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• Published: 18 January 2023

Investigating factors that influence the practice of exclusive breastfeeding among mothers in an urban general hospital in Ghana: a cross-sectional study

• Baaba Dadzie 1 ,
• Fidelis Bayor 2 ,
• Abdul-Razak Doat 3 ,
• Jamilatu B. Kappiah 3 ,
• Collins Adombire Akayuure 3 ,
• Aubrey A. Lamptey 4 ,
• Vida Nyagre Yakong 5 &
• Sylvanus Kampo 3 , 6  

BMC Women's Health volume  23 , Article number:  24 ( 2023 ) Cite this article

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In Ghana, only 52% of mothers exclusively breastfeed their babies and the rate of increase has been steadily slow across all geographical areas of Ghana. The purpose of this study was to determine the various factors that influence exclusive breastfeeding (EBF) among mothers who visited the child welfare clinic at the Tema General Hospital, Accra, Ghana.

Methodology

This descriptive cross-sectional study was carried out at the Child Welfare Clinic of the Tema General Hospital, Accra, Ghana. A random sampling technique was used to recruit mothers with children between the ages of 6 months and 24 months attending the Child Welfare Clinic. Mothers were interviewed with the aid of a structured questionnaire.

Out of the 222 of mothers interviewed, 68.8% of them exclusively breastfed their infants up to 6 months. Mothers who have good knowledge were more than 3 times (AOR = 3.484, 95% CI 1.200, 10.122, P  = 0.022) likely to breastfeed their children exclusively. Those who had positive attitudes towards EBF were about 4 times (COR: 4.018, 95% = 1.444, 11.181, P  = 0.008) more likely to exclusively breastfeed than those who had poor attitudes towards EBF. Also, mothers whose spouses complained about EBF were about 3 times (AOR: 2.655, 95% CI 0.620, 11.365, P  = 0.018) at increased odds of not exclusively breastfeeding their babies.

Conclusions

High rate of EBF among mothers who visited the child welfare clinic was found. The mothers' level of knowledge and attitude towards EBF significantly influenced the 6 months of EBF. Spouses also showed a high influence on whether or not mothers should exclusively breastfeed their babies.

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Introduction

The World Health Organization recommends that mothers exclusively breastfeed their babies for the first 6 months after birth [ 1 ]. EBF is defined as providing infants with only breast milk as their sole source of nutrition, with the exception of necessary oral rehydration solution, drops, and syrups of vitamins, minerals or medications [ 2 , 3 ]. The benefits associated with EBF include: healthier eating habits, a shorter hospital stay, more favourable weight gain, a lower body mass index, less adiposity, lower total cholesterol values, better cognitive and behavioural development, and metabolic level stability in children with metabolic disorders [ 4 ]. EBF plays a significant role in reducing infant morbidity and mortality as well as certain illnesses such as type II diabetes [ 4 , 5 , 6 , 7 ]. The American Academy of Paediatrics considers breastfeeding as the ideal and optimal source of nutrition in the first year of life, most importantly the first half, and recommends that mothers and caregivers exclusively breastfeed for the first 6 months after a baby is born, followed by complementary feeding with solid foods [ 8 ].

According to the United Nations International Children’s Emergency Fund (UNICEF), the infant mortality rate in Ghana as of 2019 stood at 34 deaths per 1000 live births and the under 5 mortality rate stood at 46 deaths per 1000 live births [ 9 ]. In 2008, infections and malnutrition accounted for a huge proportion of the causes of infant mortality of which a reasonable number could have been prevented with EBF [ 10 ]. The Ghana Demographic and Health Survey conducted in 2008 showed that 63% of infants below 6 months were being exclusively breastfed [ 10 ]. The survey re-conducted in 2014 however showed a decrease in this number, as only 52% of infants below 6 months were exclusively breastfed [ 11 ]. This represents an 11% decrease in the EBF rate from 2008 to 2014.

In order to achieve Sustainable Development Goals 3.2 which tackles preventable deaths in neonates and children under five, efforts need to put in place globally, and even more specifically in developing countries like Ghana, in the area of EBF as it contributes enormously to reducing mortality in infants. Knowing the wide array of benefits EBF provides, it is of relevance to decipher ways and means to achieve maximum numbers in terms of EBF among mothers. This will help reduce drastically the infant mortality rates, infectious illnesses that could have been otherwise prevented by EBF as well as malnutrition in their children.

Despite extensive research and the advantages associated with EBF, the practice remains low globally, with rates declining fastest in developing nations due to the significant influence by contextual and environmental factors [ 4 , 5 ]. Evidence shows a significant difference in EBF between urban and rural areas. For example, Astika et al. [ 12 ] discovered that mothers who reside in urban areas were more likely to commence early breastfeeding and breastfeed exclusively than those in rural areas. Also, low patronage were attributed largely to sociodemographic and cultural practices in Ghana and other Sub-Saharan African countries, as well as low levels of knowledge, misconceptions, maternal age and health conditions, antenatal care services, the economic situation of the family, access to information, and employment issues [ 13 , 14 , 15 , 16 , 17 , 18 ]. In order to maximize positive perception and attitude toward the practice of EBF in these areas, educational interventions to help women better understand the benefits of EBF is required. While studies on exclusive breastfeeding in Ghana have focused on the knowledge level, socioeconomic and cultural practices as being the major factors affecting the practice of EBF [ 13 , 16 , 17 , 18 , 19 ], information on the effect of family support from parents, spouse and healthcare professionals on the practice of EBF has remained inadequate.

According to the theory of planned behaviour, the intention to carry out a specific behaviour is said to be the primary motivator behind an individual's particular behaviour. These intentions are presumptively intended to capture the driving forces behind motivation, including attitude, subjective norm (perceived expectations from others and how they value them), and perceived behaviour control (individual's level of knowledge or competences) [ 20 ]. This has the power to affect how decisions are made. As a result, motivational factors like a maternal knowledge, attitude, and perceived expectations from others, such as family support, may affect her intentions or willingness to exclusively breastfeed her infants. This study intends to provide additional information by assessing the factors including level of support from family members influencing the practice of EBF among mothers in an urban general hospital in Ghana. This crucial information has not been captured in the studies conducted so far in Ghana creating a knowledge gap that this study seeks to fill. It will also contribute to scientific knowledge and enable formulation of relevant, attainable and realistic policies aimed at increasing the rates of EBF.

Research design

A retrospective quantitative cross-sectional study design using researcher administered questionnaire was employed to describe the factors that influence EBF among mothers visiting the Tema General Hospital, Ghana. This study adopted the theory of planned behaviour [ 20 ] as its conceptual framework. This allowed access to information on the practice of exclusive breastfeeding among the study population, knowledge, level of support provided as well as the attitude of these mothers toward EBF.

The study was conducted at the Child Welfare Clinic of the Tema General Hospital, a highly patronized district hospital located in the Greater Accra Region of Ghana. This healthcare facility is equipped with the necessary infrastructure to deliver both primary and specialist health care to all clients within the region and its environs. The Child Welfare Clinic undertakes activities such as growth monitoring of children, vaccinations and other services including birth registry. Most children visit this facility from birth to 5 years when vaccinations are completed.

Inclusion and exclusion criteria

The inclusion criteria were made up of mothers who visited the Child Welfare Clinic of the Tema General Hospital. All registered postnatal mothers and parent/legal guardian with children aged between 6 and 24 months who were of sound mind and competent enough to give assent/consent were included in the study. This was done to obtain information from those who had completed the recommended 6 months of EBF and was limited to mothers with babies under 24 months in order to reduce recall errors and biases. We excluded all mothers with conditions which do not support breastfeeding such as babies with an established diagnosis of galactosemia, babies of deceased mothers, mothers who had mastectomy, those actively receiving cancer treatment, taking drugs (e.g. amphetamines, statins and antidepressants), those with active TB and mothers with Human T-lymphotropic virus as well as all eligible mothers who declined to participate in this study. Mothers with babies less than 6 months were exempted because EBF is recommended for the first 6 months and it cannot be ascertained as to whether they would practice EBF for the period until their babies turned 6 months.

Sampling procedure

Using a simple random sampling technique, all eligible mothers who had their written informed consent taken were required to randomly pick confidentially prepared slips that had either a YES or NO inscribed. Only qualified participants who met the selection criteria and picked a slip with YES inscribed were enrolled for the study.

The sample size for the study was estimated using the Cochran formula below;

where N = sample size to be determined, Z = Z score (reliability coefficient) of 1.96 at 95% confidence level, P = the estimated proportion of the population who practiced exclusive breastfeeding. This was determined using a single population proportion from a study by Boakye-Yiadom et al., 2016 [ 21 ] to be 84.3% = 0.85, and D = margin of error of 5% = 0.05. The sample size calculated was 202. Assuming a non-response rate of 10%, the total sample size required for the study was 222.

Data collection process

The total time used for this study was 9 weeks, starting from 21st of June to 20th of August, 2021. The first 5 weeks were used for data collection and the subsequent four for analysis. After obtaining ethical approval from the Research Ethics Committee of the University of Health and Allied Sciences (UHAS-RECA.12 [171] 21-21), permission to commence data collection was sought from the clinical coordinator and the in-charge of the Child Welfare Clinic of the Tema General Hospital, Ghana. Written informed consent was also obtained from the individual mothers who met the selection criteria after providing them with adequate explanations regarding the aims of the study. For participants who were below 18 years, informed consent was sought from their parents/legal guardians who accompanied them.

Following informed consent and recruitment, study participants were interviewed using a standard structured self-administered questionnaire which was developed and validated by the authors for this study. The validity of the questionnaire was determined by the adoption of the checklist/guideline by the Centers for Disease Control and Prevention (CDCP), 2014 [ 22 ], Global Opinion Panels [ 23 ] and the breastfeeding self-efficacy scale [ 24 ] and was pre-tested on five participants which served as a pilot study and the reliability determined through a review with two public health physicians and a paediatrician. The study participants were approached and assessed for their eligibility to participate in the study following the determination of the age of their children between 6 to 24 months. In all, a total of 222 eligible mothers were enrolled in the study. The questionnaire was prepared in English and had it translated and explained to mothers in their local language where necessary. Questionnaires were numbered and coded prior to data collection. The questionnaires sought to provide information on the various factors that influence EBF among mothers. This was done by assessing the practice of EBF among the study population, knowledge of EBF, the attitude of mothers toward EBF as well as the level of support received from spouses.

Measurement of variables

Independent variables.

Age of mother and baby, sex of the baby as well as the level of education of the mother, marital status of the mother, religion, occupation, place of residence and the number of children she had were defined as independent variables. The occupation of the mothers was then defined as formal, informal or unemployed with those being unemployed including students. The place of residence was also categorised into various districts. Also, questions were asked on what hospital the mothers attended for antenatal care, where they delivered and the gestational age at which they delivered. The hospitals mothers attended for antenatal care were categorised into either a government facility or a private facility. For the birth weight, all babies born with birth weight from 2.5 to 4.5 kg were noted to have normal weight whereas all those less than 2.5 kg or more than 4.5 kg were considered to have a low birth weight and a high birth weight respectively. The current weight of the children was assessed using the weight for age chart for the various sexes and all those between the -2 standard deviation and + 2 standard deviation were considered to have normal weight. Those above + 2 standard deviation and those below -2 standard deviation were evaluated to be overweight and underweight respectively.

Dependent/outcome variables

The WHO criteria or indicators for assessing infant feeding practices, Geneva, 2021, were used to assess EBF [ 25 ]. The main dependent variable was mothers’ practice of EBF. EBF was defined as the babies receiving only breast milk as a source of nutrition. The first type of feed was also asked together with whether they fed the first yellowish breast milk or not and if they fed their babies with other foods or fluids. Mothers were also asked when they stopped breastfeeding and if they were still breastfeeding at the time of the study.

