Breast milk not only protects the baby from infections and diseases, but it is also thought to predispose a person to good health over his/her lifetime (Varaei et al, 2009). There is a wealth of evidence on the short- and long-term benefits of breastfeeding on both the woman's and infant's health (Lucas et al, 1990; Singhal et al, 2001; Sadauskaite-Kuehne et al, 2004; Pollard and Guill, 2009). Breastfeeding is also known to help strengthen the mother–infant bond and is a cost-effective and practical strategy to reduce infant mortality (Jacdonmi et al, 2016). Despite the support of national and international organisations in promoting breastfeeding, there are a number of factors that can affect the success of breastfeeding and reduce women's self-efficacy (O'Brien et al, 2008; Saied et al, 2013):
Self-efficacy is one of the constructs of Bandura's (1986) social-cognitive theory and includes self-confidence in one's ability to carry out health behaviours, such as successful exclusive breastfeeding. Dennis (2003) argued that there is a significant relationship between the increase of breastfeeding self-efficacy in women and the increase of breastfeeding duration. Breastfeeding self-efficacy depends on the woman's ability or confidence in breastfeeding and affects her decision to continue (Blyth et al, 2002); it is one of the predictive factors of health behaviour that shows the woman's consistency in and movement towards continuing breastfeeding (Loke and Chan, 2013).
A study in Indonesia showed that self-efficacy has an effect on breastfeeding practice (Handayani et al, 2010). Another study on 437 pregnant women over 18 in their 37th week of pregnancy found that women with high self-efficacy were more likely to exclusively breastfeed and for a longer duration compared with women with low self-efficacy (Varaei et al, 2009). Meanwhile, studies in Iran have reported that about half of Iranian mothers have low breastfeeding self-efficacy. The results of a study by Varaei et al (2009) showed that 44% of women had high breastfeeding self-efficacy, while a study by Rahmatnejad and Bastani (2012) showed 49% self-efficacy; however, Hassanpoor et al (2010) found that just 2.5% of Iranian women had high breastfeeding self-efficacy. To increase women's breastfeeding self-efficacy, appropriate strategies, such as social support are recommended (Rahmatnejad and Bastani, 2012).
Social support has been defined as
‘an individual's perception of supportive behaviours from others in their social network that will ultimately be beneficial to that individual’
Taylor and Sirois (2012) suggest that social support involves a person's perception of the availability of individuals that care for them. Findings from previous studies about the influence of social support on breastfeeding are varied. In a qualitative study by Barona-Vilar et al (2009), it was reported that women with high social support were more successful in breastfeeding. Another study reported that social relationships and friendships, social support, the woman's knowledge about the benefits of breast milk, and convenience were some of the facilitating factors of breastfeeding (Nesbitt et al, 2012). In their study about the effect of telephone support on mothers with preterm infants, Ericson et al (2013) found that the prevalence and duration of exclusive breastfeeding in the intervention group was higher than in the control group. However, other studies have shown that social support does not have a significant effect on exclusive breastfeeding (Bowman, 2013; Sinha et al, 2015).
The prevalence and duration of exclusive breast-feeding have decreased during recent years (Almasi et al, 2010). The rate of exclusive breastfeeding has been reported to be 23% in Iran as a whole, and just 13% in East Azarbaijan Province (Rashidian et al, 2014). Owing to the importance of breastfeeding (Kramer et al, 2001; Singhal et al, 2001; Pollard and Guill, 2009), it is necessary to address the reduction in rates of exclusive breastfeeding and the inconsistent results regarding the effect of social support on breastfeeding. The acquired understanding may contribute to planning interventions aimed at promoting breastfeeding self-efficacy among Iranian women, and enhancing their breastfeeding practice.
Aims
This study aimed to determine the status of social support and breastfeeding self-efficacy in Iranian women and examine the extent to which perceived social support and sociodemographic variables explain breastfeeding self-efficacy.
Materials and methods
Study design and participants
A cross-sectional study was carried out with 220 breastfeeding women who were referred to health centers in Tabriz, East Azerbaijan Province, Iran in 2014–2015.
