Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19

https://doi.org/10.1186/s12884-019-2701-0

RESEARCH ARTICLE Open Access

Impacts of antenatal nursing interventions

on mothers’ breastfeeding self-efficacy: an
experimental study
Safiya Sabri Piro1,2* and Hamdia Mirkhan Ahmed2,3

Abstract
Background: A considerable amount of research demonstrates how breastfeeding self-efficacy significantly
influences breastfeeding outcomes. The aim of this study was to evaluate the role of nursing intervention on
mother’s breastfeeding self-efficacy.
Methods: In this experimental investigation, 130 pregnant women who attended a primary health care centre
were randomly assigned to the experimental (n = 65) or control (n = 65) groups. The experimental group received
two 60–90 min group breastfeeding educational sessions based on the breastfeeding self-efficacy theory along with
routine care. Mothers’ knowledge, attitudes, prenatal and postnatal self-efficacy towards the breastfeeding were
compared between both groups. The Iowa Infant Feeding Attitude Scale measured the attitudes. Prenatal
Breastfeeding Self-Efficacy Scale measured the self-efficacy during pregnancy and Breastfeeding Self-Efficacy-Short
Form measured the self-efficacy in postnatal period.
Results: Breastfeeding self-efficacy during pregnancy and following two months of delivery in the experimental group
was significantly higher. The experimental group had a higher level of knowledge and attitude in comparison with
subjects in the control group. In addition, the mothers who breastfed exclusively had higher levels of postnatal self-
efficacy in both experimental and control groups compared to formula feeding women (52.00 vs. 39.45 in the control
and 57.69 vs. 36.00 in the experimental subjects; P < 0.001).
Conclusion: The present investigation suggests that antenatal breastfeeding education is an effective way to increase
the level of breastfeeding self-efficacy, which increases exclusive breastfeeding practice.
Keywords: Breastfeeding self-efficacy, Knowledge, Attitude, Exclusive breastfeeding

Background after birth and only 40% of all infants under six months
Breastfeeding (BF) is an art, and human milk has no an- of age are exclusively breastfed. And only 45% of chil-
other exact alternative for feeding babies. Breastfeeding dren are still BF at two years of age [3].
assists in developing an indelible connection between Although, there is a lack of recent data on infant and
the mother and baby [1]. Recently, the promotion of BF young child feeding practices in Iraq, a presented report
has increased by health systems in line with World by International Baby Food Action Network (IBFAN)
Health Organization (WHO) and United Nations Inter- claimed low rates of early initiation of BF (43%), exclu-
national Children’s Emergency Fund (UNICEF) policies, sive BF under 6 months (20%), BF at 2 years (23%) and
and there have been numerous efforts to support, pro- high rates of bottle feeding (64%) in Iraq [4].
mote and retain BF [2]. Despite these efforts on BF, glo- Maternal self-efficacy in BF is one of the potentially
bally only 44% of infants initiate BF within the first hour modifiable factors which is consistently linked with posi-
tive BF outcomes [5]. The literature declares that
“mother’s inadequate breastfeeding self-efficacy (BSE),”
* Correspondence: [email protected]
1
College of Nursing, University of Duhok, Duhok, Kurdistan Region, Iraq
“incompetency of BF services”, and “family’s neglect to
2
College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq breast milk” are challenges and barriers to BF promotion
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 2 of 12

