Breastfeeding knowledge assessment tools among nursing and midwifery students: a systematic review

Exclusive breastfeeding is defined as ‘giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts, drops and syrups (vitamins, minerals and medicines)’ (World Health Organization (WHO), 2015). The WHO recommends exclusive breastfeeding for 6 months, with the introduction of complementary foods from 6 months, and continued breastfeeding for up to 2 years. However, breastfeeding rates globally show that this recommendation is not being met; the global rate of exclusive breastfeeding for infants under 6 months was 44% over the period 2015–2020 (WHO, 2023). The WHO (2022) has campaigned for an increase in the rate of exclusive breastfeeding to 50% by 2025.

Annually, effective breastfeeding could help prevent 823 000 infant mortalities and 20 000 maternal deaths from breast cancer globally (Victora et al, 2016). In addition, low breastfeeding rates worldwide are currently estimated to generate economic losses of around $302 billion a year, or 0.49% of the world's gross national income (Ministry of Health and Social Protection, 2022).

Morocco has made substantial strides in promoting breastfeeding, which could significantly contribute to achieving the 2030 sustainable development goals. The rate of exclusive breastfeeding rose from 27.8% in 2011 to 35% in 2018 (Ministry of Health and Social Protection, 2011; 2018). Those working in the health sector must promote and protect exclusive breastfeeding, which is an essential determinant of children's health (Ministry of Health and Social Protection, 2022).

In line with the national nutrition strategy, the Ministry of Health and Social Protection (2011) in Morocco has made the promotion, support and protection of breastfeeding a priority strategy. Under ‘promoting infant and young child nutrition’, three objectives are given: to promote breastfeeding and good infant and young child feeding practices, support breastfeeding and infant feeding in health facilities, and create a favourable environment for good breastfeeding and infant feeding practices (Ministry of Health and Social Protection, 2011).

A systematic review of 34 studies demonstrated that breastfeeding support practices led to a significant increase in breastfeeding rates (McFadden et al, 2017). Evidence suggests that healthcare professionals' theoretical knowledge of breastfeeding is predictive of supportive behaviour and mental attitude, but this knowledge needs to be exact and comprehensive to facilitate optimal breastfeeding promotion (Bernaix, 2000). However, studies have reported that nurses' and midwives' knowledge of how to help mothers breastfeed is limited (Ouyang et al, 2012; McFadden et al, 2017; Ramos et al, 2019) and the support provided is insufficient (McInnes and Chambers, 2008; Kervin et al, 2010).

Simmons (2002) highlighted the difficulties encountered by new breastfeeding families, including receiving erroneous or inconsistent advice from nurses. Women can find this advice distressing, unsatisfying and difficult to understand (Vandewark, 2014). Keleş (2021) suggested that it is essential to improve students' knowledge of breastfeeding. Various tools have been developed to assess theoretical knowledge and practical support for breastfeeding. The present study's aim was to explore these tools and how they can be mobilised among nursing and midwifery students in Morocco.

Methods

This systematic review was conducted to identify tools that have been developed to evaluate breastfeeding knowledge and practice among nursing and midwifery students. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, 2020) guideline.

The review included studies published since 2013 written in English, including case studies, qualitative and quantitative studies, mixed studies and trials. Conference abstracts, pathways, letters, textbooks, studies that did not mention a tool developed for evaluation of breastfeeding knowledge and those published before 2013 were excluded. This time limit was selected to ensure that only relevant literature from the last 10 years was included, as during this time, there were significant reforms to training of healthcare professionals in Morocco.

Search strategy

The search was carried out in December 2023 of the online scientific databases accessible through IMIST/CNRST, namely Scopus, Web of Science and PubMed. The keywords used were: (‘breastfeeding’ AND ‘knowledge’) AND (‘nursing student’ OR ‘midwifery student’) AND (‘scale’ OR ‘evaluation tool’).

The full selection process is shown in Figure 1. A total of 14 articles were initially found. After applying inclusion/exclusion criteria, 11 articles were selected for screening. After title and abstract screening, 5 articles were included in the review after a second reading to refine the selection.

Data extraction

To eliminate the risk of data gathering, three bias were assessed: selection (inclusion and exclusion criteria were used to avoid random selection of data), detection (exhaustiveness of articles and identification of all relevant studies were guaranteed as the search was carried out in different databases), and interpretation (to ensure an objective interpretation, a reading committee took part in the studies assessment and synthesis process).