Inclusion criteria were: Iranian nationality; intention to participate in the study; currently breastfeeding; ability to read and write; 4–6 months post-birth; and having a full-term singleton pregnancy. Exclusion criteria were: stressful events such as divorce, family disputes or the death of loved ones in the previous 6 months; unwanted pregnancy; self-reported psychological problems; and congenital anomalies in infants.
Considering an acceptable error of 0.05 around the mean (m = 101.7), 95% confidence coefficient, 90% statistical power, and the highest standard deviation of 19.12 related to breastfeeding self-efficacy scale (Barona-Vilar et al, 2007), the necessary sample size was determined to be 110 women. Regarding acceptable error of 0.05 around the mean (m = 134.3), 95% confidence coefficient, 90% statistical power, and standard deviation of 17.9 related to perceived social support (Baheiraei et al, 2012), the necessary sample size was determined to be 56 women, based on PRQ-85 (Weinert and Brandt, 1987). As the sample size based on breastfeeding self-efficacy was greater, this was the sample size sought. Regarding cluster sampling and design effect of 2, the final sample size was considered to be 220 women.
Sampling
Sampling began after obtaining ethical approval from the Ethics Committee of Tabriz University of Medical Sciences (Ethics code: Code: 5/4/7619). Sampling was conducted at health centres/posts in Tabriz. Tabriz has a population of about 1.7 million people and is the capital city of the East Azerbaijan Province. There are 81 public health centres/posts in different regions of the city that provide primary care services, including postpartum care and infant care, free of charge. All mothers and infants had health records in these health centres/posts.
A double-stage cluster sampling was carried out. Of 39 health centres and 42 health posts, 13 and 14, respectively, were selected using randomiser software, and the number of samples was determined proportional to the population of the centre or post. The lists of all breastfeeding mothers at each centre were extracted from the health records and the samples were randomly selected from the ordered numbers. The researcher called the selected potentially eligible women via phone numbers accessed from the health records and explained the objectives and methods of the study, reassured them of confidentiality of information, and scheduled an appointment for eligible women to attend the determined health centre/post to complete the study questionnaires. At the centres/posts, the researcher obtained informed consent, emphasised the importance of honest answers on the questionnaire, and asked study participants to complete the anonymous questionnaires in a private room.
Study tools
Data collection tools were socio demographic characteristics and social support (PRQ-85-part 2) questionnaires and breastfeeding self-efficacy scale.
The sociodemographic characteristics ques tionnaire consisted of questions about the mother's and father's ages, the mother's education, income, living situation, number of pregnancies, number of deliveries, pregnancy interval, and the infant's age and sex.
The Personal Relationship Questionnaire was designed by Weinert and Brandt (1987). This questionnaire consisted of two parts, and only the second part was used in this study. Part 1 comprises 10 life situations in which one might need assistance; it is designed to gather information about the person's resources, satisfaction with those resources, and whether or not they have had a need in the past 6 months. This section is not scored in the usual sense, but can be viewed from a variety of perspectives to give an indication of the person's network. Part 2 is a 25-item scale based on the five dimensions of support: the indication that one is valued (worth); the indication that one is an integral part of a group (social integration); the provision for attachment (intimacy); the opportunity for nurturance; and the availability of information, emotional, and material help (assistance). Each item's response is scored on a 7-point Likert scale where 1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = neutral, 5 = somewhat agree, 6 = agree, and 7 = strongly agree. Scores range from 25–175, with higher scores indicating higher levels of perceived social support. Over the years of use, the alpha reliability of Part 2 has been demonstrated to be around 0.90. Depending on the research needs, either part of the questionnaire can be administered as they are not dependent. It has been the authors' experience that often the level of perceived support is the area of interest and the researcher administers only Part 2. This part assesses the perceived social support of an individual (Weinert and Brandt, 1987). The PRQ85-Part 2 was chosen for this study for its ease of use, clarity, and proven reliability and validity in measuring perceived social support. Cronbach's alpha and interclass correlation coefficient for Part 2 of this questionnaire were respectively reported 84% and 0.9% in a previous study in Iran (Baheiraei et al, 2012).
