579654
research-article2015
JHLXXX10.1177/0890334415579654Journal of Human LactationHenshaw et al
Original Research
Breastfeeding Self-Efficacy, Mood, and Breastfeeding Outcomes among Primiparous Women
Journal of Human Lactation 2015, Vol. 31(3) 511–518 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415579654 jhl.sagepub.com
Erin J. Henshaw, PhD1, Rachel Fried, BA2, Emily Siskind, BA1, Linda Newhouse, MSN, RNC, WHNP3, and Marie Cooper, RNC-LRN, BSN, MBA3 Abstract Background: A link between postpartum mood and breastfeeding has been established in the literature, but little is known about the relationship of breastfeeding self-efficacy (BSE) to breastfeeding and mood outcomes, particularly in primiparous women. Objectives: The purpose of this study was to prospectively evaluate the relationship among BSE, mood, and breastfeeding outcomes in primiparous women. A secondary purpose was to explore self-reported reasons for difficult emotional adjustment during the transition to motherhood. Methods: Primiparous women who initiated breastfeeding were surveyed at 2 days, 6 weeks, and 6 months postpartum. Breastfeeding self-efficacy, depressive symptoms, work status, breastfeeding difficulties, partner support, and use of lactation services were included in a hierarchical multiple regression analysis. Women who identified as emotionally distressed provided open-ended responses identifying the main cause of their stress. Results: High BSE at 2 days postpartum predicted positive emotional adjustment and fewer depressive symptoms at 6 weeks postpartum, as well as more exclusive breastfeeding at 6 months postpartum. Among distressed mothers, breastfeeding concerns were among the most commonly named reasons for stress, along with lack of sleep, lack of social support, and overwhelming learning demands involved with being a new parent. Conclusion: Breastfeeding perceptions are associated with emotional health and breastfeeding outcomes. Bolstering women’s early BSE may be an important goal for multiple dimensions of postpartum health. Keywords attitudes, breastfeeding, breastfeeding attitudes, breastfeeding barriers, breastfeeding duration, breastfeeding knowledge, breastfeeding rates, depression
Well Established High breastfeeding self-efficacy, defined as the confidence in one’s ability to effectively breastfeed, has been identified as a contributing factor to more exclusive breastfeeding in prospective studies of Canadian and Australian mothers, as well as in correlational designs within the United States.
Newly Expressed High breastfeeding self-efficacy at 2 days postpartum is negatively correlated with 6-week postpartum depressive symptoms and positively correlated with 6-month breastfeeding exclusivity among primiparous women after accounting for work status, depression risk factors, and other psychosocial factors.
United States initiate breastfeeding during the postpartum (PP) hospital stay, less than 19% of women maintain exclusive breastfeeding at 6 months PP.2 A variety of demographic factors have been identified as predictors of extended breastfeeding duration, such as older age, being married, being well educated, and having a higher income. In addition, psychosocial factors, such as strong intentions to breastfeed and professional and partner support, have emerged as important predictors.3
1
Denison University, Granville, OH, USA Case Western Reserve University, Cleveland, OH, USA 3 Riverside Methodist Hospital, Columbus, OH, USA 2
Date submitted: July 24, 2014; Date accepted: March 7, 2015.
Background Exclusive breastfeeding of infants is recommended for the first 6 months of life.1 Although most (79.2%) women in the
Corresponding Author: Erin J. Henshaw, PhD, Denison University, Psychology Department, Box 8100, Granville, OH 43023, USA. Email: [email protected]
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One potentially modifiable breastfeeding predictor is breastfeeding self-efficacy (BSE). Self-efficacy, originating in Bandura’s4 social cognitive theory, is generally defined as confidence in one’s ability to effectively perform a specific task or reach a specific goal. Specific BSE is thought to influence breastfeeding outcomes by providing motivation and confidence to persevere through common challenges such as early latching difficulties, supply concerns, and return to work.5,6 Prospective studies with mothers in Australia7 and Canada8 provide support for high BSE predicting levels of breastfeeding exclusivity up to 6 months PP. Maternity leave policies and funding in Australia and Canada contrast starkly with policies in the United States, however, making comparisons across countries difficult. Many authors have identified a relationship between breastfeeding and PP depression, but to our knowledge, only 2 studies have directly evaluated the relationship between BSE and mood.9-11 First, a recent study of Norwegian mothers surveyed at 6 weeks, 3 months, and 6 months PP found that mothers with high BSE reported lower depression scores at all time points.12 Generalization of these findings to US mothers, however, is complicated by large discrepancies between breastfeeding rates in Norway and the United States. Breastfeeding is highly normative in Norway: 99% of Norwegian mothers initiate breastfeeding in the hospital and 80% of mothers continue at 6 months PP.13 In the United States, rates are much lower, and it is unknown if BSE is as pertinent for mood in a culture where breastfeeding is not as wholly normative. The second study evaluating BSE and mood was conducted with a US sample of mothers. The authors used a prospective survey design and found a negative relationship between BSE and depression scores at 1, 4, and 8 weeks PP; however, the potential influence of factors such as breastfeeding intention, depression risk factors, and level of breastfeeding exclusivity was not fully explored.14 Also, neither of the studies of BSE described here were limited to first-time mothers, for whom the effect of self-efficacy may be different from mothers whose efficacy beliefs may be shaped by previous PP experiences. For example, mothers with previous breastfeeding experience have reported higher BSE than those without previous experience.7,15 Taken together, these findings provide preliminary support for a link between BSE, depressive symptoms, and breastfeeding exclusivity. Further evaluation of this hypothesized relationship among primiparous women in the United States should address limitations of previous work through the use of a prospective design accounting for other known predictors of depression and breastfeeding.
Study Objectives The current study aims to explore the relationship between BSE and mood. We predict that lower hospital BSE will be associated with poorer emotional adjustment and greater
depressive symptoms at 6 weeks and 6 months PP among first-time mothers. Furthermore, the study explores the relationship between BSE and breastfeeding exclusivity levels at 6 weeks and 6 months PP. We predict that higher hospital BSE will correlate with more exclusive breastfeeding at 6 weeks and 6 months PP among first-time mothers, after accounting for other factors. Finally, the study explores women’s reported reasons for discontinuing breastfeeding as well as reported reasons for experiencing difficult emotional adjustment.
Methods Procedure The OhioHealth Hospital Systems and Denison University Institutional Review Boards approved this study. Research assistants approached women in their hospital rooms during their 2-day PP hospital stay. After receiving information about the study and confirming eligibility, interested women signed an informed consent document and were then administered the first survey (T1 survey). The survey included questions regarding demographics and depression history, as well as several measurement scales related to breastfeeding efficacy and maternal expectations. Participants received the 6-week survey (T2 survey) and the 6-month survey (T3 survey) via email invitation using participant ID numbers to link survey data. Participants received a $10 gift card to a national grocery chain for completing the 6-week PP survey and received a $25 gift card for completing the 6-month PP survey.
Participants Participants were recruited from the PP unit of a large midwestern level III tertiary care center. Eligible participants were English-speaking, primiparous, and age 18 or older, whose infants were not in the neonatal intensive care unit and who initiated breastfeeding during the PP hospital stay. Of the 276 women who agreed to be screened, 204 met all study criteria. From this sample of 204 women, 146 completed all 3 survey time points, yielding a response rate of 71.6%. After removing cases with incomplete data on key variables, the total number of participants who initiated breastfeeding and completed all 3 survey time points was 142. Participant characteristics are summarized in Table 1.