To measure mothers’ level of knowledge on EBF, they were asked about whether or not they had heard of EBF and subsequently about where they heard about it from and also when they heard about it. The respondents were asked when one should initiate breastfeeding after delivery and when one should start giving water and then food to their children. They were also asked if breast milk alone was enough for the babies in the first 6 months and what one should do with the first breast milk. Knowledge about the benefits of EBF was assessed. The overall level of knowledge of mothers was considered to either be good or poor. The criteria for assessing knowledge on EBF was used based on literature [ 23 , 25 , 26 , 27 , 28 ].

A score from zero to four implied you had poor knowledge of EBF whereas a score of more than four implied a good knowledge of exclusive breastfeeding. The level of support obtained from the family, community and health professionals was ascertained. This was done by finding out whom they stayed with, then who helps take care of the baby followed by who provides money to take care of the baby. Further questions were asked about whether the spouse or the parents of the respondents complained about EBF.

Finally, attitude of the mothers towards exclusive breastfeeding was determined. The questions required answers using the 3-point Likert scale. The questions began with asking the mothers if they found it difficult exclusively breastfeeding for 6 months and continued by asking if they felt it was okay to give their children formula if they were not producing enough breast milk. They were also asked if it was okay to give complementary feeds before 6 months if the baby was not satisfied after feeds or if it was okay to give water to their babies before 6 months if the babies were thirsty. Again, they were asked if they found it difficult to breastfeed in public and if they felt confident expressing breast milk to be given to their children in their absence. To evaluate mothers as having a good or poor attitude towards EBF, choosing disagree scored one point while disagree or unsure scored zero point. Cumulatively, mothers could score from zero to seven. A mother with a score less than four was deemed to have a poor attitude towards EBF and one who scored four through to seven was noted to have a good attitude towards EBF.

Data analysis

Data were double entered into Microsoft excel, validated for entry errors and exported onto Statistical Package for Social Sciences Software (SPSS) version 20.01 (IBM Corporation, Armonk, NY, USA) for statistical analysis [ 29 , 30 ]. The results were presented as means, frequencies and tables. The confidence interval was 95% and considered statistically significant at P  < 0.05. The frequency distribution was done for all variables. The Pearson chi-square test was used to test the significance of the association between the practice of EBF and knowledge, attitude, support received and complaints of relatives. Factors found to have significant associations were analyzed using a multiple logistic regression model which was used to calculate the odds ratio and confidence interval. P-values of variables in the chi-square table with only significant terms as predictors of EBF was the criteria for variable selection to fit the multiple logistic regression model. Socioeconomic indicators such as income level, maternal health condition or mental state relation, parity, maternal age, gestational age, educational level, occupation and employment issues were perceived as major confounders to the multiple logistic regression model. These were chosen because many previous studies [ 14 , 17 , 18 , 19 , 20 ] have reported the influence of socio-economic and cultural factors on the practice of EBF. Missing data was managed using a listwise or case deletion. To address data bias, multiple people were used to code the data; results were reviewed and were verified from other data sources and compared with other studies’ results.

Baseline information of participants

A total of 222 mothers with their children were recruited for this study of which 30 (13.5%) were within the age range of 16–25 years, 134 (60.4%) were within the age bracket of 26–35 years, and 58 (26.1%) aged between 36 and 45 years (Table 1 ). The mean age was 32 years. The average age of the children of mothers recruited was 11 months with 53 in every 100 of them being females. The average weight of the children at birth was 3.2 kg. With regards to the educational background of the mothers, 53 (23.9%) of them had Junior high school education, 82 (36.9%) had senior high school education, 65 (29.3%) had Tertiary education, whereas 14 (6.3%) had primary education (Table 1 ). The parity of 205 (92.3%) of the mothers was between 1–4, and 17 (7.7%) of them were greater than 4 (Table 1 ). 187 (84.2%) of the mothers were employed, while 35 (15.8%) of them were unemployed (Table 1 ). Those who were residents of Ashaiman constituted the majority, 104 (46.9%) of our study participants, 98 (44.1%) were residents at Tema and 20 (9%) were residents at other places in Accra. Also, 204 (91.4%) of the participants said they had term deliveries compared to the 19 (8.6%) preterm deliveries reported (Table 1 ).

Knowledge on exclusive breastfeeding

A vast majority (94.1%) of mothers were knowledgeable of EBF. About 218 (87.9%) reported the hospital was their primary source of information about EBF. Compared to the 50 (22.5%) mothers who thought breast milk during the first 6 months does not give appropriate nourishment to their babies, more than three-quarters (76.1%) of the mothers believed that EBF was a source of adequate nutrition to their babies. Out of the mothers who felt they were not producing enough breast milk for their babies, 46 (20.7%) continued breastfeeding, 56 (25.2%) reported to the hospital, and 20 (9.1%) provided supplemental feedings (Table 2 ).

Practice of exclusive breastfeeding

To investigate the practice of EBF among mothers, we first determined mothers who practised EBF for the recommended period. The data showed that 146 (65.8%) mothers practised EBF for the recommended period compared to the 76 mothers (34.2%) who did not. 219 (98.6%) of the mothers fed their babies with colostrum. The study indicated that 115 (51.8%) of mothers initiated breastfeeding immediately after birth, 40 (18.0%) initiated breastfeeding the day after birth, and 66 (29.7%) of the mothers-initiated breastfeeding 2 or more days delivery (Table 3 ). The initial food given to babies immediately after birth by mothers were; breast milk (85.5%), formula (14.0%) and only one mother (0.5%) gave glucose water.

Level of support

In our study, 196 (88.3%) lived with their spouses. Up to 79.7% of the respondents had support from their spouse, parents, and extended family members when they had difficulties with EBF and 95.5% of the mothers had their income provided by their spouses (Table 4 ). According to the study’s findings, 55 (24.8%) of those who complained about EBF were their parents and 22 (9.9%) were their spouses.

Attitude towards exclusive breastfeeding

Among the respondents interviewed for this study, 67.1% (n = 149) agreed to give formula when they feel that the breast milk is not enough for their babies. 50.9% (n = 112) of the mother were confident expressing their breast milk and 40.1% (n = 89) agreed that they will give complementary feeding if they feel that their babies are not satisfied with the breast milk (Fig.  1 ).

Attitude towards exclusive breastfeeding. Mothers had good attitude towards EBF. However, one out of every five mothers had a poor attitude towards EBF

Association between maternal factors and the practice of EBF

To determine the various factors that influence the practice of EBF among mothers visiting the Child Welfare Clinic of the Tema General Hospital, a bivariate analysis was done using Chi-square (x 2 ) test. The practice of EBF was significantly associated with 69.4% (n = 145) of the women who had adequate level of knowledge compared to those who did not adhere to EBF for 6 months ( p  < 0.001, x 2  = 20.684). 75.1% (n = 127) of the mothers who practiced EBF said giving breast milk alone for 6 months is enough compared to those who did not practice EBF ( p  < 0.001, x 2  = 29.018). Furthermore, while EBF was significantly associated with positive attitude toward EBF ( p  < 0.001, x 2  = 51.917), only about 41.9% (n = 26) had a difficulty with EBF ( p  < 0.001, x 2  = 24.212), 53.0% (n = 79) agreed that they will give their babies formula ( p  < 0.001, x 2  = 32.862 and 44.9% (n = 40) were okay with complementary foods ( p  < 0.001, x 2  = 28.691). Although there was no significant associations between EBF and support received ( p  = 0.881, × 2 = 0.022), 68.2% (n = 15) had their spouse complained ( p  < 0.001, x 2  = 12.500) (Table 5 ).

Multiple logistic regression analysis

The factors found to have significant associations were analysed using a multiple logistic regression. The model had an overall accuracy value of 89.6 with a P -value of 0.000. Multivariate analysis shows that mothers’ level of education was significantly associated with the practice of EBF. Mothers who have good knowledge were more than 3 times (AOR = 3.484, 95% CI 1.200, 10.122, P  = 0.022) likely to exclusively breastfeed their children. Those who had positive attitudes towards EBF were about 4 times (COR: 4.018, 95% = 1.444, 11.181, P  = 0.008) more likely to exclusively breastfeed as opposed to those who had poor attitudes towards exclusive breastfeeding. Also, mothers whose spouses complained about EBF were about 3 times (AOR: 2.655, 95% CI 0.620, 11.365, P  = 0.018) increased odds not to exclusively breastfeed their babies (Table 6 ).

The purpose of this study was to determine the factors that influence exclusive breastfeeding among mothers who visited the Tema General Hospital. This was done to identify additional factors (e.g. mothers’ level of knowledge, practice of EBF and level of support from family and spouse) that influenced the practice of EBF among mothers who visited the child welfare clinic. In previous studies, significant determinants of exclusive breastfeeding (EBF) have been identified to include maternal attitude and knowledge, as well as socio-demographic and cultural factors [ 17 , 18 ]. In order to reduce infant morbidity and mortality in settings with limited resources, mothers should be encouraged to breastfeed exclusively for the first 6 months [ 31 , 32 ]. Also, EBF is well known to play a critical role in fostering infant development, immunity, and illness prevention [ 33 , 34 ]. Key findings of this study were as follows:

Our study demonstrated that over 95% of the women had good knowledge of EBF before their last delivery. The mothers viewed that prevention of neonatal sepsis, provision of adequate nutrition, enhancement of brain development; family planning, reducing the financial burden, time saving and enhancing bonding between mother and baby were some of the benefits that could be derived from EBF. Almost 66% of the mothers practiced EBF for the first 6 months and of those who failed to adhere to EBF, 65% were due to insufficient breast milk. One-third of the mothers had complaints about EBF from either their spouse or parents although about 58% of support was from their spouse, parents, extended family members or health personnel when they had difficulties with EBF. Again, 76.13% of the mothers had a good attitude toward EBF.

It is important to note that good knowledge (perceived behavior control) about the benefits of EBF according to the theory of planned behaviour may influence positive attitude and the intention or desire to exclusively breastfeed [ 20 ]. This study demonstrated significant maternal knowledge and positive attitude of the mothers toward EBF. This good knowledge on EBF is reflected in their view that water and other complementary foods should be initiated after 6 months of EBF and that colostrum is ideal for initiating breastfeeding in infants. As several studies have shown, about 94.14% of the mothers had good knowledge on EBF among mothers vising the Tema General Hospital with a large percentage (98.64%) of them obtaining the information on EBF from hospitals [ 21 , 35 , 36 ]. The child welfare and antenatal clinics of the facility carry out educational talks to clients every morning on various topics including EBF and this could have played a role in the high level of knowledge these mothers had. Out of every five mothers interviewed, four thought breast milk alone was enough for the first 6 months which certainly plays a role in determining whether or not a mother introduces supplementary feeds before the 6 months is completed. Our findings also agree with Dukuzumuremyi et al. [ 1 ] in East Africa who reported that almost 96.2% of mothers knew about EBF with an awareness rate of 84.4% and 49.2% knew that EBF should be done for the first 6 months only. In their study, maternal attitude toward EBF was good [ 1 ]. In Zimbabwe, although the practice was low, Mundagowa et al. [ 37 ] found a significant good maternal knowledge and positive attitude toward breastfeeding. Both good maternal knowledge and positive attitude were also demonstrated by Hoseini et al. [ 38 ] in a cross-sectional study in Mashhad. In contrast, Haghighi and Varzandeh [ 39 ] in Iran found a low level of maternal knowledge although they had a good attitude toward breastfeeding. Ekambaram et al. [ 40 ] also found poor maternal knowledge, especially regarding the time of initiation of breastfeeding, colostrum feeding, and duration of EBF, expressed breast milk and continuation of breastfeeding while the baby is sick. However, significant correlations were found between higher maternal age, better maternal education, higher socioeconomic status and having received antenatal care from tertiary care centers and private practitioners. There is still a need for a programme, which support and encourage breastfeeding particularly at a primary care level, focusing more on younger, less well-educated women and those from lower socioeconomic class.

