library/senoi.html. 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