Measures Edinburgh Postnatal Depression Scale (EPDS).16 The EPDS is a well-validated 10-item self-report depression screening tool, in which endorsement of each item is based on how women feel during the previous 7 days. Possible scores range from 0 to 30, with high scores reflecting more depressive symptoms. Internal consistency of the scale was found to be adequate in this sample (Cronbach’s α = .84).
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Henshaw et al Table 1. Participant Characteristics at 2 Days Postpartum.a Variable Age, mean (SD) EPDS Total, mean (SD) ≥ 10 < 10 Race/ethnicity Black/African American White Hispanic Asian Other Education High school graduate or less College graduate Master’s degree or higher Relationship status Married Living with partner Single Income $0-19 999 $20 000-59 999 $60 000-99 000 More than $100 000
Total Participants (N = 204) 30 (5.12) 3.43 (2.89) 6 (2.94) 198 (97.06) 22 (10.78) 175 (85.78) 3 (1.47) 11 (5.39) 2 (.98) 55 (26.96) 88 (43.14) 61 (29.90) 150 (73.53) 38 (18.63) 16 (7.84) 21 (10.29) 53 (25.98) 59 (28.92) 71 (34.80)
Abbreviation: EPDS, Edinburgh Postnatal Depression Scale. a All data presented as No. (%) unless otherwise noted. Percentages may not sum to 100% due to missing data. Participants could choose more than 1 racial or ethnic category.
Postpartum Depression Predictors Inventory–Revised (PDPIR).17 The PDPI-R is a dichotomous checklist inventory of 13 risk factors significantly related to PP depression (PPD): prenatal depression, child care stress, life stress, social support, prenatal anxiety, marital satisfaction, depression history, infant temperament, maternity blues, self-esteem, socioeconomic status, marital status, and unplanned/ unwanted pregnancy. Developed as a brief measure to identify women at risk for PPD, the PDPI-R was shown to have good predictive construct and concurrent validity among a sample of 139 pregnant women who were followed for 8 months after birth.18 Being a Mother Scale (BaM-13).19 The BaM-13 is a 4-point Likert-style self-report measure developed to evaluate women’s emotional adjustment to motherhood for women with children ranging from infants to preschool age. The 13 items aim to summarize a woman’s satisfaction with a broad range of maternal experiences including social isolation, parenting confidence, infant bonding, coping, and guilt. Higher scores indicate greater distress. This scale has been shown to have good psychometric properties, with moderate to high levels
of reliability and validity, with similar results in this sample (total scale Cronbach’s α = .82). As part of the BaM-13 inventory, all participants were given an open-ended prompt during the 6-week PP and 6-month PP surveys: “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” Mothers were encouraged to answer “this does not apply to me” if they did not feel that this description applied to their experience of motherhood. All responses were coded by 2 of the authors. Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF).15 The 14 items of this 5-point scale represent a condensed version of the 33-item BSES.20 Higher scores indicate greater selfefficacy, and the BSES-SF has demonstrated reliability and validity comparable with the original BSES.15 High internal consistency was demonstrated in the current sample (Cronbach’s α = .91). Breastfeeding ease. Women were also asked to evaluate their feelings about how breastfeeding was going using a single item rating on a scale of 1 (very well, only a couple of minor difficulties) to 5 (terrible, many major difficulties). Partner support. Partner support for breastfeeding was measured using a single item asking, “Which do you think best represents your partner’s feelings about feeding the infant?” Responses range from 1 (strongly supports exclusive formula feeding) to 5 (strongly supports exclusive breastfeeding). Use of breastfeeding education resources. Participants were asked at each time point whether they had attended a breastfeeding class or had contact with a lactation consultant using yes/no question formats. Level of breastfeeding exclusivity. Rather than conceptualizing breastfeeding as a dichotomous outcome, participants’ level of breastfeeding exclusivity was measured as a continuous variable differentiating among exclusive, partial, and token breastfeeding as suggested by previous authors.21 Women were asked to identify the level that most accurately described their breastfeeding behaviors within the previous 24 hours. Two levels from the scale that were reported by no participants (almost exclusive and high breastfeeding, representing less than 1 bottle of formula per day) were removed, leaving 4 levels reported: exclusive breastfeeding (breast milk only), partial breastfeeding (breast milk and at least 1 bottle of formula per day), token breastfeeding (breast given to comfort baby, not for nutrition), and no breastfeeding. Higher values represent more exclusive breastfeeding. Hierarchical regression analyses were conducted to evaluate the unique predictive contribution of BSE to depressive symptoms, emotional adjustment, and breastfeeding exclusivity at 6 weeks and 6 months PP. Predictive demographic variables previously demonstrated to be related to mood and breastfeeding outcomes were entered first in the regression
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Table 2. Breastfeeding and Mood among Breastfeeding Initiators.a 2 Days PP (n = 204)
6 Weeks PP (n = 170)
6 months PP (n = 165)
No. (%) or Mean (SD)
No. (%) or Mean (SD)
No. (%) or Mean (SD)
Exclusive breastfeeding (breast milk and vitamins as needed) Partial breastfeeding Token breastfeeding (given to comfort, not nourish, baby) No breastfeeding (exclusive formula feeding) Breastfeeding self-efficacy Breastfeeding ease Attend breastfeeding class Seek lactation consultation Partner support of breastfeeding Depressive symptoms (EPDS) EPDS ≥ 10 Emotional adjustment (BaM-13)
154 (75.55%)
105 (61.76%)
63 (38.18%)
37 (18.14%) 13 (6.37%)
32 (18.82%) 6 (3.53%)
20 (12.12%) 5 (3.03%)
27 (15.88%)
77 (46.67%)
3.29 (1.53) 4.29 (.96) — 84 (49.41%) 4.11 (1.09) 4.89 (3.60) 20 (11.76%) 3.33 (.43)
— 4.51 (0.91) — 66 (41.32%) — 4.98 (3.76) 16 (9.61%) 3.43 (0.39)
0 3.62 (0.68) 4.06 (0.81) 145 (71.08%) — 4.39 (1.20) 3.43 (2.89) 6 (2.94%) —
Abbreviations: BaM-13, Being a Mother Scale; EPDS, Edinburgh Postnatal Depression Scale; PP, postpartum; —, variable not measured. a Breastfeeding self-efficacy, breastfeeding ease, and partner attitude toward breastfeeding are all presented so that high scores = greater efficacy, ease, and support on a 5-point scale. Breastfeeding class attendance and lactation consultation questions are represented by the percentage of women who answered “yes” to a question asking if they had completed each of these activities. Total for each time point listed here includes participants who completed 2, but not 3, time-point surveys, as well as those who may be missing demographic data. Total participants who completed all time points with no missing data are 146.
model (race/ethnicity, education, income), followed by participants’ depressive symptoms and risk factors at 2 days PP (PDPI-R, EPDS) and other breastfeeding predictor variables (breastfeeding ease, breastfeeding exclusivity at 2 days PP, use of breastfeeding class or lactation consultation, partner support of breastfeeding, and work status at 6 months). Finally, BSE reported at 2 days PP was entered into each model. All variables were standardized and cases missing data for any variable were dropped from the analysis.