Again, the 76.0% positive attitude recorded in this study was significantly associated with adequate maternal knowledge, the attitude of the mother and whether or not the spouse complained about EBF. Also, mothers who have good knowledge had increased odds to exclusively breastfeed their children and those who had positive attitudes towards EBF were 4 times likely to exclusively breastfeed, while mothers whose spouses complained about EBF were 3 times likely not to adhere to EBF.

It is worth noting that having a good understanding of the benefits of breastfeeding has a bigger impact on EBF compliance. The mothers' high knowledge and positive attitude toward EBF, as in the current study, could be linked to their strong belief that exclusive breastfeeding is associated with significant benefits. Our findings were not different from Smith and Forrester [ 41 ] where EBF was said to minimize public health costs. Similarly, Allen and Hector [ 42 ] reported that EBF is associated with several health benefits similar to those reported by Couto et al. [ 4 ]. As a result, emphasizing the maternal benefits of EBF could encourage mothers to breastfeed their infants exclusively.

According to Oche et al. breastfeeding continues to be the most straightforward, healthiest, and affordable feeding method for almost all infants [ 43 ]. In their study, although the practice of EBF was found to be low (31%) in Sokoto state, Nigeria, the proportion of mothers who practiced EBF for the recommended 6 months was almost 66%, with one in every four women who start EBF stopping before the 6 months is up. This proportion is similar to the 64% recorded in 2013 across Ghana [ 44 ]. It was 14.2% higher than the estimated 52% by the Ghana Demographic and Health Survey in 2014 [ 11 ] but lower than the study by Boakye-Yiadom et al. in Mamprusi West by 18.5% which could be attributed to the mother-to-mother support group created in the area by non-governmental organizations. Those who failed to practice EBF, 65% were due to insufficient breast milk. The increased desire and willingness to comply with EBF practices among our study participants may be largely due to the good knowledge and understanding about the numerous advantages associated with EBF. Our finding on mothers’ practice of EBF was a little higher than those reported by Dukuzumuremyi et al.

The theory of planned behavior states according to Ajzen [ 20 ], intentions are what drive individual behaviors and are influenced by things like attitudes, subjective norms, and perceived behavioral controls. Therefore, depending on how accurately perceived behavior control represents actual behavior control; external factors such as level of support or expectations from family and healthcare professionals (subjective norm) may directly affect behavior regardless of the intention [ 20 ]. Our study also identified that mothers had about 58% supports from spouses, parents, close relations and healthcare professionals. Although few complaints from close relations were reported, support from immediate family members contributed enormously to building a strong mental and positive attitude, serving as a major determinant of the high patronage toward EBF among the mothers. On the other hand, studies in Ethiopia, Nigeria and Ghana reported that the major determinants of EBF were directly linked to maternal sociodemographic and economic status such as maternal age, maternal monthly earnings, level of education, employment status, mothers who delivered at a healthcare facility, antenatal attendance [ 34 , 45 , 46 ]. Even though 95.5% of the mothers who participated in this study were financially supported by their spouses, only two in every five of them were assisted by their spouse in taking care of the child. Two again out of the five mothers interviewed was assisted by other people besides their spouse implying that one out of every five of them did not receive any assistance in the care of the infants. However, there was no association between 6 months of EBF and mothers receiving support when they faced challenges EBF ( p  = 0.881). Again, there was no association between EBF and mothers whose parents complained about EBF ( p  = 0.090) unlike parts of the Greater Accra Region where grandmothers of the baby were the most powerful influencers [ 46 ]. However, spouses seemed to influence the practice of EBF the most in this study evidenced by a significant association between the practice of EBF and mothers whose spouses complained about EBF. Mothers whose spouses complained about EBF had 79.5% decreased odds of EBF. This could be due to poor knowledge on EBF of the spouses causing them to not appreciate the importance of this practice. Also, up to three out of five of the mothers did not receive help from their spouses when they had difficulties with EBF. This could mean that more than half of these spouses are not actively involved in the care of their babies and as such may not be able to make positive contributions towards the practice of EBF.

In conclusion, a high rate of EBF was observed among mothers who visited the child welfare clinic at Tema General Hospital. The increased rate of practice and a positive attitude toward EBF was as a result of their significant knowledge of the advantages associated with EBF. Also, whether or not mothers should exclusively breastfeed their babies was highly influenced by support from their spouse, parents, and healthcare professionals. Therefore, midwives, nutritionists, and public health nurses should continuously educate mothers about EBF both before and after delivery at both antenatal and child welfare clinics. In order to identify knowledge gaps, particularly with regard to EBF, mothers must be thoroughly evaluated during antenatal visits and at child welfare clinics. This will allow for the delivery of more thorough education. Male participation in the care of their infants should be encouraged, and these educational sessions should be expanded to include spouses.

Strength and limitation

The strength of this study included the determination of maternal knowledge and attitude toward EBF and the incorporation of support from immediate family as well as knowledge about the benefits associated with it. The study was structured based on the theoretical framework of planned behavior by Ajzen [ 20 ] and the incorporation of the WHO criteria or guidelines on EBF added strength to the study. The main limitation of this study was the time frame used for data collection and small the sample size which did not allow the inclusion of other relevant variables. This may result in measurement error due to recall errors or social desirability bias. A longitudinal study is therefore recommended to follow up with mothers and babies until they are toddlers to assess the complete benefits of EBF.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the Medical Director of the Tema General Hospital and the staff of the Child Welfare Clinic for making available all the necessary materials needed for this study.

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BD and SK conceived and designed the study. SK was responsible for the supervision and coordination of this study. BD, FB, ARD, JK, CAA, AAL, VNY and SK conducted the data collection. BD and SK led the data analysis with inputs from FB, ARD, JK, AAL and VNY. FB wrote the first draft of the manuscript, and then BD, ARD, JK, CAA, AAL, VNY and SK contributed to revising and reviewing the manuscript. All authors read and approved the final manuscript before submission.

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Dadzie, B., Bayor, F., Doat, AR. et al. Investigating factors that influence the practice of exclusive breastfeeding among mothers in an urban general hospital in Ghana: a cross-sectional study. BMC Women's Health 23 , 24 (2023). https://doi.org/10.1186/s12905-023-02164-y

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A Critical Review of Instruments Measuring Breastfeeding Attitudes, Knowledge, and Social Support

Corrine s. casal.

1 Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA

Sera L. Young

2 Department of Anthropology, Northwestern University, Evanston, IL, USA

Emily L. Tuthill

3 School of Nursing, University of California, San Francisco, CA, USA

Background:

Breastfeeding provides beneficial health outcomes for infants and their mothers, and increasing its practice is a national priority in many countries. Despite increasing support to exclusively breastfeed, the prevalence at 6 months remains low. Breastfeeding behavior is influenced by a myriad of determinants, including breastfeeding attitudes, knowledge, and social support. Effective measurement of these determinants is critical to provide optimal support for women throughout the breastfeeding period. However, there are a multitude of available instruments measuring these constructs, which makes identification of an appropriate instrument challenging.

Research aim:

Our aim was to identify and critically examine the existing instruments measuring breastfeeding attitudes, knowledge, and social support.

A total of 16 instruments was identified. Each instrument’s purpose, theoretical underpinnings, and validity were analyzed.

An overview, validation and adaptation for use in other settings was assessed for each instrument. Depth of reporting and validation testing differed greatly between instruments.

Conclusion:

Content, construct, and predictive validity were present for most but not all scales. When selecting and adapting instruments, attention should be paid to domains within the scale, number of items, and adaptation.

Breastfeeding provides optimal health for infants in the first 6 months of life and provides valuable health benefits for the mother ( UNICEF, 2015 ). The World Health Organization recommends exclusive breastfeeding (EBF) for the first 6 months for maximum health benefits and continued breastfeeding with appropriate complementary foods for 2 or more years ( UNICEF, 2015 ; World Health Organization, 2015 ).

However, despite increased EBF support from organizations like the World Health Organization, EBF rates at 6 months remain low (37% globally) and global suboptimal breastfeeding practices contribute to 11.6% of mortality for children younger than 5 years ( Victora et al., 2016 ). A better understanding of breastfeeding determinants and barriers to its practice is needed to improve global breastfeeding levels.

Breastfeeding practices can be understood as being determined by a constellation of factors that span the ecological framework from the individual-level characteristics to family (or microsystem) to the political systems (or macrosystem) that influence breastfeeding practice ( Bronfenbrenner, 2009 ; Tuthill, McGrath, Graber, Cusson, & Young, 2016 ). Breastfeeding attitudes and knowledge and breastfeeding social support represent the microsystem and macrosystem levels of the ecological framework ( Bronfenbrenner, 2009 ) and are important predictors of breastfeeding behavior. Each construct can affect breastfeeding practice independently, or through influencing one other.

Breastfeeding attitudes and knowledge (i.e., feelings, moods, or emotions and the facts, truths, or principles toward breastfeeding, respectively) ( De Jager, Skouteris, Broadbent, Amir, & Mellor, 2013 ) operate mainly at the microsystem level. It has been shown that attitudes and knowledge toward breastfeeding are strongly predictive of EBF duration ( Chezem, Friesen, & Boettcher, 2003 ; De Jager et al., 2013 ). Although breastfeeding attitudes and knowledge are referred to jointly, it is important to note that they are two closely related, albeit separate, constructs that are commonly assessed together. Whereas breastfeeding attitudes are an affective (i.e., a characteristic or trait related to feelings or emotions; McCoach, Gable, & Madura, 2013 ) determinant, breastfeeding knowledge is factual. Breastfeeding social support is a third breastfeeding construct that may affect breastfeeding practice ( Chezem et al., 2003 ) and operates at the microsystem and macrosystem levels (e.g., support toward a mother directly and support that is established through political systems). Greater breastfeeding social support is linked to EBF initiation and duration ( Chezem et al., 2003 ; De Jager et al., 2013 ). Together, breastfeeding knowledge, attitudes, and social support represent a substantial portion of a mother’s orientation toward breastfeeding and warrant an inclusive examination. Consequently, the ability to assess breastfeeding attitudes, knowledge, and social support could help identify those at risk for suboptimal breastfeeding practices.

There are a number of scales to measure each of these separate, but related, constructs. However, the selection of an appropriate scale from among these possibilities is daunting, given that there has been no descriptive examination or critical comparison of the instruments. Therefore, the purpose of this article is to provide a descriptive overview of existing instruments measuring breastfeeding knowledge, attitudes, and social support, including the theoretical frameworks on which they were built, their validation (if any), and their application beyond the original settings. It is our intention that this review will facilitate the improved assessment of these important determinants of breastfeeding by both researchers and practitioners. By facilitating more rigorous and harmonized measurements, we hope to help pinpoint instruments that result in meaningful and relevant data that enhance our knowledge of breastfeeding determinants.

A literature search was conducted between February and March 2014 and updated October 2015 to identify instrument development articles on mother’s (1) breastfeeding attitudes and/or knowledge or (2) breastfeeding social support. The electronic databases PubMed, CINAHL, PsycINFO, Google Scholar, and Health and Psychosocial Instruments were searched using the keywords breastfeeding, human milk, infant feeding, instrument, questionnaire, instrument , and tool . The MeSH term “breast feeding” was used for PubMed. Additional search terms to identify breastfeeding attitudes and knowledge instruments included development, attitude, belief, knowledge , and information . Additional search terms to identify breastfeeding social support instruments included social, family , and systems support . The references of related articles and the gray literature were also searched to identify eligible papers.

Inclusion criteria included being (1) an original instrument development article focused on women’s breastfeeding attitudes, knowledge, or social support and (2) written in English. There were no limits placed on publication date. Because two people oversaw the critique process, any uncertainties about the suitability of the inclusion of the instrument were discussed as a group until resolution.