[6]. Breastfeeding self-efficacy refers to a mother’s confi- Those pregnant subjects with the following conditions
dence in her capability to breastfeed her infant [7]. were excluded from the study:
Mother’s self-efficacy is an essential variable in BF out-
comes as it predicts: (1) whether a mother chooses to 1. Medical issue could significantly impact on BF
breastfeed as the desired infant feeding method. (2) how 2. Had inverted nipple
much effort she will expend during BF. (3) whether 3. Expected to deliver a preterm new-born or a new-
mother will persevere in her attempts until mastery is born with complications and/or congenital abnor-
achieved. (4) whether she has self-enhancing or self- mality (diagnosed based on the medical and clinical
defeating thought patterns. (5) how she emotionally re- examinations)
sponds to breastfeeding difficulties [7]. 4. Intended to exclusive formula feed
Educational interventions have an impact on the 5. Dropped during the study time (Fig. 1).
health of the pregnant woman as well as, on the health
and wellbeing of the next human generations. Antenatal Study tools for data collection
BF education is beneficial in preparing women for effect- The data set of the study was collected, measured, and
ive BF by promoting their confidence level, knowledge, recorded in a pre-designed investigator-administered
and skills [8]. questionnaire. The questionnaire had five parts as
Invariably, nurses guide and assist women throughout following:
their pregnancy and puerperal period. She also plays a
vital role in health education programs during perinatal Part A: The demographic characteristics of the
care [9]. A nurse can encourage the advancement of BF subjects were collected prior to implementation of the
by providing BF teaching and positive support before BF education. The general information was based on:
birth and after hospital discharge [10]. age (years), age at marriage (years), education (years),
Few studies concentrated on the effect of antenatal gestational age (weeks), occupation (categorized as
education on BSE of Kurdish women in the Kurdistan employed/housewife), family type (categorized as
region of Iraq. Therefore, the researchers attempted to nuclear/ extended), gravida (primigravida
evaluate the effectiveness of the nursing intervention on /multigravida), para (primiparous/multiparous), and
BSE, knowledge and attitude of a sample of women in abortion (non-aborted/aborted).
Iraqi Kurdistan. The authors hypothesized that the BSE Part B: A questionnaire format was developed by the
of the women who receive a nursing intervention pro- researcher after an extensive literature review regarding
gram would be higher compared to those women who BF and according to the recommendations of WHO
do not receive the nursing intervention program. and UNICEF. The questionnaire of mothers’ knowledge
toward BF consisted of 21 items that were divided into
Methods three sections. Items were scored as one when
Study design and subjects’ recruitment answered correctly or zero when answered incorrectly.
An experimental study was conducted on 130 pregnant The total score of the scale ranged from 0 to 21 points,
women who attended a primary health care centre with a higher score indicating a higher degree of
(PHCC) for antenatal care, medical check-up, and vac- maternal BF knowledge. The first section had 8
cination. The PHCC is one of the biggest health setting question items relating to the benefits of BF for the
in Erbil city and provides primary health care for a sig- infant. (1) Provides perfect and healthy nutrition. (2)
nificant target population. The participants were selected Protects against infection and illnesses. (3) Promotes
from a total of 300 pregnant women who met all eligibil- bonding between mother and child. (4) Breastfeed baby
ity criteria of the study. The study was conducted from is rarely constipated. (5) Protect baby from obesity. (6)
October 2017 until July 2018. The subjects were Strengthen child’s bones. (7) Enhances development.
assigned either into intervention (n = 65) or control (n = (8) Enhances intelligence. The second section
65) group in a random way through generating a ran- consisted of 6 question items about the benefits of BF
dom digit number by Microsoft Excel 2013. The subjects for the mother (1) Leads to uterine involution (2)
were Kurdish speakers and pregnant women who en- Decreases incidence of breast cancer (3) Decreases
rolled in the maternal care unit of PHCC, from 30th to incidence of ovarian cancer (4) Provides emotional
38th weeks of their gestational age, had a normal preg- satisfaction to the mother (5) Loses pre-pregnancy
nancy without complications, expected to have a single- weight faster (6) Spaces birth. The third section in-
ton, were full term and normal new-born, either by cluded 7 question items recommended by WHO and
vaginally or caesarean section. The included subjects UNICEF. The question items were; (1) Do you know
agreed to participate in the study and were ready to be about early skin-to-skin contact? (2) When the mothers
followed-up by the researcher during the study period. have to initiate the BF after childbirth? (3) Should
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 3 of 12

Fig. 1 Flow diagram of participants’ recruitment

Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 4 of 12

colostrum be given to the baby? (4) Is it necessary to language by a translation office that is authorized by
give prelacteal feeds to baby? (5) Up to which age child Ministry of Justice of Kurdistan/Iraq. Then the Kurdish
should receive exclusive breast milk? (6) At which age version was reviewed by four academic experts (two in
the complementary food should be introduced? (7) maternity nursing and two in paediatric nursing) whose
What is the optimal time for weaning the infant? mother tongue is Kurdish language, but they are fluent
Part C: In this part of the questionnaire, the mothers’ in English language. The one by one translation items of
attitudes were measured using the Iowa Infant Feeding these scales were discussed by the experts. They were
Attitude Scale (IIFAS). IIFAS was developed by Mora reconciled to a Kurdish version.
and Russell (1999) for assessment of mothers’ attitude
toward breastfeeding. IIFAS is a valid and reliable Nursing intervention
analytical tool with Cronbach’s alpha ranging from 0.85 A direct interview technique was used by the researcher
to 0.86. IIFAS consists of 17 attitude questions rated by to gather the required information before the interven-
a 5-point Likert ranging from 5 (strongly agree) to 1 tion. The investigators reviewed the daily appointment
(strongly disagree). According to this scale, approxi- schedule of pregnant women in antennal care unit in
mately one-half of the items are favourable to BF, and Mala Afendy PHCC in Erbil city. Determination of eli-
the remaining favourable to formula feeding. Items gible participants was based on the selection criteria.
favouring formula feeding are reverse scored and a total Verbal consent was obtained after explaining the pur-
attitude score computed via an equally weighted sum of pose of the study and the process of intervention. The
responses. Total attitude scores range from 16 (indicat- subjects in the intervention group were masked to the
ing positive attitudes towards artificial feeding) to 80 fact that they would be compared to a control group in
(reflecting positive attitudes towards BF). The last item the health centre. They were allocated either into the
of the scale was “A mother who occasionally drinks al- intervention or the control group randomly upon agree-
cohol should not breastfeed her baby” did not receive ment. After taking the demographic data, a baseline of
any score in this study, as all subjects of the study were mother’s knowledge, attitude and prenatal BSE scale was
non-alcoholics [11]. completed for both groups as a pre-test by the second
Part D: The prenatal BSE of study participants were researcher. Researchers made a schedule to demonstrate
measured through Prenatal Breastfeeding Self-Efficacy date and time of meetings for two educational sessions
Scale (PBSES). The scale was developed and provided just for the participants in the intervention group. Post-
evidence for internal consistency (Cronbach’s alpha = test of knowledge, attitude and prenatal BSE scale was
0.89), as well as validity by Wells et al. (2006). This in- taken for both intervention and control group two weeks
strument was designed to a 20-item Likert scale after the pre-test. All participants in the intervention
method with responses ranging from 1 (not sure) to 5 group were called and educated in small groups. If the
(completely sure). Possible overall scores range from 20 participants could not attend according to the schedule
to 100, with higher scores indicative of greater BSE of in the educational sessions, another appointment was ar-
mothers during pregnancy [12]. Items 11 and 20 were ranged by the investigator with another group.
slightly modified to be compatible with Kurdish The intervention was an antenatal BF educational pro-
culture. gram which was developed after reviewing an extensive
Part E: Postnatal BSE of the subjects two months after literature and standards of BF education that was based
birth was measured by Breastfeeding Self-Efficacy on the BSE framework of Dennis (1999). Dennis theo-
Scale-Short Form (BSES-SF). The Cronbach’s alpha co- rized the role of self-efficacy in breastfeeding in order to
efficient for the BSES-SF was 0.97. It consists of 14 explain and predict behaviour in her framework [7]. The
positive statement inquiries as developed by Dennis in theory of self-efficacy suggests that four factors can in-
2003 to measure BSE. Participants were asked to rate fluence the level of self-efficacy of a person. These are
their agreement with the statements based on a 5-point personal achievements, vicarious experiences, verbal per-
Likert-type scale. A response of ‘1’ indicates that the suasion, and psychological and affective states [7, 14].
participant strongly disagrees or not at all confident Also, for the educational session, the required infor-
and response of ‘5’ indicates that the participant mation on BF aspects with related images were collected
strongly agrees or very confident with the statement. in a forty page booklet in local language by researchers.
The scores are then summed to produce a possible The information were simple anatomy and physiology of
range from 14 to 70, with higher scores indicating BF, the benefits of BF for both infant and mother, initi-
higher levels of BSE [13]. ation of BF, benefits of skin-to-skin contact, common
position of BF. Moreover, other information was the
The questionnaire of mothers’ BF knowledge, IIFAS, baby attachment to the breast, signs of effective sucking,
PBSES and BSES-SF were translated into Kurdish methods of milk expression, successful BF tips and
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 5 of 12

