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Abstract

Background:

Although challenges in breastfeeding are more common in mothers of preterm infants, maternal breastfeeding self-efficacy is a modifiable factor that may improve breastfeeding rates.

Objective:

To evaluate the factors affecting breastfeeding self-efficacy among mothers with preterm babies.

Design:

A cross-sectional study.

Methods:

This study was carried out using a double-stage cluster sampling method. In total, 360 mothers of preterm infants under 6 months of age were included. Data were collected using sociodemographic characteristics, Breastfeeding Self-efficacy Scale-Short Form (BSES-SF), multiple scales of perceived social support, and Depression, Anxiety, and Stress questionnaires.

Results:

The results showed social support (15.6%), depression (12.2%), anxiety (11%), and stress (12.2%) contributed independently, and together they explained 25% of the variance in BSES-SF. The higher levels of social support (β = 0.283), lower levels of mental health problems (β = −0.340), having breastfeeding experience (β = −0.253), and higher gestational age at birth (β = 0.106) were significantly related to the high level of BSES-SF.

Conclusion:

These findings can help healthcare providers be aware of effective factors in improving breastfeeding self-efficacy. Increased access to counselors, active support for mothers after preterm labor, and increased support facilities for mothers with preterm delivery may be helpful to improve breastfeeding self-efficacy.

Plain language summary

Can the status of social support and psychological factors of women with preterm babies affect their breastfeeding efficiency?

Why we did this study: There is little evidence of current factors affecting breastfeeding self-efficacy among mothers of preterm infants in Iran.

What we wanted to learn: We wanted to know, if there is a relationship between perceived social support and the mental health of mothers with preterm babies, their self-efficacy, and their sense of breastfeeding ability. Additionally, we investigated the impact of other socio-demographic factors.

What we did: We asked mothers of preterm infants to complete breastfeeding self-efficacy, perceived social support, and depression, anxiety, and stress questionnaires.

What we learned: We found that Iranian mothers of preterm infants had very low rates of breastfeeding self-efficacy. Factors associated with breastfeeding self-efficacy included higher levels of social support, lower levels of mental health problems, previous breastfeeding experience, and higher gestational age at birth. Support and education are needed for mothers of preterm infants and their families to facilitate breastfeeding.

Keywords

breastfeeding self-efficacy preterm infants social support mental health

Introduction

Today, preterm births are a major public healthcare issue worldwide.¹ Compared with full-term infants, premature infants meet many more challenges.² Based on the evidence, premature birth accounts for more than 3% of the Global Burden of Diseases.³ The rate of preterm labor varies between 5.5% and 20% in Iran.⁴ In the previous systematic and metanalysis study, the overall prevalence of preterm labor, based on the random effects model, was estimated to be a total of 10% (95% confidence interval: 9–12), with the lowest prevalence of preterm labor being 5.4% in Bam, and the highest prevalence was 19.85% in Tehran.⁵ Worldwide, 15 million premature infants are born each year, which is estimated to account for about 11% of all births.⁶ Chawanpaiboon et al. have mentioned a ratio of 10.6% for the worldwide prevalence of preterm labor.⁷ Moreover, preterm infants’ morbidity and mortality rates are more than in full-term babies.^2,3