Results Breastfeeding Duration and Exclusivity Among women who attempted breastfeeding (n = 204) at 2 days PP, 61.8% were exclusively breastfeeding at 6 weeks PP and 38.2% were exclusively breastfeeding at 6 months PP (Table 2). Less than 25% of the sample reported partial or token breastfeeding across all 3 time points. At 6 months PP, nearly half (46.7%) of women who had initiated breastfeeding in the hospital reported complete discontinuation of breastfeeding.
Breastfeeding Self-Efficacy and Mood Outcomes We predicted that lower BSE during the hospital stay would be associated with poorer emotional adjustment and greater depressive symptoms at 6 weeks PP and 2 and 6 months PP. Results of 4 hierarchical regression tests suggest that 2 days
PP BSE is a significant predictor of both of the mood outcomes at 6 weeks, but not 6 months PP (Table 3). Predictor variables were entered in 4 blocks to determine the additional contribution of each new block to the model. As expected, both the PDPI-R and EPDS scores at 2 days PP were significant risk factors for higher EPDS scores at 6 weeks and 6 months. Results suggest that BSE is inversely related to EPDS scores, with high BSE scores predicting lower 6-week depressive symptoms and greater emotional adjustment. All other breastfeeding measures (ease, exclusivity, education, and partner support) were entered as a separate block and did not contribute significantly to prediction of mood outcomes. Although BSE predicted mood outcomes at 6 weeks, it was not a significant factor in either of the 6-month mood models.
Breastfeeding Self-Efficacy and Breastfeeding Exclusivity We predicted that higher BSE during the hospital stay would predict greater breastfeeding exclusivity at 6 weeks and 6 months PP among first-time mothers, after accounting for other known factors. Hierarchical multiple regression analysis indicated that BSE at 2 days PP was a significant predictor of 6 month, but not 6 week, breastfeeding exclusivity levels (Table 3) after accounting for mood, work status, and other known predictors of breastfeeding outcomes. At 6 months, more exclusive breastfeeding was also predicted by less time working for pay, breastfeeding exclusively or
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.04
Step 1 Race/ethnicity Education Income Step 2 T1 PDPI-R T1 EPDS Step 3 T3 work status Step 4 T1 breastfeeding ease T1 breastfeeding T1 breastfeeding class T1 partner support T2 lactation consultation Step 5 T1 breastfeeding efficacy Total adjusted R2 No. b
.43
−.32
.08 .08 .01 .07 .01
.32 .23 .32 .19 .45
.25 .40b
.24 .26
b
.04 −.08 −.06
β
.75 .19 .14
SE
.32b 151
.10b
.01
.23b
.04
ΔR
.06
.04 .03 .04 .03 .06
.03 .03
.10 .03 .02
SE
c
.41
b
−.19c −.05 −.05 −.01 .02
−.22 −.31b
−.10 −.01 .12
β
.01 149
.00
.00
.01
−.02
ΔR
2
.24
.18 .13 .18 .11 .25
.13 .14
.43 .11 .08
SE
β
c
.14
−.09 .08 .06 −.06 .15
.21 −.08
−.03 .01 .08
Breastfeeding
.16 135
.01
.01
.19b
.03
ΔR
2
.58
.42 .31 .45 .26 .61
.33 .36
1.02 .27 .19
SE
β
b
−.11
−.04 .06 −.04 −.03 −.02
.34 .16
.07 −.10 .06
Depressive Symptoms
.17 135
0
.01
.19b
.04
ΔR
2
.06
.05 .03 .05 .03 .07
.04 .04
.11 .03 .02
SE
β
.05
−.03 −.07 −.02 .01 −.03
−.28d −.27d
−.12 .05 −.03
Emotional Adjustment
.15c 133
.03c
.07
.09b
.03
.01
.36
.26 .19 .28 .17 .37
.19
.21 .22
.62 .16 .11
SE
β .01 .05 .03 .12 −.12 −.28d −.13 .23d .04 −.11 .19c .22c
Breastfeeding ΔR2
6 Months Postpartum (T3)
Abbreviations: β, regression coefficient; BaM-13, Being a Mother Scale19; EPDS, Edinburgh Postnatal Depression Scale16; PDPI-R, Postpartum Depression Predictors Inventory–Revised17; R2, multiple correlation squared; ∆R2, incremental change in R2; SE, standard error; T1, 2 days postpartum; T2, 6 weeks postpartum; T3, 6 months postpartum. a Work status included as regression step only in 6-month breastfeeding rates. Emotional adjustment measured by BaM-13. Breastfeeding measured by level of exclusivity on 1-4 scale (4 = exclusive breastfeeding). b P < .001. c P < .05. d P < .01.
.40b 152
.06b
.01
.33b
ΔR
2
2
Variable
Emotional Adjustment
Depressive Symptoms
6 Weeks Postpartum (T2)
Table 3. Predictors of Mood, Adjustment, and Breastfeeding at 6 Weeks and 6 Months Postpartum.a
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Table 4. Reasons for Parenting-Related Stress Reported by Self-Identified Distressed Mothers.a 6 Weeks Postpartum (n = 53) Coded Reason Breastfeeding concerns Lack of sleep So much to adjust to/learn Lack of social support Worry about baby Crying/colic Lack of personal time/break Too many demands Return to work Other nonparenting stressors
6 Months Postpartum (n = 44)
No.
%
No.
%
7 12 10 7 6 5 3 2 0 1
13.21 22.64 18.87 13.21 11.32 9.43 5.66 3.77 0 1.89
3 3 7 6 3 0 5 7 7 3
6.82 6.82 15.91 13.64 6.82 0 11.36 15.91 15.91 6.82
a
omen responded to open-ended prompt, “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” W Women could choose to respond or not to respond.
almost exclusively at 2 days PP, and speaking with a lactation consultant after leaving the hospital. The only variable significantly predicting levels of breastfeeding at 6 weeks PP was the PDPI-R depression risk inventory.
Identified Parenting-Related Stressors Responses to the BAM-13 open-ended question, “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” were coded and are summarized in Table 4. At 6 weeks PP, 13.2% of respondents reported breastfeeding difficulties (e.g., difficulty latching, low milk supply, worry about whether infant is fed sufficiently) as the reason for finding motherhood stressful, difficult, or unenjoyable. By comparison, at 6 months PP, only 6.8% cited breastfeeding difficulties as a stressor. Mothers identifying breastfeeding as a major stressor of parenthood did not differ significantly from those who did not in reported BSE at either 2 days PP [t(202) = .88, P = .68] or 6 weeks PP [t(167) = .52, P = .60]. Sleep deprivation and worry about the infant were also prominent stressors at 6 weeks, but not 6 months. General adjustment and learning involved with parenthood remained a highly reported stressor at both time points.
Discussion Considering the many social and logistical issues that women may encounter in maintaining breastfeeding, being equipped to manage barriers and challenges is an important skill for first-time mothers. The current study contributes to the understanding of BSE’s relationship to mood and breastfeeding outcomes by using a 6-month prospective design in a sample of first-time mothers while controlling for major known predictors of breastfeeding and mood outcomes. In this study, we aimed to evaluate BSE’s relationship to breastfeeding and mood outcomes among primiparous women. High BSE correlated with fewer depressive symptoms and
greater enjoyment of motherhood at 6 weeks, but not 6 months, PP. In addition, high BSE, along with work status, lactation consultation, and in-hospital breastfeeding exclusivity, was associated with higher levels of breastfeeding exclusivity at 6 months, but not 6 weeks, PP. Breastfeeding concerns were cited as 1 of the top 4 reasons for significant stress at 6 weeks, but not 6 months, PP.