common problems that lactating mothers encountered centre. The level of intervention that was applied to the
during the initial stages of BF, and how these challenges participants in the experimental group was considered
were overcome. to be safe. Data were collected from mothers who agreed
The PHCC did not present the official antenatal edu- to participate in the study. The required information
cational services on BF to the participants. Both groups was explained to all participants. Participation was vol-
received routine antenatal care which included checking untary, anonymous and their right to withdraw from the
weight, blood pressure, urine for protein and sugar, and study was protected. Verbal consent was obtained from
foetal heart rate. These tests were delivered by the med- all study participants. Also, the confidentiality of all per-
ical health care provider in the PHCC. In addition to the sonal information of the study sample was protected
routine care, participants in the intervention group re- throughout the study duration. Participants’ consent was
ceived a BF booklet and two BF education sessions in taken to publish the information reported in the present
small groups of four to six participants with two days trial.
interval, each session lasting for 60–90 min. During
these sessions, the researcher explained all contents of Results
the booklet to the participants. In addition, some related Baseline information of the participants in the experi-
videos were downloaded on a laptop and were displayed mental and control groups was checked before the ana-
for approximately 15 min to participants to facilitate the lysis of the impact of antenatal education. The analysis
educational process. The educational sessions were open identified that both control and experimental groups
to the discussion of the participants’ issues on BF. We were similar in age (26.80 vs 26.38 years, P = 0.724); age
gave an opportunity to the subjects who did not under- at marriage (20.26 vs. 20.94 years, P = 0.360); education
stand the information given in the face to face counsel- (7.58 vs. 8.25 years, P = 0.472); gestational age (33.94 vs.
ling, booklet, or videos to make a contact with the 33.97 weeks, P = 0.948); occupation (housewife: 92.3% vs.
researcher for further clarification through a phone 86.2%, P = 0.258); Gravida, Para and Abortion (P > 0.05)
counselling. Two months after childbirth at the time of and lactation history (45.6% vs. 42.6%, P = 0.749). The
vaccination of new-born baby, all participants in both only difference was the type of family (nuclear family
groups were again interviewed by filling out the postna- 73.8% vs 56.9%, P = 0.043) (Table 1).
tal BSES-SF and enquired on infant feeding status. The homogeneity of knowledge, attitudes, and prenatal
BSE of the participants were assessed after randomization
Statistical analysis process (pre-test) by the same measurement tools for both
The collected data were coded, entered, verified, and an- study groups. The assessment of the knowledge showed a
alyzed using the Statistical Package for Social Sciences non-significant difference (p > 0.05) between two groups.
version 25:00 (SPSS 25:00; IBM Corp; USA). In addition, the total degree of prenatal BSE between the
The categorical and numerical characteristics of experimental and control groups; 53.57 (SD: 9.53) vs.
mothers were present in frequency (percentage) and 53.88 (SD: 9.63); P = 0.855 and their contents were not dif-
mean (Sta. Deviation), respectively. The homogeneity of ferent significantly (P > 0.05). The total level of attitudes
baseline information between the experimental and con- between the two study groups were not different substan-
trol groups was examined in the Pearson Chi-Square test tially; 58.02 (SD: 4.06) vs. 58.35 (SD: 4.20); P = 0.641 and
or independent t-test. The difference of knowledge and their contents (P > 0.05).
attitude items between both groups were determined in Two week after completing the educational intervention
Pearson Chi-square tests and independent t-test, re- a post-test of knowledge, attitudes, and prenatal BSE was
spectively. The difference of prenatal and postnatal BSE taken for both groups of the present study, the results indi-
items between the study and experimental groups were cated that the total number of correct knowledge answers
determined in independent t-test, respectively. The dif- (21 knowledge items) after intervention were significantly
ferences between postnatal BSE and exclusive BF were higher (780, 65.15%) in the experimental group compared
examined in independent t-test. Binary logistic regres- to those items answered correctly by control subjects (421,
sion was performed for predictors of exclusive BF in the 33.41%). As well, the total attitude score of the subjects in
experimental group. The null hypothesis was rejected in the experimental group was significantly higher (Mean [M]:
a P-value of less than 0.05. 62.88, SD: 3.35) compared to the control group (M: 58.57,
SD: 4.25), P < 0.0001 (Table 2).
Ethical considerations After intervention the total prenatal BSE level was sub-
The protocol of the study was approved by the Scientific stantially higher in the experimental group (M: 70.84,
and Ethical committee of College of Nursing/ Hawler SD: 8.68) compared to the control group (M: 55.02, SD:
Medical University (registration number: 9 in 16/3/ 9.49), P < 0.0001. The significant higher scores were
2016). Formal permission was given by the health care found in all items of prenatal BSE in the experimental
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 6 of 12

