Volume 29, Issue 3 (6-2019)                   J Holist Nurs Midwifery 2019, 29(3): 61-68 | Back to browse issues page

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Shahsavan Z, Oveisi S, Jourabchi Z. The Effect of Cognitive-Behavioral Counseling on Breastfeeding Self-Efficacy of Pregnant Women. J Holist Nurs Midwifery. 2019; 29 (3) :61-68
URL: http://hnmj.gums.ac.ir/article-1-1080-en.html
1- Midwifery (MSc.), Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
2- Associated Professor, Metabolic Diseases Research Center, School of Medical, Qazvin University of Medical Sciences, Qazvin, Iran.
3- Assistant Professor, Social Determinants of Health Research Center, Department of Midwifery and Maternal and Child Health, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.
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Breastfeeding is a unique way to provide the ideal food for the growth and development of infants. It is also an integral part of the reproductive process with important implications for maternal health. The population studies have shown that exclusive breastfeeding for 6 months is a good feeding way for infants. After that, the infants should receive complementary foods with continued breastfeeding up to 2 years of age or more [1]. Breast milk is the best food for the infant. It contains rich nutrients and protects against diseases and leads to better infant development. American Academy of Pediatrics recommends breastfeeding as the standard nutrition for all infants [2]. Unfortunately, according to studies conducted in the world, the rate of exclusive breastfeeding worldwide is less than 40%. In this regard, at the 65th World Health assembly, it was agreed to increase this rate up to 50% by 2025 [3, 4]. 
According to the report of the World Health Organization (WHO), in many Eastern Mediterranean countries, the early initiation of breastfeeding of infants is above 60%, and more than 60% of them continue to breastfeed up to 1 year. However, only 40% or less of infants are being exclusively breastfed until 6 months [5]. According to the deputy health department of Qazvin Province in Iran, in 2010, the percentage of exclusive breastfeeding in infants under 6 months was 53.1% in Iran and 39.1% in Qazvin Province [6].
Unfortunately, many mothers stop breastfeeding because of self-doubt on breastfeeding, problems with baby’s sucking, chest pain, and their perception of insufficient milk supply. According to one study conducted in Iran, one of the reasons for discontinuation of exclusive breastfeeding is the low breastfeeding self-efficacy in mothers [3]. However, if mothers know the benefits of breastfeeding or receive counseling, some of these problems can be solved. So it is better for mothers to be prepared mentally for exclusive breastfeeding [7].
Counseling is a communication and a process to help people choose their ways and solve their problems [8]. Among the various presented counseling techniques is cognitive-behavioral counseling which is a combination of cognitive and behavioral approaches. It can help people identify patterns of distorted thinking and ineffective behavior. Cognitive-Behavioral counseling focuses on the interaction of an individual’s cognition, emotions, and behaviors [9]. 
The results of Safaralinezhad et al. study support the effectiveness of cognitive-behavioral therapy in the reduction of gestational depression [10]. Sikander et al. reported that cognitive-behavioral counseling increased the duration of exclusive breastfeeding, and this technique was useful in exclusive breastfeeding [11].
On the other hand, breastfeeding self-efficacy is one of the constructs used in this technique. It is one of the constructs of Bandura’s social cognitive theory which refers to believe in one’s ability to successfully perform health practices, including exclusive breastfeeding [12]. Dennis [13] reported that breastfeeding self-efficacy had a significant association with the duration of exclusive breastfeeding. Breastfeeding self-efficacy is a suitable theoretical framework to guide interventions that are expected to increase duration and level of breastfeeding. It is also a reliable tool for identifying mothers at risk of breastfeeding cessation [14]. It seems that by conducting educational interventions during pregnancy, breastfeeding self-efficacy and duration of breastfeeding can be increased [12, 15]. 