Studies have demonstrated that breastfeeding improves the growth and development of premature infants,^2,8,9 protects the infant from different types of infections, especially gastrointestinal and respiratory infections, and reduces morbidity and mortality rates.³ Other advantages of breastfeeding include improving the mother’s physical/mental health and her connection with the infant and protecting the mother against gynecologic and breast cancer.^10,11 In other words, breastfeeding benefits infants, mothers, and society. Health organizations in the world recommend that exclusive breastfeeding continues until 6 onths after birth, especially for premature infants.^12,13 Unfortunately, due to various reasons, the statistics on exclusive breastfeeding in Iran and the world are not satisfactory.^14,15 It was reported that 101.1 million children in low- and middle-income countries were not breastfed according to international standards, including encouraging early initiation after birth, exclusive breastfeeding for up to 6 months, and continued breastfeeding to 2 years of age.¹⁶ In Iran, the breastfeeding rate in 2006 was 90% overall, with 57% of infants continuing to be breastfed at 1 year and 2 years of age, respectively.^17,18 The exclusive breastfeeding rates 0–6 months, as measured by the cross-sectional Demographic Health Surveys were 44% in 2000 and 40% in 2004.^18,19 In 2010, exclusive breastfeeding up to 6 months of age was 53.1% in total and 27.8% and 62.8% in the urban and rural areas, respectively.¹⁸ These rates are still below the national targets and international recommendations. According to the report, it is necessary to take basic measures to reach the desired level of exclusive breastfeeding in Iran.¹⁴ The situation is even more unfavorable for premature infants.³ Based on the results of a study in Iran, the prevalence of exclusive breastfeeding among full-term babies was 57%, whereas it was 46.5% among preterm babies. Although the rate of exclusive breastfeeding was lower in preterm babies than in full-term babies, this difference was not statistically significant.²⁰ However, another study in Iran found that gestational age less than 37 weeks at birth was a predictor of discontinuing and stopping exclusive breastfeeding.²¹ Furthermore, research indicates that a smaller percentage of preterm infants are breastfed exclusively at discharge compared to term infants. For example, only 45% of preterm infants in Sweden²² and 68% in Denmark²³ are breastfed exclusively at discharge, compared to 75% of 10-day-old term infants.²⁴ Outside Scandinavia, exclusive breastfeeding rates at discharge are often lower: 55% of preterm infants in Australia,²⁵ 22% in the United States for very preterm infants,²⁶ and 20% in a European study across 11 countries.²⁷

Breastfeeding initiation in premature infants is typically more complex than in full-term infants due to their developmental immaturity.²⁸ These babies are much less alert and have more challenges with sucking and swallowing,²⁹ and the incidence of breastfeeding full-term children continues to be more than that of preterm babies.^1,28 This can be explained by the fact that the vulnerable position of women with premature babies can affect their attachment to babies and their breastfeeding behavior.³⁰ Previous studies have referred to several factors that can be effective in starting and continuing the breastfeeding process, such as personal attributes, health status, and psychological factors like self-efficacy are included as essential factors.^9,31,32 The mentioned items are of potential importance, especially in the cases of women with preterm babies. Because they face more obstacles than other mothers, which can delay the initiation of breastfeeding,⁸ additional studies must be conducted to recognize better inhibitors and facilitators of breastfeeding in infants, especially preterm infants.³

Breastfeeding self-efficacy of women is defined as the level of understanding and feeling of their ability to start and continue breastfeeding their infant.¹ A study conducted on full-term infants in Sweden reported that self-efficacy scores were lower in mothers who fed their children with formula than those with exclusive breastfeeding.³³ Furthermore, breastfeeding self-efficacy was a predictor factor of the duration of breastfeeding among Chinese women with full-term³⁴ and preterm infants.³⁵ As well as women’s perceived social support and health status can also influence the level of breastfeeding self-efficacy.¹³ Social support is a key factor that increases the probability of breastfeeding, especially in women with preterm babies,¹ and family support is especially important in this regard.³⁶ Reportedly, social support can predict the chance of exclusive breastfeeding for 6 months after birth.³⁷ Moreover, although many researchers have identified an association between breastfeeding and mental health status like postpartum depression, few studies have directly evaluated the association between breastfeeding self-efficacy with mood status.^38,39 Focusing on factors that affect breastfeeding is the best way to achieve successful breastfeeding; however, there are not adequate studies about the experience of breastfeeding after preterm delivery.⁴⁰ The literature review showed that there was little evidence that could apply to Iranian mothers with preterm infants, particularly in the area of breastfeeding. Therefore, the present study aimed to investigate the factors affecting breastfeeding self-efficacy among women with preterm babies.