Table 1 Comparaison of mothers’baseline information

Subjects’ characteristics Control (n = 65) Experimental (n = 65) P-Value (Two-Sided)
Age (Years) 26.80 (6.60) 26.38 (6.80) 0.724*
Age at marriage (Years) 20.26 (4.07) 20.94 (4.32) 0.360**
Education (Years) 7.58 (5.38) 8.25 (5.08) 0.472*
Gestational Age (weeks) 33.94 (2.62) 33.97 (2.78) 0.948 Independent t-test
Occupation
Employed 5 (7.7) 9 (13.8) 0.258*
Housewife 60 (92.3) 56 (86.2)
Family Type
Nuclear 48 (73.8) 37 (56.9) 0.043*
Extended 17 (26.2) 28 (43.1)
GPA
Gravida
Primigravida 31 (47.7) 35 (53.8) 0.483*
Multigravida 34 (52.3) 30 (46.2)
Para
Primiparous 36 (55.4) 40 (61.5) 0.477*
Multiparous 29 (44.6) 25 (35.8)
Abortion
Non-Aborted 50 (76.9) 54 (83.1) 0.380*
Aborted 15 (23.1) 11 (16.9)
Lactation history 26 (45.6) 23 (42.6) 0.749*
*Chi-Squared and ** Fishers’ Exact tests were performed for statistical analyses

group compared to those in the control group (P < situation to their satisfaction (M: 3.83, P < 0.0001). (6)
0.001), (Table 3). Manage to breastfeed even if their baby was crying (M:
The postnatal BSE was measured after two months of 3.79, P < 0.0001). (7) Kept wanting to breastfeed (M:
delivery in both groups. The findings showed that the 4.04, P = 0.039). (8) Breastfeed comfortably with pres-
total postnatal BSE mean score was substantially higher ence of their family members (M: 3.92, P < 0.0001). (9)
in the experimental groups (M: 53.98, SD: 8.50) com- Were satisfied with their BF experience (M: 4.08, P <
pared to the control group (M: 43.41, SD: 8.12), P < 0.0001). (10) Deal with the fact that BF can be time-
0.0001. Generally all postnatal BSE items score were sig- consuming (M: 3.87, P = 0.013). (11) Finish feeding their
nificantly higher in the experimental group compared to baby on one breast before switching to the other breast
the control group. The subjects in the experimental (3.69, P = 0.001). (12) Continue to breastfeed their baby
group agreed with having the ability of achieving the fol- for every feeding (M: 3.71, P < 0.0001). (13) Manage to
lowing statement: (1) Determine their baby was getting keep up with their baby’s BF demands (M: 3.85, P <
enough milk (M: 3.87, P < 0.0001). (2) Cope successfully 0.0001). (14) Tell when their baby was finished BF (M:
with breastfeeding as with other challenging tasks (M: 3.83, P = 0.001), (Table 4).
3.79, P < 0.0001). (3) Breastfeed their baby without using The comparison of total postnatal BSE two months
formula as a supplement (M: 3.96, P < 0.0001). (4) En- following of delivery showed that its level was higher in
sure their baby was properly latched on for the whole those mothers who exclusively breastfed compared to
feeding (M: 3.77, P < 0.0001). (5) Manage the BF those subjects who had partially breastfeed and formula

Table 2 Comparison of mothers’ overall knowledge and attitude towards BF after intervention (post-test)
Subjects’ Knowledge and attitude Control (n = 60) Experimental (n = 57) P-Value (Two-Sided)
Total correct answers 421 (33.41) 780 (65.15) < 0.0001*
Total attitude 58.57 (4.2) 62.88 (3.4) < 0.0001**
*Pearson Chi-Square and **Independent t-test were performed for statistical analyses
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 7 of 12

Table 3 Comparison of mother’s prenatal BSE after intervention (post-test)