Breastfeeding Self-Efficacy and Breastfeeding Outcomes Breastfeeding duration and exclusivity rates in this study followed similar trends to other assessments of US samples.2 Exclusivity remained relatively high at 6 weeks PP but dropped sharply by 6 months PP, such that only half of women who were exclusively breastfeeding during the first 2 days PP still reported exclusive breastfeeding at 6 months. The significant negative association of returning to full- or part-time work on breastfeeding outcomes that was evident in our analyses has been found elsewhere22 in samples of US women. Perhaps the most compelling finding in this analysis is that BSE in the hospital remains a predictor of 6-month feeding outcomes even after accounting for work status, breastfeeding difficulty, partner support, and in-hospital breastfeeding exclusivity. In introducing self-efficacy theory, Bandura suggested that this is true: “When beset with difficulties people who entertain serious doubts about their capabilities slacken their efforts or give up altogether, whereas those who have a strong sense of efficacy exert greater effort to master the challenges.”23 Grounded theory qualitative work with US mothers revealed a concept quite similar to self-efficacy (labeled “confident commitment” by the authors) as an essential component of success in breastfeeding.24 Taken together, these findings suggest that in addition to the techniques of breastfeeding being taught to new mothers, an equal emphasis should be placed on women’s confidence
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Henshaw et al and perceptions of themselves as skilled and effective in breastfeeding.
Breastfeeding Self-Efficacy and Mood We found partial support for the hypothesis that high BSE would predict positive mood outcomes. The relationship between in-hospital BSE and 6-week mood and adjustment suggests that how a breastfeeding woman perceives her skill in breastfeeding is related to her early emotional experience of motherhood. Previous longitudinal evaluation found that BSE consistently predicted change in depressive symptoms across time for Norwegian mothers.12 Together with the current findings, this suggests a potential role for BSE in emotional adjustment, defined clinically (depressive symptoms) or within the spectrum of normative adjustment.19 If replicated in future research, this implies that goals of breastfeeding education might be widened to conceptualize breastfeeding confidence as a goal for emotional well-being in addition to the known benefits of breastfeeding to mother and infant. Open-ended responses in the current study suggest that among women who self-identify as having a difficult transition to motherhood, breastfeeding concerns are commonly named as a source of stress. This finding also adds complexity to ongoing research regarding the potential protective role of breastfeeding against PP depression.9 In addition to the hypothesized roles of infant bonding and hormonal response, these findings suggest a possible socialcognitive influence as well. Some women may view breastfeeding as an early sign of success or failure in the role of motherhood, and how a woman feels she is doing at this task may be important in shaping her early PP emotional experience. Recent qualitative work in England has concluded that mothers who struggled to establish breastfeeding perceived themselves as failing at an early task of motherhood.25 It is important to note, however, that we did not find evidence that this early self-efficacy is related to mood at the 6-month time point. Open-ended responses at 6 months also suggested that breastfeeding becomes less prominent as a self-identified stressor, giving way to other stressors such as work demands.
Methodological Considerations The strengths of this study lie in the use of a prospective design and the limitation of analyses to first-time mothers who had attempted to initiate breastfeeding in the hospital. Inclusion of women who did not intend to breastfeed or for whom breastfeeding is contraindicated by medication or health concerns can confound explorations of breastfeeding predictors. Furthermore, by focusing on primiparous women, we were able to assess BSE among women inexperienced in breastfeeding an infant, rather than self-efficacy beliefs among multiparous women that may be shaped by their previous breastfeeding successes or failures. In addition to these
strengths, the study findings should be considered in light of the following methodological limitations. The study sample was from a large Midwestern level III tertiary care center and comprised women who identified as white, with relatively high education and income. Therefore, caution should be used in generalizing these findings to women of different backgrounds or in different countries. Recent findings26 suggest that hospital practices influence the rates and perceptions of breastfeeding in patients, and the current results are likely shaped in part by the specific practices of the hospital from which all of the participants were recruited. In this particular hospital setting, individual lactation consultation and group breastfeeding instruction were voluntarily available for breastfeeding mothers. For this reason, the amount of instruction that women received may vary depending on whether or not they chose to engage in breastfeeding education.
Developing Breastfeeding Self-Efficacy Work exploring the development of BSE has been relatively recent. Although traditionally, self-efficacy has been addressed through individual-level interventions, a recent evaluation of an individual-level intervention suggests that structural conditions that create conditions for greater breastfeeding success, such as the Baby-Friendly Hospital Initiative,27 may be essential to successful intervention. A recent control-comparison intervention in Japan found that individually focused BSE intervention effectively affected BSE and exclusive breastfeeding outcomes only in the context of a Baby-Friendly Hospital, with no effect for the same intervention when delivered in a non-Baby-Friendly certified hospital.26 This suggests that system-level conditions, not only individual interventions, should be considered when working toward a goal of increasing BSE.
Conclusion Breastfeeding self-efficacy assessed during the PP hospital stay was found to correlate with positive emotional adjustment in the early PP period as well as higher levels of exclusivity in breastfeeding through 6 months PP. Our findings suggest that women’s perceptions of their breastfeeding ability are linked in important ways to early PP emotional experience and continued breastfeeding. Bolstering women’s breastfeeding self-efficacy may be an important goal for multiple dimensions of PP health. Future research should include the development and evaluation of breastfeeding interventions designed to increase self-efficacy in the early PP period. Acknowledgments The authors would like to acknowledge Eve Sussman for her contribution to the collection of data for the project. They would also like to thank the Denison University Research Foundation, as well as
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the Denison University Sharfstein and Anderson Summer Scholar programs for support of this research.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Denison University Research Foundation, as well as the Denison University Sharfstein and Anderson Summer Scholar programs. No conflict of interest exists for any of the authors.
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12. Haga SM, Ulleberg P, Slinning K, Kraft P, Steen TB, Staff A. A longitudinal study of postpartum depressive symptoms: multilevel growth curve analyses of emotional regulation strategies, breastfeeding self-efficacy, and social support. Arch Womens Ment Health. 2012;15(3):175-184. 13. Lande B, Andersen L, Bærug A, et al. Infant feeding practices and associated factors in the first six months of life: the Norwegian Infant Nutrition Survey. Acta Paediatr. 2003;92(2):152-161. 14. Dennis CL. The Breastfeeding Self-Efficacy Scale: psychometric assessment of the short form. J Obstet Gynecol Neonatal Nurs. 2003;32(6):734-744. 15. McCarter-Spaulding DE, Dennis C. Psychometric testing of the Breastfeeding Self-Efficacy Scale–Short Form in a sample of black women in the United States. Res Nurs Health. 2010;33(2):111-119. 16. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786. 17. Beck CT. Revision of the Postpartum Depression Predictors Inventory. JOGNN. 2001;31(4):394-402. 18. Records K, Rice M, Beck CT. Psychometric assessment of the Postpartum Depression Predictors Inventory–Revised. J Nurs Meas. 2007;15(3):189-202. 19. Matthey S. Assessing the experience of motherhood: the Being a Mother Scale (BaM-13). J Affect Disord. 2011;128(1-2): 142-152. 20. Dennis CL, Faux S. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health. 1999;22(5):399-409. 21. Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Stud Fam Plann. 1990;21(4):226-230. 22. Ogbuanu C, Glover S, Probst J, Liu J, Hussey J. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics. 2011;127(6):e1414-e1427. doi:10.1542/ peds.2010-0459. 23. Bandura A. Self-efficacy mechanism in human agency. Am Psychol. 1982;37(2):122-147. 24. Avery A, Zimmermann K, Underwood PW, Magnus JH. Confident commitment is a key factor for sustained breastfeeding. Birth. 2009;36(2):141-148. 25. Redshaw M, Henderson J. Learning the hard way: expec tations and experiences of infant feeding support. Birth. 2012;39(1):21-29. 26. Otsuka K, Taguri M, Dennis CL, et al. Effectiveness of a breastfeeding self-efficacy intervention: do hospital practices make a difference? Matern Child Health J. 2014;18(1): 296-306. 27. World Health Organization. Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva, Switzerland: World Health Organization; 2009. http://www. ncbi.nlm.nih.gov/books/NBK153495/. Accessed April 1, 2014.
