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A LONGITUDINAL STUDY OF THE EFFECT OF PSYCHOSOCIAL FACTORS ON
EXCLUSIVE BREASTFEEDING DURATION
Dr Emily de Jager, Dr Jaclyn Broadbent, Dr Matthew Fuller-Tyszkiewicz, Dr Cate Nagle, Dr Skye
McPhie, Dr Helen Skouteris
To contact the author:
Dr Helen Skouteris PhD
Professor of Developmental Psychology
Deakin University
School of Psychology
221 Burwood Highway
Burwood, Vic 3125
Phone: +61 3 9251 7699
Fax: +61 3 9244 6858
Helen.skouteris@deakin.edu.au
To cite this paper:
de Jager, E., Broadbent, J., Fuller-Tyszkiewicz, M., Nagle, C., McPhie, S., & Skouteris, H. (2015).
A longitudinal study of the effect of psychosocial factors on exclusive breastfeeding duration.
Midwifery, 31(1), 103-111. doi:10.1016/j.midw.2014.06.009
The final, definitive version of this paper has been published by Midwifery by Elsevier, All rights
reserved. Dr Helen Skouteris.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0
Australia License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-
nd/3.0/au/ or send a letter to Creative Commons, PO Box 1866, Mountain View, CA 94042, USA.
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Abstract
Objective: To examine the effect of psychosocial factors on exclusive breastfeeding duration to six
months postpartum
Design: Longitudinal, prospective questionnaire based study
Setting: Participants were recruited from a publically funded antenatal clinic located in the western
metropolitan region of Melbourne, Victoria, Australia and asked to complete questionnaires at three
time points; 32 weeks pregnancy, 2 months postpartum and six months postpartum.
Participants: The participants were 125 pregnant women aged 22 to 44 years.
Measurements and findings: Psychosocial variables such as breastfeeding self-efficacy, body
attitude, psychological adjustment, attitude towards pregnancy, intention, confidence and
motivation to exclusively breastfeed and importance of exclusive breastfeeding were assessed using
a range of psychometrically validated tools. Exclusive breastfeeding behaviour up to six months
postpartum was also measured. At 32 weeks gestation a woman’s confidence to achieve exclusive
breastfeeding was a direct predictor of exclusive breastfeeding duration to six months postpartum.
At two months postpartum, psychological adjustment and breastfeeding self-efficacy were
predictive of exclusive breastfeeding duration. Finally, at six months postpartum, psychological
adjustment, breastfeeding self-efficacy, confidence to maintain and feeling fat were directly
predictive of exclusive breastfeeding duration.
Key conclusions: Psychosocial factors are significantly predictive of exclusive breastfeeding
duration. Self-efficacy, psychological adjustment, body image, motivation and confidence are all
important psychosocial factors implicated in a woman’s ability to maintain exclusive breastfeeding
over time.
Implications for practice: Individualized antenatal breastfeeding education and support may be
strengthened by strategies that build a woman’s confidence to exclusive breastfeeding.
Implementing psychosocial supports and methods providing positive feedback that increase a
women’s self-efficacy to exclusively breastfeed to six months are also important two months
postpartum.
Keywords: Exclusive breastfeeding, breastfeeding duration, psychosocial factors
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Introduction
Breast milk is the optimal source of nutrition for the growth and development of an infant. The
health advantages associated with exclusive breastfeeding at both the individual and population
level are well documented in the literature (Batrick & Reinhold, 2010; Cattaneo et al., 2006;
Kramer & Kakuma, 2012; Oddy et al., 2002). Since 2001 The World Health Organization (2011)
has recommended that infants worldwide are exclusively breastfed (breast milk as the only
nutrition) for the first six months of life. A systematic review published by the Cochrane
Collaboration (Kramer & Kakuma, 2002), has demonstrated the significant advantages of exclusive
breastfeeding to six months, compared to three to four months for selected infant and maternal
outcomes. Despite this, over the last decade, there has only been an increase of 8% in the rate of
women maintaining exclusive breastfeeding beyond four months postpartum (Australian Bureau of
Statistics [ABS], 2013). In the most recent Australian data the 2011 to 2012 National Health Survey
showed that less than 60% of Australian infants were exclusively breastfed to two months
postpartum, less than 40% to four months and only 17% of children aged six months to three years
had been exclusively breastfed to at least six months postpartum (ABS, 2013). Similar rates have
been reported in other developed countries including the United States (Jones, 2011), United
Kingdom (McAndrew et al., 2012) and Canada (Bolling, Grant, Hamlyn & Thornton, 2007). Low
income countries report higher rates of exclusive breastfeeding beyond four months than high
income countries and proportions of infants being exclusively breastfed between four to six months
postpartum have been reported (UNICEF, 2011).