Prenatal BSE items Control (n = 60) Experimental (n = 57) P-Value (Two-sided)
I can make time to breastfeed my baby even when I feel busy. 2.82 (1.03) 3.42 (1.00) 0.002
I can breastfeed my baby even when I am tired. 2.65 (1.15) 3.47 (1.02) < 0.0001
I can schedule my day around the breastfeeding of my baby. 2.52 (0.93) 3.16 (1.07) 0.001
I can breastfeed my baby when I am upset. 2.53 (1.07) 3.42 (1.07) < 0.0001
I can breastfeed my baby even if it causes mild discomfort. 2.65 (1.12) 3.19 (1.09) 0.009
I can use a breast pump to obtain milk. 2.22 (1.08) 2.96 (1.13) < 0.0001
I can prepare breast milk so others can breastfeed my baby. 2.37 (1.25) 3.05 (1.09) 0.002
I can find out what I need to know about breastfeeding my baby. 2.45 (0.91) 3.53 (.80) < 0.0001
I can find the information I need about problems I have breastfeeding my baby. 2.38 (0.85) 3.42 (.87) < 0.0001
I know who to ask if I have any questions about breastfeeding my baby. 2.43 (0.98) 3.65 (.77) < 0.0001
I can call a physician if I have problems breastfeeding. 1.93 (0.97) 2.81 (1.01) < 0.0001
I can talk to my healthcare provider about breastfeeding my baby. 2.78 (0.98) 3.82 (.71) < 0.0001
I can breastfeed my baby when my family or friends are with me. 2.70 (1.18) 3.58 (1.21) < 0.0001
I can breastfeed my baby around people I do not know. 2.12 (1.14) 3.28 (1.26) < 0.0001
I can breastfeed my baby when my husband is with me. 3.37 (1.03) 4.19 (0.79) < 0.0001
I can breastfeed my baby without feeling embarrassed. 2.47 (1.02) 3.12 (0.91) < 0.0001
I can choose to breastfeed my baby even if my husband does not want me to. 3.38 (0.92) 4.25 (0.76) < 0.0001
I can choose to breastfeed my baby even if my family does not want me to. 4.03 (0.82) 4.40 (0.56) 0.005
I can talk to my husband about the importance of breastfeeding my baby. 3.92 (0.85) 4.35 (0.64) 0.002
I can breastfeed my baby for two years. 3.30 (1.03) 3.75 (0.87) 0.001
Total prenatal BSE 55.02 (9.49) 70.84 (8.68) < 0.0001
Independent t-test was performed for all statistical analyses. The numbers are in mean (standard deviation).

Table 4 Comparison of mothers’ postnatal BSE two months after birth

Postnatal BSE items Control (n = 54) Experimental (n = 52) P-Value (Two-Sided)
1. Determine that my baby is getting enough milk 3.13 (0.97) 3.87 (0.79) < 0.0001
2. Successfully cope with breastfeeding as I have with other challenging tasks 2.76 (1.23) 3.79 (0.83) < 0.0001
3. Breastfeed my baby without using formula as a supplement. 2.39 (1.24) 3.96 (1.03) < 0.0001
4. Ensure that my baby is properly latched on for the whole feeding. 3.04 (0.85) 3.77 (0.92) < 0.0001
5. Manage the breastfeeding situation to my satisfaction. 2.91 (1.05) 3.83 (0.83) < 0.0001
6. Manage to breastfeed even if my baby is crying 3.07 (0.95) 3.79 (0.94) < 0.0001
7. Keep wanting to breastfeed. 3.74 (0.81) 4.04 (0.66) 0.039
8. Comfortably breastfeed with my family members present. 3.19 (0.80) 3.92 (0.68) < 0.0001
9. Be satisfied with my breastfeeding experience. 3.07 (1.06) 4.08 (0.65) < 0.0001
10. Deal with the fact that breastfeeding can be time-consuming. 3.52 (0.75) 3.87 (0.66) 0.013
11. Finish feeding my baby on one breast before switching to the other breast. 3.06 (0.88) 3.69 (1.04) 0.001
12. Continue to breastfeed my baby for every feeding. 3.11 (0.97) 3.71 (0.89) < 0.0001
13. Manage to keep up with my baby’s breastfeeding demands. 3.13 (0.78) 3.85 (0.87) < 0.0001
14. Tell when my baby is finished breastfeeding 3.30 (0.84) 3.83 (0.76) 0.001
Total postnatal BSE 43.41 (8.12) 53.98 (8.50) < 0.0001
Independent t-test was performed for all statistical analyses. The numbers are in mean (standard deviation)
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 8 of 12

Table 5 Comparison of mothers’ total postnatal BSE with infants feeding status (two months after delivery)
Postnatal BSE Control P-Value (Two -Sided) Experimental P-Value (Two-Sided)
Infants feeding status n Mean (SD) n Mean (SD)
Exclusively BF 13 52.00 (10.5) < 0.001 29 57.69 (4.86) < 0.001
Partially BF 30 41.46 (6.17) 19 52.11 (5.16)
Formula feeding 11 39.45 (4.55) 4 36.00 (16.15)
Pearson Chi-squared test was performed for statistical analysis

fed in both intervention and control groups (P < 0.001), were 14 to 18 years of age and were in high school, par-
(Table 5). ticipated in a pre and post-intervention study. The re-
The Logistic Regression Analysis of the study showed sults reported no significant differences in prenatal BSE
that higher postnatal BSE predicted a higher level of ex- scores in pre and post-intervention (an antenatal educa-
clusive BF in the experimental study groups; OR: 0.661 tional intervention) [19].
(95% CI: 0.50–0.87); P = 0.004 (Table 6). Probably this difference between the results of our
study and that project could be interpreted as following:
Discussion Important reason is low sample size (eight participants
Breastfeeding self-efficacy compared to 130 in our study is very low), which did
Self-efficacy is crucial in BF and it is regarded to be a de- not support the achievement of statistical significance.
termining parameter in relation to choosing BF method In addition, design of study has a great importance, as
and level of compliance in solving BF problems [15, 16]. our study design is a case - control study while, the
The results of the present study were compatible with mentioned study was a pre and post-intervention design.
the hypothesis that BSE can be increased through pre- Therefore, there may be a confounding factor affected
natal nursing intervention. the BSE at pre-test, whereas control group could have
Many researches have supported prenatal BF interven- solved this problem. The other reason for the difference
tions as being effective in increasing BSE regardless of reflected in the characteristics variation of participants
the types of educational intervention [16–18]. A recent in both study. For instance, all participants in that pro-
meta-analysis from Canada investigated the effect of ject were nulliparous, so they did not experience breast-
education or support based interventions on improve- feeding. While approximately half of the subjects in our
ment of BSE. The interventions were implemented in research had at least one child and more than 40% of
the postpartum, prenatal or perinatal period. The results them had lactation history. In the other hand, all
indicated that the mothers in the intervention groups mothers in the mentioned project were adolescent stu-
had significantly higher BSE score compared to the dents, while the majority of participants in our study
mothers in the control groups [15]. were housewives and nearly at mean age of 26 years.
In contrast with our results, in an evidence-based Furthermore a study from Portugal found an association
practice project, eight nulliparous pregnant women who between BSE and women’s parity, educational level,