Methods

A multicenter cross-sectional study was conducted on Iranian mothers with preterm infants who visited health centers from March to September 2022 in Tabriz, Iran. The inclusion criteria were the ability to read and write, gestation age at birth of 28–37 weeks, maternal age of 18 years or older, having a living and healthy infant, having an infant less than 6 months, and having initiated breastfeeding (exclusive breastfeeding or partial breastfeeding). The exclusion criteria included having formula feeding only, unwillingness to participate in the study, and failure to complete the questionnaire. Reporting followed the STROBE checklist.⁴¹

Sample size and sampling method

The sample size was calculated based on psychological factors reported by Ngo et al.¹³ It was determined to be 240 cases using the following formula, considering a 95% confidence coefficient, 90% statistical power, an acceptable error of 0.07 around the mean (m = 8.3), and the highest standard deviation (SD = 4.6). The final sample size was 360 women, with cluster sampling and a design effect of 1.5:

n = \frac{{(Z_{1} - \frac{α}{2})}^{2} \times s^{2}}{d^{2}} .

Sampling was conducted at health centers. There are 82 public health centers in our city (Tabriz). A double-stage cluster sampling was carried out. We chose 35 health centers using randomizer software, after that the lists of all women of premature infants <6 months were extracted from the health records at each center. After receiving the necessary ethical approval and obtaining sampling permission from the healthcare center authorities, the researcher visited centers where all women have health records. The researcher contacted participants via phone numbers, and if they had inclusion criteria for the study, they were invited to complete the questionnaires in the health center. Only three mothers refused to participate in our study despite sampling continued until the calculated sample size was reached.

Data collection

The data were collected using four questionnaires.

Sociodemographic Information: This included the mother’s and spouse’s age, the mother’s previous breastfeeding experience, gestational age at birth, and the infant’s age and gender.

Multiple Scale of Perceived Social Support Questionnaire (MSPS): The scale has 12 items based on a 7-point Likert questionnaire. Dimensions of the questionnaire included perceived support from family, acquaintances, and friends.⁴² The total score was classified into three categories: low (scores 12–48), moderate (scores 49–68), and high (scores 69–84).⁴³ The validity was confirmed through content analysis and reliability was established using Cronbach’s alpha coefficient (α = 0.86–0.9) for the subscales and 0.86 for the whole instrument in Iran.⁴⁴

Depression, Anxiety, and Stress Scale (DASS-21): The 21-item instrument assesses the three negative affective states over the past month. Scores range from 0 to 21 in each of the three domains and are then multiplied by two to produce a possible score of 0 to 42. We categorized women as minimal (score 0–9), mild (score 10–13), moderate (score 14–20), and severe (score Z21) depressive symptoms. The anxiety subscale was categorized as minimal (score 0–7), mild (score 8–9), moderate (score 10–14), and severe (score Z15) also the stress subscale was categorized as minimal (score 0–14), mild (score 15–18), moderate (score 19–25), and severe (score ⩾ 26).³⁹ In Iran, the validity of DASS has been confirmed using forward–backward translation, factor analysis, and criterion validity. The correlation between the Beck Depression Inventory (BDI) and the depression subscale was 0.7, in the range of the Zung Self-Rating Anxiety Scale (SAS), the anxiety subscale was 0.67, and in the range of the Perceived Stress Scale (PSS), the stress subscale was 0.49. In addition, its reliability was reported to be 0.73 for the anxiety subscale, 0.81 for the depression subscale, and 0.81 for the stress subscale.⁴⁵

Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF): The questionnaire has 14 items and is scored by a 5-point Likert scale (range 14–70), all the items are presented positively, and their scores are summed to produce a total score ranging from 14 to 70. Higher scores were considered the high levels of breastfeeding self-efficacy.⁴⁶ The English version was translated by Amini et al., in Iran, and they reported the Cronbach’s alpha coefficient for internal consistency for the BSES-SF 0.910.⁴⁶ According to Nanishi et al.,⁴⁷ in Japan, interventions to support exclusive breastfeeding might be considered for new mothers who have BSES-SF scores that are less than or equal to 50.

Statistical analyses

We used SPSS-24 software (IBM Corp, Armonk, NY, USA; version. 24. statistical package software) to analyze the data. The association between main variables including sociodemographic, DASS-21, and MSPS (as independent variables) with BSES-SF (as dependent variable) was assessed using the Mann–Whitney and Kruskal–Wallis H tests. Then, independent variables including DASS-21 and MSPS and sociodemographic variables with p ⩽ 0.05 as control variables were inserted into the univariate and multivariate linear regression model (enter method). There were 10% missing data in demographic characteristics, which were imputed with the mean substitution method. The normality of data was assessed with the Kolmogorov–Smirnov test. Since the total BSES-SF score did not follow a normal distribution, it was first converted using a natural logarithm (Ln) transformation before being used in linear regression analysis. All the statistical tests were two-sided, using a significance level of p < 0.05.

