Factors Associated with Breastfeeding Self-Efficacy of Mothers

Within 6 Weeks of Delivery

Farzaneh Poorshaban¹, Sedigheh Pakseresht^2*, Zahra Bostani Khalesi³, EhsanKazemNejad Leili⁴

¹Pediatrics of Nursing (MSC), RasoulAkram Hospital, Rasht, Iran

²Social Determinants of Health Research Center (SDHRC),Department of Midwifery, Associate Professor, Guilan University of Medical Sciences, Rasht, Iran

³Department of Midwifery, Assistant Professor, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

⁴Social Determinants of Health Research Center (SDHRC), Bio-Statistics, Associate Professor, Guilan University of Medical Sciences, Rasht, Iran

*Corresponding author: Social Determinants of Health Research Center (SDHRC),Department of Midwifery, Associate Professor, Guilan University of Medical Sciences, Rasht, Iran

E-mail: paksersht@yahoo.com

Received: 2014December 28; Accepted: 2015May 17

Introduction

Breastmilk, the best food for newborns, is a complex biological fluid that can qualitatively and quantitatively provide them with maximal nutritional balance [1]. Hence, it is emphasized infants enjoy exclusive breastfeeding for the first 6 months and continue it along with supplementary foodfor 2 years [2]. Breastfeeding should be practiced by mothers as one of the most effective ways to prevent diseases and promote health behaviors [3].However, despite the benefits of exclusive breastfeeding up to 6 months after birth, reduced rates of breastfeeding is one of the fundamental public health concernstoday [4]. An important variablein breastfeeding is breastfeeding self-efficacy which is the confidence and belief of mothersin their ability to breastfeed [5]. Rahmatnegad and Bastani stated that Dennis introduced a predictive, multi-factor model for breastfeeding self-efficacy in the first week after delivery in Canada in 2006. They concluded that Breastfeeding Self-Efficacy Scale (BSES) can be used to identify risk factors so that health professionals become able to improve the quality of nursing care for new mothers [6].Breastfeeding self-efficacy is essential for breastfeeding continuation.Breastfeeding self-efficacy is influenced by four main factors:performance accomplishments, vicarious experiences, verbal persuasion, and physiological responses.Healthcare workers can elevate breastfeeding self-efficacy through these factors [7].

Evidence shows increasedduration of breastfeeding and exclusive breastfeeding increase breastfeeding benefits, while most women stop breastfeeding, which is counterproductive, especially in the first 6 months after delivery for the mother, infant, and society and protective effects of breastfeeding rapidly disappear after breastfeeding discontinuation [8].

Self-efficacy can be affected by many factors, including personal-social factors such asmothers' age, educational level, training, thenumber of pregnancies, employment,family incomeand previous breastfeeding experience [9].

Breastfeeding self-efficacy is inherently a modifiable variable because many demographic variables including age, educational level and socioeconomic status appear to be non-modifiable [10].Self-efficacy plays a key role in initiating breastfeeding, its duration, and exclusivity [11],but the results from different communities are contradictory.

Furthermore, no studies have been conducted in this regard in Rasht. Therefore, the present study was conducted to determine breastfeeding self-efficacy in Rasht in order to identify mothers at risk of breastfeeding discontinuationand factors associated with it and that appropriate interventions can be applied by responsible centersto maintain this healthy behavior.

Materials and Methods

Thisdescriptive-analytical cross-sectional study aimed to determine factors associated with mothers'breastfeeding self-efficacy within six weeks after delivery in Rasht in 2013.Research setting was the Family Health Research Center in Rasht, Iran. The subjects were mothers presenting to the center on the 3^rd-5^th days after delivery for their infants' thyroid testing.Inclusion criteria were mothers living in Rasht with no history of systemic physical or mental disease, or addiction to alcohol, cigarettes or drugs (self-report).The present study used consecutive sampling method.The sample size was estimated at 660 subjects according to the results of a study by Hassanpoor et al. with a standard deviation of 21, α= 0.01 and d=2.1. For possible sample loss, 30% was added to the initial number.Initially, 858 patients were enrolled, but91 women were excluded because of unavailability and lack of response to phone interviews at the 6^th week after delivery, so the final sample size was 767 subjects.

Data was collected using a two-part questionnaire. The first part contained 24 questions about factors associated with breastfeeding self-efficacy (personal, socioeconomic, physical, emotional and neonatal factors) and the second part included the standard Dennis Breastfeeding Self-Efficacy Scale (BSES), which were completed by the interviewer through interviews with mothers.In order to assess related factors and compare the breastfeeding self-efficacy, the BSES was again completed on the 6^th week after delivery through phone. During the first phase, mothers were informed that the BSES would be completed again on the 6^th week after delivery on thephone.The phone numbers of participants were collectedfor this purpose. The time scale for comparison of breastfeeding self-efficacy was selected 6 weeks after delivery because this is the recovery time after childbirth and many of the problems that mothers have in the first few days after delivery are removed and this can be a good scale for comparison.