Given that the majority of women initiate breastfeeding, it is important to investigate the factors
associated with maintaining exclusive breastfeeding. It is likely that a range of psychosocial factors
contribute to a woman’s ability to maintain exclusive breastfeeding (O’Brien et al., 2008; de Jager
et al., 2013; de Jager et al., in press). Selected psychosocial factors have been identified as
potentially modifiable factors, however, to date, there has been very limited research examining
these factors, specifically for exclusive breastfeeding and for duration beyond three months
postpartum. A recent systematic review of the literature, reviewed nine papers from the last 10
years, which had examined psychosocial factors and exclusive breastfeeding to four to six months
postpartum (de Jager et al., 2013). The systematic review showed that psychosocial factors such as
self-efficacy (Blyth et al., 2002, 2004; Kronborg and Vaeth, 2004; Scott et al., 2006; Semenic et al.,
2008), postpartum depression (Henderson et al., 2003; Akman et al., 2008), anxiety (Clifford et al.,
2006), intention to breastfeed (Blyth et al., 2004; Kronborg & Vaeth, 2004; Bai et al., 2010),
attitude towards breastfeeding (Scott et al., 2006; Semenic et al., 2008; Bai et al., 2010) and social
support (Bai et al., 2010) were associated with exclusive breastfeeding duration beyond four months
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postpartum. In a more recent paper, a conceptual model of psychosocial correlates of exclusive
breastfeeding duration was evaluated with a sample of 174 women who had given birth in the
previous two years completing a questionnaire on their breastfeeding experience (de Jager et al.. in
press). The findings revealed that breastfeeding self-efficacy was an independent and significant
predictor of both intention to exclusively breastfeed and exclusive breastfeeding duration to six
months. Maternal attitude towards pregnancy, psychological adjustment and breastfeeding
difficulties were also established as having a significant influence on exclusive breastfeeding
intention and duration (de Jager et al., in press). Although this study demonstrated the role that
psychosocial factors are likely to play in the maintenance of exclusive breastfeeding duration, the
findings were limited by the retrospective design. Hence, the aim of the current study was to
replicate and extend the findings of de Jager et al. (in press) by evaluating a conceptual model of
psychosocial predictors using a more robust prospective longitudinal design.
Methods
Sample: Participants were recruited via advertising on mother, child and baby forums, parenting
magazines, baby and children’s markets, obstetrician referrals, general media advertising and
through a publically funded antenatal clinic located in the western metropolitan region of
Melbourne, Victoria, Australia. Participants were provided with a Plain Language Statement and
Consent Form and were offered the opportunity to ask any questions before voluntary written
informed consent was obtained. A total sample of 196 pregnant women was recruited, however only
125 women continued their participation to six months postpartum. Power analyses revealed that for
adequate power (.80 for effect size .20 at α = .05) a sample size of 130 was required for these
analyses; results below are interpreted with caution given are final sample size was slightly under
the target required.
Ethical consideration: The Deakin University Human Research Ethics Committee and Melbourne
Health granted Ethics approval for this study.
Data collection: The participants completed written self-administered questionnaires at three time
points; 32 weeks gestation (Time 1), two months postpartum (Time 2) and six months postpartum
(Time 3). The questionnaires were mailed to the participants at a nominated address and returned in
reply paid envelopes included with the questionnaire. Each questionnaire took between 30 and 45
minutes to complete and were mailed to the participants approximately one week prior to the
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required time point. Participants were requested to complete the questionnaire within one to two
weeks.
Measures: The following psychosocial variables were assessed in this study Table 1 provides an
overview of which measures were assessed at each time point. Reliability analyses were conducted
on the scales and subscales used in the analyses. Cronbach’s alpha scores of greater than α = .70 are
considered sufficient for the use of a scale (DeVellis, 2003). All scales had a Cronbach’s alpha
score greater than or equal to α = .70 (see Table 2). The possible range of scores for each scale is
also shown in Table 2.
Attitude towards pregnancy
A scale of 13 items was developed by the researchers to measure participants’ attitudes towards
pregnancy. The participants were asked to indicate to what extent each statement applied to them
and how they felt during pregnancy. The content of the items asked how women feel about the
changes to their body and their experience of the pregnancy stage. Items included ‘I am happy with
my growing body during pregnancy’ and ‘I enjoy being pregnant’. Higher scores indicate a more
positive attitude towards pregnancy. Participants completed this scale at 32 weeks pregnancy and
the scale met reliability criteria for use with this sample.
Body Attitude Questionnaire- Short Form
The short form of the Body Attitude Questionnaire (BAQ; Ben-Tovim & Walker, 1991) consists of
four subscales: ‘Feeling Fat’, ‘Strength and Fitness’, ‘Salience of Weight and Shape’ and
‘Attractiveness’. The scale was developed using an Australian sample and initial testing showed
that the subscales yield high convergent and discriminant validity and good test-retest reliability (r
= .64 to .90). Higher scores indicate stronger perceptions of each subscale (Ben-Tovim & Walker,
1991). This study used three of the subscales: feeling fat, salience of weight and shape and
attractiveness. Participants completed the BAQ at each time point and each subscale met scale
reliability criteria for use with this sample.
Exclusive Breastfeeding Intention
In the initial questionnaire completed at 32 weeks gestation, participants were asked to document
their intention to exclusively breastfeed with response options “Yes”, “No” or “Unsure”, and if
relevant the duration they intended to exclusively breastfeed (less than 1 month; 1-2 months; 2-3
months; 3-4 months; 4-5 months; 6 months).. These two questions were recoded and combined in a
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total ‘exclusive breastfeeding intention’ score, where a higher score indicated intention to
exclusively breastfeed for a longer duration.
Breastfeeding Self-Efficacy Scale – Short Form
The 14-item Breastfeeding Self-Efficacy Scale (BSES-SF; Dennis & Faux, 1999) measures a
mother’s confidence in her ability to successfully breastfeed her infant. Higher scores indicate
higher levels of breastfeeding self-efficacy. Psychometric testing of the BSES-SF showed strong
predictive validity of exclusive breastfeeding outcomes with significant differences in self-efficacy
for mothers who exclusively breastfeed compared to bottle-feed their infant (p < .001; Dennis,
2003). The BSES-SF also has strong construct validity, with significant differences between scores
for first time mothers and mothers with previous breastfeeding experience, at 1 week (p < .001) and
8 weeks postpartum (p < .05; Dennis 2003). Participants completed the BSES-SF at two months
postpartum and six months postpartum. The BSES-SF met scale reliability criteria for use with this
sample.