Results

The mean (SD) age of mothers was 30.76 (6.70). Most of the participants had high school and university education levels (76.4%) were housewives (85.2%), and had their first child and a monthly family income of <5 million Rials. The average gestational age at birth was 32.96 weeks (SD = 2.41, range 28–37), and most of them were born between 28–33 weeks. Finally, the mean (SD) infant’s age was 3.67 (1.59) months at the time of sampling (Table 1).

Table 1.

Participant sociodemographic characteristics and association with BSES-SF (N = 360).

Variable	n (%)/range (mean(SD))	Total BSES-SF	p-value
Mother’s age groups (year) 18–45 (30.76 (6.70))			<0.001
⩽20	26 (7.2)	42.76 (10.85)
20–30	162 (45.0)	39.56 (13.39)
30–40	133 (36.9)	45.58 (13.90)
⩾40	39 (10.8)	50.02 (6.82)
Mother’s educational status			0.056
Elementary	85 (23.6)	41.62 (14.92)
High school	158 (43.9)	45.06 (12.48)
University	117 (32.5)	41.69 (13.01)
Mother’s employment status			0.97
Housewife	306 (85.2)	43.16 (13.49)
Employed	54 (15.0)	43.09 (12.51)
Spouse’s educational status			0.004
Elementary	53 (14.7)	37.77 (13.40)
High school	154 (42.8)	44.74 (13.86)
University	153 (42.5)	43.41 (12.34)
Spouse’s employment status			0.129
Jobless	4 (1.1)	39.25 (20.27)
Employed	92 (25.6)	40.88 (12.23)
Self-employed	264 (73.3)	44.00 (13.54)
Birth order			0.437
1	208 (57.8)	42.87 (13.16)
2	117 (32.5)	42.82 (13.87)
⩾3	35 (9.7)	45.91 (12.57)
Mothers’ previous breastfeeding experience			<0.001
Yes	116 (32.2)	47.75 (12.07)
No	244 (67.8)	40.96 (13.37)
Infant’s gender			0.459
Female	211 (58.6)	42.72 (13.27)
Male	149 (41.4)	43.79 (13.51)
Gestational age at birth (weeks) 28–37 (32.96 (2.41))			0.026
28–33	182 (50.6)	41.31 (12.55)
34–36	159 (44.2)	45.19 (14.15)
37	19 (5.3)	44.00 (12.11)
Infant’s age (month) 2–6 (3.67 (1.59))			0.270
2	133 (36.9)	41.67 (13.12)
3–4	110 (30.6)	44.18 (12.90)
5–6	117 (32.5)	43.87 (13.93)
Breast milk			<0.001
Exclusive	155 (43.1)	49.30 (12.73)
Partial	205 (56.9)	38.50 (11.83)
Income 1–20 (4.54 (2.93))			0.204
<5 million rials	229 (63.6)	44.10 (13.44)
5–10 million rials	99 (27.5)	41.61 (12.61)
⩾10 million rials	32 (8.9)	41.15 (15.69)

BSES-SF: Breastfeeding Self-Efficacy Scale-Short Form.

In the preliminary analysis, the only statistically significant difference was obtained between mother’s age groups, different levels of spouse’s education, and age at birth with BSES-SF. The total mean scores of BSES-SF in participants of older age, especially those >40 years old were higher than in younger ones (p < 0.001). There was also a significant difference between BSES-SF scores at higher levels of spouse education than primary education (p = 0.004). Infants of women who gave birth at 34 weeks of gestation or later had higher self-efficacy scores than those born before 34 weeks of gestation (p = 0.026). Furthermore, the total score of BSES-SF in women with exclusive was higher than in those with partial breastfeeding (Table 1).

In this study, the mean score of breastfeeding self-efficacy was quite moderate, 43.15 (13.33). Based on the cut point, 184 (51.4%) participants had low breastfeeding self-efficacy. Most participants perceived moderate to high social support (84.2%). Results on the DASS-21 showed that most of the participants had mild-to-severe stress, anxiety, and depression.