Table 6 Predictors of exclusively breastfeeding in the experimental group

Predictors Dependent variable: Exclusively and noon-exclusively breastfeeding in the experimental group
B S.E. Wald P-Value OR 95% C.I. OR
Lower Upper
Age (Years) −0.343 0.190 3.255 0.071 0.710 0.49 1.03
Age at marriage (Years) 0.269 0.197 1.867 0.172 1.308 0.89 1.92
Education level 2.122 1.449 2.145 0.143 8.346 0.49 142.78
Occupation −1.524 1.586 0.923 0.337 0.218 0.01 4.88
Type of family 0.710 1.136 0.390 0.532 2.034 0.22 18.85
Gravida −3.462 1.930 3.217 0.073 0.031 0.001 1.38
Para 3.594 2.161 2.765 0.096 36.367 0.53 2513.92
Lactation history 1.292 1.647 0.616 0.433 3.641 0.14 91.80
Total attitude 0.281 0.207 1.831 0.176 1.324 0.88 1.99
Total postnatal BSE −0.413 0.142 8.441 0.004 0.661 0.50 0.87
Binary logistic regression was performed for statistical analysis
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 9 of 12

occupational status, and previous breastfeeding experi- Brandão et al. (2018), found that the women who had
ence [15, 20]. a higher BSE scores during pregnancy were BF exclu-
Aguirre, et al. (2018), noted that the effect of the pre- sively at the first month postpartum, while women who
natal intervention on BSE could be changed over time were mixed feeding or who had stopped BF at the first
point. In this regard, they did not find a significant dif- month postpartum had a lower antenatal BSE scores
ference between intervention and control group at base- [15, 20].
line or during the early days postpartum. However, A study from Brazil, reported that the high score of
differences in self-efficacy scores were considerable at BSE and the age of mothers were the protection factors
week 6 and months 3 and 6 [21]. to the exclusive BF [17]. Results of this study corre-
Literature supports positive effectiveness of antenatal sponds with our findings regarding the BSE as an associ-
education on increasing BSE but, sometimes the context ated factor with exclusive BF, but in our study we did
and circumstances may impact on the effectiveness of not find any association between mothers’ age and
the interventions. In this regards, a Japanese study ex- exclusive BF.
plored impact of a self-efficacy intervention on BSE and A USA-based study could not find the antenatal edu-
exclusive BF and assessed the difference in effect by cation, postnatal BSE and BFexperience, as contributing
hospital-routine type. The eligible pregnant women at factors of exclusive breastfeeding [18]. While our results
third trimester were enrolled from non-Baby-Friendly indicated that there was a link between antenatal educa-
Hospitals (nBFH) and “Baby-Friendly”-certified hospitals tion and postnatal BSE with exclusive breastfeeding, but
(BFH). They were assigned to either the intervention both studies agreed that the BFexperience was not a
group or the control group. A breastfeeding self-efficacy contributing factor to exclusive breastfeeding.
workbook was provided only for the participants in the Globally, it is recognized that a range of cultural vari-
intervention group from both types of hospitals. In ables affect infant feeding practices including cultural ta-
BFHs, the intervention improved both BSE and exclusive boos [15, 27]. But, there are few studies on cultural
BF at four weeks postpartum. But, in nBFHs, no positive variables influencing BF in a developing country context
result was observed on BSE or on the exclusive BF rate [15, 28]. We do not have official data about the effect of
through four weeks postpartum [22]. Therefore, more Kurdish culture and norms on BF among Kurdish
attention should be paid to mothers’ conditions and women. But according to our experiences of living in
their limitations concerning time and place of their this context, generally Kurdish people encourage the
education [23]. women to breastfeed their infants.
In the present study postnatal BSE was found to be a
predictor of exclusive BF in experimental group but not Breastfeeding knowledge and attitudes
regarding other variables such as age, age at marriage, The effect of nursing education on increasing knowledge
educational level, occupation, type of family, gravidity, and attitude is obvious; as the results of the present
parity and lactation history. Although many studies in study also proves the improvement in the breastfeeding
the Kurdistan region were done on knowledge and atti- knowledge and attitude of mothers after BF education in
tude of breastfeeding, but the present study is the first experimental group compared to control group. Con-
one which examined the BSE of Kurdish mothers cerning the effect of knowledge on BF, several studies
through nursing intervention. reported that poor maternal knowledge was a relevant
risk factor for BF abandonment [29–31]. Similar with
Exclusively breastfeeding our findings, a study from Saudi Arabia reported signifi-
The findings of the present study suggest that the pre- cant differences within the intervention group in know-
natal nursing intervention was effective in increasing ledge and attitude [32]. A quasi-experimental study from
postnatal BSE which led to enhancing the exclusive BF Iran revealed that the women who receive antenatal edu-
practice after two months of birth. In consequence, a cation have significantly better scores in terms of self-
higher postnatal BSE score associated with a higher level efficacy, knowledge, and attitude scores [33]. As knowing
of exclusive BF practice in both groups of study. that Saudi Arabia and Iran are neighbour countries of
Brockway et al. (2018), claimed that self-efficacy can Iraq and there is culture similarity between the countries
predict BF outcomes in first and second months follow- with Islamic religious background that have favourable
ing birth in mothers of full-term infants, and it is a attitude toward breastfeeding. Another study found that
modifiable factor that can affect BF success [15, 24]. introducing the prenatal education resources in the ob-
Literature proved that mothers’ breastfeeding self- stetrician’s waiting room significantly increased breast-
efficacy and intention to BF were the most important feeding attitudes and knowledge among the education
predictors of initiation, continuing exclusive BF and group [34]. It is worth mentioning that, one of the lead-
length of BF during six months after birth [15, 25, 26]. ing causes of neonatal mortality and morbidity is
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 10 of 12