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research-article2015
JHLXXX10.1177/0890334415579654Journal of Human LactationHenshaw et al
Original Research
Breastfeeding Self-Efficacy, Mood, and Breastfeeding Outcomes among Primiparous Women
Journal of Human Lactation 2015, Vol. 31(3) 511–518 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415579654 jhl.sagepub.com
Erin J. Henshaw, PhD1, Rachel Fried, BA2, Emily Siskind, BA1, Linda Newhouse, MSN, RNC, WHNP3, and Marie Cooper, RNC-LRN, BSN, MBA3 Abstract Background: A link between postpartum mood and breastfeeding has been established in the literature, but little is known about the relationship of breastfeeding self-efficacy (BSE) to breastfeeding and mood outcomes, particularly in primiparous women. Objectives: The purpose of this study was to prospectively evaluate the relationship among BSE, mood, and breastfeeding outcomes in primiparous women. A secondary purpose was to explore self-reported reasons for difficult emotional adjustment during the transition to motherhood. Methods: Primiparous women who initiated breastfeeding were surveyed at 2 days, 6 weeks, and 6 months postpartum. Breastfeeding self-efficacy, depressive symptoms, work status, breastfeeding difficulties, partner support, and use of lactation services were included in a hierarchical multiple regression analysis. Women who identified as emotionally distressed provided open-ended responses identifying the main cause of their stress. Results: High BSE at 2 days postpartum predicted positive emotional adjustment and fewer depressive symptoms at 6 weeks postpartum, as well as more exclusive breastfeeding at 6 months postpartum. Among distressed mothers, breastfeeding concerns were among the most commonly named reasons for stress, along with lack of sleep, lack of social support, and overwhelming learning demands involved with being a new parent. Conclusion: Breastfeeding perceptions are associated with emotional health and breastfeeding outcomes. Bolstering women’s early BSE may be an important goal for multiple dimensions of postpartum health. Keywords attitudes, breastfeeding, breastfeeding attitudes, breastfeeding barriers, breastfeeding duration, breastfeeding knowledge, breastfeeding rates, depression
Well Established High breastfeeding self-efficacy, defined as the confidence in one’s ability to effectively breastfeed, has been identified as a contributing factor to more exclusive breastfeeding in prospective studies of Canadian and Australian mothers, as well as in correlational designs within the United States.
Newly Expressed High breastfeeding self-efficacy at 2 days postpartum is negatively correlated with 6-week postpartum depressive symptoms and positively correlated with 6-month breastfeeding exclusivity among primiparous women after accounting for work status, depression risk factors, and other psychosocial factors.
United States initiate breastfeeding during the postpartum (PP) hospital stay, less than 19% of women maintain exclusive breastfeeding at 6 months PP.2 A variety of demographic factors have been identified as predictors of extended breastfeeding duration, such as older age, being married, being well educated, and having a higher income. In addition, psychosocial factors, such as strong intentions to breastfeed and professional and partner support, have emerged as important predictors.3
1
Denison University, Granville, OH, USA Case Western Reserve University, Cleveland, OH, USA 3 Riverside Methodist Hospital, Columbus, OH, USA 2
Date submitted: July 24, 2014; Date accepted: March 7, 2015.
Background Exclusive breastfeeding of infants is recommended for the first 6 months of life.1 Although most (79.2%) women in the
Corresponding Author: Erin J. Henshaw, PhD, Denison University, Psychology Department, Box 8100, Granville, OH 43023, USA. Email: [email protected]
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One potentially modifiable breastfeeding predictor is breastfeeding self-efficacy (BSE). Self-efficacy, originating in Bandura’s4 social cognitive theory, is generally defined as confidence in one’s ability to effectively perform a specific task or reach a specific goal. Specific BSE is thought to influence breastfeeding outcomes by providing motivation and confidence to persevere through common challenges such as early latching difficulties, supply concerns, and return to work.5,6 Prospective studies with mothers in Australia7 and Canada8 provide support for high BSE predicting levels of breastfeeding exclusivity up to 6 months PP. Maternity leave policies and funding in Australia and Canada contrast starkly with policies in the United States, however, making comparisons across countries difficult. Many authors have identified a relationship between breastfeeding and PP depression, but to our knowledge, only 2 studies have directly evaluated the relationship between BSE and mood.9-11 First, a recent study of Norwegian mothers surveyed at 6 weeks, 3 months, and 6 months PP found that mothers with high BSE reported lower depression scores at all time points.12 Generalization of these findings to US mothers, however, is complicated by large discrepancies between breastfeeding rates in Norway and the United States. Breastfeeding is highly normative in Norway: 99% of Norwegian mothers initiate breastfeeding in the hospital and 80% of mothers continue at 6 months PP.13 In the United States, rates are much lower, and it is unknown if BSE is as pertinent for mood in a culture where breastfeeding is not as wholly normative. The second study evaluating BSE and mood was conducted with a US sample of mothers. The authors used a prospective survey design and found a negative relationship between BSE and depression scores at 1, 4, and 8 weeks PP; however, the potential influence of factors such as breastfeeding intention, depression risk factors, and level of breastfeeding exclusivity was not fully explored.14 Also, neither of the studies of BSE described here were limited to first-time mothers, for whom the effect of self-efficacy may be different from mothers whose efficacy beliefs may be shaped by previous PP experiences. For example, mothers with previous breastfeeding experience have reported higher BSE than those without previous experience.7,15 Taken together, these findings provide preliminary support for a link between BSE, depressive symptoms, and breastfeeding exclusivity. Further evaluation of this hypothesized relationship among primiparous women in the United States should address limitations of previous work through the use of a prospective design accounting for other known predictors of depression and breastfeeding.
Study Objectives The current study aims to explore the relationship between BSE and mood. We predict that lower hospital BSE will be associated with poorer emotional adjustment and greater
depressive symptoms at 6 weeks and 6 months PP among first-time mothers. Furthermore, the study explores the relationship between BSE and breastfeeding exclusivity levels at 6 weeks and 6 months PP. We predict that higher hospital BSE will correlate with more exclusive breastfeeding at 6 weeks and 6 months PP among first-time mothers, after accounting for other factors. Finally, the study explores women’s reported reasons for discontinuing breastfeeding as well as reported reasons for experiencing difficult emotional adjustment.