According to Table 2, mothers with high perceptions of social support had a statistically significant higher level of self-efficacy than mothers with lower social support (48.20 versus 35.6). And mothers with high mean scores of depression, anxiety, and stress had lower self-efficacy scores than mothers with lower perceptions of depression, anxiety, and stress (37.48 versus 54.57, 40.78 versus 55.20, and 37.8 versus 51.57, respectively) (Table 2).

Table 2.

The score and the association between DASS-21and MSPS with BSES-SF.

Variable	Mean (SD)	Min	Max
Total BSES-SF	43.15 (13.33)	14	70
Total MSPS	60.76 (14.59)	12	84
DASS—depression score	19.30 (8.00)	10	52
DASS—anxiety score	19.93 (9.43)	8	52
DASS—stress score	23.80 (9.91)	10	52
DASS—total score	63.04 (23.01)	30	146
The level of variables	N (%)	Mean (SD)	p-value
Level of social support
Mild	57 (15.8)	35.61 (13.42)	<0.001
Moderate	200 (55.6)	42.70 (12.64)
High	103 (28.6)	48.20 (12.53)
Level of depression
Mild	73 (20.3)	54.57 (7.17)	<0.001
Moderate	171 (47.5)	42.12 (14.7)
Severe	116 (32.2)	37.48 (10.63)
Level of anxiety
Mild	60 (16.7)	55.20 (9.50)	<0.001
Moderate	58 (16.1)	40.60 (11.42)
Severe	242 (67.2)	40.78 (13.98)
Level of stress
Low	88 (24.4)	51.57 (11.98)	<0.001
Mild	50 (13.9)	42.80 (13.12)
Moderate	80 (22.2)	43.58 (13.25)
Severe	142 (39.4)	37.81 (11.51)

BSES-SF: Breastfeeding Self-Efficacy Scale-Short Formal; DASS-21: Depression, Anxiety, and Stress Scale; MSPS: Multiple Scale of Perceived social Support Questionnaire; SD: standard deviation.

The correlations between related factors (social support, depression, anxiety, and stress) and breastfeeding self-efficacy among Iranian mothers with preterm infants were analyzed with the magnitude of the relationship as follows: r < 0.30 = low, r = 0.31–0.50 = moderate, and r > 0.50 = high.¹ Social support had a positive and moderate relationship with breastfeeding self-efficacy (r = 0.378, p < 0.001), whereas depression (r = −0.386 2, p < 0.001), anxiety (r = −0.372, p < 0.001), and stress (r = −0.392, p < 0.001) had a moderate and negative relationship with breastfeeding self-efficacy.

According to the univariate linear model, there was a significant relationship between perceived social support, depression, anxiety, and stress with breastfeeding self-efficacy which they were able to predict 15.6%, 12.2%, 11%, and 12.3% of the variance of breastfeeding self-efficacy score, respectively. After that in models two and three, due to the high alignment of the depression, stress, and anxiety, the total score of (total DASS-21) was used. According to model 2 and multivariate linear regression, the perceived social support and total DASS scores were able to predict 25% of the variance of the breastfeeding self-efficacy score. Finally, based on the multivariate linear model, the perceived social support, total DASS scores, mother’s age, gestational age at birth, mother’s previous breastfeeding experience, and level of spouse’s education were able to predict 31.5% of the variance of breastfeeding self-efficacy score. The higher perceived social support, lower total DASS scores, higher gestational age at birth, and having mothers’ previous breastfeeding experience were significant predictors of the high level of breastfeeding self-efficacy (Table 3).

Table 3.

Univariate and multivariant linear regression analysis of breastfeeding self-efficacy.