According to Rahmatnejad and Bastani, one of the reasons for cessation of exclusive breastfeeding is the low breastfeeding self-efficacy in mothers [3]. Considering the importance of exclusive breastfeeding, its impact on mother and infant health, the decline in the global rate of exclusive breastfeeding, and the reasons for early discontinuation of breastfeeding, we attempted to investigate the effect of cognitive-behavioral counseling on breastfeeding self-efficacy of pregnant mothers living in Qazvin City, Iran.
Materials and Methods
This study was a randomized controlled clinical trial conducted in Qazvin City, Iran, in 2016. The study population consisted of all pregnant women referred to health centers in Qazvin. Six health centers were selected randomly out of 26 centers in this city. The sample size was determined 120 (60 for the intervention group and 60 for the control group) according to the study of Karbandi et al. and considering a standard deviation of 8 for self-efficacy score, 5% alpha coefficient, 0.8 test power, and at least 20% sample drop [16]. 
For sampling, the researchers referred to the health centers, and by reviewing the records and the inclusion criteria, 1100 mothers were initially selected for the study. The inclusion criteria were as follows: being 18-35 years old, having a gestational age of 24-28 weeks according to their last menstrual period and ultrasound records, being in a low-risk group for prenatal care, having at least a middle school education, being able to communicate, and lacking lactation problems in the previous pregnancy. On the other hand, the exclusion criteria were as follows: having any pregnancy complications (e.g. preeclampsia), premature delivery, or having any disorder and illness that prevents communication.
The data collection tool was a two-part questionnaire; the first part surveyed demographic characteristics (age, occupation, education of samples, and their husbands). The second part was the Breastfeeding Self‐Efficacy Scale, Short Form (BSES-SF) which was used before and after the intervention (last session). This 14-item scale was designed by Bandura in 1997 and first used in breastfeeding assessment by Dennis (Figure 1) [13]. We used its Persian version prepared by Araban et al. for the Iranian population who reported its good validity and reliability (α=0.91) [17]. They omitted one item, “comfortably breastfeed with my family members present”, because of religious norms after obtaining permission from the main author, and then performed the psychometric assessment on 13 items. The items are rated based on a 5-point Likert scale, and the total score ranged from 13 to 65.
The samples were divided into two groups of intervention (n=60) and control (n=60) using quadruple blocks. There were 6 possible outcomes for the blocks: ABBB, BBAA, ABAB, BABA, ABBA, and BAAB. The letters were written on six cards and put in the deck. Then, to select 20 people from each health center, a card was drawn four times, and their order was written on a sheet. The samples were divided into two groups according to the written order. This study was approved by the Research Ethics Committee (Code: IR.QUMS.REC.1396.113). It is also a registered clinical trial (Code: IRCT2017050533823N1). 
The women in the intervention group received counseling in groups of 10. The control group received routine prenatal care. The intervention included eight 90-minute sessions of cognitive-behavioral counseling offered by a psychologist and a midwife. Table 1 presents the details of the intervention program. The data analysis was conducted in SPSS V. 22 using the t-test and the Chi-squared test. The normality of data distribution was examined by the Kolmogorov-Smirnov test.
Based on the results, the intervention and the control groups were not significantly different from each other before cognitive-behavioral counseling in terms of demographic and gestational characteristics. The Mean±SD age of the samples was 28.47±4.37 years in the control group and 28.28±4.52 years in the intervention group. Most of the samples had high school education (36.5%) and were housewife. Based on the Chi-squared test, there was no significant difference between groups concerning their education and occupation. Moreover, the majority of samples reported that it was their first pregnancy, and no significant difference was found between two groups in this regard, too (Table 2).
The Independent t-test was used to compare breastfeeding self‐efficacy score between the two groups. The Mean±SD pretest breastfeeding self‐efficacy score was 47.55±5.92 in the control group and 47.70±7.83 in the intervention group (showed no significant difference between the two groups). After the intervention, the Mean±SD breastfeeding self‐efficacy score was 48.8±5.94 in the control group and 57.49±5.62 in the intervention group. The Independent t-test results showed that both groups were not significantly different from each other before the intervention, but after receiving cognitive-behavioral counseling, their difference in breastfeeding self‐efficacy was significantly different (P<0.001) (Table 3). The breastfeeding self‐efficacy scores of the intervention group considerably increased after counseling, but for the controls, the difference was not noticeable (Figure 2).