Depression Anxiety Stress Scale (Psychological adjustment)
The Depression Anxiety Stress Scale 21 (DASS-21) was used as an overall measure of
psychological adjustment. The DASS-21 is an efficient, reliable screening measure for clinical
symptoms of depression, anxiety and stress (Lovibond & Lovibond, 1995). Validity testing in a
non-clinical sample (n = 1794) yielded reliability scores of α =.82 to α=.93 for each of the scales
and total scores (Henry & Crawford, 2005). Participants are asked to respond to each item in terms
of the presence of symptoms over the last seven days. Higher scores reflect elevated
symptomatology. Participants completed the DASS-21 at each time point (32 weeks, two months
postpartum and six months postpartum) and the scale met reliability criteria for use with this
sample.
Motivation to exclusively breastfeed
Participants were asked to rate on a scale of 0 to 10 how much they agreed with two statements “I
am motivated to initiate exclusive breastfeeding (breast milk only) after the birth” and “I am
motivated to maintain exclusive breastfeeding (breast milk only) until my baby is six months of
age”. Participants completed this scale at 32 weeks pregnancy and at six months postpartum. Items
were treated as two separate variables; motivation to initiate and motivation to maintain exclusive
breastfeeding until six months postpartum.
Importance to exclusively breastfeed
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Participants were asked to rate on a scale of 0 to 10 how much they agreed with two statements “I
feel that initiating exclusive breastfeeding (breast milk only) after the birth is important” and “I feel
that maintaining exclusive breastfeeding (breast milk only) until my baby is six months of age is
important”. Participants completed this scale at 32 weeks pregnancy and at six months postpartum.
Items were treated as two separate variables; importance to initiate and to maintain exclusive
breastfeeding until six months postpartum.
Confidence to exclusively breastfeed
Participants were asked to rate on a scale of 0 to 10 how much they agreed with two statements “I
am confident that I can initiate exclusive breastfeeding (breast milk only) after the birth” and “I am
confident that I can maintain exclusive breastfeeding (breast milk only) until my baby is six months
of age”. Participants completed this scale at 32 weeks pregnancy and at six months postpartum.
Items were treated as two separate variables; confidence to initiate and confidence to maintain
exclusive breastfeeding until six months postpartum.
Exclusive breastfeeding at two months postpartum
In the questionnaire completed at two months postpartum, participants were asked to respond ‘Yes’
or ‘No’ to the question “Are you currently exclusively breastfeeding your infant? (i.e. feeding
nothing but breast milk)”.
Exclusive breastfeeding at six months postpartum
In the questionnaire completed at two months postpartum, participants were asked to respond ‘Yes’
or ‘No’ to the question “Are you currently exclusively breastfeeding your infant? (i.e. feeding
nothing but breast milk)”.
Exclusive breastfeeding duration
Exclusive breastfeeding duration was used as the outcome variable in the path analyses at each time
point. Participant’s exclusive breastfeeding status at each time to six months postpartum was scored
and combined to provide an overall exclusive breastfeeding duration score. Higher scores indicate
exclusivity and longer duration of breastfeeding.
Demographic details
Participant information including age, relationship status, parity, household income, highest level of
education and nationality were collected at 32 weeks gestation time point.
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Data analyses:
Correlational analyses using SPSS version 20 (IBM corporation, 2011) were conducted to examine
the interrelationships between the psychosocial variables in this study. Table 2 displays the
correlation matrix.
Path analysis using SPSS AMOS version 20 (IBM corporation, 2011) was used to test three
proposed conceptual models of the relationships between psychosocial variables on exclusive
breastfeeding duration at three different time points (32 weeks pregnancy, two months postpartum
and six months postpartum; Figures 1 to 3). The path models were used to analyse the data
longitudinally by examining the effect of psychosocial variables at each time point on overall
exclusive breastfeeding duration. Exclusive breastfeeding duration was the outcome variable at each
time point. The models were developed based on previous research (de Jager et al., 2013) and the
significant relationship between variables in the correlation matrix (Table 2). Thus, the path models
are based on the previous literature but are also exploratory in nature. The model fit was measured
using chi-square goodness-of-fit statistics, the chi-square divided by degrees of freedom
(CMIN/DF; < 3 denoting good fit), the comparative fit index (CFI; good fit >.95, acceptable fit
>.90; Hu & Bentler, 1999), and the root mean square error of approximation (RMSEA; good fit
<.06, acceptable fit <.08; Hu & Bentler, 1999).
The reported values in Figures 1 to 3 are the standardised regression weights of the model (β, beta
weights). Standardised regression weights indicate the strength of a relationship between a given
predictor and an outcome in a standardised form. It is interpreted as the change in the outcome
variable (in standard deviations) associated with a one standard deviation change in the predictor
variable (Field, 2009). Additionally, the correlations between the factors in the path model are
included in the analysis however are not depicted in these figures for ease of interpretation, and are
instead presented in Table 3. The standardised regression weights for the non-significant pathways
are displayed in Table 4.
Findings
Participant characteristics
The age of the participants ranged from 22 to 44 years (Median = 31.0, Interquartile Range = 6.75).