Quality assessment

The quality of the articles' content was assessed using the AGREE II tool (Brouwers et al, 2013). The grid contains 23 elements arranged in 6 fields: scope and purpose, stakeholder engagement, rigour of development, clarity of presentation, applicability and editorial independence. The items are rated on a Likert scale from 1 (strongly disagree) to 7 (strongly agree).

Data analysis

The extracted data were organised into pre-established themes that aligned with the objective of the review.

Results

Five articles were included in the review (Table 1). The articles included quasi-experimental (Keleş et al, 2021; Yu et al, 2023), descriptive cross-sectional (Melchionda et al, 2023; Zhu et al, 2024) and mixed-method (Vandwark, 2014) studies conducted in Turkey, China, Italy and the USA. In quality appraisal, no study scored under 5 out of 7 for any component. The full quality appraisal results are available from the authors on reasonable request.

Instruments

The studies used a variety of tools designed to examine theoretical and practical breastfeeding knowledge among nursing and midwifery students:

• Iowa infant feeding attitudes scale
• Breastfeeding knowledge evaluation form
• Breastfeeding knowledge questionnaire
• Breastfeeding initiation practices
• Breastfeeding promotion intention scale
• Comprehensive breastfeeding knowledge scale.

Iowa infant feeding attitudes scale

The Iowa infant feeding attitude scale by De La Mora et al (1999) examines women's attitudes to breastfeeding, their preferred feeding method, and estimated duration of breastfeeding. The 17-question scale has eight items on formula feeding and nine on positive expressions of breastfeeding. Answers are given on a 5-point Likert-type scale from 1 (strongly disagree) to 5 (strongly agree). Formula feeding and breastfeeding scores are reversed. The final attitude score can range from 17 (indicating a positive attitude to formula feeding) to 85 (indicating a positive attitude to breastfeeding) (Keleş, 2021).

Breastfeeding knowledge evaluation form

The breastfeeding knowledge evaluation form was designed by Keleş (2021) to assess students' knowledge of breastfeeding and breast milk. The survey included 11 questions answered ‘correct’, ‘incorrect’ or ‘don't know’. The total score is the sum of correct answers, with a higher score indicating better knowledge.

Breastfeeding knowledge questionnaire

The breastfeeding knowledge questionnaire was created by Freed et al (1996). The questionnaire's three subscales explore the benefits of breastfeeding, the physiology of lactation and management of breastfeeding (Mora et al, 1999; Riley, 2007; Ahmed and El-Guindy, 2011; Vandewark, 2014). It was first used in the USA, and then later in Australia to explore breastfeeding knowledge among midwives registered at the Australian College of Midwives (Cantrill et al, 2003; Melchionda et al, 2019). A modified version was developed by Brodribb et al (2008) to examine physicians' knowledge of breastfeeding (Ahmed and El-Guindy, 2011; Vandewark, 2014). Ahmed and El-Guindy (2011) added three additional questions to the original questionnaire. In 2012, a Chinese version was designed by Ouyang et al (2012).

The survey includes 18 items on basic breastfeeding knowledge (advantages, timing and management of common issues), and is suitable for use with different populations. Answers are divided into ‘true’ or ‘false’, and the total score for each item corresponds to the rate of correct answers (Yu et al, 2023). Scores are categorised, with correct answers given a score of 1 and incorrect answers given a score of 0 (Li et al, 2020). Yu et al (2023) added an additional answer, ‘don't know’, which was scored 0. The total score ranges from 0–18, with a higher score indicating better knowledge.

Breastfeeding initiation practices

The breastfeeding initiation practices tool was designed to assess theoretical and practical breastfeeding knowledge (Melchionda et al, 2019). It has been used alongside the newborn ability questionnaire and found to be well suited to evaluate midwifery students' theoretical and practical training needs (Melchionda et al, 2019). The scale comprises 12 items and incorporates a case scenario featuring typical birthing room events. Respondents are asked to evaluate the likelihood of the baby finding the nipple, latching on and breastfeeding effectively within the first hour after birth. Each item is rated on a 5-point Likert scale, with half of the items reverse scored, resulting in a possible total score of 60. Higher scores indicate better breastfeeding practices.

Breastfeeding promotion intention scale

The breastfeeding promotion intention scale was developed by Zastrow et al (2019), based on the socioecological system model to evaluate intention to promote breastfeeding (Yu et al, 2023). The survey consists of 7 items coded on a 7-point Likert scale ranging from 1 (never) to 7 (definitely). Scale items address students' desire to breastfeed babies (micro system), recommend breast milk and provide information and support to customers, relatives and friends (mezo system). The total score ranges from 7–49, with a higher score indicating a stronger intention to promote breastfeeding (Yu et al, 2023).