The breastfeeding self-efficacy questionnaire was designed by Dennis (2003). This questionnaire is a 33-item scale and is scored by a 5-point Likert scale from always confident (5) to not at all confident (1). Scores range from 33–165, with 33–76 considered low self-efficacy, 77–120 average self-efficacy, and 121–165 regarded as high self-efficacy. The reliability of this questionnaire was reported 82% in a study by Varaei et al (2009).
Data analysis
Data were analysed using SPSS version 21. Descriptive statistics including frequency, percentage, mean, and standard deviation were used to describe sociodemographic charac teristics, breastfeeding self-efficacy and social support. The Pearson test was applied to determine the relationship between social support and breastfeeding self-efficacy, and one-way ANOVA and independent t-test were used to determine the relationship between sociodemographic characteristics and breastfeeding self-efficacy. All the variables that had P < 0.05 based on bivariate tests were then entered into an adjusted general linear model for controlling the confounding variables to determine the relationship between social support and breastfeeding self-efficacy.
Results
The mean age of women in the study was 29.5 years (standard deviation (SD) = 0.4 years). Most of the women (n = 180, 81.8%) were housewives and half of their husbands worked on a freelance basis (n = 123, 53.6%). More than three quarters (n = 175, 79.5%) of the women and their husbands had a diploma and higher education levels. There was an interval of more than 5 years between the last pregnancy and the previous one in almost half of the participants (not including those in their first pregnancy) (n = 61, 46.5%). About two thirds of women (n = 138, 62.7%) expressed that they had a fairly favourable income and most of them (n = 193, 87.7%) had wanted the pregnancy. Over three quarters of participants (n = 168, 76.4%) had an independent house. About one third of participants' infants (n = 80, 36.4%) were 6 months old, and almost half of the participants (n = 109, 49.5%) had previously breastfed (Table 1).
| Variable | Number | Mean (SD) | P-value |
|---|---|---|---|
| Age* | 0.304 | ||
| 15–25 years | 40 | 136.86 (14.14) | |
| 25–30 years | 93 | 138.18 (11.93) | |
| More than 30 years | 85 | 140.13 (12.23) | |
| Education | 0.450 | ||
| Less than diploma | 45 | 138.09 (12.33) | |
| Diploma | 94 | 138.82 (11.52) | |
| More than diploma | 81 | 140.01 (12.23) | |
| Occupation | 0.023 | ||
| Housewife | 180 | 137.82 (12.06) | |
| Working | 40 | 142.55 (10.70) | |
| Income | 0.891 | ||
| Favourable | 32 | 138.69 (11.08) | |
| Fairly favourable | 138 | 138.43 (11.76) | |
| Unfavourable | 50 | 139.38 (13.14) | |
| Number of preganancies | 0.919 | ||
| 1 | 89 | 138.55 (12.11) | |
| 2 | 103 | 138.58 (11.47) | |
| 3 or more | 28 | 139.95 (8.54) | |
| Infant's age | 0.219 | ||
| 4 months | 67 | 136.57 (13.32) | |
| 5 months | 73 | 139.75 (11.39) | |
| 6 months | 80 | 139.47 (11.11) | |
| Pregnancy interval** | 0.009 | ||
| Less than 3 years | 35 | 133.94 (15.19) | |
| 3–5 years | 35 | 142.34 (10.44) | |
| More than 5 years | 61 | 139.49 (9.55) | |
| Infant's gender | 0.697 | ||
| Female | 102 | 138.34 (12.27) | |
| Male | 118 | 138.97 (11.69) | |
| Husband's age | 0.596 | ||
| 20–30 years | 5 | 135.14 (13.00) | |
| 31–40 years | 51 | 140.30 (11.63) | |
| More than 40 years | 164 | 139.47 (11.12) | |
| Husband's education | 0.184 | ||
| Less than diploma | 45 | 136.44 (13.80) | |
| Diploma | 92 | 138.24 (11.69) | |
| More than diploma | 83 | 140.38 (11.01) | |
| Living with family | 0.020 | ||
| Independent | 168 | 139.72 (11.39) | |
| With spouse's family | 52 | 135.33 (13.15) | |
| Husband's occupation | 0.001 | ||
| Unemployed/worker | 19 | 135.58 (16.41) | |
| Employed | 78 | 142.58 (9.83) | |
| Freelance | 123 | 136.65 (11.84) | |
| Number of births | 0.677 | ||
| 1 | 105 | 137.95 (12.16) | |
| 2 | 97 | 139.26 (10.95) | |
| 3 | 18 | 139.83 (15.79) | |
| Number of living children | 0.665 | ||
| 1 | 107 | 137.93 (12.05) | |
| 2 | 97 139.42 | (10.98) | |
| 3 | 16 139.19 | (16.62) | |
| Previous breastfeeding experience | 0.318 | ||
| Yes | 109 | 139.49 (11.79) | |
| No | 111 137.69 | (12.41) | |
| Wanted pregnancy | 0.658 | ||
| Yes | 193 | 138.80 (11.93) | |
| No | 27 | 137.69 (12.41) | |
SD–standard deviation
The mean breastfeeding self-efficacy score was 138.6 (SD = 11.9; range 33–165) (Table 2). The majority of participants had high breastfeeding self-efficacy (n = 197, 89.7%), with 10.3% (n = 23) of the participants displaying average breastfeeding self-efficacy, and no participants reporting low breastfeeding self-efficacy. The mean social support score was 141.2 (SD = 19.6; range 25–175), and there was a significant statistical relationship between social support and breastfeeding self-efficacy (r = 0.306; P < 0.001) (Table 2).