Seventy five percent (n = 94) of the participants were married, 19% (n = 24) were in a defacto
relationship and 5% (n = 6) were single. The sample was predominantly an Australian born 81% (n
= 101), with the remaining participants born in New Zealand 2% (n = 3), Asia 8% (n = 10), the
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UK/Europe 6% (n = 7) or the U.S. 2% (n = 3). In this sample, 19% (n = 24) had completed
postgraduate education, 44% (n = 55) a bachelor degree, 28% (n = 35) had completed other formal
education past secondary school (certificates, diploma, advanced diploma’s etc.), 5% had a year 12
equivalent education and 3% (n = 4) had completed less than a year 12 equivalent.
At 32 weeks pregnancy 98% of participants (n = 123) intended to breastfeed (any breast milk) their
infant, one participant did not intend to breastfeed and one participant was undecided. Of those
intending to breastfeed, 78% (n = 96) intended to exclusively breastfeed their infant (nothing but
breast milk), 16% (n = 20) were undecided and 6% (n = 7) had decided not to exclusively
breastfeed. Of the participants who intended to exclusively breastfeeding their infant, 53% (n = 66)
intended to do so to six months postpartum, 23% (n = 29) for four to five months, 6% (n = 7) for
three to four months, 1% (n = 2) for two to three months, 1% (n = 2) for one to two months and 1%
(n = 2) intended to exclusively breastfeed for less than one month.
At six months postpartum 12% (n = 15) of participants reported they were currently exclusively
breastfeeding their infant, 1% (n = 2) reported using breastfeeding and formula, 6% (n = 8) were
using formula only, 39% were breastfeeding and giving their infant solids, 21% were breastfeeding,
formula and solids and 20% (n = 25) were feeding their infant formula and solids only. Of the
participants who were not currently exclusively breastfeeding at six months postpartum, 88% (n =
97) reported exclusively breastfeeding for a period of time. Of these participants, 33% (n = 37)
reported exclusively breastfeeding for between five to six months, 24% (n = 26) for more than four
but less than five months, 12% (n = 13) for less than four but more than three months, 4% (n = 5)
for less than three but more than two months, 6% (n = 7) for less than two months but more than six
weeks and 12% (n = 13) reported exclusively breastfeeding for less than six weeks.
Approximately half the participants (n = 64) in this study were pregnant for the first time
(primigravida). At 32 weeks gestation, women who had been pregnant at least one time previously
(multigravida) were more likely to intend to exclusively breastfeed their infant (M = 8.70, SE = .14)
than primigravida participants (M = 7.96, SE = .23). This difference was statistically significant
t(85) = -2.71, p < .01. However this difference in intention did not translate into behaviour as there
was no significant differences between multigravida and primigravida women and exclusive
breastfeeding duration at 2 months t(20) = -1.69, p > .05, or at 6 months postpartum t(121) = .40, p
= >.05.
Model 1- 32 weeks pregnancy
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Figure 1 displays Model 1 at 32 weeks gestation. The fit indices suggest that the path model
provides a good fit to the data, χ² = 32.0 (20), p < .05, CMIN/DF = 1.60, CFI = .97 and RMSEA =
.07. This path model estimated 45 parameters (pathways). Of these, 3 directional pathways and 13
co-variances were significant. At 32 weeks pregnancy, a woman’s level of confidence in her ability
to maintain exclusive breastfeeding was the only direct predictor of exclusive breastfeeding
duration (β = .26, p < .05). However, both motivation to initiate (β = .22, p < .01) and confidence to
maintain exclusive breastfeeding (β = .44, p < .001) were predictive of their intention to exclusively
breastfeed their infant. At this time point, psychological adjustment was not associated directly with
exclusive breastfeeding duration, however, it was correlated significantly with aspects of body
image (attractiveness; r = -.21, salience of weight and shape; r = .27, and feeling fat; r = .32) and
maternal attitude towards pregnancy (r = -.27). Maternal attitude towards pregnancy was
significantly correlated with body image (attractiveness, r = .45; salience of weight and shape, r = -
.50; feeling fat, r = -.67).
Model 2 – 2 months postpartum
Figure 2 displays Model 2 at two months postpartum. The fit indices suggest that Model 2 path
model provides a good fit to the data, χ² = 6.15 (6), p > .05, CMIN/DF = 1.03, CFI = 1.00 and
RMSEA = .014. This path model estimated 22 parameters (pathways). Of these, five directional
pathways and four co-variances were significant. In this model, psychological adjustment (β = .10,
p < .01), breastfeeding self-efficacy (β = .12, p < .01) and exclusive breastfeeding status (β = .88, p
< .001), at two months postpartum were all directly predictive of exclusive breastfeeding to six
months postpartum. Psychological adjustment was related negatively to breastfeeding self-efficacy
(β = -.29, p < .001), indicating that greater symptoms of depression, anxiety and stress are
associated with lower breastfeeding self-efficacy. Breastfeeding self-efficacy at two months
postpartum was also predictive of current exclusive breastfeeding status (at two months postpartum;
β = .27, p < .01). In this model, body image was not related directly to breastfeeding self-efficacy or
exclusive breastfeeding duration, however, a woman’s salience of weight and shape was correlated
significantly with her psychological adjustment (r = .13, p < .05), which had both direct and indirect
pathways to self-efficacy and exclusive breastfeeding duration. This suggests that although body
image may not directly predict a woman’s breastfeeding confidence or duration it may have an
indirect effect through psychological adjustment.