Comprehensive breastfeeding knowledge scale

The breastfeeding knowledge scale was designed in the light of training requirements for the baby-friendly hospital initiative training, initiated in 1991 by UNICEF and the WHO (Zhu et al, 2024). Some items were retrieved from published questionnaires to assess breastfeeding knowledge (Abbass-Dick et al, 2020; Zhu et al, 2024).

The questionnaire consists of 28 questions with three possible answers: disagree, uncertain or agree. Items are divided into three sections: milk supply management, persisting through challenges and overcoming misconceptions. ‘Agree’ is the correct answer for 21 of the 28 questions, while questions 3, 8, 17, 20, 21, 23 and 27 are reverse-coded. Responses are categorised into three options: disagree (scored 1), unsure (scored 2) and agree (scored 3). The total score is determined by summing the scores of all items, with higher scores reflecting greater levels of breastfeeding knowledge (Zhu et al, 2024).

Training

Yu et al (2023) reported that graduate students (both in and outside of the healthcare field) saw university as the best place to receive appropriate breastfeeding training. An initial breastfeeding course was introduced in the USA in the 1980s and in China, students in specific healthcare specialties were reported to benefit from existing courses delivered by one training department (Yu et al, 2023). Only two optional courses about breastfeeding were available to multidisciplinary students in China, which was mainly provided by nurses, midwives and home visitors (Yu et al, 2023).

In higher education in China, breastfeeding training is incorporated into courses in paediatric nursing, midwifery and gynaecology. This is part of infant nutrition and puerperal healthcare, and includes information on the constituents of human milk, the advantages of breastfeeding and techniques for breastfeeding (Yu et al, 2023).

Duration and content

An American quasi-experimental study offered nursing students an educational programme for breastfeeding structured around 10 hours of theoretical courses and 8 weeks of clinical enrolment in a perinatal ward (Melchionda et al, 2019). Zhu et al (2024) recommended that teaching hours devoted to breastfeeding be expanded to improve the breadth of content and provide students with the skills and the knowledge needed to encourage mothers to breastfeed.

Training in breastfeeding counselling was organised by Keleş (2021) for midwifery students at a university in Turkey. The course encompassed lactation physiology and milk production, breast anatomy, the relevance of breastfeeding counselling and self-efficacy assessment and methods, and was taught for 2 hours per week over 14 weeks (Keleş, 2021).

Gaps in training

Several studies highlighted gaps in training for nursing and midwifery students on breastfeeding. Vandewark (2014) reported that a significant number of final-year students felt that they need further information or clinical background before being involved in breastfeeding support. Graduate students suggested that complete, in-depth breastfeeding training should include knowledge and attitudes as part of the nursing programme (Vandewark, 2014).

Several of the included studies cited other research that demonstrated that breastfeeding knowledge was limited among healthcare professional students, and that a broad breastfeeding curriculum was needed (Vandewark, 2014; Yu et al, 2023; Zhu et al, 2024). Zhu et al (2024) concluded that professionals from a variety of fields of competence and teaching pedagogy were required to help learners acquire knowledge and understand new theories, for instance, how the nervous system is linked to breastfeeding and the oral anatomy of infants. Clinical enrolment was recommended to enhance students' breastfeeding knowledge. This can include observation or experience practice directed by breastfeeding specialists, visits to breastfeeding units and discussion of breastfeeding cases (Yu et al, 2023).

Impact on breastfeeding knowledge

Several studies reported the positive effects of training for nursing and midwifery students on breastfeeding knowledge, skills and attitudes (Vandewark, 2014; Keleş, 2021; Yu et al, 2023). Vandewark (2014) highlighted that students who benefited from training achieved better results in terms of knowledge and confidence after attending a breastfeeding programme. Keleş (2021) concluded that breastfeeding counselling training, delivered through peer-learning, enhanced nursing and midwifery students' knowledge about breastfeeding and significally impacted their breastfeeding decisions, as well as their attitudes and behaviours regarding breastfeeding (Keleş 2021).

Yu et al (2023) showed that, after receiving breastfeeding training, students demonstrated greater knowledge and significantly more positive attitudes to breastfeeding. When comparing the results from students who had attended gynaecology or paediatrics lectures with those who had not, Zhu et al (2024) highlighted positive differences seen for students' total scores and most individual items. Singletary et al (2016), cited in Keleş (2021), affirmed that school-based breastfeeding education enabled students from different socioeconomic and cultural backgrounds to refine their knowledge, overcome poorly understood issues and positively influence attitudes and beliefs.