For attitudes and knowledge, 1,952 attitudes and knowledge articles were identified by CSC (see Figure 1 ). After abstract screening, 229 articles were included and 1,723 were excluded due to failure to mention an instrument meeting inclusion criteria. In a second round of screening that included a review of articles, 203 articles were excluded for reasons such as not matching the definition of knowledge or attitudes, not focusing on original instrument development, not focusing on women as the target demographic, or consisting entirely of closed-ended items to facilitate objective scoring.

Inclusion process.

Twenty-six articles were fully reviewed. Of these, 5 did not match the definition of knowledge or attitudes (i.e., Caswell, 2008 ; Kelley, Kviz, Richman, Kim, & Short, 1993 ; Lakshman et al., 2011 ; Leff, Jefferis, & Gagne, 1994 ; Mulder & Johnson, 2010 ), 6 did not focus on original instrument development (i.e., Anchondo et al., 2012 ; Dick et al., 2002 ; Fantasia, Sutherland, & Fontenot, 2012 ; Fonseca-Machado, Haas, Stefanello, Nakano, & Gomes-Sponholz, 2012 ; Radaelli, Riva, Verduci, Agosti, & Giovannini, 2012 ), 1 consisted of open-ended items (i.e., Cusson, 1985 ), 1 was directed exclusively toward a non-mother demographic (i.e., Ekström, Matthiesen, Widström, & Nissen, 2005 ), and 5 more were excluded because no electronic means of communicating with the author could be found (i.e., Dávila Torres, Parilla, & Gorrín Peralta, 2000 ; Giles et al., 2007 ; Grossman, Harter, & Hasbrouck, 1991 ; Siddell, Marinelli, Froman, & Burke, 2003 ; Verma, Saini, & Singh, 1993 ).

For breastfeeding social support, a total of 3,082 articles was initially identified by AL (see Figure 1 ). An initial abstract screening excluded 2,925 articles because no information regarding breastfeeding social support was mentioned. After reviewing the remaining manuscripts, an additional 126 articles were excluded for reasons such as (1) breastfeeding social support was not measured, (2) the manuscript purpose was to conduct a qualitative study and not instrument development, and (3) instrument development procedures were not described. With the remaining manuscripts, a full-text evaluation was completed. Eleven articles were excluded, leaving 8 articles that met the inclusion criteria for an original instrument development article on women’s perceived social support toward breastfeeding.

A total of 16 instruments met inclusion criteria. Their authors were contacted to obtain the original breastfeeding instruments (cf. online supplementary material for those that were made available). For each of these 16 instruments, the stated purpose, underlying theoretical frameworks, and number of times each instrument has been used in its original or an adapted version are reviewed. Theoretical frameworks and definitions allow instrument developers to apply conceptual definitions to their research of interest ( Grant & Osanloo, 2014 ). As such, the application of a theoretical framework in instrument development is essential for understanding the item meaning and to ensure that the instrument reflects study intention ( McCoach et al., 2013 ).

Validity is the extent to which the interpretation of test scores supports the proposed uses of the instruments ( McCoach et al., 2013 ). In this review, we report on three levels of validity testing considered standard reporting in instrument development procedures ( McCoach et al., 2013 ), which include content, construct, and predictive. There are multiple options to testing each type of validity. The standard definition and approach to validating each construct is as follows.

Content validity includes the conceptual definition and the operational definition or how the construct is measured in practice ( McCoach et al., 2013 ). The construct’s definition must capture aspects of the construct investigated, and the operational definition must comprehensively and accurately capture the conceptual definition ( McCoach et al., 2013 ). The intended domains of an instrument signify areas of breastfeeding that the authors deem important but also indicate which segments of their respective theoretical frameworks were addressed. Content experts review each item for its relevance to, its fit with, and understandability of the intended concept to ensure strong content validity. To obtain more objective findings, a content validity index scale may be applied, which requires content experts to rate each item on a number of criteria (e.g., fit, relevance, understandability), which the developer then uses to revise items if needed (see Lynn, 1986 , as a reference).

Construct validity aims to measure how well relationships among items reflect their intended domain. This is typically assessed using factor analyses ( McCoach et al., 2013 ). Depending on the instrument development process, there are several types of factor analyses that may be performed (e.g., confirmatory or exploratory) and statistical functions used (e.g., types of rotations).

To forecast future behaviors or characteristics based on a criterion variable, predictive validity is used to illustrate how effective an instrument is at determining future behavior. Successful predictions allow instrument administrators to forecast future characteristics based on instrument results ( McCoach et al., 2013 ). In this review, we describe the validity and reliability testing that was reported by instrument developers.

In sum, the standard way to report validity is through three separate validity tests: (1) content validity testing with content experts, (2) construct validity by way of a factor analysis, and (3) predictive validity that is performed using different statistical tests, looking at how the instrument can predict a specific outcome in the future. In addition to validity testing, reliability of the data is reported using Cronbach’s alpha.

Reliability, defined as the extent to which data results produce similar findings on repeated trials, is similar to but different from construct validity. Reliability refers to the consistency of test scores, whereas validity refers to the accuracy of inferences made from intended concepts being measured. A Cronbach’s alpha serves as a statistical metric of how reliable the data generated from the instrument are ( McCoach et al., 2013 ). Generally, a Cronbach’s alpha of > 0.70 is considered to be the minimum threshold for research purposes ( Peterson, 1994 ).

In this review, validity testing is reported per the original instrument developer’s description. Although most adhered to standard reporting criteria, if instrument developers reported validity or reliability testing in other formats or provided only partial results, their processes were described according to the original manuscript text. Testing an instrument among the target population to ensure that it is valid and yields data that are reliable increases confidence in research results and may assist researchers and health care providers in choosing an appropriate breastfeeding attitudes and knowledge or breastfeeding social support instrument.

Each instrument is critically assessed by way of an overview (see Tables ​ Tables1 1 and ​ and2), 2 ), discussion of validation (see Tables ​ Tables3 3 and ​ and4), 4 ), and summary of instrument use beyond original instrument development (see Tables ​ Tables5 5 and ​ and6). 6 ). If present, domains (referred to as factors by some instrument developers) of each instrument are also described (see Tables ​ Tables3 3 and ​ and4). 4 ). Of note, the consistency with which construct validity is reported varies greatly between instruments; therefore, we describe the results to match the detail and specificity of that included within the original text (for additional information, see Tables ​ Tables3 3 and ​ and4 4 ).

Overview of Breastfeeding Knowledge and Attitude Instruments.

Overview of Breastfeeding Social Support Assessment Tools.

Validation Studies of Breastfeeding Attitudes and Knowledge Assessment Tools.

Validation Studies of Breastfeeding Social Support Assessment Tools.

Overview of Research Studies Using Knowledge and Attitudes Tool.

Adaptation and Reliability of Breastfeeding Social Support Instruments in Novel Settings.

Note . N/A = not applicable.

Breastfeeding Attitudes and Knowledge Instruments

Australian breastfeeding knowledge and attitude questionnaire.

The purpose of Brodribb, Fallon, Jackson, and Hegney’s (2008) Australian Breastfeeding Knowledge and Attitude Questionnaire is to describe the relationship between breastfeeding knowledge and attitudes and duration of personal breastfeeding experience. No theoretical framework was discussed. Higher scores indicate more positive attitudes and more knowledge regarding breastfeeding. The instrument has been used once since original development in an adapted format ( Srinivasan, Graves, & D’Souza, 2014 ).

Validation.

Content validity was assessed by three doctors with breastfeeding experience and a researcher with a background in breastfeeding education. Construct validity was tested by administering the instrument to 161 Australian general practice registrars (residents by U.S. standards) in their final year of training. Reliability was demonstrated by a Cronbach’s alpha of 0.83 for the knowledge scale and 0.84 for the attitude scale, and item-total correlations of less than 0.2 for each scale. Predictive validity was not discussed.

Iowa Infant Feeding Attitude Scale

The purpose of de la Mora, Russell, Dungy, Losch, and Dusdieker’s (1999) Iowa Infant Feeding Attitude Scale (IIFAS) is to develop a measure of attitudes toward infant feeding through an easily administered instrument. A theoretical framework was not discussed. The IIFAS was tested in three separate studies on three different populations. Half of the items favored breastfeeding, and the remaining half favored formula feeding. Higher scores indicate more positive attitudes toward breastfeeding. The instrument has been used at least 27 times since original development in both original and adapted formats ( Dowling et al., 2012 ; Dowling, Madigan, Anthony, Elfettoh, & Graham, 2009 ; Dowling, Shapiro, Burant, & Elfettoh, 2009 ; Flaherman et al., 2013 ; Flaherman et al., 2011 ).

Three separate studies were conducted for validation. Content validity was not discussed in any of the studies. Construct validity was tested by administering the instrument to 125 postpartum women in the first study, 130 postpartum women in the second study, and 725 postpartum women who had initiated breastfeeding while in the hospital in the third study. Reliability varied among the three studies and their different populations. In the first and second studies, reliability was relatively consistent with Cronbach’s alpha of 0.86 and 0.85. Reliability dropped in the third study with a Cronbach’s alpha of 0.68 and an item-total correlation range of 0.07 to 0.45. Predictive validity showed that maternal attitudes toward breastfeeding were indeed a predictor of the mother’s choice of feeding method.

Preterm Infant Feeding Survey

The purpose of Dowling, Madigan, et al.’s (2009) Preterm Infant Feeding Survey (PIFS) is to measure attitudes toward infant feeding in mothers of preterm infants. The PIFS was adapted from Janke’s (1992) Breast-feeding Attrition Prediction Tool (BAPT). The BAPT focused on mothers of healthy, full-term infants; the PIFS was created to focus instead on preterm, hospitalized infants. Like the BAPT, the PIFS applies Ajzen’s (1991) Theory of Planned Behavior as a theoretical framework, the major tenets of which are that “behavioral intention determines actual behavior, while outcome beliefs, subjective norms, and perceived behavioral control influence behavioral intention.” The BAPT was intended to measure five domains: beliefs and attitudes concerning breastfeeding and formula feeding, subjective norms, control beliefs, and two weighting scales for importance of attitudes and importance of attitudes of significant people. Higher scores indicate stronger or more positive beliefs and attitudes toward breastfeeding. The instrument has been used twice since original development in its original format ( Dowling et al., 2012 ; Dowling, Shapiro, et al., 2009 ).

Content validity was evaluated by five doctorally prepared nurses who had experience with mothers of preterm infants. Construct validity was tested by administering the instrument to 105 postpartum mothers of preterm infants. It was tested via exploratory factor analysis using principal axis factoring with oblimin rotation (eigenvalues > 1) and examination of scree plots of eigenvalues. Factor analysis resulted in a four-factor solution: negative breastfeeding sentiment, positive breastfeeding sentiment, subjective norms, and breastfeeding control. Reliability was indicated by a Cronbach’s alpha of 0.80. Predictive validity showed scores that indicated that negative attitudes toward breastfeeding, lower subjective norm, and lower breastfeeding control were associated with premature weaning.

Breast Milk Expression Experience

The purpose of Flaherman et al.’s (2013) Breast Milk Expression Experience (BMEE) is “to develop a measure to evaluate women’s experiences of expressing milk.” No theoretical framework was discussed. Items associated with negative breastfeeding experiences were reverse scored. Higher scores indicate better experiences with breastfeeding. The instrument has been used once since original development in its original format ( Flaherman et al., 2011 ).

Content validity was evaluated by an interdisciplinary panel of four content experts. The authors determined that their study did not have the statistical power to report on construct validity. The instrument was administered to 68 mothers immediately after postpartum milk expression. Reliability of the instrument was reported with a Cronbach’s alpha of 0.703. Predictive validity showed that higher scores were associated with greater likelihood of breast milk expression at 1 month.