The results of this study indicate that cognitive-behavioral counseling increases breastfeeding self‐efficacy of mothers. The difference in breastfeeding self‐efficacy scores in the control and the intervention groups after counseling was significant. Parsa et al. in a study on the effect of 4-session lactation counseling on the self-efficacy and continuation of breastfeeding in primipara mothers, found out that those underwent counseling had higher self-efficacy scores [18]. Their results are in agreement with our results. The difference is that they carried out the intervention after delivery. Dodt et al. reported that educational intervention could increase breastfeeding self‐efficacy and the duration of breastfeeding [15]. 
In Azhari et al. study, it was found that breastfeeding without the direct intervention of educator could increase breastfeeding self‐efficacy [19]. However, the results of Mirmohammad Ali et al. study support the effect of education with the direct intervention of educators on increasing self-efficacy of breastfeeding [20]. 
Studies of Muhammad Owais et al. [8], Sikander et al. [11], and Raeisi Dehkordi et al. [21] also support the effectiveness of counseling on exclusive breastfeeding; Raeisi Dehkordi et al. used telephone counseling, and others employed direct counseling. However, only in the study of Sikander et al. cognitive-behavioral counseling was used. Since exclusive breastfeeding is one of the items of BSES-SF and in the case of exclusive breastfeeding, the self-efficacy score was higher; therefore, regardless of the type of intervention, the results of this study are consistent with the above studies. 
The results of Hasanpoor et al. [22] indicate that the breastfeeding self-efficacy score decreases during the last month of pregnancy, while the results of the present study indicate that self-efficacy can be increased with counseling.
Most studies have examined the impact of counseling and education on exclusive breastfeeding and its duration. The present study was conducted considering that breastfeeding self-efficacy could be a powerful predictor of exclusive breastfeeding and identifying mothers at risk of early cessation of breastfeeding. Therefore, considering the importance of lactation, we suggest that more and broader studies be conducted in this regard. This study led to a significant increase in breastfeeding self-efficacy score compared to routine care that the control group received. According to the WHO report on the low rate of exclusive breastfeeding in the world, including Iran and Qazvin, the related interventions will be necessary [6, 23, 24].
Given that breastfeeding self-efficacy can be a determinant factor in exclusive breastfeeding, it is recommended that cognitive-behavioral group counseling be prepared by the maternal health departments at comprehensive health centers and midwifery counseling centers to improve the health of mothers and the community. Furthermore, about the study results and promotion of breastfeeding, the counseling is better to be conducted at mothers’ homes. Also, it is recommended that future studies examine breastfeeding self-efficacy and exclusive breastfeeding up to 6 months after delivery. Because our study data have been collected by a questionnaire before delivery, the results may not be predictive of all lactation behaviors of postpartum women. Thus, we suggest that breastfeeding behavior be assessed up to 6 months after delivery and counseling intervention.
Ethical Considerations
Compliance with ethical guidelines
Before collecting data, written consent was obtained from samples, and they were assured of the confidentiality of their information. This study was approved by the Research Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1396.113). It is also a registered clinical trial (Code: IRCT2017050533823N1).
The present paper was extracted from the master thesis of the first author, in Department of Midwifery Counseling, Qazvin University of Medical Sciences.
Authors' contributions
All authors contributed in designing, running, and writing all parts of the research.
Conflict of interest
The authors declared no conflict of interest.
The authors would like to thank the Research Deputy and Faculty of Nursing and Midwifery of Qazvin University of Medical Sciences and the study health centers.

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Article Type : Research | Subject: General
Received: 2019/06/18 | Accepted: 2019/06/18 | Published: 2019/06/18

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