Breastfeeding Adequacy Across DASS-21 Stress Severity Levels: A Cross-Sectional Study in Primary Midwifery Care

Husnul Muthoharoh; Ida Susila; Lilik Darwati; Asyaul Wasiah; Iin Nilawati

doi:10.21070/midwiferia.v12i2.1924

Authors

Husnul Muthoharoh Diploma III Midwifery Study Program, Universitas Islam Lamongan, Jawa Timur, Indonesia
Ida Susila Diploma III Midwifery Study Program, Universitas Islam Lamongan, Jawa Timur, Indonesia
Lilik Darwati Diploma III Midwifery Study Program, Universitas Islam Lamongan, Jawa Timur, Indonesia
Asyaul Wasiah Diploma III Midwifery Study Program, Universitas Islam Lamongan, Jawa Timur, Indonesia
Iin Nilawati Sekolah Tinggi Ilmu Kesehatan Sapta Bakti Bengkulu, Bengkulu, Indonesia

DOI:

https://doi.org/10.21070/midwiferia.v12i2.1924

Keywords:

breast milk production, breastfeeding mothers, DASS-21, lactation, maternal stress

Abstract

Introduction Psychological stress may hinder breastfeeding, but little is known about how breastfeeding adequacy varies across graded stress levels in primary midwifery care. This study explored the association between DASS-21 stress severity and indicator-based milk adequacy among mothers of infants aged 0–6 months.

Methods This exploratory cross-sectional study was conducted at a single independent midwifery practice in Lamongan, Indonesia, in January 2026. Of 21 registered breastfeeding mothers, 18 eligible mothers were included through purposive sampling (n = 18). Stress was measured with the DASS-21 stress subscale. Milk adequacy was assessed with a seven-item yes/no checklist of maternal and infant indicators that does not measure milk volume; adequacy was defined as at least five indicators. Data were analyzed using the two-sided Fisher Freeman Halton exact test.

Results Seven mothers had normal stress, six mild, four moderate, and one severe stress; 12 of 18 (66.7%) met the adequacy criterion. Inadequate milk adequacy was observed in 0/7 mothers with normal stress, 2/6 (33.3%) with mild, 3/4 (75.0%) with moderate, and 1/1 with severe stress (p = 0.017). The association was unadjusted and imprecise.

Discussion and Conclusion Higher stress categories were associated with a greater proportion of checklist-defined inadequacy in this small single-site sample. The findings do not establish causality; they support larger longitudinal studies using validated adequacy measures and suggest that maternal psychological wellbeing deserves attention in lactation support.

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