Barriers to practice

Lack of knowledge

In China, one of the most common problems for breastfeeding promotion was that information given by healthcare professionals was often incomplete or incorrect (Zhu et al, 2024). Researchers reported insufficient support from nursing staff and a lack of breastfeeding knowledge (Yu et al, 2023; Zhu et al, 2024).

Vandewark (2014) reported that nursing students frequently disregarded that breastfeeding was the advised feeding method of choice for children under 1 year old, and almost half were opposed to breastfeeding in public. Furthermore, students were unaware of some of the fundamental breastfeeding facts that were essential to know before interacting with a pregnant or new mother (Vandewark, 2014). Second-year students reported they did not feel prepared to advise families of the advantages or methods of breastfeeding, and did not feel comfortable helping a woman breastfeed (Vandewark, 2014).

Lack of training courses

Breastfeeding training was not addressed in a satisfactory manner in nursing education programmes (Vandewark, 2014; Keleş, 2021). Melchionda et al (2019) cited Renfrew et al (2006), who reported a lack of knowledge and skills among healthcare providers in all sectors. They also cited Ward and Byrne (2011), who found that healthcare professionals, including midwives, were inadequately trained in breast anatomy and physiology, while their ability to support and handle challenging situations was only earned on the job. Similarly, Zhu et al (2024) highlighted the limited breastfeeding course content for undergraduate nursing students in two universities in China.

Discussion

This review explored the results of five studies that used breastfeeding assessment instruments to measure nursing and midwifery students' knowledge of breastfeeding.

Instruments

The studies used different assessment tools to determine students' knowledge, including the Iowa infant feeding attitudes scale, the breastfeeding knowledge evaluation form, the breastfeeding knowledge questionnaire, the breastfeeding initiation practices tool, the breastfeeding promotion intention scale and the comprehensive breastfeeding knowledge scale.

Most questionnaires were specifically designed to assess breastfeeding women's, doctors' or other healthcare professionals' knowledge and beliefs. Only the breastfeeding promotion intention scale was developed to evaluate students' intention to promote breastfeeding (Yu et al, 2023).

Keleş (2021) used a personal information form, breastfeeding knowledge evaluation form and the Iowa infant feeding attitudes scale. Yu et al (2023) used the breastfeeding knowledge questionnaire, Iowa infant feeding attitude scale and breastfeeding promotion intention scale. Melchionda et al (2019) used 34 out of 37 questions from an Australian questionnaire (Blackman et al, 2015) to test self-efficacy in assisting breastfeeding mothers. Vandewark (2014) used the Iowa infant feeding attitude scale and the breastfeeding knowledge questionnaire. Zhu et al (2024) used the comprehensive breastfeeding knowledge scale.

The Australian questionnaire (Melchionda et al, 2019) had been validated and the comprehensive breastfeeding knowledge scale was validated and cross-culturally adapted (Zhu et al, 2024). The five tools were found to be valid, reliable and feasible instruments for assessing students' breastfeeding knowledge. The breastfeeding knowledge evaluation form was also identified as a tool, but was only tested in one study (Keleş, 2021).

Another breastfeeding evaluation tool, the AprendeLact questionnaire, was developed by Lopez-Peña et al (2020) to assess nursing students' knowledge of breastfeeding. The survey consists of 21 multiple choice items, where students were required to select a single correct answer from four possible answers. The total score is obtained by calculating the sum of correct answers, with higher scores indicating more accurate breastfeeding knowledge (Lopez-Peña et al, 2020).

Training

Breastfeeding education is crucial for nursing and midwifery students to gain the knowledge and skills to support breastfeeding mothers (Yang et al, 2019; Keleş, 2021; Yu et al, 2023). Practitioners need to assess their theoretical abilities, while being confident in their ability to practice (Freed et al, 1996; Cantrill et al, 2003; Melchionda et al, 2019). In the USA, the Surgeon General highlighted the lack of adequate education and training in breastfeeding for nurses and physicians (Vandewark, 2014).

The WHO and UNICEF recommend that healthcare students receive at least 20 hours of breastfeeding training. (Melchionda et al, 2019; Keleş, 2021) However, studies have demonstrated deficiencies in breastfeeding training for nursing students (Spear, 2006; Ahmed and El-Guindy, 2011; Vandewark, 2014; Kakrani et al, 2015; Keleş 2021). A study in Egypt highlighted the need to improve the quality and efficiency of breastfeeding education in nursing student training programmes through more detailed content on breastfeeding (Ahmed and El-Guindy 2011).