Model 3 – 6 months postpartum
Figure 3 displays Model 3 at six months postpartum. The fit indices suggest that Model 2 path
model provides a good fit to the data, χ² = 18.15 (18), p > .05, CMIN/DF = 1.01, CFI = 1.00 and
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RMSEA = .01. This path model estimated 27 parameters (pathways) and of these, four directional
pathways and nine co-variances were significant. At six months postpartum, feeling fat (β = .27, p <
.05), breastfeeding self-efficacy (β = .24, p < .001), psychological adjustment (β = .20, p < .01) and
confidence to maintain exclusive breastfeeding (β = .44, p < .001) were all significantly related to
exclusive breastfeeding duration. At six months postpartum, although attractiveness and salience
were not related directly to exclusive breastfeeding duration, all three body image variables were
correlated significantly with psychological adjustment (salience of weight and shape, r = .27, p <
.01; feeling fat, r =.19, p < .05; attractiveness, r -.29, p < .01) again suggesting that the effect of
body image on breastfeeding outcomes is likely to be through psychological adjustment.
The standardised regression weights for the non significant pathways of each model are shown in
Table 4. Although these pathways are non significant in these models, many of these variables were
significantly correlated (see correlation matrix, Table 2). It is also worth noting that the direction of
relationships is consistent with the model (for example, six months psychological adjustment to
breastfeeding self-efficacy β = -.15, p = .08), however not strong enough to reach significance in
this sample.
Discussion
This study was a longitudinal study, which followed 125 women from 32 weeks gestation through
to six months postpartum. The aim of this study was to examine the relationship between
psychosocial factors on the duration of exclusive breastfeeding during the first six months
postpartum. This study used path analysis to examine the direct, and indirect, associations between
the psychosocial factors and exclusive breastfeeding at three time points: 32 weeks pregnancy, two
months postpartum and six months postpartum.
The main limitation of this study was the sample size. Although a sample of 125 participants is
considered moderate for use with path analysis (Klein, 1998), the statistical power was reduced by
the large amount of pathways being examined within each model. Reduced statistical power
increases the likelihood that the null hypothesis will be supported (Ellis, 2010). Accordingly, results
need to be interpreted with caution. Given the reduced statistical power, it is possible that some
non-significant results may have reached statistical significance had the sample size been larger. For
example, in Model 2 (2 months postpartum) the pathway between ‘feeling fat’ to ‘breastfeeding
self-efficacy’ was negative (β = -.21) which is consistent with previous literature, however, was not
sufficiently powered to reach significance in the path model (p = .11), despite being significantly
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correlated (r = -.25, p < .01). Similarly in Model 3 (six months postpartum) there was a positive
relationship between motivation to maintain exclusive breastfeeding and exclusive breastfeeding
duration (β = .07), however this effect was also not strong enough to reach significance (p = .59),
despite being significantly correlated (r = .26, p < .05).
A further limitation of this study was the inclusion of both primigravida and multigravida women
together in the analyses. Women who have had previous pregnancies may have a different
experience of pregnancy and the postpartum than first time mothers. For example, Dennis and Faux
(1999) showed that breastfeeding self-efficacy was significantly lower for first time mothers
compared to mothers with previous breastfeeding experience. Additionally, reports of body image
may be different for women who are experiencing changes to their body for the first time compared
to women who have experienced pregnancy before and psychological adjustment may differ
between these populations (Fuller-Tyszkiewicz, Skouteris, Watson, & Hill, 2013). Separating
primigravida and multigravida participants in the analyses was beyond the scope of this paper,
given our sample size restricted the number of analyses we could conduct. Finally, there was a
participant attrition rate of 36% in the current study despite efforts by the research team to prevent
women from dropping out including contacting the women via telephone or email with reminders if
their questionnaires weren’t received within three to four weeks. High attrition rates are a common
problem of longitudinal research and may be heightened in this population due to pregnancy and the
postpartum often being a period of significant adjustment; indeed, other longitudinal studies in
Australia have reported attrition rates of up to 60% (Soloff, Millward & Sanson, 2003; Hure et al.,
2013). Replication of the current study with a larger sample size is warranted, albeit strategies to
prevent high attrition rates need to be considered and carefully planned at the outset in order to
curtail excessive study drop out.
In this study, at 32 weeks gestation, 52.8% of participants reported that they intended to exclusively
breastfeed their infant to six months postpartum. At six months postpartum only 12% had
maintained exclusive breastfeeding. There has been considerable research focusing on the effect of
maternal intention on breastfeeding outcomes. Studies that have examined both any breastfeeding
including exclusive breastfeeding have reported that women’s infant feeding behaviour is
associated with their infant feeding intention (Blyth et al., 2004; Kronborg & Vaeth, 2004; Dennis
& McQueen, 2007; Bai et al., 2010). Further, studies have shown that the effect of intention to
breastfeed is stronger when the decision to exclusively breastfeed is made before the birth compared
to after the birth (Scott et al., 2001; O’Brien & Fallon, 2005). The results of this study contradict
previous research and indicate that intention alone is not sufficient to predict a woman’s
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breastfeeding outcomes. Further, it indicates that the ability to maintain exclusive breastfeeding
over time is likely to be positively and negatively influenced by the interaction of a range of
psychosocial factors.
Intention to exclusively breastfeed at 32 weeks gestation was not a direct predictor of exclusive
breastfeeding duration in the path model reported in this study (Model 1). However, intention to
breastfeed was correlated strongly with how confident and motivated a woman felt she was to
initiate and maintain exclusive breastfeeding and how important she believed initiating and
maintaining exclusive breastfeeding was for her infant. At 32 weeks gestation (Model 1) a
woman’s motivation to initiate and confidence to maintain exclusive breastfeeding were both
predictive of exclusive breastfeeding intention. This is consistent with self-efficacy theory and the
development of self-efficacy (Bandurra, 1977; Dennis & Faux, 1999). The stronger self-efficacy a
woman has in her ability to be able to maintain exclusive breastfeeding, the higher her motivation is
likely to be to initiate exclusive breastfeeding (Bandurra, 1977; Dennis & Faux, 1999). Although
breastfeeding self-efficacy was not measured specifically at this time point (32 weeks gestation) the
associations between motivation to initiate, confidence to maintain and exclusive breastfeeding
intention is indicative of the role of self-efficacy on maternal intention to exclusively breastfeed.