BSES contains 14 items scored based on the Likert scale from strongly agree (score 5) to strongly disagree (score 1). According to Bandura suggestions in self-efficacy theory, the tool is designed with positive statements as all the sentences begin with "I can always".The minimum and maximum breastfeeding self-efficacy

scores are 14 and 70, respectively. If the score is above average, the person has high breastfeeding self-efficacy and vice versa. (The scale was used in a study by Rahmatnegad and Bastani in Iran [6]).The scale's English text was first translated into Persian and then Content Validity Index (CVI) and Content Validity Ratio (CVR) were used to evaluate the scientific validity of the scale.The questionnaire was then evaluated by ten nursing and midwifery professors and their points were applied in the final correction. The items with an appropriate CVI higher than 0.79 were accepted and those with a CVI between 0.70 and 0.79 were revised.There was no item with a score less than 0.70.The mean score showed that the CVR of all statements can remain in the scale. A pilot study on 20 eligible samples was conducted to determine the reliability of the scale, and yielded a Cronbach's alpha coefficient of 0.88.Data was collected through interviews after receiving informed consent from the mothers during sampling.SPSS version 21, descriptive statistics (mean, standard deviation) and inferential statistics (chi-square test, Mann-Whitney test, Pearson’s correlation coefficient and multiple regressions) were used to analyze the data. The confidence interval of 95% and asignificance level of P<0.05 were considered.

^*Dependent T-Test

Results

The mean age of mothers participating in the study was 20.28±5.38 years.Among the participants, 1.2% was illiterate, 8.3% had primary school education, 2.17% had secondary school education, 43.4% had ahighschool diploma, and 29.9% had anacademic education.The mean and standard deviation of breastfeeding self-efficacy score of mothers on the 3^rd-5^th days after delivery was 57.64±9.94 and on the 6th week after delivery was 62.66±7.57 (Table 1).

The chi-square test showed that there was a significant relationship between mothers' educational level and their breastfeeding self-efficacy (P=0.001). Type of delivery in 82.8% of the mothers was cesarean section and in 17.2% was normal vaginal delivery.The Mann-Whitney test showed that there was a significant relationship between type of delivery and breastfeeding self-efficacy (on the 3^rd-5^th days after delivery) (P=0.001) such that mothers who had normal delivery had higher breastfeeding self-efficacy than mothers that had a C-section.Pearson’s correlation coefficient showed that there was a significant correlation between the number of children and breastfeeding self-efficacy onthe 3^rd-5^th days after delivery (P=0.001).

In this study, only 14% of mothers were employed and the chi-square test showed that there was a significant relationship between mothers' occupation and their self-efficacy scores on the 6^thweek after delivery (P=0.008), and the housewiveshad a higher breastfeeding self-efficacy scores than employed mothers(table 2).

* Pearson correlation coefficient

** Chi-square Test

*** Mann-Whitney

Mann-Whitney test showed that among physical factors, pain (P=0.001), breast fissures (P=0.001),and flat or inverted nipples (P=0.001) were associated with breastfeeding self-efficacy such that mothers with such problems had lower breastfeeding self-efficacy than others.Also, it showed that a successful breastfeeding experience (P=0.001) among the emotional factors and prematurity (P=0.01) among neonatal factors were associated with breastfeeding self-efficacy.-square test showed that infants'nutritionwas associated with breastfeeding self-efficacy (P=0.001).

Multivariate regression model showed that the variables of educational level (secondary and high school), pain, breastfeeding discontinuation because of pain, successful experience of breastfeeding, and exclusive breastfeeding had a significant relationship with breastfeeding self-efficacy (P<0.05) (Table 3).Breastfeeding self-efficacy of mothers with secondary school and high school educational levels was 2.25 (P=0.002) and 1.51 (P=0.03) timesthat of mothers with academic education, respectively. In addition, the breastfeeding self-efficacy score of mothers that had no pain after delivery was 1.6 times that of mothers with this problem (P=0.01). The breastfeeding self-efficacy score of mothers with breastfeeding experience was 1.93 times that of mothers without any experience (P=0.001). Finally, the breastfeeding self-efficacy score of mothers who exclusively breastfed their babies was 6.28 times that of mothers that used a combined diet (P=0.001).

* Multivariate Regression

Discussion

The results showed that the mean and standard deviation of breastfeeding self-efficacy score on the 6^th week after delivery increased compared to the score on the 3^rd-5^th days after delivery.Also, mothers who exclusively breastfed their infants had a breastfeeding self-efficacy mean score higher than those who did not.