Methods Procedure The OhioHealth Hospital Systems and Denison University Institutional Review Boards approved this study. Research assistants approached women in their hospital rooms during their 2-day PP hospital stay. After receiving information about the study and confirming eligibility, interested women signed an informed consent document and were then administered the first survey (T1 survey). The survey included questions regarding demographics and depression history, as well as several measurement scales related to breastfeeding efficacy and maternal expectations. Participants received the 6-week survey (T2 survey) and the 6-month survey (T3 survey) via email invitation using participant ID numbers to link survey data. Participants received a $10 gift card to a national grocery chain for completing the 6-week PP survey and received a $25 gift card for completing the 6-month PP survey.
Participants Participants were recruited from the PP unit of a large midwestern level III tertiary care center. Eligible participants were English-speaking, primiparous, and age 18 or older, whose infants were not in the neonatal intensive care unit and who initiated breastfeeding during the PP hospital stay. Of the 276 women who agreed to be screened, 204 met all study criteria. From this sample of 204 women, 146 completed all 3 survey time points, yielding a response rate of 71.6%. After removing cases with incomplete data on key variables, the total number of participants who initiated breastfeeding and completed all 3 survey time points was 142. Participant characteristics are summarized in Table 1.
Measures Edinburgh Postnatal Depression Scale (EPDS).16 The EPDS is a well-validated 10-item self-report depression screening tool, in which endorsement of each item is based on how women feel during the previous 7 days. Possible scores range from 0 to 30, with high scores reflecting more depressive symptoms. Internal consistency of the scale was found to be adequate in this sample (Cronbach’s α = .84).
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Henshaw et al Table 1. Participant Characteristics at 2 Days Postpartum.a Variable Age, mean (SD) EPDS Total, mean (SD) ≥ 10 < 10 Race/ethnicity Black/African American White Hispanic Asian Other Education High school graduate or less College graduate Master’s degree or higher Relationship status Married Living with partner Single Income $0-19 999 $20 000-59 999 $60 000-99 000 More than $100 000
Total Participants (N = 204) 30 (5.12) 3.43 (2.89) 6 (2.94) 198 (97.06) 22 (10.78) 175 (85.78) 3 (1.47) 11 (5.39) 2 (.98) 55 (26.96) 88 (43.14) 61 (29.90) 150 (73.53) 38 (18.63) 16 (7.84) 21 (10.29) 53 (25.98) 59 (28.92) 71 (34.80)
Abbreviation: EPDS, Edinburgh Postnatal Depression Scale. a All data presented as No. (%) unless otherwise noted. Percentages may not sum to 100% due to missing data. Participants could choose more than 1 racial or ethnic category.
Postpartum Depression Predictors Inventory–Revised (PDPIR).17 The PDPI-R is a dichotomous checklist inventory of 13 risk factors significantly related to PP depression (PPD): prenatal depression, child care stress, life stress, social support, prenatal anxiety, marital satisfaction, depression history, infant temperament, maternity blues, self-esteem, socioeconomic status, marital status, and unplanned/ unwanted pregnancy. Developed as a brief measure to identify women at risk for PPD, the PDPI-R was shown to have good predictive construct and concurrent validity among a sample of 139 pregnant women who were followed for 8 months after birth.18 Being a Mother Scale (BaM-13).19 The BaM-13 is a 4-point Likert-style self-report measure developed to evaluate women’s emotional adjustment to motherhood for women with children ranging from infants to preschool age. The 13 items aim to summarize a woman’s satisfaction with a broad range of maternal experiences including social isolation, parenting confidence, infant bonding, coping, and guilt. Higher scores indicate greater distress. This scale has been shown to have good psychometric properties, with moderate to high levels
of reliability and validity, with similar results in this sample (total scale Cronbach’s α = .82). As part of the BaM-13 inventory, all participants were given an open-ended prompt during the 6-week PP and 6-month PP surveys: “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” Mothers were encouraged to answer “this does not apply to me” if they did not feel that this description applied to their experience of motherhood. All responses were coded by 2 of the authors. Breastfeeding Self-Efficacy Scale–Short Form (BSES-SF).15 The 14 items of this 5-point scale represent a condensed version of the 33-item BSES.20 Higher scores indicate greater selfefficacy, and the BSES-SF has demonstrated reliability and validity comparable with the original BSES.15 High internal consistency was demonstrated in the current sample (Cronbach’s α = .91). Breastfeeding ease. Women were also asked to evaluate their feelings about how breastfeeding was going using a single item rating on a scale of 1 (very well, only a couple of minor difficulties) to 5 (terrible, many major difficulties). Partner support. Partner support for breastfeeding was measured using a single item asking, “Which do you think best represents your partner’s feelings about feeding the infant?” Responses range from 1 (strongly supports exclusive formula feeding) to 5 (strongly supports exclusive breastfeeding). Use of breastfeeding education resources. Participants were asked at each time point whether they had attended a breastfeeding class or had contact with a lactation consultant using yes/no question formats. Level of breastfeeding exclusivity. Rather than conceptualizing breastfeeding as a dichotomous outcome, participants’ level of breastfeeding exclusivity was measured as a continuous variable differentiating among exclusive, partial, and token breastfeeding as suggested by previous authors.21 Women were asked to identify the level that most accurately described their breastfeeding behaviors within the previous 24 hours. Two levels from the scale that were reported by no participants (almost exclusive and high breastfeeding, representing less than 1 bottle of formula per day) were removed, leaving 4 levels reported: exclusive breastfeeding (breast milk only), partial breastfeeding (breast milk and at least 1 bottle of formula per day), token breastfeeding (breast given to comfort baby, not for nutrition), and no breastfeeding. Higher values represent more exclusive breastfeeding. Hierarchical regression analyses were conducted to evaluate the unique predictive contribution of BSE to depressive symptoms, emotional adjustment, and breastfeeding exclusivity at 6 weeks and 6 months PP. Predictive demographic variables previously demonstrated to be related to mood and breastfeeding outcomes were entered first in the regression
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Table 2. Breastfeeding and Mood among Breastfeeding Initiators.a 2 Days PP (n = 204)
6 Weeks PP (n = 170)
6 months PP (n = 165)
No. (%) or Mean (SD)
No. (%) or Mean (SD)
No. (%) or Mean (SD)
Exclusive breastfeeding (breast milk and vitamins as needed) Partial breastfeeding Token breastfeeding (given to comfort, not nourish, baby) No breastfeeding (exclusive formula feeding) Breastfeeding self-efficacy Breastfeeding ease Attend breastfeeding class Seek lactation consultation Partner support of breastfeeding Depressive symptoms (EPDS) EPDS ≥ 10 Emotional adjustment (BaM-13)
154 (75.55%)
105 (61.76%)
63 (38.18%)
37 (18.14%) 13 (6.37%)
32 (18.82%) 6 (3.53%)
20 (12.12%) 5 (3.03%)
27 (15.88%)
77 (46.67%)
3.29 (1.53) 4.29 (.96) — 84 (49.41%) 4.11 (1.09) 4.89 (3.60) 20 (11.76%) 3.33 (.43)
— 4.51 (0.91) — 66 (41.32%) — 4.98 (3.76) 16 (9.61%) 3.43 (0.39)
0 3.62 (0.68) 4.06 (0.81) 145 (71.08%) — 4.39 (1.20) 3.43 (2.89) 6 (2.94%) —
Abbreviations: BaM-13, Being a Mother Scale; EPDS, Edinburgh Postnatal Depression Scale; PP, postpartum; —, variable not measured. a Breastfeeding self-efficacy, breastfeeding ease, and partner attitude toward breastfeeding are all presented so that high scores = greater efficacy, ease, and support on a 5-point scale. Breastfeeding class attendance and lactation consultation questions are represented by the percentage of women who answered “yes” to a question asking if they had completed each of these activities. Total for each time point listed here includes participants who completed 2, but not 3, time-point surveys, as well as those who may be missing demographic data. Total participants who completed all time points with no missing data are 146.