inadequate BF due to a lack of understanding of a settings across the country. In addition, data collection
mother of its importance and benefits [35]. Insufficient were based on the mothers’ subjective views. Therefore,
knowledge, poor attitude or inappropriate practice, of response bias might have occurred since participants
BF may lead to undesirable consequences for both may have tended to provide favourable responses so that
mother and child [36]. Antenatal education is an import- they would be perceived as successful BF mothers. Con-
ant factor in developing BF knowledge and fostering BF sequently, the results may have been influenced by the
skills and confidence for initiating and maintaining BF personality and environment of the mother. Alternately,
until the sixth month [29] which effects the health of the preconceived expectations of the researcher may have
baby. Mother’s knowledge and skills can increase the also affected interaction with participants.
rate and duration of breastfeeding and are a relevant
component of effective decisions and actions related to Recommendations
BF [29, 37]. Since antenatal BF education program is a valid inter-
vention for modifying some variables (i.e. knowledge, at-
Considerations on breastfeeding self-efficacy scales titude, and BSE), results of this research could be used
There are several measurements of BSE which have been by nurses and health educators to guide the women in
used cross-culturally with good reliability [38]. Six scales their daily practice. Consequently, there is a need to pro-
for measuring BSE were reported based on a critical re- duce a standard breastfeeding educational package for
view of available BSE instruments in 2015 [39]. Each of pregnant mothers by health professionals. Although the
these instruments were intended to measure the BSE. present study supports the effect of intervention during
The majority of the instruments were based on Ban- pregnancy on BSE, maybe this effect could be increased
dura’s social cognitive theory directly or indirectly [39]. by extension of interventions to the intrapartal and post-
Three of these scales were developed to measure pre- partal period. Furthermore, this type of intervention
natal BSE, while others were developed to measure post- could be repeated in larger samples and with diverse
natal BSE. Breastfeeding Self-Efficacy Scale – Short populations. The study also recommends the further use
Form (BSES - SF) was used more frequently than any of qualitative studies to gain a deeper understanding of
other BSE instrument. More than forty articles have those mothers who do not successfully breastfeed. Using
been published using this instrument [39]. Since none of BSE scale as a screening tool in the prenatal period by
the instruments can be used to measure prenatal and health care providers could identify women who need
postnatal BSE over time, especially between anticipated interventions during the prenatal period.
self-efficacy and experience self-efficacy, the effectiveness
and improvement were observed at both prenatal and
postnatal period. Whereas, most available studies that Conclusions
measured the prenatal and postnatal BSE, used BSES Exclusive BF practise is affected by increasing BSE of
-Short Form for measuring both prenatal and postnatal mothers through antenatal nursing interventions, which
BSE [16, 40]. This particular instrument was not appro- also enhance the mother’s BF knowledge, and attitudes.
priate for administering to women in the prenatal period The level of BSE is a predictor of exclusive BF practice
since many of the questions which assess BF confidence during the first two month after birth. Since has been
require a woman to have actual interaction with her evidenced that there is a association between increasing
baby [12, 41]. exclusive BF (as an optimal infants’ nutrition) and redu-
Therefore, in this study the authors decided to meas- cing infants’ morbidity/mortality, as well provide better
ure maternal BSE in the prenatal and postnatal period health status for mothers, thus a comprehensive ante-
by two distinct instruments, that the wording of the each natal educational programs on BF can play important
scales was compatible with a specific time period. The role in the achievement of better health outcome for
BSES-Short Form of Dennis is more suitable for postpar- both infants and mothers.
tum which was used for measuring postnatal BSE in the
Abbreviations
present study. The scale was developed by Wells et al. BF: Breastfeeding; BSE: Breastfeeding Self-Efficacy; BSES-SF: Breastfeeding Self-
was used for measuring of prenatal BSE. Efficacy Scale-Short Form; IIFAS: Iowa Infant Feeding Attitude Scale;
PBSES: Prenatal Breastfeeding Self-Efficacy Scale; PHCC: Primary Health Care
Centre; SPSS: Statistical Package for Social Sciences; UNICEF: United Nations
Limitations of this study International Children’s Emergency Fund; WHO: World Health Organization
Experimental design, random group assignment and
using validated instruments for measuring BF attitude Acknowledgements
and self-efficacy were strong points of the present study. The authors of the study would like to present their deep thanks to the staff
of Mala Afendy primary health centre in Erbil city for their kind cooperation
However, as study sample had derived from one PHCC, and assistance. In addition, the authors would like to present their profound
this precluded us from generalizing the findings to other thanks to Mr. Deldar M. Abdulah for statistical analysis of the data.
Piro and Ahmed BMC Pregnancy and Childbirth (2020) 20:19 Page 11 of 12