In Morocco, a gap in breastfeeding education for nursing students has been reported (Abou Malham et al, 2015). The two institutes that provide nursing training in Morocco (the Higher Institute of Health Sciences and the Higher Institute of Nursing Professions and Health Techniques) have not established a training module for breastfeeding in undergraduate nursing students' curricula.

The studies included in the present review emphasised the significant impact of specialised breastfeeding education for nursing and midwifery students on breastfeeding knowledge and attitudes. Nursing students' knowledge increased after receiving theoretical and clinical education (Yang et al, 2019; Keleş, 2021; Yu et al, 2023). The positive impacts of education include improving self-confidence, knowledge, decisions, behaviours and beliefs, as well as addressing poor understooding (Vandewark, 2014; Melchionda et al, 2019; Keleş, 2021; Yu et al, 2023; Zhu et al, 2024).

Barriers to breastfeeding practice

The reviewed studies highlighted factors that influence the practice of breastfeeding, including a lack of knowledge, clinical experience and training courses. This has been verified by a number of studies. Practical and emotional support and prompting from healthcare professionals influence a mother's decision to start and continue breastfeeding (Yang et al, 2019).

A systematic review by Yang et al (2018) highlighted that barriers to breastfeeding practice include gender norms, students' year of study, cultural practices, previous experience and government legislation. Cricco-Lizza (2006) reported that, in nursing students, high-level knowledge was associated with being married, having a family history of breastfeeding, or living in a rural area. Pajalic (2014) noted that nursing students' beliefs about the advantages of breastfeeding were affected by government restrictions on infant formula, as well as traditions and cultural acceptance. Bowdler et al (2022) highlighted that pre-registration nursing students' knowledge about breastfeeding was influenced by their experiences and the quality and relevance of education.

Limitations

This review had several limitations. Studies published before 2013 were excluded, which may have yielded more information. The professions covered were those related to nursing, although other professions may be relevant for future research, such as gynecologists, pediatricians and nutritionists. This broader approach would lead to a more comprehensive understanding of the factors influencing breastfeeding practices and the support systems available to mothers.

Additionally, the review explored a number of tools for collecting breastfeeding data, which may have led to a generalised understanding that lacks depth, obscuring the unique strengths and weaknesses of each tool. It may also have introduced variability in methodology, making meaningful comparisons difficult. Important contextual differences could be overlooked, preventing insights into the effectiveness of specific instruments.

Finally, grey literature can contribute to an exhaustive review of the literature but was not included in this review. The exclusion was justified based on several considerations. Grey literature often lacks rigorous peer review, resulting in variability in the quality and reliability of the information presented. The primary focus of this review was peer-reviewed journal articles to ensure a high standard of evidence and maintain consistency in the quality of the studies included. The inclusion of grey literature could have introduced biases, such as publication and selection bias. Grey literature can be difficult to systematically search and identify, leading to an incomplete and potentially skewed dataset.

Conclusions

Outlining the available measures to evaluate nursing and midwifery students' knowledge of breastfeeding allows reearchers to select the ideal instrument to use in this population. The present review highlighted that the majority of tools are dedicated to assessing breastfeeding mothers' knowledge and there is a lack of such instruments specifically designed for nursing and midwifery students.

Future healthcare professionals play an important role in breastfeeding behaviour, and their own knowledge and attitudes can impact women's practice. The reviewed studies highlighted that nursing and midwifery students' knowledge was insufficient as a result of the lack of training courses. Therefore, the authors would suggest increasing the teaching hours devoted to breastfeeding in undergraduate students' curricula and, in cases where this is not currently available, for a comprehensive breastfeeding training module to be provided.

Key points

• Summarising the tools to assess nursing and midwifery students' knowledge of breastfeeding allows researchers to identify the ideal instrument for studies among this population.
• This review identified several assessment tools designed to determine knowledge about breastfeeding, although most were aimed at breastfeeding mothers or other healthcare professionals.
• Ensuring that healthcare professionals have good knowledge of breastfeeding enables these professionals to support breastfeeding women.

CPD reflective questions

• How can breastfeeding knowledge assessment tools be used among healthcare professionals?
• How can evaluation of breastfeeding knowledge contribute to improving breastfeeding practice?
• How can existing tools be adapted for nursing and midwifery students?