model (race/ethnicity, education, income), followed by participants’ depressive symptoms and risk factors at 2 days PP (PDPI-R, EPDS) and other breastfeeding predictor variables (breastfeeding ease, breastfeeding exclusivity at 2 days PP, use of breastfeeding class or lactation consultation, partner support of breastfeeding, and work status at 6 months). Finally, BSE reported at 2 days PP was entered into each model. All variables were standardized and cases missing data for any variable were dropped from the analysis.
Results Breastfeeding Duration and Exclusivity Among women who attempted breastfeeding (n = 204) at 2 days PP, 61.8% were exclusively breastfeeding at 6 weeks PP and 38.2% were exclusively breastfeeding at 6 months PP (Table 2). Less than 25% of the sample reported partial or token breastfeeding across all 3 time points. At 6 months PP, nearly half (46.7%) of women who had initiated breastfeeding in the hospital reported complete discontinuation of breastfeeding.
Breastfeeding Self-Efficacy and Mood Outcomes We predicted that lower BSE during the hospital stay would be associated with poorer emotional adjustment and greater depressive symptoms at 6 weeks PP and 2 and 6 months PP. Results of 4 hierarchical regression tests suggest that 2 days
PP BSE is a significant predictor of both of the mood outcomes at 6 weeks, but not 6 months PP (Table 3). Predictor variables were entered in 4 blocks to determine the additional contribution of each new block to the model. As expected, both the PDPI-R and EPDS scores at 2 days PP were significant risk factors for higher EPDS scores at 6 weeks and 6 months. Results suggest that BSE is inversely related to EPDS scores, with high BSE scores predicting lower 6-week depressive symptoms and greater emotional adjustment. All other breastfeeding measures (ease, exclusivity, education, and partner support) were entered as a separate block and did not contribute significantly to prediction of mood outcomes. Although BSE predicted mood outcomes at 6 weeks, it was not a significant factor in either of the 6-month mood models.
Breastfeeding Self-Efficacy and Breastfeeding Exclusivity We predicted that higher BSE during the hospital stay would predict greater breastfeeding exclusivity at 6 weeks and 6 months PP among first-time mothers, after accounting for other known factors. Hierarchical multiple regression analysis indicated that BSE at 2 days PP was a significant predictor of 6 month, but not 6 week, breastfeeding exclusivity levels (Table 3) after accounting for mood, work status, and other known predictors of breastfeeding outcomes. At 6 months, more exclusive breastfeeding was also predicted by less time working for pay, breastfeeding exclusively or
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.04
Step 1 Race/ethnicity Education Income Step 2 T1 PDPI-R T1 EPDS Step 3 T3 work status Step 4 T1 breastfeeding ease T1 breastfeeding T1 breastfeeding class T1 partner support T2 lactation consultation Step 5 T1 breastfeeding efficacy Total adjusted R2 No. b
.43
−.32
.08 .08 .01 .07 .01
.32 .23 .32 .19 .45
.25 .40b
.24 .26
b
.04 −.08 −.06
β
.75 .19 .14
SE
.32b 151
.10b
.01
.23b
.04
ΔR
.06
.04 .03 .04 .03 .06
.03 .03
.10 .03 .02
SE
c
.41
b
−.19c −.05 −.05 −.01 .02
−.22 −.31b
−.10 −.01 .12
β
.01 149
.00
.00
.01
−.02
ΔR
2
.24
.18 .13 .18 .11 .25
.13 .14
.43 .11 .08
SE
β
c
.14
−.09 .08 .06 −.06 .15
.21 −.08
−.03 .01 .08
Breastfeeding
.16 135
.01
.01
.19b
.03
ΔR
2
.58
.42 .31 .45 .26 .61
.33 .36
1.02 .27 .19
SE
β
b
−.11
−.04 .06 −.04 −.03 −.02
.34 .16
.07 −.10 .06
Depressive Symptoms
.17 135
0
.01
.19b
.04
ΔR
2
.06
.05 .03 .05 .03 .07
.04 .04
.11 .03 .02
SE
β
.05
−.03 −.07 −.02 .01 −.03
−.28d −.27d
−.12 .05 −.03
Emotional Adjustment
.15c 133
.03c
.07
.09b
.03
.01
.36
.26 .19 .28 .17 .37
.19
.21 .22
.62 .16 .11
SE
β .01 .05 .03 .12 −.12 −.28d −.13 .23d .04 −.11 .19c .22c
Breastfeeding ΔR2
6 Months Postpartum (T3)
Abbreviations: β, regression coefficient; BaM-13, Being a Mother Scale19; EPDS, Edinburgh Postnatal Depression Scale16; PDPI-R, Postpartum Depression Predictors Inventory–Revised17; R2, multiple correlation squared; ∆R2, incremental change in R2; SE, standard error; T1, 2 days postpartum; T2, 6 weeks postpartum; T3, 6 months postpartum. a Work status included as regression step only in 6-month breastfeeding rates. Emotional adjustment measured by BaM-13. Breastfeeding measured by level of exclusivity on 1-4 scale (4 = exclusive breastfeeding). b P < .001. c P < .05. d P < .01.
.40b 152
.06b
.01
.33b
ΔR
2
2
Variable
Emotional Adjustment
Depressive Symptoms
6 Weeks Postpartum (T2)
Table 3. Predictors of Mood, Adjustment, and Breastfeeding at 6 Weeks and 6 Months Postpartum.a
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Table 4. Reasons for Parenting-Related Stress Reported by Self-Identified Distressed Mothers.a 6 Weeks Postpartum (n = 53) Coded Reason Breastfeeding concerns Lack of sleep So much to adjust to/learn Lack of social support Worry about baby Crying/colic Lack of personal time/break Too many demands Return to work Other nonparenting stressors
6 Months Postpartum (n = 44)
No.
%
No.
%
7 12 10 7 6 5 3 2 0 1
13.21 22.64 18.87 13.21 11.32 9.43 5.66 3.77 0 1.89
3 3 7 6 3 0 5 7 7 3
6.82 6.82 15.91 13.64 6.82 0 11.36 15.91 15.91 6.82
a
omen responded to open-ended prompt, “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” W Women could choose to respond or not to respond.
almost exclusively at 2 days PP, and speaking with a lactation consultant after leaving the hospital. The only variable significantly predicting levels of breastfeeding at 6 weeks PP was the PDPI-R depression risk inventory.