Authors’ contributions 9. Mélo NS, da Nóbrega MM, Leite KNS. Silva SdCR, Antas EMV, da Silva APD,
HMA initiated the idea, prepared the proposal and made substantial Oliveira SX, César ESR, Lima TNFA, de Souza TA: nurses participation in
contributions to conception and design of the study. SSP collected the data, promoting breastfeeding. Int Arch Med. 2016;9.
interpreted the data and drafted the manuscript. All authors have read and 10. Flower KB, Willoughby M, Cadigan RJ, Perrin EM, Randolph G. Team FLPI:
approved the final version of the manuscript. As well as, they have agreed to Understanding breastfeeding initiation and continuation in rural
be personally accountable for the author’s own contributions. communities: a combined qualitative/quantitative approach. Matern Child
Health J. 2008;12(3):402–14.
Authors’ information 11. Adl M, Russell DW, Dungy CI, Losch M, Dusdieker L. The Iowa infant feeding
SSP is Assistant Lecturer in College of the Nursing / University of Duhok; attitude scale: analysis of reliability and validity 1. J Appl Soc Psychol. 1999;
Duhok- Kurdistan Region –Iraq and Ph.D. student in Maternity Nursing in 29(11):2362–80.
College of Nursing / Hawler Medical University, Erbil - Kurdistan Region – 12. Wells KJ, Thompson NJ, Kloeblen-Tarver AS. Development and psychometric
Iraq. HAM, is Assistant Professor; Ph.D. in Maternity Nursing; Dean of College testing of the prenatal breast-feeding self-efficacy scale. Am J Health Behav.
of Health Sciences; Director of the Center for Research and Education in 2006;30(2):177–87.
Women’s Health in Hawler Medical University, Erbil - Kurdistan Region - Iraq. 13. Dennis CL. The breastfeeding self-efficacy scale: psychometric assessment of
the short form. J Obstet Gynecol Neonatal Nurs. 2003;32(6):734–44.
14. Bandura A. Self-efficacy: toward a unifying theory of behavioral change.
Funding Psychol Rev. 1977;84(2):191.
This study is authors-based funded. 15. Brockway M, Benzies K, Hayden KA. Interventions to improve breastfeeding
self-efficacy and resultant breastfeeding rates: a systematic review and
Availability of data and materials meta-analysis. J Hum Lact. 2017;33(3):486–99.
The datasets analyzed and the materials used during the current report are 16. Ansari S, Abedi P, Hasanpoor S, Bani S. The effect of interventional program
available from the corresponding author on reasonable request. on breastfeeding self-efficacy and duration of exclusive breastfeeding in
pregnant women in Ahvaz, Iran. Int Sch Res Notices. 2014;2014:1-6.
Ethics approval and consent to participate 17. Margotti E, Epifanio M. Exclusive maternal breastfeeding and the
The ethical approval of the present study was obtained from the Ethics breastfeeding self-efficacy scale. Rev Rene. 2014;15(5):771–9.
Committee of Hawler Medical University (registration number: 9 in 16/3/ 18. Davis RM: does prenatal breastfeeding education impact exclusive
2016). The verbal consents were taken from the all patients prior to the breastfeeding in the hospital? An examination of prenatal classes, self-
study recruitment after explaining the purposes and procedure of the study efficacy, previous experience, hospital practices, race, and intention as
and it mentioned in the special form requested by the Ethics Committee. contributing factors.: University of North Carolina 2013.
Confidentiality and anonymity of all participants were ensured throughout 19. El Harit J. The effect of an antenatal breastfeeding intervention on
the study in line with the instructions of the Ethics Committee. breastfeeding self-efficacy and intention among Inner City adolescents;
2015.
20. Brandão S, Mendonça D, Dias CC, Pinto TM, Dennis C-L, Figueiredo B. The
Consent for publication breastfeeding self-efficacy scale-short form: psychometric characteristics in
Not applicable. Portuguese pregnant women. Midwifery. 2018;66:49–55.
21. Aguirre TM, A J, AE K, EK R, SL W. Impact of a computer-based
Competing interests breastfeeding education program on breastfeeding self-efficacy and
The authors declare no conflict of interest. duration in rural Hispanic women. Health Prim Car. 2018;2(4):1–5.
22. Otsuka K, Taguri M, Dennis C-L, Wakutani K, Awano M, Yamaguchi T, Jimba
Author details M. Effectiveness of a breastfeeding self-efficacy intervention: do hospital
1
College of Nursing, University of Duhok, Duhok, Kurdistan Region, Iraq. practices make a difference? Matern Child Health J. 2014;18(1):296–306.
2
College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq. 23. Mohseni H, Jahanbin I, Sekhavati E, Tabrizi R, Kaviani M, Ghodsbin F. An
3
College of Health Sciences, Hawler Medical University, Erbil, Kurdistan investigation into the effects of prenatal care instruction at home on breast-
Region, Iraq. feeding self-efficacy of first-time pregnant women referred to shiraz clinics,
Iran. Int J Women's Health Reprod Sci. 2018;6(1):41–6.
Received: 8 April 2019 Accepted: 24 December 2019 24. Brockway M, Benzies KM, Carr E, Aziz K. Breastfeeding self-efficacy and
breastmilk feeding for moderate and late preterm infants in the family
integrated care trial: a mixed methods protocol. Int Breastfeed J. 2018;13(1):29.
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