Consistent with previous literature, breastfeeding self-efficacy was found to be a significant
predictor of exclusive breastfeeding duration at both two months and six months postpartum. High
breastfeeding self-efficacy has been shown consistently to be predictive of positive breastfeeding
outcomes (Blyth et al., 2002, 2004; Kronborg & Vaeth, 2004; Scott et al., 2006; Semenic et al.,
2008). In this study, the effect of self-efficacy on exclusive breastfeeding duration was stronger at
six months than at two months postpartum. This may be reflective of the self-efficacy concept of
‘master of experience’. Self-efficacy theory states that one way of developing or strengthening self-
efficacy is through experiencing some success with the behaviour or drawing on past successes of a
similar behaviour (referred to as ‘mastery of experience’; Bandurra, 1977; Dennis, 1999). At six
months postpartum, exclusively breastfeeding women are more likely to have experienced greater
success at exclusive breastfeeding and overcome more barriers along the way than they had at two
months postpartum, strengthening their level of breastfeeding self-efficacy. Self-efficacy is an
important psychosocial construct to examine in relation to breastfeeding, as it is consistently shown
to have a strong effect on breastfeeding outcomes and it also amendable to change with appropriate
intervention (Semenic et al., 2008). What needs to be examined further is the mechanism of the
effect of breastfeeding self-efficacy on breastfeeding duration. One possible explanation,
demonstrated in Model 2 is through the interaction with psychological adjustment.
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Psychological adjustment was predictive of exclusive breastfeeding duration at both two months
and six months postpartum. At two months postpartum, psychological adjustment was significantly
predictive of both breastfeeding self-efficacy and exclusive breastfeeding duration, however, this
same interaction was not seen at six months postpartum. This may suggest that the impact of
symptoms of depression, anxiety and stress negatively impact breastfeeding outcomes at two
months postpartum through reducing a woman’s breastfeeding self-efficacy or confidence in her
ability to breastfeed. Previous studies have shown that women with increased symptoms of
postnatal depression were at greater risk of early cessation of exclusive breastfeeding than women
who did not show depressive symptoms (Henderson et al., 2003; Akman et al., 2008). Further,
women who have stronger symptoms of psychological distress may not be able to expend as much
effort maintaining breastfeeding, may have more self-defeating thought patterns and respond
negatively to breastfeeding difficulties, all of which would reduce their level of self-efficacy earlier
on in the postpartum as opposed to later on when women are more efficient at breastfeeding
(Bandura, 1977; Dennis, 1999).
To date there has been very limited research that has examined the effect of body image on
breastfeeding outcomes. Given that pregnancy and the postpartum is a time of significant changes
to a woman’s body size and shape, it is likely that dissatisfaction with these changes may negatively
influence her psychological adjustment and comfort with breastfeeding. Clark et al. (2009) showed
that during the postpartum period, women’s feelings of fatness and their salience of weight and
shape increased significantly and was at its peak at six months postpartum. Further, women with
more depressive symptoms tend to report higher levels of body dissatisfaction throughout both
pregnancy and the postpartum (Clark et al., 2009; Rallis et al., 2007; Skouteris et al., 2005). In the
current study, we examined the effect of body image at all three time points. In each model, all
three body image variables showed no direct relationship with exclusive breastfeeding duration.
However, at both 32 weeks gestation and six months postpartum, all three aspects of body image
(fatness, salience, attractiveness) were correlated significantly in the path model with psychological
adjustment, which at six months postpartum, was a direct predictor of exclusive breastfeeding
duration. At six months postpartum, feeling fat was also predictive directly of exclusive
breastfeeding duration. Clark et al. (2009) suggest that by six months postpartum women may have
stronger feelings of fatness if they feel as though they have not regained their pre-pregnancy body,
whereas there is less pressure for this to have occurred by two months postpartum. This would
explain the effect of feeling fat influencing exclusive breastfeeding duration at six months but not at
two months postpartum in these models.
15
Consistent with previous literature, the findings of this study highlighted the importance of
psychosocial factors on a woman’s ability to maintain exclusive breastfeeding over time. In
particular, self-efficacy, psychological adjustment and body image are key psychosocial factors
implicated in a woman’s ability to maintain exclusive breastfeeding for a longer duration. What this
study added was a prospective longitudinal design, investigating a range of psychosocial factors
with the specificity of exclusive breastfeeding to six months postpartum. Previous studies have
tended to focus on one psychosocial factor, have been inconsistent with the definition of ‘exclusive’
breastfeeding and have not measured breastfeeding outcomes to six months postpartum. This study
informs clinical practice in a number of ways with the identification of a woman’s confidence to
achieve exclusive breastfeeding in pregnancy as a predictor of exclusive breastfeeding duration to
six months postpartum. Individualized antenatal breastfeeding education and support may be
strengthened by strategies that build a woman’s confidence to exclusive breastfeeding.
Implementing psychosocial supports and methods providing positive feedback that increases a
women’s self-efficacy to exclusively breastfeed to six months may also be beneficial postnatally.