The examination of the relationship between demographic variables and self-efficacy score showed mothers with secondary school and high school educational level had higher self-efficacy scores than mothers with academic education, which was consistent with the findings of Yim et al. in China, where mothers with low educational levels had higher self-efficacy scores [12], however, this was inconsistent with the findings of Tokat et al. and the findings of Hassanpoor et al. where the self-efficacy scores of mothers increased with an increase in their educational level [8, 13].This can be attributed to the relationship between mothers' education and occupation. It appears that mothers' education and occupation are influential factors, that is, higher levels of education in mothers facilitate their employment [14]. Since the majority of mothers in this study were housewives (with secondary school and high school education) and they were sure that they could spend all their time with their infants and can breastfeed them have increased their breastfeeding self-efficacy score.

The results also indicated that mothers with natural delivery had higher self-efficacy scores than mothers who had
C-section.This was consistent with the findings of Tokat et al. [13].This could be because of problems caused by C-sectionfor the motherat the start of breastfeeding. The type of delivery affects breastfeeding self-efficacy and mothers that have C-section need more support than mothers with natural delivery [9].All of these factors may affect mothers' confidence in breastfeeding and thus reduce breastfeeding self-efficacy.

The present study revealed a significant relationship between the number of children and self-efficacy such that mothers withmore children had more breastfeeding self-efficacy. Melo et al. found no relationship between the number of pregnancies and breastfeeding self-efficacy [15].Usually, mothers with more children have more experience in breastfeeding and solving the relevant problems. This can elevate self-confidence and thus self-efficacy in mothers.

Furthermore, working mothers had lower self-efficacy scores than housewives, which is inconsistent with the findings of Cláudiaetal. Who found no relationship between those variables [16].This could be due to the fact that working mothers have concerns about returning to work, which cause problems in breastfeeding and thus reduce their self-efficacy.Starting to work and responsibility for a job impose extra pressure on the mother, making her need encouragement and support from consultants and family members so that she can foster her self-confidence and pay attention to her own and her infant’s healthand adapt to her new life program [17].

Pain, breast fissures, and flat or inverted nipples were variables with a negative relationship with breastfeeding self-efficacy.This is consistent with the findings of Dennis in Canada in which self-efficacy increased during the first week after delivery by reduction of pain [18]. Such problems cause discomfort and dissatisfaction for themothers during breastfeeding and negatively affect their self-efficacy.

The present study also found a relationship between prematurity and breastfeeding self-efficacy, such that mothers with premature infants had lower self-efficacy scores than other mothers. This is consistent with the findings of Uchoa etal. [19], but contradicted with the findings of Hassanpoor et al.in which self-efficacy

reduced by increasing gestational age [8].This could be due to the fact that lower gestational age might create problems at the start of breastfeeding, especially in the early hours of the baby's life, while term neonates with Apgar scores of 7 or more can have contact with the mother to start breastfeeding sooner, which results in more confidence in mothers with term infants and thus higher self-efficacy scores.In addition, mothers with premature infants have more stress and fear about caring and breastfeeding their newborns. This stress and fatigue resulting from spending more time for breastfeeding the newborns result in less satisfaction with breastfeeding and thus reduces their confidence and self-efficacy.

In this study, mothers who exclusively breastfed their infants had a higher breastfeeding self-efficacy mean score than those who did not. That is, mothers with higher self-efficacy had more exclusive breastfeeding than others. This is consistent with the findings of Rahmatnegad and Bastani[6] and Varei[20].

The results showed that mothers with low breastfeeding self-efficacy are at risk of early breastfeeding discontinuation, especially exclusive breastfeeding. Thus, breastfeeding needs to be supported in order to elevate self-efficacy. The main strategy for breastfeeding support is active participation in all aspects. Learning skills that will result in breastfeeding onset immediately after childbirth is very important in thepostpartum period.

Providing information to the husbands, family and friends (by intervention groups) about breastfeeding and its problems, including fear of insufficient breast milk, return to work, breast congestion and mastitis, refusal to breastfeed, and teaching ways to overcome these problems can result in a proper understanding of these issues.

In this study, information obtained through questionnaires and interviews with the mothers was based on self-reporting, so it is likely that mothers reportedwhat sounds better and not the reality, which is a limitation in this study.

Acknowledgement

This paper was extracted from a registered M.Sc. thesis of a (pediatrics) nursing student (902126).Hereby, we appreciate the Research and Health Deputy of the Guilan University of Medical Sciences, theSocial Determinants of Health Research Center (SDHRC), authorities of Rasht Health Centers and all the mothers that cooperated with us in this study.

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