Predictors	R	R ²	R ² _adj	p-value	B	S.E	β	95% CI	F
Model 1
Perceived social support	0.398	0.158	0.156	<0.001	0.010	0.001	0.398	0.007 to 0.012	67.30
Depression	0.353	0.125	0.122	<0.001	−0.015	0.002	−0.353	−0.020 to −0.011	51.00
Anxiety	0.335	0.112	0.110	<0.001	−0.012	0.002	−0.335	−0.016 to −0.009	45.19
Stress	0.351	0.123	0.121	<0.001	−0.012	0.002	−0.351	−0.016 to −0.009	50.42
Model 2
	0.504	0.254	0.250	<0.001					60.77
Perceived social support				<0.001	0.007	0.001	0.304	0.398 to 0.320
Total DASS				<0.001	−0.005	0.001	−0.323	−0.411 to 0.337
Model 3
	0.571	0.327	0.315	<0.001					28.52
Perceived social support				<0.001	0.007	0.001	0.283	0.005 to 0.009
Total DASS				<0.001	−0.005	0.001	−0.340	−0.007 to −0.004
Mother’s age				0.090	0.004	0.002	0.081	−0.001 to 0.009
Gestational age at birth				0.020	0.062	0.027	0.106	0.010 to 0.114
Spouse’s educational status				0.723	0.008	0.023	0.016	−0.036 to 0.052
Mothers’ previous breastfeeding experience				<0.001	−0.190	0.035	−0.253	−0.258 to −0.121

CI: confidence interval; DASS: Depression, Anxiety, And Stress Scale.

Discussion

Considering the many social and structural inequities that may influence a woman’s ability to imitate breastfeeding, being aware of obstacles and challenges is important to designing interventions, especially in women with premature infants. This study aimed to evaluate the factors affecting breastfeeding self-efficacy among women with preterm babies. Based on the obtained results in the present study, significant predictors of high breastfeeding self-efficacy included a high level of social support; a low level of depression, anxiety, and stress; higher gestational age at birth; and a history of previous breastfeeding.

In this study, more than half of the mothers with a preterm infant had a lower level of breastfeeding self-efficacy, indicating the low confidence of mothers with premature babies regarding their breastfeeding ability. Although in our study the number of mothers with exclusive breastfeeding was less than mothers with partial breastfeeding, they had higher level of breastfeeding self-efficacy compared to mothers with partial breastfeeding. Nankumbi et al. reported the same results and attributed the low self-efficacy of these mothers to the lack of adequate education or information on breastfeeding that should have been offered by healthcare providers.⁴⁸ Similarly, the total means self-efficacy score was low in the study by Zhu et al. since most participants were first-time mothers with no prior breastfeeding experience.⁴⁹ However, the total mean score of breastfeeding self-efficacy was higher in studies conducted in Australia⁵⁰ and Vietnam¹³ found the mean scores of breastfeeding self-efficacy higher than in our study. This difference could be attributed to the timing of the study, specifically the gestational age at birth and the period following delivery when the study was conducted. Mothers of babies born between 28 and 32 weeks may have lower breastfeeding self-efficacy due to different breastfeeding patterns. Additionally, as the breastfeeding period progresses and the mother’s ability to breastfeed improves, the level of breastfeeding self-efficacy can vary depending on when the study is conducted. Women of premature infants face many obstacles to breastfeeding compared to women of term ones,⁵¹ probably due to a variety of factors regarding the circumstances of preterm delivery, including women’s medical conditions after delivery and failure to communicate adequately. Therefore, there may be obstacles regarding attachment, bonding, and the mother’s adaptation to her new situation. Evidence showed that a mother’s adaptation strengthens her self-efficacy.^51,52 Moreover, in some previous studies, most women were multiparous with previous breastfeeding experience. They had significantly higher breastfeeding self-efficacy than those without prior breastfeeding experience^13,49,50, whereas in our study most participants were first-time mothers who were experiencing breastfeeding for the first time. In previous studies, self-efficacy has been addressed through individual-level interventions.^53,54 However, based on researchers, creating conditions for greater breastfeeding success, such as baby-friendly hospitals, is essential for successful breastfeeding intervention.^38,55 Recent reports have shown that the application of group interventions, rather than traditional interventions at the individual level, increases breastfeeding self-efficacy in mothers.^38,55