Breast-feeding Attrition Prediction Tool

The purpose of Janke’s (1992) BAPT is to identify women at risk for premature weaning based on breastfeeding attitudes. Ajzen’s (1991) Theory of Planned Behavior was used as a theoretical framework to guide the development of the BAPT. The instrument was intended to measure three domains: attitudes, control, and subjective norms. The interpretation of the scores obtained from using the instrument was not mentioned. The instrument has been used eight times since original development in both original and adapted formats ( Gill, Reifsnider, Lucke, & Mann, 2007 ; Joshi, Trout, Aguirre, & Wilhelm, 2014 ; Kafulafula, Hutchinson, Gennaro, Guttmacher, & Kumitawa, 2013 ; Lewallen et al., 2006 ; Wambach et al., 2011 ).

Content validity was assessed by 10 lactation experts. Construct validity was tested by exploratory factor analysis, using the scree test for factor extraction and an orthogonal (Varimax) rotation for factor rotation, after administering the questionnaire to 157 mothers at 16 weeks postpartum. Factor analysis demonstrated a six-factor solution: negative breastfeeding sentiment, negative formula-feeding sentiment, positive breastfeeding sentiment, breastfeeding control, professional support, and support of family and friends. Reliability was demonstrated by a Cronbach’s alpha of 0.80. Predictive validity was tested by determining if a significant difference in mean regression factor scores existed between women who were exclusively breastfeeding and those who had switched to exclusive formula feeding. The authors found that all but one factor of their instrument were significantly predictive of feeding method.

Breastfeeding Knowledge,Attitude, and Confidence Scale

The purpose of Laanterä, Pietilä, and Pölkki’s (2010) Breastfeeding Knowledge, Attitude, and Confidence Scale is to assess breastfeeding knowledge of parents and its related demographic variables. No theoretical framework was discussed. Most, but not all, of the knowledge items were negatively worded so that common misconceptions regarding breastfeeding could be included. The instrument was intended to measure three domains: knowledge, attitude, and confidence. Higher scores indicate greater knowledge. The instrument has been used once since original development in an adapted format ( Laanterä, Pölkki, Ekström, & Pietilä, 2010 ).

Content validity was assessed by five breastfeeding experts who were health care officials acquainted with breastfeeding counseling. Construct validity was tested by administering the instrument to 123 pregnant mothers and 49 fathers. Reliability of the instrument was demonstrated by a Cronbach’s alpha of 0.84. Item-total correlations ranged from 0.215 to 0.604, and 70% of the correlations were above 0.30. Predictive validity of the instrument was not discussed.

Breast-feeding Attitude Scale

The Breast-feeding Attitude Scale (BrAS) ( Lewallen et al., 2006 ) was created as an adaptation of the BAPT ( Janke, 1992 ) with the same purpose of identifying women at risk for premature weaning based on breastfeeding attitudes in addition to making the instrument easier to administer and score. No theoretical framework was discussed. Higher scores indicate more positive attitudes toward breastfeeding. The BrAS has not been used in other studies.

Content validity was not discussed. Construct validity was tested by administering the instrument to 108 postpartum mothers. Reliability was reported with a Cronbach’s alpha of 0.85. The authors considered the predictive validity of the BrAS to be sufficient in that the instrument was able to predict breastfeeding initiation by distinguishing between mothers who initiated breastfeeding and those who chose formula feeding. However, the authors found that the BrAS was unable to predict breastfeeding duration, as it could not distinguish between mothers who would continue breastfeeding and those who would wean early.

Breastfeeding Behavior Questionnaire

The purpose of Libbus’ (1992) Breastfeeding Behavior Questionnaire (BBQ) is to examine the attitudes and beliefs that affect infant-feeding choice among different demographics. No theoretical framework was discussed. A lower score indicates more positive attitudes and more accurate knowledge concerning breastfeeding. The instrument has been used four times (twice by the instrument’s creator) since original development in original and adapted formats ( Libbus, 2000 ; Libbus & Kolostov, 1994 ; Marrone, Vogeltanz-Holm, & Holm, 2008 ; Nabulsi et al., 2014 ).

Content validity was assessed by a panel of local experts in nutrition and nursing. Original testing was conducted by administering the instrument to 17 pregnant previous or current breastfeeders. Results from this study compared breastfeeding attitudes between members of La Leche League and those in the Special Supplemental Nutrition Program for Women, Infants, and Children. Results showed that those in the La Leche League group saw more favorable attitudes and accurate information toward breastfeeding. Reliability and predictive validity of the BBQ were not discussed.

Breastfeeding Social Support Instruments

Workplace breastfeeding support scale.

The purpose of Bai, Peng, and Fly’s (2008) Workplace Breastfeeding Support Scale is to measure a mother’s perception of breastfeeding support in her workplace. No theoretical framework was discussed, and specific intended domains for measurement were not mentioned. Higher scores indicate more positive workplace breastfeeding support. The instrument has been used once since original development in an adapted format ( Bai & Wunderlich, 2013 ).

Four experts in nutrition, lactation, scale development, and survey instrument development, respectively, tested the content validity of the instrument. The construct validity was tested with 66 pregnant or 6- to 12-month postpartum mothers who worked outside the home. The Kaiser-Meyer-Olkin test (0.71) was used for factor analysis and resulted in a four-factor solution: technical support, breastfeeding-friendly environment, facility support, and peer support ( Dziuban & Shirkey, 1974 ). Reliability was demonstrated by a Cronbach’s alpha of 0.77. The predictive validity of the instrument was not discussed.

Utilization of Support Network Questionnaire

The purpose of Buckner and Matsubara’s (1993) Utilization of Support Network Questionnaire is to determine the functions of various support resources to determine effective nursing interventions that promote breastfeeding in new mothers. No theoretical framework is discussed. Higher scores indicate more social support. The items concern seven different support groups including lactation consultants, husbands, and friends. The instrument has not been used since original development.

The content validity was conducted by lactation consultants and expert review. Construct validity was not discussed. Reliability was demonstrated by a Cronbach’s alpha of 0.93. Predictive validity was not discussed.

Modified Breastfeeding Attrition Prediction Test

The purpose of Evans, Dick, Lewallen, and Jeffrey’s (2004) Modified Breastfeeding Attrition Prediction Test (modified BAPT) is to predict new mothers’ breastfeeding attrition prior to 8 weeks based on breastfeeding attitude, social support, and control. The original BAPT is based on the theoretical framework of Ajzen’s Theory of Planned Behavior ( Ajzen, 1991 ; Janke, 1992 ). The original and modified BAPT are separated into four domains: the positive breastfeeding sentiment attitudinal scale, negative breastfeeding sentiment attitudinal scale, social and professional support scale, and breastfeeding control scale. Higher scores indicate greater breastfeeding support. The instrument has been used once since original development in an adapted format ( Muslu, Basbakkal, & Janke, 2011 ).

Content validity was not discussed, most likely because it was modified from a pre-existing instrument ( Janke, 1992 ). The method of testing construct validity was not discussed. Reliability was demonstrated by a Cronbach’s alpha of 0.753 and 0.851 for the prenatal and postpartum time periods, respectively, among 117 new mothers. Predictive validity was tested in the postpartum period, and mothers who had a higher education level (i.e., control) and close relatives who breastfed (i.e., social support) had a lower rate of breastfeeding attrition.

Supportive Needs of Adolescents Breastfeeding Scale

The purpose of Grassley, Spencer, and Bryson’s (2013) Supportive Needs of Adolescents Breastfeeding Scale (SNABS) is to measure adolescent perceptions of nurse support when initiating breastfeeding. The theoretical framework of the instrument is based on House’s Theory of Social Support, which conceptualizes support as the four areas of emotional, informational, instrumental, and appraisal support ( LaRocco, House, & French, 1980 ). The scale is divided into four domains based on 25 supportive nurse behaviors: informational, instrumental, emotional, or appraisal support. Higher scores indicate greater support to pregnant adolescents from nurses. The instrument has been used once since original development in an adapted format ( Pentecost & Grassley, 2014 ).

Eight certified lactation consultants evaluated the content validity of the SNABS. Factor analysis using a Kaiser-Meyer-Olkin test was used to test construct validity on 101 15- to 20-year-old new mothers. Factor analysis resulted in a three-factor solution: instrumental, appraisal, and emotional support (Cronbach’s alpha = 0.81), informational, appraisal, and emotional support (Cronbach’s alpha = 0.76), and “miscellaneous items about engaging the adolescents’ support persons and providing immediate skin-to-skin care” (Cronbach’s alpha = 0.68). Reliability was demonstrated with a Cronbach’s alpha of 0.83. Predictive validity was not discussed.

Employee Perceptions of Breastfeeding Support Questionnaire

The purpose of Greene, Wolfe, and Olson’s (2008) Employee Perceptions of Breastfeeding Support Questionnaire (EPBSQ) is to measure working new mothers’ perspectives of workplace breastfeeding support. The EPBSQ is based on the theoretical framework of Glanz’s social ecological model that emphasizes how multiple layers of influences affect health behaviors ( Glanz, Rimer, & Viswanath, 2008 ). The EPBSQ measured the five domains of company, manager, coworkers, workflow, and physical environment. The instrument has been used once since original development in its original format ( Burks, 2014 ).

Content validity was evaluated by 10 lactation experts, an evaluation design expert, and 14 women working in Michigan who had delivered within the past year. Construct validity was tested with 117 women who worked in Michigan and were pregnant or had given birth within the past year using the Multidimensional Random Coefficients Multinomial Logit Model of the Rasch measurement model ( Wright & Mok, 2000 ). Reliability of separation values for the instrument’s subscales—(1) company policies/work culture and (2) manager/coworker support—is between 0.68 and 0.89. Predictive validity was not discussed.

Perceived Breastfeeding Support Assessment Tool

The purpose of Hirani, Karmaliani, Christie, Parpio, and Rafique’s (2013) Perceived Breastfeeding Support Assessment Tool (PBSAT) is to measure urban Pakistani working mothers’ perceptions of breastfeeding support. The theoretical framework uses Bronfenbrenner’s (2009) Ecological Systems Theory, which states that various ecological systems influence human development. The instrument is divided into four domains: informational support, social support, health care support, and workplace environmental support. Meaning of the score was not discussed. The instrument has not been used since original development.

Seven experts including a lactation consultant, nutritionist, pediatric consultant, physician, nurse, and psychologist tested the content validity of the instrument. Construct validity was tested through a factor analysis consisting of a Kaiser-Meyer-Olkin test, principal components analysis, and Varimax (rotation with Kaiser normalization) on 20 working, breastfeeding mothers. Factor analysis revealed 12 factors (eigenvalues > 1). After additional screening, two domains emerged: workplace environmental support and social environmental support. Reliability was demonstrated with internal Cronbach’s alpha of 0.86 and 0.77, respectively, and 0.85 in total. Predictive validity shows that mothers who are more educated, work more hours, and have maternal leave perceive higher levels of workplace support and that those mothers with higher levels of environmental and workplace social support are more likely to continue breastfeeding with employment.

Hughes Breastfeeding Support Scale

The purpose of Hughes’ (1984) Hughes Breastfeeding Support Scale (HBSS) is to measure various types of support that breastfeeding mothers receive. The theoretical framework of the instrument is based on the Theory of Social Support by Cobb (1979) and House (1981) , which emphasizes that the usefulness of social support is dependent on the recipient’s perception ( LaRocco et al., 1980 ; Riley, Abeles, & Teitelbaum, 1979 ). The HBSS is divided into three domains: emotional, instrumental, and informational breastfeeding support. Higher scores indicate more social support. The instrument has been used three times since original development in both original and adapted formats ( Boettcher, Chezem, Roepke, & Whitaker, 1999 ; Hirschfeld et al., 1977 ; McNatt & Freston, 1992 ).