| Variable | Mean (SD) | Obtainable range | Obtained practical range | Correlate with social support r (P-value) |
|---|---|---|---|---|
| Breastfeeding self-efficacy | 138.6 (11.9) | 33–165 | 95–165 | 0.306 (<0.001) |
| Social support | 141.2 (19.6) | 25–175 | 52–175 |
SD–standard deviation
According to one-way ANOVA and independent t-test, there was a significant relationship (P < 0.05) between breastfeeding self-efficacy and the woman's job (P = 0.023), her husband's job (P = 0.001), pregnancy interval (P = 0.009), and independent living (P = 0.033). Based on the adjusted general linear model, there was a significant relationship between social support, husband's job and breastfeeding self-efficacy (P < 0.05), and these two variables predicted 14.7% of variance in breastfeeding self-efficacy score in breastfeeding women (Table 3).
| Variable | B (95% CI) | P-value |
|---|---|---|
| Social support | 0.1 (0.01 to 0.23) | 0.038 |
| Mother's job (reference: Employee) | ||
| Housewife | -1.7 (-7.7 to 4.3) | 0.570 |
| Husband's job (reference: Freelancer) | ||
| Unemployed and worker | 0.2 (-6.7 to 7.2) | 0.945 |
| Employee | 5.2 (0.9 to 9.6) | 0.019 |
| Pregnancy interval (reference: More than 5) | ||
| Less than 3 | -3.6 (-8.5 to 1.3) | 0.147 |
| 3–5 | 4.6 (-0.3 to 9.4) | 0.064 |
| Living condition (reference: With husband/wife's family) | ||
| Independently | 2.3 (-3.04 to 7.6) | 0.397 |
CI–confidence interval
Discussion
In this study, most of the participants had high breastfeeding self-efficacy. Social support, by adjusting other sociodemographic variables, was one of the predictors of breastfeeding self-efficacy.
The mean score of breastfeeding self-efficacy was 138.6, and most of the participants had high breastfeeding self-efficacy. Breastfeeding self-efficacy refers to a woman's confidence in her ability to breastfeed her infant and it predicts the following (Dennis, 1999):
There is a correspondence between the results of this study and the study by Varaei et al (2009) on breastfeeding women in Tehran. However, the breastfeeding self-efficacy mean score in this study was higher than the mean score reported in Ahwaz, Iran by Hasanpoor et al (2010). The type of delivery (Sullivan, 2014) and breastfeeding experiences (Dodt et al, 2012) can affect breastfeeding self-efficacy. In the study by Hasanpoor et al (2010), all the participants were in their first pregnancy and had no experience with breastfeeding, whereas in this study almost half of the participants had previously breastfed.