Other findings of our study include the examination of the association between demographic variables and BSES score which showed that BSES score was significantly higher in mothers with higher maternal age, gestational age at birth, and spouse’s education level compared to younger mothers with lower gestational age and lower levels of the spouse’s education. In this regard, maternal age could be associated with multiparity and experience of breastfeeding. In a study by Oliver-Roig et al., the education level of mothers was not related to breastfeeding self-efficacy.⁵⁶ Another study observed a positive correlation between higher gestational age and breastfeeding self-efficacy.³⁵ In our study, mothers with previous breastfeeding experience had a higher score of BSES than mothers who did not have such experience. In addition, mothers with a high-school educational level and a birth order ⩾3 had higher self-efficacy scores than mothers with academic education and a birth order >2; however, these differences were not statistically significant. In addition, we detected no significant association between a mother’s education level, employment status, and infant gender with BSES. However, this result was inconsistent with those obtained in other studies conducted in Turkey⁵⁷ and Iran⁵⁸ where the breastfeeding self-efficacy scores of women are positively related to their education level. The results of a study by Dennis⁵⁹ showed no association between BSES scores and socioeconomic characteristics including maternal age, marital status, education, and income. In a study conducted in Australia, multiparous women reported having higher breastfeeding self-efficacy scores than primiparous women; however, no significant difference was found between breastfeeding self-efficacy scores with ethnic, marital, or educational status.⁶⁰ Nankumbi et al. found that maternal breastfeeding self-efficacy was related to the mode of delivery, presence of a spouse, and employment status; however, they did not find any association between the previous breastfeeding experience with BSES.⁴⁸ The discrepancy between the results of different studies could be due to the difference in the sample studied and the time of the survey. It seems that cultural factors also play a role in the differences. It has been shown that cultural factors and social norms, can influence the behavior of mothers, especially those with breastfeeding concerns.⁶¹ For example, in some regions and cultures, breastfeeding a baby is considered a sacred matter; therefore, the desire to breastfeed is high among mothers.⁶² Socio-demographic information about mothers plays a key role in shaping experiences and creating breastfeeding challenges, and appropriate interventions in this field can improve results. Individual breastfeeding education along with the adaptation of education based on the educational background and previous knowledge of the mother can be helpful. Practical training on breastfeeding techniques and baby positioning, which may require more hands-on guidance due to size and health needs, would be helpful. Easier educational materials considering the low literacy level will help to overcome potential language barriers, and for men with a high literacy level, more detailed information and advanced counseling can be considered. Furthermore, financial support for low-income families, for example, to provide breast pumps, breastfeeding counseling, or other resources that may be necessary for successful breastfeeding, should be considered, in addition to community programs that provide free or low-cost support services and resources. It can play a role in improving breastfeeding self-efficacy.

The results of this study showed that participants had high levels of depression, stress, and anxiety with varying degrees from moderate to severe. This result indicates a particularly alarming level of potential postnatal distress among participants. According to researchers, levels of postpartum depression and stress are high following premature birth. Premature birth and the subsequent hospitalization of a preterm infant cause significant psychological distress in mothers.^63
–65 For example, in a comparison conducted by Davis et al.,⁶⁴ mothers of preterm infants had higher rates of depression compared to the general population (40% versus 10%–15%). Furthermore, Bouras et al.⁶³ also found that mothers of preterm infants experienced higher levels of depression and anxiety during infancy compared to mothers of full-term infants. Based on the findings of Leahy-Warren et al., symptoms of depression may be exacerbated by receiving low levels of social support, especially in mothers of hospitalized infants, and it may continue after discharge from the NICU.⁶⁶

The regression model revealed that psychological factors are a more important predictor of breastfeeding self-efficacy than sociodemographic factors. These factors play a more significant role in the prediction of the BSES than sociodemographic factors. This finding is consistent with the results of previous studies conducted in Brazil⁶⁷ and Taiwan.¹³ Henshaw et al. reported that breastfeeding self-efficacy scores have a negative association with depressive symptoms.³⁸ The previous longitudinal evaluation showed that BSES could anticipate changes in depressive symptoms throughout time for Norwegian women.⁶⁸ Providing counseling services and psychological support to relieve any anxiety or stress related to breastfeeding can be considered in the care of these mothers, which can include counseling sessions or support groups for new mothers. Support from healthcare providers, including continuous encouragement and positive reinforcement, can play an important role in building the mother’s self-confidence about her ability to breastfeed.