A pediatrician, pediatric resident, three registered nurses, and a pediatric nurse practitioner and clinical specialist reviewed the content validity of the instrument. Construct validity was tested on 30 breastfeeding mothers in the southeastern United States using the Spearman-Brown prophecy formula. Reliability was demonstrated for the three factors by a Cronbach’s alpha of 0.86 for emotional, 0.88 for instrumental, and 0.84 for informational support. Predictive validity was not discussed.

Matich and Sims Scale

The purpose of Matich and Sims’ (1992) scale is to discover various aspects of social support perceived by women in Pennsylvania during their last trimester of pregnancy and 3 to 4 weeks after breastfeeding. No theoretical framework was discussed. The instrument is divided into three domains: tangible, emotional, and informational support. Higher scores indicate increased levels of support from a variety of individuals including the baby’s father, relatives, and physicians. The instrument has not been used since original development.

Experts in the fields of nutrition and social support measurement assessed the content validity of the instrument. Testing for construct validity was conducted with factor analysis, principal components analysis, and orthogonal rotation factors on 85 women who intended to breastfeed and 74 women who intended to bottle feed. Factor analysis resulted in a three-factor solution: tangible, emotional, and informational support. Reliability was demonstrated by Cronbach’s alpha of 0.88, 0.93, and 0.94, respectively. Predictive validity was not tested.

Although each of these instruments offers strengths, some are more robust or appropriate than others.

Theoretical Framework

Ajzen’s Theory of Planned Behavior was the most widely applied. It was used by three of eight attitudes and knowledge instruments and one of eight social support instruments ( Ajzen, 1991 ). Two social support instruments incorporated socioecological frameworks congruent ( Bronfenbrenner, 2009 ) with the multilevel attributes of social support. However, the majority of instruments (i.e., five attitudes and knowledge; four social support) did not mention any theoretical framework. The omission of a description of theoretical underpinnings is a weakness in these respective instruments (see Tables ​ Tables1 1 and ​ and2) 2 ) ( Grant & Osanloo, 2014 ).

A well-developed instrument should not only be based on a theoretical framework, but the relevant domains or constructs (also reported as factors by some authors) should be articulated. The elaboration of domains being measured helps researchers understand the meaning behind instrument results. Presumably, all instruments intended to measure components of attitudes, knowledge, or social support; however, the lack of explanation regarding the conceptual and operational definitions behind item development and the domain that each item was intending to measure makes interpretation of instrument results and its adaptation more challenging.

Only two attitudes and knowledge instruments identified domains (i.e., breastfeeding sentiment, breastfeeding control from the PIFS; breastfeeding sentiment, professional support, and family support from the BAPT), which represents a major comparative advantage of these instruments. It is interesting that the domains were similarly defined, which may be attributed to the fact that both used Ajzen’s Theory of Planned Behavior as their theoretical framework.

All but one (i.e., modified BAPT) social support instrument discussed domains in their instrument development process. Given that social support comes from many different venues (e.g., workplace, family), selecting a suitable social support instrument is highly germane to the research topic. Thus, taking domains into consideration is one point of consideration when evaluating existing social support instruments for future work.

Instruments with both strong content and construct validity are obviously more likely to be measuring intended constructs. For all instruments, nurses, lactation experts, or nutrition experts were the professionals called upon to evaluate content validity with varying degrees of intensity. However, two out of eight attitudes and knowledge instruments (i.e., IIFAS, BrAS) failed to describe content validity (see Table 3 ), which is a major weakness (all of the social support instruments discussed content validity) (see Table 4 ).

Lack of assessment of construct validity means that we cannot know if the instrument is valid and decreases our ability to critique if the instrument is measuring its intended domains. It also diminishes our ability to evaluate the reliability of the data; given data with strong reliability but lacking validation may mean that the data are showing reliable strength toward a construct that is unknown. Four of the eight attitudes and knowledge instruments did not discuss construct validity; however, reliability of the data was reported for all instruments. An omission of complete construct validity (i.e., factor analysis) leads to instrument development research results being less confident of meaningful results in an adapted version.

In contrast, of the social support instruments, all but two (i.e., Utilization of Support Network Questionnaire, modified BAPT) reported on the construct validity. All but one (i.e., EPBSQ) reported a Cronbach’s alpha and otherwise all had Cronbach’s alpha coefficients ≥ 0.80, except for the BAPT (Cronbach’s alpha = 0.75), indicating stronger internal consistency among all social support instruments. The IIFAS has been adapted for use in other settings more than any other attitudes and knowledge scale (see Table 5 ). Although the IIFAS had some limitations in original testing, subsequent adaptations reported higher, but not ideal, reliability of the data from 0.73 to 0.86.

Predictive validity was discussed in four attitudes and knowledge instruments (i.e., IIFAS, PIFS, BMEE, BAPT). Predictive validity was evaluated based on certain breastfeeding behaviors, such as initiation, duration, early weaning in preterm infants, or human milk expression. The four instruments evaluating if their items predicted breastfeeding behavior had strong results (see Table 5 ), showcasing how that instrument may be used for screening or proactively targeting individual-level attitudes and knowledge to ensure greater breastfeeding practice.

Only two social support instruments looked at predictive validity; that is, the proportion of relatives who breastfed (for the modified BAPT) and the supportiveness of the workplace environments and social support (i.e., PBSAT) were indeed predicted by the respective scales. Researchers interested in these specific components to predictive outcomes from breastfeeding attitudes and knowledge or social support may find an instrument with strong predictive validity results more useful (i.e., IIFAS, PIFS, BMEE, BAPT, modified BAPT, PBSAT). Testing predictive validity provides valuable feedback on how the constructs being measured in the instrument affect actual breastfeeding outcomes (e.g., initiation, duration) and strengthen the instrument development process.

Number of Items

An instrument’s number of items has great implications for its likelihood of adaptation by researchers, mostly due to participant burden and resources required to administer and analyze ( McCoach et al., 2013 ). Half of all instruments had 10 to 20 item numbers, whereas three attitudes and knowledge instruments had 78 or more items, which is more or less unrealistic in most settings. A longer instrument is not always more informative, and a factor analysis of initial scale items may be useful for paring down items prior to widespread implementation.

Adaptability is an important consideration in choosing an instrument to use in a novel setting. For attitudes and knowledge, six of eight instruments were adapted by authors in other settings at least once. The IIFAS and BAPT have been used many times outside of their original setting (e.g., Lebanon, South Africa, Canada, Malawi, Continental United States), whereas others (i.e., Australian Breastfeeding Knowledge and Attitude Questionnaire, PIFS, BMEE) have been adapted within a similar population to the original development testing by the original author ( de la Mora et al., 1999 ; Janke, 1992 ). In addition, despite the lack of reports on original validity results, authors adapting the BBQ reported strong test-retest reliability findings. This reporting enhances the field’s overall knowledge and confidence in the BBQ, and more generally, research adapting existing instruments can add to the field’s body of knowledge by reporting on validation testing and reliability.

For social support instruments, only half have been adapted, with the HBSS being the most frequent (two times). The variation in types of social support needed (e.g., family, friends, workplace) may account for the lack of adaptation or use in novel settings. The IIFAS has been adapted more than any other instrument; however, data from these adaptations (in addition to original testing) show some weaknesses (e.g., Cronbach’s alpha = 0.64, Charafeddine et al., 2015 ; 0.79, Van Wagenen, Magnusson, & Neiger, 2015 ) in reliability results. In addition, language/concepts used in the IIFAS may be confusing or too advanced for some populations (e.g., “weaned” and “nutritional benefits”). Reasons for this more frequent adaptation could be for the ability to compare across sites or that its items are relevant in many settings. Rigorous cross-cultural adaptation ensures a more meaningful instrument when choosing to use any existing instrument in novel settings.

Conclusion and Practice Guidelines

In conclusion, although there are a multitude of instruments available for the assessment of attitudes and knowledge and social support, there is no clear best one. We can, however, offer some considerations when selecting and implementing these assessments. We recommend that researchers answer the following questions as they select the scale that best fits their needs.

Purpose: What is the purpose of the assessment?

A first step in instrument selection is to identify the purpose of the measurement. This means to clarify the outcome of interest (e.g., any breastfeeding, EBF). The specificity of some of these instruments makes it very clear that one could be more fitting if the purposes match the interest, for example, adolescent breastfeeding attitudes or intention in the prenatal period. However, the lack of demonstrated validity/reliability for some of these should give pause to uncritical adaptation.

Defining purpose also means to be clear about the target audience (e.g., policy makers, expectant parents, clinicians) for this information and what the data will be used for (e.g., monitor at-risk dyads, assess changes in behavior over time, measure program effect, evaluate programs and policies, or advocacy). This will help to identify the data that will be most compelling.

Comparability: How important is comparability?

For the ability to compare levels of social support, attitudes, or knowledge across settings, it is ideal to use instruments that have been previously used. Should any national- or international-level endeavors to assess this occur, it will be very important to harmonize instruments to collect analogous data.

Validation: Are you measuring what you think you are measuring?

Validity testing is critical to report for both original instrument development and cross-cultural adaption of an existing instrument. In this review, construct validity was reported in varying degrees of depth and methodologies. A systematic approach to testing that includes content and construct validity as well as reliability and the depth of reporting such results would make comparisons across instruments and the adaptation of them more feasible (instrument development and psychometric testing are outlined by McCoach et al., 2013 ).

Likewise, adapting an instrument cross-culturally requires validation among the target population. This is a procedure that is often unclear to health researchers and clinicians. This process includes testing the adapted version with a sample of the population of interest and performing construct validity analysis (e.g., factor analysis and Cronbach’s alpha). Sample size is dependent on the number of constructs being measured and the items making up that construct (see McCoach et al., 2013 , as a guide). Disseminating the process of and findings from cross-cultural adaptation can build knowledge in the field as well as serve as a guide for other researchers considering adapting an existing instrument. Using multiple validation steps to ensure effective translation and cultural fit is considered best practice ( Beaton, Bombardier, Guillemin, & Ferraz, 2000 ).

Resources to implement: How much money, participant time, and analytic skill do you have?

Time to administer and effort to analyze are another consideration. Administering a 78-item questionnaire measuring one construct is often impractical. In a study measuring multiple constructs, the number of items that effectively measures one is an important consideration in order to reduce participant burden.

Implications for Future Research

As future work on scale development occurs, we would also make several pleas. First, each scale created should report (1) how the instrument was developed, including its purpose, theoretical framework, constructs being measured, and their conceptual and operational definitions, and (2) how the instrument was tested, including methodology for testing (i.e., sample, setting, how instrument was administered) and psychometric results, including validity (content, construct, predictive) and reliability.

Second, each scale being adapted should report (1) an overview of the existing instrument being adapted, (2) cross-cultural adaptation methodology undertaken, (3) adaptations or changes made to the original instrument, results from translation, or content validity index scoring, and (4) findings from psychometric testing of the adapted instrument. They should also publish the scales as online supplemental material. In the case of this review, obtaining the original scales was difficult or, for some, impossible.

In sum, by laying out that which is currently available for adaptation and use by researchers and practitioners and suggesting considerations with subsequent scale implementations, it is our intention that this review will facilitate the improved assessment of these important determinants of breastfeeding.

Acknowledgments

ELT and SLY were supported by F31MH099990 and K01 MH098902, respectively, from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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• Open access
• Published: 26 November 2021

Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature

• Bridget Beggs 1 ,
• Liza Koshy 1 &
• Elena Neiterman 1  

BMC Public Health volume  21 , Article number:  2169 ( 2021 ) Cite this article

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Despite public health efforts to promote breastfeeding, global rates of breastfeeding continue to trail behind the goals identified by the World Health Organization. While the literature exploring breastfeeding beliefs and practices is growing, it offers various and sometimes conflicting explanations regarding women’s attitudes towards and experiences of breastfeeding. This research explores existing empirical literature regarding women’s perceptions about and experiences with breastfeeding. The overall goal of this research is to identify what barriers mothers face when attempting to breastfeed and what supports they need to guide their breastfeeding choices.