In the present study, there was a significant relationship between breastfeeding self-efficacy and social support. For the purpose of this study, breastfeeding support is defined as women's perception of supportive behaviour from their social networks (Meedya et al, 2010). There are three main aspects of social support: emotional (i.e. feeling loved, valued, and appreciated), informational (i.e. advice or guidance), and instrumental (i.e. tangible help) (Thornton et al, 2006). Women experience support when they receive care, concern, respect, understanding, advice, encouragement, and practical help (Meedya et al, 2010; Mirghafourvand et al, 2015).
Breastfeeding self-efficacy and social support have a theoretical relationship based on Bandura's social cognitive theory (Bandura, 1997). Using this theory as a framework, a person's perception of self-efficacy is influenced by information received from various sources. One such source is social or verbal persuasion, which can be understood as emotional support and encouragement. A social support network for breastfeeding can provide these sources of information and theoretically influence a woman's perception of her ability to successfully breastfeed her infant (McCarter-Spaulding and Gore, 2009). Iranian culture, as a collectivist culture, emphasises social networks and support (Aflakseir, 2010). A social network of family members constitutes an important aspect of social support for women of reproductive age, including breastfeeding women (Baheiraei et al, 2012). A woman's infant feeding attitude and practice may be influenced by specific individuals in her social networks, including the infant's father, the mother or grandmother, close friends, and health care providers (Meedya et al, 2010). In a study in Iran, spouses and parents were reported as the key social support providers (Baheiraei et al, 2014). Cultural and religious beliefs play an important role within the family as the most important provider of social support in Iranian culture (Rambod and Rafii, 2010). Therefore, breastfeeding interventions should focus on social support networks that include the father and other family members, such as the woman's mother.
A study observing social-cultural patterns related to breastfeeding found that breastfeeding is affected by cultural patterns, economic or social conditions, and social support (Dodgson et al, 2002). A review by Meedya et al (2010) revealed that some factors—including the husband's beliefs about breastfeeding, interventions like breastfeeding training, and the husband's and parents' support—affect breastfeeding. Nesbitt et al (2012) conducted a qualitative study with 16 Canadian women about facilitating factors and decision-making barriers related to breastfeeding. The results showed that the husband's and family's beliefs affect breastfeeding, and factors like social and friendly relations, social support, the woman's knowledge and the woman's comfort, promote breastfeeding (Nesbitt et al, 2012). The results of these studies correspond with the results of the present study. However, an American study involving 155 black women who were breastfeeding their infants reported that there was no direct relationship between social support and the duration and pattern of breastfeeding (McCarter-Spaulding and Gore, 2009). This does not concur with the current study, but this may be because of cultural differences between the studies' participants.
Perceived social support can promote self-care and self-confidence and have a positive effect on an individual's physical, psychological and social conditions, and may improve breastfeeding practice. The results of a study by Loke and Chan (2013) showed that women with a high level of breastfeeding self-efficacy—along with women who planned to breastfeed for at least 6 months and those whose infants had high Infant Breastfeeding Assessment Tool scores—were more likely to breastfeed exclusively. As there is a significant relationship between breastfeeding self-efficacy and exclusive breastfeeding duration (Dennis, 2003), high breastfeeding self-efficacy is important. Therefore, regarding the effective role of social support in increasing breastfeeding, native variables and social support should be considered in addition to individual variables in promoting plans of breastfeeding.
As this is a cross-sectional study, the relationship shown between social support and breastfeeding self-efficacy does not necessarily indicate a causal relationship. This study can be helpful for educating families and society about the importance of supporting breastfeeding women to promote exclusive breastfeeding. Breastfeeding self-efficacy is a potential factor that can predict the duration and level of breastfeeding; therefore, promoting breastfeeding self-efficacy among women can improve their breastfeeding status.
Conclusion
The results of the study show that more than half of the women had high breastfeeding self-efficacy. Considering the relationship between social support and breastfeeding self-efficacy, breastfeeding practice can be promoted by sensitising family and society to support breastfeeding women. Counselling services that offer practical advice, help to resolve breastfeeding problems and assess breastfeeding status should be implemented in health centres, to empower women to breastfeed. In addition, educational materials about breastfeeding should be provided by health professionals and women should be directed to materials available on the internet, and social networks to encourage breastfeeding support. Interventions should be designed to establish a woman's social support system, including the infant's father and other family members. Such interventions should be culturally sensitive and encourage the establishment of a breastfeeding peer support network.