Identified Parenting-Related Stressors Responses to the BAM-13 open-ended question, “If you have found being a mother very stressful, very difficult, or unenjoyable, why do you think this is?” were coded and are summarized in Table 4. At 6 weeks PP, 13.2% of respondents reported breastfeeding difficulties (e.g., difficulty latching, low milk supply, worry about whether infant is fed sufficiently) as the reason for finding motherhood stressful, difficult, or unenjoyable. By comparison, at 6 months PP, only 6.8% cited breastfeeding difficulties as a stressor. Mothers identifying breastfeeding as a major stressor of parenthood did not differ significantly from those who did not in reported BSE at either 2 days PP [t(202) = .88, P = .68] or 6 weeks PP [t(167) = .52, P = .60]. Sleep deprivation and worry about the infant were also prominent stressors at 6 weeks, but not 6 months. General adjustment and learning involved with parenthood remained a highly reported stressor at both time points.
Discussion Considering the many social and logistical issues that women may encounter in maintaining breastfeeding, being equipped to manage barriers and challenges is an important skill for first-time mothers. The current study contributes to the understanding of BSE’s relationship to mood and breastfeeding outcomes by using a 6-month prospective design in a sample of first-time mothers while controlling for major known predictors of breastfeeding and mood outcomes. In this study, we aimed to evaluate BSE’s relationship to breastfeeding and mood outcomes among primiparous women. High BSE correlated with fewer depressive symptoms and
greater enjoyment of motherhood at 6 weeks, but not 6 months, PP. In addition, high BSE, along with work status, lactation consultation, and in-hospital breastfeeding exclusivity, was associated with higher levels of breastfeeding exclusivity at 6 months, but not 6 weeks, PP. Breastfeeding concerns were cited as 1 of the top 4 reasons for significant stress at 6 weeks, but not 6 months, PP.
Breastfeeding Self-Efficacy and Breastfeeding Outcomes Breastfeeding duration and exclusivity rates in this study followed similar trends to other assessments of US samples.2 Exclusivity remained relatively high at 6 weeks PP but dropped sharply by 6 months PP, such that only half of women who were exclusively breastfeeding during the first 2 days PP still reported exclusive breastfeeding at 6 months. The significant negative association of returning to full- or part-time work on breastfeeding outcomes that was evident in our analyses has been found elsewhere22 in samples of US women. Perhaps the most compelling finding in this analysis is that BSE in the hospital remains a predictor of 6-month feeding outcomes even after accounting for work status, breastfeeding difficulty, partner support, and in-hospital breastfeeding exclusivity. In introducing self-efficacy theory, Bandura suggested that this is true: “When beset with difficulties people who entertain serious doubts about their capabilities slacken their efforts or give up altogether, whereas those who have a strong sense of efficacy exert greater effort to master the challenges.”23 Grounded theory qualitative work with US mothers revealed a concept quite similar to self-efficacy (labeled “confident commitment” by the authors) as an essential component of success in breastfeeding.24 Taken together, these findings suggest that in addition to the techniques of breastfeeding being taught to new mothers, an equal emphasis should be placed on women’s confidence
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Henshaw et al and perceptions of themselves as skilled and effective in breastfeeding.
Breastfeeding Self-Efficacy and Mood We found partial support for the hypothesis that high BSE would predict positive mood outcomes. The relationship between in-hospital BSE and 6-week mood and adjustment suggests that how a breastfeeding woman perceives her skill in breastfeeding is related to her early emotional experience of motherhood. Previous longitudinal evaluation found that BSE consistently predicted change in depressive symptoms across time for Norwegian mothers.12 Together with the current findings, this suggests a potential role for BSE in emotional adjustment, defined clinically (depressive symptoms) or within the spectrum of normative adjustment.19 If replicated in future research, this implies that goals of breastfeeding education might be widened to conceptualize breastfeeding confidence as a goal for emotional well-being in addition to the known benefits of breastfeeding to mother and infant. Open-ended responses in the current study suggest that among women who self-identify as having a difficult transition to motherhood, breastfeeding concerns are commonly named as a source of stress. This finding also adds complexity to ongoing research regarding the potential protective role of breastfeeding against PP depression.9 In addition to the hypothesized roles of infant bonding and hormonal response, these findings suggest a possible socialcognitive influence as well. Some women may view breastfeeding as an early sign of success or failure in the role of motherhood, and how a woman feels she is doing at this task may be important in shaping her early PP emotional experience. Recent qualitative work in England has concluded that mothers who struggled to establish breastfeeding perceived themselves as failing at an early task of motherhood.25 It is important to note, however, that we did not find evidence that this early self-efficacy is related to mood at the 6-month time point. Open-ended responses at 6 months also suggested that breastfeeding becomes less prominent as a self-identified stressor, giving way to other stressors such as work demands.
Methodological Considerations The strengths of this study lie in the use of a prospective design and the limitation of analyses to first-time mothers who had attempted to initiate breastfeeding in the hospital. Inclusion of women who did not intend to breastfeed or for whom breastfeeding is contraindicated by medication or health concerns can confound explorations of breastfeeding predictors. Furthermore, by focusing on primiparous women, we were able to assess BSE among women inexperienced in breastfeeding an infant, rather than self-efficacy beliefs among multiparous women that may be shaped by their previous breastfeeding successes or failures. In addition to these
strengths, the study findings should be considered in light of the following methodological limitations. The study sample was from a large Midwestern level III tertiary care center and comprised women who identified as white, with relatively high education and income. Therefore, caution should be used in generalizing these findings to women of different backgrounds or in different countries. Recent findings26 suggest that hospital practices influence the rates and perceptions of breastfeeding in patients, and the current results are likely shaped in part by the specific practices of the hospital from which all of the participants were recruited. In this particular hospital setting, individual lactation consultation and group breastfeeding instruction were voluntarily available for breastfeeding mothers. For this reason, the amount of instruction that women received may vary depending on whether or not they chose to engage in breastfeeding education.
Developing Breastfeeding Self-Efficacy Work exploring the development of BSE has been relatively recent. Although traditionally, self-efficacy has been addressed through individual-level interventions, a recent evaluation of an individual-level intervention suggests that structural conditions that create conditions for greater breastfeeding success, such as the Baby-Friendly Hospital Initiative,27 may be essential to successful intervention. A recent control-comparison intervention in Japan found that individually focused BSE intervention effectively affected BSE and exclusive breastfeeding outcomes only in the context of a Baby-Friendly Hospital, with no effect for the same intervention when delivered in a non-Baby-Friendly certified hospital.26 This suggests that system-level conditions, not only individual interventions, should be considered when working toward a goal of increasing BSE.
Conclusion Breastfeeding self-efficacy assessed during the PP hospital stay was found to correlate with positive emotional adjustment in the early PP period as well as higher levels of exclusivity in breastfeeding through 6 months PP. Our findings suggest that women’s perceptions of their breastfeeding ability are linked in important ways to early PP emotional experience and continued breastfeeding. Bolstering women’s breastfeeding self-efficacy may be an important goal for multiple dimensions of PP health. Future research should include the development and evaluation of breastfeeding interventions designed to increase self-efficacy in the early PP period. Acknowledgments The authors would like to acknowledge Eve Sussman for her contribution to the collection of data for the project. They would also like to thank the Denison University Research Foundation, as well as
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the Denison University Sharfstein and Anderson Summer Scholar programs for support of this research.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Denison University Research Foundation, as well as the Denison University Sharfstein and Anderson Summer Scholar programs. No conflict of interest exists for any of the authors.
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