This paper uses a scoping review methodology developed by Arksey and O’Malley. PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched utilizing a predetermined string of keywords. After removing duplicates, papers published in 2010–2020 in English were screened for eligibility. A literature extraction tool and thematic analysis were used to code and analyze the data.

In total, 59 papers were included in the review. Thematic analysis showed that mothers tend to assume that breastfeeding will be easy and find it difficult to cope with breastfeeding challenges. A lack of partner support and social networks, as well as advice from health care professionals, play critical roles in women’s decision to breastfeed.

While breastfeeding mothers are generally aware of the benefits of breastfeeding, they experience barriers at individual, interpersonal, and organizational levels. It is important to acknowledge that breastfeeding is associated with challenges and provide adequate supports for mothers so that their experiences can be improved, and breastfeeding rates can reach those identified by the World Health Organization.

Peer Review reports

Public health efforts to educate parents about the importance of breastfeeding can be dated back to the early twentieth century [ 1 ]. The World Health Organization is aiming to have at least half of all the mothers worldwide exclusively breastfeeding their infants in the first 6 months of life by the year 2025 [ 2 ], but it is unlikely that this goal will be achieved. Only 38% of the global infant population is exclusively breastfed between 0 and 6 months of life [ 2 ], even though breastfeeding initiation rates have shown steady growth globally [ 3 ]. The literature suggests that while many mothers intend to breastfeed and even make an attempt at initiation, they do not always maintain exclusive breastfeeding for the first 6 months of life [ 4 , 5 ]. The literature identifies various barriers, including return to paid employment [ 6 , 7 ], lack of support from health care providers and significant others [ 8 , 9 ], and physical challenges [ 9 ] as potential factors that can explain premature cessation of breastfeeding.

From a public health perspective, the health benefits of breastfeeding are paramount for both mother and infant [ 10 , 11 ]. Globally, new mothers following breastfeeding recommendations could prevent 974,956 cases of childhood obesity, 27,069 cases of mortality from breast cancer, and 13,644 deaths from ovarian cancer per year [ 11 ]. Global economic loss due to cognitive deficiencies resulting from cessation of breastfeeding has been calculated to be approximately USD $285.39 billion dollars annually [ 11 ]. Evidently, increasing exclusive breastfeeding rates is an important task for improving population health outcomes. While public health campaigns targeting pregnant women and new mothers have been successful in promoting breastfeeding, they also have been perceived as too aggressive [ 12 ] and failing to consider various structural and personal barriers that may impact women’s ability to breastfeed [ 1 ]. In some cases, public health messaging itself has been identified as a barrier due to its rigid nature and its lack of flexibility in guidelines [ 13 ]. Hence, while the literature on women’s perceptions regarding breastfeeding and their experiences with breastfeeding has been growing [ 14 , 15 , 16 ], it offers various, and sometimes contradictory, explanations on how and why women initiate and maintain breastfeeding and what role public health messaging plays in women’s decision to breastfeed.

The complex array of the barriers shaping women’s experiences of breastfeeding can be broadly categorized utilizing the socioecological model, which suggests that individuals’ health is a result of the interplay between micro (individual), meso (institutional), and macro (social) factors [ 17 ]. Although previous studies have explored barriers and supports to breastfeeding, the majority of articles focus on specific geographic areas (e.g. United States or United Kingdom), workplaces, or communities. In addition, very few articles focus on the analysis of the interplay between various micro, meso, and macro-level factors in shaping women’s experiences of breastfeeding. Synthesizing the growing literature on the experiences of breastfeeding and the factors shaping these experiences, offers researchers and public health professionals an opportunity to examine how various personal and institutional factors shape mothers’ breastfeeding decision-making. This knowledge is needed to identify what can be done to improve breastfeeding rates and make breastfeeding a more positive and meaningful experience for new mothers.

The aim of this scoping review is to synthesize evidence gathered from empirical literature on women’s perceptions about and experiences of breastfeeding. Specifically, the following questions are examined:

What does empirical literature report on women’s perceptions on breastfeeding?

What barriers do women face when they attempt to initiate or maintain breastfeeding?

What supports do women need in order to initiate and/or maintain breastfeeding?

Focusing on women’s experiences, this paper aims to contribute to our understanding of women’s decision-making and behaviours pertaining to breastfeeding. The overarching aim of this review is to translate these findings into actionable strategies that can streamline public health messaging and improve breastfeeding education and supports offered by health care providers working with new mothers.

This research utilized Arksey & O’Malley’s [ 18 ] framework to guide the scoping review process. The scoping review methodology was chosen to explore a breadth of literature on women’s perceptions about and experiences of breastfeeding. A broad research question, “What does empirical literature tell us about women’s experiences of breastfeeding?” was set to guide the literature search process.

Search methods

The review was undertaken in five steps: (1) identifying the research question, (2) identifying relevant literature, (3) iterative selection of data, (4) charting data, and (5) collating, summarizing, and reporting results. The inclusion criteria were set to empirical articles published between 2010 and 2020 in peer-reviewed journals with a specific focus on women’s self-reported experiences of breastfeeding, as well as how others see women’s experiences of breastfeeding. The focus on women’s perceptions of breastfeeding was used to capture the papers that specifically addressed their experiences and the barriers that they may encounter while breastfeeding. Only articles written in English were included in the review. The keywords utilized in the search strategy were developed in collaboration with a librarian (Table  1 ). PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched for the empirical literature, yielding a total of 2885 results.

Search outcome

The articles deemed to fit the inclusion criteria ( n  = 213) were imported into RefWorks, an online reference manager tool and further screened for eligibility (Fig.  1 ). After the removal of 61 duplicates and title/abstract screening, 152 articles were kept for full-text review. Two independent reviewers assessed the papers to evaluate if they met the inclusion criteria of having an explicit analytic focus on women’s experiences of breastfeeding.

Prisma Flow Diagram

Quality appraisal

Consistent with scoping review methodology [ 18 ], the quality of the papers included in the review was not assessed.

Data abstraction

A literature extraction tool was created in MS Excel 2016. The data extracted from each paper included: (a) authors names, (b) title of the paper, (c) year of publication, (d) study objectives, (e) method used, (f) participant demographics, (g) country where the study was conducted, and (h) key findings from the paper.

Thematic analysis was utilized to identify key topics covered by the literature. Two reviewers independently read five papers to inductively generate key themes. This process was repeated until the two reviewers reached a consensus on the coding scheme, which was subsequently applied to the remainder of the articles. Key themes were added to the literature extraction tool and each paper was assigned a key theme and sub-themes, if relevant. The themes derived from the analysis were reviewed once again by all three authors when all the papers were coded. In the results section below, the synthesized literature is summarized alongside the key themes identified during the analysis.

In total, 59 peer-reviewed articles were included in the review. Since the review focused on women’s experiences of breastfeeding, as would be expected based on the search criteria, the majority of articles ( n  = 42) included in the sample were qualitative studies, with ten utilizing a mixed method approach (Fig.  2 ). Figure  3 summarizes the distribution of articles by year of publication and Fig.  4 summarizes the geographic location of the study.

Types of Articles

Years of Publication

Countries of Focus Examined in Literature Review

Perceptions about breastfeeding

Women’s perceptions about breastfeeding were covered in 83% ( n  = 49) of the papers. Most articles ( n  = 31) suggested that women perceived breastfeeding as a positive experience and believed that breastfeeding had many benefits [ 19 , 20 ]. The phrases “breast is best” and “breastmilk is best” were repeatedly used by the participants of studies included in the reviewed literature [ 21 ]. Breastfeeding was seen as improving the emotional bond between the mother and the child [ 20 , 22 , 23 ], strengthening the child’s immune system [ 24 , 25 ], and providing a booster to the mother’s sense of self [ 1 , 26 ]. Convenience of breastfeeding (e.g., its availability and low cost) [ 19 , 27 ] and the role of breastfeeding in weight loss during the postpartum period were mentioned in the literature as other factors that positively shape mothers’ perceptions about breastfeeding [ 28 , 29 ].

The literature suggested that women’s perceptions of breastfeeding and feeding choices were also shaped by the advice of healthcare providers [ 30 , 31 ]. Paradoxically, messages about the importance and relative simplicity of breastfeeding may also contribute to misalignment between women’s expectations and the actual experiences of breastfeeding [ 32 ]. For instance, studies published in Canada and Sweden reported that women expected breastfeeding to occur “naturally”, to be easy and enjoyable [ 23 ]. Consequently, some women felt unprepared for the challenges associated with initiation or maintenance of breastfeeding [ 31 , 33 ]. The literature pointed out that mothers may feel overwhelmed by the frequency of infant feedings [ 26 ] and the amount as well as intensity of physical difficulties associated with breastfeeding initiation [ 33 ]. Researchers suggested that since many women see breastfeeding as a sign of being a “good” mother, their inability to breastfeed may trigger feelings of personal failure [ 22 , 34 ].

Women’s personal experiences with and perceptions about breastfeeding were also influenced by the cultural pressure to breastfeed. Welsh mothers interviewed in the UK, for instance, revealed that they were faced with judgement and disapproval when people around them discovered they opted out of breastfeeding [ 35 ]. Women recalled the experiences of being questioned by others, including strangers, when they were bottle feeding their infants [ 9 , 35 , 36 ].

Barriers to breastfeeding

The vast majority ( n  = 50) of the reviewed literature identified various barriers for successful breastfeeding. A sizeable proportion of literature (41%, n  = 24) explored women’s experiences with the physical aspects of breastfeeding [ 23 , 33 ]. In particular, problems with latching and the pain associated with breastfeeding were commonly cited as barriers for women to initiate breastfeeding [ 23 , 28 , 37 ]. Inadequate milk supply, both actual and perceived, was mentioned as another barrier for initiation and maintenance of breastfeeding [ 33 , 37 ]. Breastfeeding mothers were sometimes unable to determine how much milk their infants consumed (as opposed to seeing how much milk the infant had when bottle feeding), which caused them to feel anxious and uncertain about scheduling infant feedings [ 28 , 37 ]. Women’s inability to overcome these barriers was linked by some researchers to low self-efficacy among mothers, as well as feeling overwhelmed or suffering from postpartum depression [ 38 , 39 ].

In addition to personal and physical challenges experienced by mothers who were planning to breastfeed, the literature also highlighted the importance of social environment as a potential barrier to breastfeeding. Mothers’ personal networks were identified as a key factor in shaping their breastfeeding behaviours in 43 (73%) articles included in this review. In a study published in the UK, lack of role models – mothers, other female relatives, and friends who breastfeed – was cited as one of the potential barriers for breastfeeding [ 36 ]. Some family members and friends also actively discouraged breastfeeding, while openly questioning the benefits of this practice over bottle feeding [ 1 , 17 , 40 ]. Breastfeeding during family gatherings or in the presence of others was also reported as a challenge for some women from ethnic minority groups in the United Kingdom and for Black women in the United States [ 41 , 42 ].

The literature reported occasional instances where breastfeeding-related decisions created conflict in women’s relationships with significant others [ 26 ]. Some women noted they were pressured by their loved one to cease breastfeeding [ 22 ], especially when women continued to breastfeed 6 months postpartum [ 43 ]. Overall, the literature suggested that partners play a central role in women’s breastfeeding practices [ 8 ], although there was no consistency in the reviewed papers regarding the partners’ expressed level of support for breastfeeding.