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19
Figure 1. Model 1 – relationship between psychosocial factors at 32 weeks gestation and exclusive breastfeeding duration
* p = <.05; ** p = < .01; *** p = < .001; EBF = exclusive breastfeeding
!
Salience
Feeling'Fat
Attractiveness
Attitude'to'
Pregnancy
Psychological+
adjustment
EBF
Intention
EBF$
duration
Motivation(to(
initiate
Confidence)
to#initiate
Confidence)
to#maintain
.26*
.44***
.22**
20
Figure 2. Model 2 – relationship between psychosocial factors at 2 months postpartum and exclusive breastfeeding duration
* p = <.05; ** p = < .01; *** p = < .001; EBF = exclusive breastfeeding
Salience
Feeling'
Fat
Attractiveness
Psychological+
Adjustment
Breastfeeding,
Self-Efficacy
EBF$
duration
EBF$at$2$
months'
postpartum
-.29***
-.10**
.12**
.27**
.88***
21
Figure 3. Model 3 – relationship between psychosocial factors at 6 months postpartum and exclusive breastfeeding duration
* p = <.05; ** p = < .01; *** p = < .001; EBF = exclusive breastfeeding
Attractiveness
Salience
Feeling'Fat
Psychological+
Adjustment
Breastfeeding,
Self-Efficacy
EBF$
Duration
Confidence)to)
maintain
Motivation(to(
maintain
Importance+to+
maintain
-.27*
.24***
-.20**
.44***
22
Table 1. Questionnaire time points and measures included at each time point
Time Point
Measures
32 weeks gestation
Demographic information
Attitude towards pregnancy
Body Attitude Questionnaire
Exclusive breastfeeding intention
Psychological adjustment (DASS)
Motivation to exclusively breastfeed
Importance to exclusively breastfeed
Confidence to exclusively breastfeed
2 months postpartum
Body Attitude Questionnaire
Breastfeeding Self-Efficacy Scale
Psychological adjustment (DASS)
Current feeding practices
Exclusive breastfeeding status
6 months postpartum
Body Attitude Questionnaire
Breastfeeding Self-Efficacy Scale
Psychological adjustment (DASS)
Motivation to exclusively breastfeed
Importance to exclusively breastfeed
Confidence to exclusively breastfeed
Current feeding practices
Exclusive breastfeeding status
DASS = depression anxiety and stress scale
23
Table 2. Correlation matrix, means, standard deviations, Chronbach’s alpha and possible range of scores for all variables examined in the models
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
1. 32 EBF
Intention
1
2. 32 Attitude
.17
1
3. 32 Psych
Adjust
-.21 *
-.27 **
1
4. 2 Psych
Adjust
-.13
-.24 **
.55 **
1
5. 6 Psych
Adjust
.00
-.30 **
.63 **
.51 **
1
6. 32 Attract
.06
.45 **
-.21 *
-.05
-.25 **
1
7. 2 Attract
-.02
.40 **
-.07
-.15
-.25 **
.71 **
1
8. 6 Attract
.00
.33 **
-.08
-.13
-.29 **
.70 **
.72 **
1
9. 32 Salience
-.03
-.50 **
.27 **
.22 *
.27 **
-.33 **
-.22 *
-.27 **
1
10. 2 Salience
.06
-.34 **
.23 **
.21 *
.21 *
-.36 **
-.44 **
-.43 **
.64 **
1
11. 6 Salience
.11
-.33 **
.21 *
.21 *
.27 **
-.37 **
-.32 **
-.48 **
.50 **
.66 **
1
12. 32 Feeling
fat
-.11
-.67 **
.32 **
.21
.25 **
-.56 **
-.41 **
-.38 **
.74 **
.62 **
.54 **
1
13. 2 Feeling
fat
.04
-.34 **
.14
.11
.22 *
-.45 **
-.55 **
-.48 **
.50 **
.77 **
.59 **
.64 **
1
14. 6 Feeling
fat
.07
-.40 **
.10
.09
.19 *
-.51 **
-.52 **
-.56 **
.45 **
.61 **
.76 **
.64 **
.80 **
1
15. 2 BFSE
-.15
.10
-.15
-.31 **
-.17
.11
.10
.13
-.33 *
-.21 *
-.17
-.25 **
-.23 **
-.17
1
16. 6 BFSE
-.12
.15
-.16
-.34 **
-.19
.07
.05
.12
-.21 *
-.13
-.20
-.15
-.16
-.12
.83 **
1
17. 2 EBF
.16
.04
-.04
-.08
-.04
-.05
-.28 **
-.11
-.12
.02
.02
.10
-.08
-.16
.28 **
.32 **
1
18. 6 EBF
.15
.01
.07
-.03
-.05
.13
.14
.10
.12
.09
-.02
.04
.00
-.06
.12
.08
.23 **
1
19. EBF
duration
.19
-.07
.05
-.06
.05
.03
-.04
.09
.03
-.01
-.11
-.02
-.06
-.19
.55 **
.58 **
.92 **
.41 **
1
20. 32
Conf_Init
.43 **
.09
-.21 *
-.27 **
-.15
.13
.11
.17
-.02
.01
-.13
-.10
.02
-.11
-.03
-.01
.25 **
.02
.23 *
1
21. 32
Conf_Maint
.62 **
.16
-.15
-.19 *
-.05
.15
.05
.08
-.04
-.01
-.07
-.09
-.01
-.05
-.11
-.13
.27 **
.13
.31 **
.74 **
1
22. 32
Motiv_Init
.65 **
.18 *
-.32 **
-.27 **
-.19 *
.06
.04
.09
.04
.02
.01
-.04
.11
.05
-.05
-.09
.25 **
.04
.21 *
.81 **
.68 **
1
23. 32
Motiv_Maint
.69 **
.18
-.23 *
-.19 *
-.09
.16
.10
.08
-.05
-.06
-.03
-.11
-.01
-.01
-.14
-.18
.18
.11
.14
.60 **
.81 **
.75 **
1
24. 32 Imp_Init
.50 **
.09
-.16
-.13
.02
-.03
.00
.04
.05
.04
.04
-.02
.12
.04
-.1
-.05
.14
-.05
.09
.68 **
.55 **
.24 **
.76 **
1
25. 32
Imp_Maint
.62 **
.13
-.16
-.12
.01
.11
.04
.03
-.04
-.17
-.04
-.11
-.03
-.05
-.18
-.17
.09
.09
.03
.44 **
.70 **
.54 **
.67 **
.85 **
1
24
26. 6
Motiv_Maint
.34 **
.09
-.11
-.03
-.09
.03
-.01
-.04
.03
.03
-.02
-.01
.01
.04
-.04
.05
.37 **
.21 **
.26 *
.31 **
.34 **
.44 **
.30 **
.42 **
.32 **
1
27. 6
Imp_Maint
.40 **
.12
.01
-.01
.01
.06
.04
.01
.01
.03
-.02
-.02
.05
.07
-.01
.03
.27 *
.26 **
.19
.17
.31 **
.30**
.38**
.35**
.43 **
.77
**
1
28.