Eventually, our study results revealed that the perception of a higher level of support has a positive relationship with the total score of breastfeeding self-efficacy. According to the literature, social support is one of the important factors affecting a person’s self-efficacy since it creates emotional support that can enhance coping and competence.⁶⁹ There are many possible sources of social support including support from family, friends, and healthcare providers. However, the experience of receiving support from a spouse or partner is properly essential for the improvement of breastfeeding self-efficacy.⁷⁰ In line with the result of previous studies in Taiwan¹³ and China,⁴⁹ our analyses revealed that social support contributed to the prediction of breastfeeding self-efficacy. Therefore, it can be concluded that the amount of social support a woman receives as well as her emotional state significantly affects her breastfeeding capability. Planning to provide peer support for mothers with premature babies can be helpful. It is possible to help mothers decide to start and continue breastfeeding by strengthening peer support (mother-to-mother) and creating opportunities to talk with other breastfeeding women. The community can support mother-to-mother groups and develop peer counseling programs in healthcare settings.

Limitation

One of the limitations of this study is the inability of cross‑sectional study to express cause and effect association. Considering, the limitations of our study, it is worth noting that the relationships found between sociodemographic variables with breastfeeding self-efficacy cannot accurately reflect the causal relationships especially, because the inclusion criteria for gestational age (28–37 weeks) was for the age of birth (28–37), which is very broad, and breastfeeding in this age range can be influenced by various factors, the relationships of the variables can be distorted. Additionally, complications and challenges during pregnancy can affect a mother’s self-efficacy and mental health. However, information on this aspect was not collected in this study. Future research should consider examining other factors that may impact breastfeeding.

Implication for practice

The study’s findings suggest that nursing and midwifery documentation practices need significant improvement, particularly in addressing the needs of mothers with preterm babies. Enhancing access to counselors, providing necessary support, and improving facilities for mothers after preterm labor could help boost their breastfeeding self-efficacy.

Conclusion

Based on obtaining results, receiving social support; having mental health or less depression, anxiety, and stress, as well as higher gestational age at birth, and having previous breastfeeding experience influence breastfeeding self-efficacy among women with preterm infants. Therefore, given the association between higher degrees of self-efficacy and longer exclusive breastfeeding in mothers with low levels of depression, anxiousness, and stress, it is essential to pay more attention to the mental health and psychological status of women with preterm infants. In addition, families with preterm infants need to be informed about the importance of social support. So, social support should be considered a significant factor in providing intervention programs. Although psychological counseling is done in health centers during breastfeeding in Iran, it is recommended to pay special attention to women with preterm babies. And it is necessary to carry out relevant interventions in the field of increasing breastfeeding self-efficacy and reducing stress in these women. Generally, professionals and providers, especially midwives and nurses, must assess breastfeeding self-efficacy, social support, and mental health status to create interventions based on improving social support and reducing depression, anxiety, and stress. In this way, they will be able to enhance mothers’ self-efficacy to breastfeed exclusively for preterm infants. In this regard, reinforcement of women’s early breastfeeding self-efficacy should be considered a significant factor in achieving the goal of successful breastfeeding.

Supplemental Material

sj-doc-2-whe-10.1177_17455057241305297 – Supplemental material for Factors affecting breastfeeding self-efficacy among mothers with preterm infants

Supplemental material, sj-doc-2-whe-10.1177_17455057241305297 for Factors affecting breastfeeding self-efficacy among mothers with preterm infants by Anvar-Sadat Nayebinia, Farnaz Faroughi, GholamReza Asadi and Azita Fathnezhad-Kazemi in Women’s Health

Supplemental Material

sj-docx-1-whe-10.1177_17455057241305297 – Supplemental material for Factors affecting breastfeeding self-efficacy among mothers with preterm infants

Supplemental material, sj-docx-1-whe-10.1177_17455057241305297 for Factors affecting breastfeeding self-efficacy among mothers with preterm infants by Anvar-Sadat Nayebinia, Farnaz Faroughi, GholamReza Asadi and Azita Fathnezhad-Kazemi in Women’s Health

Footnotes

Acknowledgements

We are grateful to all the mothers who participated in the survey. We also thank the staff of the community health centers for their help with the survey

Declarations

ORCID iD

Azita Fathnezhad-Kazemi

Supplemental material

Supplemental material for this article is available online.

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