Knowledge, especially practical knowledge about breastfeeding, was mentioned as a barrier in 17% ( n  = 10) of the papers included in this review. While health care providers were perceived as a primary source of information on breastfeeding, some studies reported that mothers felt the information provided was not useful and occasionally contained conflicting advice [ 1 , 17 ]. This finding was reported across various jurisdictions, including the United States, Sweden, the United Kingdom and Netherlands, where mothers reported they had no support at all from their health care providers which made it challenging to address breastfeeding problems [ 26 , 38 , 44 ].

Breastfeeding in public emerged as a key barrier from the reviewed literature and was cited in 56% ( n  = 33) of the papers. Examining the experiences of breastfeeding mothers in the United States, Spencer, Wambach, & Domain [ 45 ] suggested that some participants reported feeling “erased” from conversations while breastfeeding in public, rendering their bodies symbolically invisible. Lack of designated public spaces for breastfeeding forced many women to alter their feeding in public and to retreat to a private or a more secluded space, such as one’s personal car [ 25 ]. The oversexualization of women’s breasts was repeatedly noted as a core reason for the United States women’s negative experiences and feelings of self-consciousness about breastfeeding in front of others [ 45 ]. Studies reported women’s accounts of feeling the disapproval or disgust of others when breastfeeding in public [ 46 , 47 ], and some reported that women opted out of breastfeeding in public because they did not want to make those around them feel uncomfortable [ 25 , 40 , 48 ].

Finally, return to paid employment was noted in the literature as a significant challenge for continuation of breastfeeding [ 48 ]. Lack of supportive workplace environments [ 39 ] or inability to express milk were cited by women as barriers for continuing breastfeeding in the United States and New Zealand [ 39 , 49 ].

Supports needed to maintain breastfeeding

Due to the central role family members played in women’s experiences of breastfeeding, support from partners as well as female relatives was cited in the literature as key factors  shaping women’s breastfeeding decisions [ 1 , 9 , 48 ]. In the articles published in Canada, Australia, and the United Kingdom, supportive family members allowed women to share the responsibility of feeding and other childcare activities, which reduced the pressures associated with being a new mother [ 19 , 20 ]. Similarly, encouragement, breastfeeding advice, and validation from healthcare professionals were identified as positively impacting women’s experiences with breastfeeding [ 1 , 22 , 28 ].

Community resources, such as peer support groups, helplines, and in-home breastfeeding support provided mothers with the opportunity to access help when they need it, and hence were reported to be facilitators for breastfeeding [ 19 , 22 , 33 , 44 ]. An increase in the usage of social media platforms, such as Facebook, among breastfeeding mothers for peer support were reported in some studies [ 47 ]. Public health breastfeeding clinics, lactation specialists, antenatal and prenatal classes, as well as education groups for mothers were identified as central support structures for the initiation and maintenance of breastfeeding [ 23 , 24 , 28 , 33 , 39 , 50 ]. Based on the analysis of the reviewed literature, however, access to these services varied greatly geographically and by socio-economic status [ 33 , 51 ]. It is also important to note that local and cultural context played a significant role in shaping women’s perceptions of breastfeeding. For example, a study that explored women’s breastfeeding experiences in Iceland highlighted the importance of breastfeeding in Icelandic society [ 52 ]. Women are expected to breastfeed and the decision to forgo breastfeeding is met with disproval [ 52 ]. Cultural beliefs regarding breastfeeding were also deemed important in the study of  Szafrankska and Gallagher (2016), who noted that Polish women living in Ireland had a much higher rate of initiating breastfeeding compared to Irish women [ 53 ]. They attributed these differences to familial and societal expectations regarding breastfeeding in Poland [ 53 ].

Overall, the reviewed literature suggested that women faced socio-cultural pressure to breastfeed their infants [ 36 , 40 , 54 ]. Women reported initiating breastfeeding due to recognition of the many benefits it brings to the health of the child, even when they were reluctant to do it for personal reasons [ 8 ]. This hints at the success of public health education campaigns on the benefits of breastfeeding, which situates breastfeeding as a new cultural norm [ 24 ].

This scoping review examined the existing empirical literature on women’s perceptions about and experiences of breastfeeding to identify how public health messaging can be tailored to improve breastfeeding rates. The literature suggests that, overall, mothers are aware of the positive impacts of breastfeeding and have strong motivation to breastfeed [ 37 ]. However, women who chose to breastfeed also experience many barriers related to their social interactions with significant others and their unique socio-cultural contexts [ 25 ]. These different factors, summarized in Fig.  5 , should be considered in developing public health activities that promote breastfeeding. Breastfeeding experiences for women were very similar across the United Kingdom, United States, Canada, and Australia based on the studies included in this review. Likewise, barriers and supports to breastfeeding identified by women across the countries situated in the global north were quite similar. However, local policy context also impacted women’s experiences of breastfeeding. For example, maintaining breastfeeding while returning to paid employment has been identified as a challenge for mothers in the United States [ 39 , 45 ], a country with relatively short paid parental leave. Still, challenges with balancing breastfeeding while returning to paid employment were also noticed among women in New Zealand, despite a more generous maternity leave [ 49 ]. This suggests that while local and institutional policies might shape women’s experiences of breastfeeding, interpersonal and personal factors can also play a central role in how long they breastfeed their infants. Evidently, the importance of significant others, such as family members or friends, in providing support to breastfeeding mothers was cited as a key facilitator for breastfeeding across multiple geographic locations [ 29 , 34 , 48 ]. In addition, cultural beliefs and practices were also cited as an important component in either promoting breastfeeding or deterring women’s desire to initiate or maintain breastfeeding [ 15 , 29 , 37 ]. Societal support for breastfeeding and cultural practices can therefore partly explain the variation in breastfeeding rates across different countries [ 15 , 21 ]. Figure  5 summarizes the key barriers identified in the literature that inhibit women’s ability to breastfeed.

Barriers to Breastfeeding

At the individual level, women might experience challenges with breastfeeding stemming from various physiological and psychological problems, such as issues with latching, perceived or actual lack of breastmilk, and physical pain associated with breastfeeding. The onset of postpartum depression or other psychological problems may also impact women’s ability to breastfeed [ 54 ]. Given that many women assume that breastfeeding will happen “naturally” [ 15 , 40 ] these challenges can deter women from initiating or continuing breastfeeding. In light of these personal challenges, it is important to consider the potential challenges associated with breastfeeding that are conveyed to new mothers through the simplified message “breast is best” [ 21 ]. While breastfeeding may come easy to some women, most papers included in this review pointed to various challenges associated with initiating or maintaining breastfeeding [ 19 , 33 ]. By modifying public health messaging regarding breastfeeding to acknowledge that breastfeeding may pose a challenge and offering supports to new mothers, it might be possible to alleviate some of the guilt mothers experience when they are unable to breastfeed.

Barriers that can be experienced at the interpersonal level concern women’s communication with others regarding their breastfeeding choices and practices. The reviewed literature shows a strong impact of women’s social networks on their decision to breastfeed [ 24 , 33 ]. In particular, significant others – partners, mothers, siblings and close friends – seem to have a considerable influence over mothers’ decision to breastfeed [ 42 , 53 , 55 ]. Hence, public health messaging should target not only mothers, but also their significant others in developing breastfeeding campaigns. Social media may also be a potential medium for sharing supports and information regarding breastfeeding with new mothers and their significant others.

There is also a strong need for breastfeeding supports at the institutional and community levels. Access to lactation consultants, sound and practical advice from health care providers, and availability of physical spaces in the community and (for women who return to paid employment) in the workplace can provide more opportunities for mothers who want to breastfeed [ 18 , 33 , 44 ]. The findings from this review show, however, that access to these supports and resources vary greatly, and often the women who need them the most lack access to them [ 56 ].

While women make decisions about breastfeeding in light of their own personal circumstances, it is important to note that these circumstances are shaped by larger structural, social, and cultural factors. For instance, mothers may feel reluctant to breastfeed in public, which may stem from their familiarity with dominant cultural perspectives that label breasts as objects for sexualized pleasure [ 48 ]. The reviewed literature also showed that, despite the initial support, mothers who continue to breastfeed past the first year may be judged and scrutinized by others [ 47 ]. Tailoring public health care messaging to local communities with their own unique breastfeeding-related beliefs might help to create a larger social change in sociocultural norms regarding breastfeeding practices.

The literature included in this scoping review identified the importance of support from community services and health care providers in facilitating women’s breastfeeding behaviours [ 22 , 24 ]. Unfortunately, some mothers felt that the support and information they received was inadequate, impractical, or infused with conflicting messaging [ 28 , 44 ]. To make breastfeeding support more accessible to women across different social positions and geographic locations, it is important to acknowledge the need for the development of formal infrastructure that promotes breastfeeding. This includes training health care providers to help women struggling with breastfeeding and allocating sufficient funding for such initiatives.

Overall, this scoping review revealed the need for healthcare professionals to provide practical breastfeeding advice and realistic solutions to women encountering difficulties with breastfeeding. Public health messaging surrounding breastfeeding must re-invent breastfeeding as a “family practice” that requires collaboration between the breastfeeding mother, their partner, as well as extended family to ensure that women are supported as they breastfeed [ 8 ]. The literature also highlighted the issue of healthcare professionals easily giving up on women who encounter problems with breastfeeding and automatically recommending the initiation of formula use without further consideration towards solutions for breastfeeding difficulties [ 19 ]. While some challenges associated with breastfeeding are informed by local culture or health care policies, most of the barriers experienced by breastfeeding women are remarkably universal. Women often struggle with initiation of breastfeeding, lack of support from their significant others, and lack of appropriate places and spaces to breastfeed [ 25 , 26 , 33 , 39 ]. A change in public health messaging to a more flexible messaging that recognizes the challenges of breastfeeding is needed to help women overcome negative feelings associated with failure to breastfeed. Offering more personalized advice and support to breastfeeding mothers can improve women’s experiences and increase the rates of breastfeeding while also boosting mothers’ sense of self-efficacy.

Limitations

This scoping review has several limitations. First, the focus on “women’s experiences” rendered broad search criteria but may have resulted in the over or underrepresentation of specific findings in this review. Also, the exclusion of empirical work published in languages other than English rendered this review reliant on the papers published predominantly in English-speaking countries. Finally, consistent with Arksey and O’Malley’s [ 18 ] scoping review methodology, we did not appraise the quality of the reviewed literature. Notwithstanding these limitations, this review provides important insights into women’s experiences of breastfeeding and offers practical strategies for improving dominant public health messaging on the importance of breastfeeding.

Women who breastfeed encounter many difficulties when they initiate breastfeeding, and most women are unsuccessful in adhering to current public health breastfeeding guidelines. This scoping review highlighted the need for reconfiguring public health messaging to acknowledge the challenges many women experience with breastfeeding and include women’s social networks as a target audience for such messaging. This review also shows that breastfeeding supports and counselling are needed by all women, but there is also a need to tailor public health messaging to local social norms and culture. The role social institutions and cultural discourses have on women’s experiences of breastfeeding must also be acknowledged and leveraged by health care professionals promoting breastfeeding.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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The authors would like to acknowledge the assistance of Jackie Stapleton, the University of Waterloo librarian, for her assistance with developing the search strategy used in this review.

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BB was responsible for the formal analysis and organization of the review. LK was responsible for data curation, visualization and writing the original draft. EN was responsible for initial conceptualization and writing the original draft. BB and LK were responsible for reviewing and editing the manuscript. All authors read and approved the final manuscript.

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BB is completing her Bachelor of Science (BSc) degree at the School of Public Health Sciences at the University of Waterloo.

LK is completing her Bachelor of Public Health (BPH) degree at the School of Public Health Sciences at the University of Waterloo.

EN (PhD), is a continuing lecturer at the School of Public Health Sciences at the University of Waterloo. Her areas of expertise are in women’s reproductive health and sociology of health, illness, and healthcare.

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Beggs, B., Koshy, L. & Neiterman, E. Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature. BMC Public Health 21 , 2169 (2021). https://doi.org/10.1186/s12889-021-12216-3

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