6_Conf_Maint
.22*
.04
-.08
-.15
-.16
.04
.00
.04
.04
.07
-.11
-.10
-.01
-.07
.09
.08
.52**
.20*
.53
.38**
.38**
.35**
.26**
.24**
.13
.53*
*
.42
**
1
M
8.3
49.5
31.7
11.7
11.2
16.3
15.7
15.8
10.5
11.5
12.7
28.1
34.7
35.
9
53.4
55.8
1.6
1.1
6.1
7.8
6.8
8.8
7.6
8.9
7.7
7.8
7.6
6.4
SD
1.4
7.1
33.8
10.4
11.6
3.3
3.4
3.9
3.2
3.7
4.3
9.9
10.8
12.
6
14.2
15.5
.5
.32
1.4
2.3
2.7
1.9
2.3
1.7
2.3
2.9
2.6
3.1
a
.87
.93
.85
.88
.72
.74
.82
.77
.83
.85
.92
.93
.95
.96
.96
Range of
scores
2-9
13-65
0-126
0-126
0-126
5-25
5-25
5-25
5-25
5-25
5-25
12-60
12-60
12-
60
14-70
14-70
0-2
0-2
0-8
0-10
0-10
0-10
0-10
0-10
0-10
0-
10
0-
10
0-
10
Note: * = p < .05; ** = p < .01
25
Table 3. Correlations between factors in the models
Correlation
P
Model 1
Motivation to initiate
Confidence to initiate
.52
.000***
Confidence to maintain
.61
.000***
Confidence to initiate
Confidence to maintain
.68
.000***
Salience of weight and shape
Feeling fat
.74
.000***
Attractiveness
-.33
.000***
Attitude towards pregnancy
-.50
.000***
Feeling fat
Attractiveness
-.56
.000***
Attitude towards pregnancy
-.67
.000***
Attractiveness
Attitude towards pregnancy
.45
.000***
Psychological Adjustment
Feeling fat
.32
.000***
Salience of weight and shape
.27
.003**
Attractiveness
-.21
.023*
Attitude towards pregnancy
-.27
.004**
Model 2
Salience of weight and shape
Feeling fat
.76
.000***
Attractiveness
-.42
.000***
Feeling fat
Attractiveness
-.55
.000***
Psychological Adjustment
Salience of weight and shape
.13
.028*
Model 3
26
Confidence to maintain
Motivation to maintain
.53
.000***
Importance to maintain
.42
.000***
Motivation to maintain
Importance to maintain
.77
.000***
Psychological Adjustment
Attractiveness
-.29
.002**
Salience of weight and shape
.27
.003**
Feeling fat
.19
.036*
Attractiveness
Salience of weight and shape
-.48
.000***
Feeling fat
-.56
.000***
Salience of weight and shape
Feeling fat
.76
.000***
Note: * p=<0.05; ** p=<0.01;
***p=<0.001
27
Table 4. Standardised regression weights and p values for non-significant pathways
Regression weights
β (beta weights)
p
Model 1
To ‘Exclusive breastfeeding duration’
Psychological adjustment
.12
.17
Motivation to initiate
.03
.79
Confidence to initiate
.02
.86
Exclusive breastfeeding intention
.05
.62
Attractiveness
.02
.84
Salience of weight and shape
.04
.73
Feeling fat
-.14
.37
Attitude towards pregnancy
-.11
.33
To ‘Exclusive breastfeeding intention’
Confidence to initiate
.02
.84
Model 2
To ‘Breastfeeding Self-Efficacy’
Salience of weight and shape
.01
.94
Feeling fat
-.21
.11
To ‘Exclusive breastfeeding at 2 months’
Attractiveness
-.04
.65
To ‘Exclusive breastfeeding duration’
Attractiveness
.02
.65
Feeling fat
-.02
.72
Salience of weight and shape
.04
.44
Model 3
To ‘Breastfeeding Self-Efficacy’
Psychological adjustment
-.15
.08
To ‘Exclusive breastfeeding duration’
Motivation to maintain
.07
.59
Importance to maintain
.01
.95
Salience of weight and shape
.13
.26
28
Attractiveness
.07
.43
