Introduction

Benefits of breastfeeding for both mothers and babies are known to everyone. Exclusive breastfeeding is recommended during the first six months of an infant's life (1). Breast milk contains all the nutrients which infant need in the first six months of life. It also ensures food security for infants worldwide. Food security means having access to sufficient food to meet dietary needs for a productive and healthy life, both in the present and in the future (2).

Evidence suggests that breastfeeding has many health benefits during all stages of life. Continuous and exclusive breastfeeding protects against a wide range of short- and long-term health outcomes that pose a significant burden on individuals, health system and societies (3). Breastfeeding may reduce the risk of acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infection, atopic dermatitis, pediatric asthma, obesity, diabetes type 1 and 2, pediatrics leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis in the infants. A history of breastfeeding is also associated with lower risks of type 2 diabetes, breast and ovarian carcinoma in the mothers. However, early breastfeeding cessation or lack of breastfeeding increases the risk of postpartum depression in the mothers (4). Early cessation of breastfeeding have important adverse health implications for women, children, and society, which increase the cost of national healthcare programs (5).

Exclusive breastfeeding rate at first 4 months was 65.8% in Iran (6). However, a descriptive study of breastfeeding in 63071 infants in Iran showed a downward trend in the prevalence of exclusive breastfeeding at first 4 and 6 months, that contradict the guidelines recommended by the World Health Organization (WHO). Therefore, according to WHO guidelines, an increase in exclusive breastfeeding for six months is recommended in Iran (7).

It is important to assess the attitudes toward breastfeeding to decide which feeding method best suits the infants to consequently increase the rate and duration of breastfeeding (8). Poor or negative attitudes toward breastfeeding were reported as barriers for initiation and continuation of breastfeeding (9). Those women who perceive breastfeeding is healthier, easier, and more convenient are more likely to breastfeed their babies than those who have a negative attitude toward breastfeeding (10). The study on 238 parents with 6-12 months children showed that maternal attitudes play an influential role to achieve an exclusive breastfeeding for first 4-6 months (11).

Breastfeeding self-efficacy refers to women’s confidence in their capabilities to successfully breastfeed their infants and perform the specific tasks and behaviors related to breastfeeding. Theoretically, breastfeeding self-efficacy is influenced by the following four main sources of information: (a) performance accomplishments (e.g., past breastfeeding experiences), (b) vicarious experiences (e.g., other women breastfeed, peer counseling), (c) verbal persuasion (e.g., encouragement from influential others such as friends, family, and lactation consultants), and (d) influence of one’s physiological and/or affective states (e.g., pain, fatigue, anxiety, and stress) (12-14). Women with a strong desire to breastfeed their infants for a longer period of time are confident in their ability, well supported by their family, and positive about their long-term breastfeeding experiences (15).

 Self-efficacy acts as a mediator in the relationship between knowledge and behavior. It is also defined as confidence in the ability to perform a task or a behavior. Therefore, it is an important prerequisite for behavioral change (16). Some factors that precede the process of behavioral change are knowledge, attitude, and self-efficacy, which create the incentives to perform a behavior (17). The results of the study which was performed in Iran showed that breastfeeding self-efficacy was the most effective factor in predicting exclusive breastfeeding in mothers, while the rate of breastfeeding self-efficacy in women three months after delivery was reported to be undesirable (18). Although there are several studies on exclusive breastfeeding, the study on the predictors of exclusive breastfeeding is very limited. In a systematic review (2017) that examined the factors associated with the timely initiation of breastfeeding and exclusive breastfeeding, some of the studies lacked a multivariate analysis. Therefore, they recommended that future studies be performed by considering the related factors and using multivariable analysis (19).

Despite the benefits of breastfeeding for both women and infants, various factors can influence the mother's intention to initiate and continue breastfeeding, including mother's knowledge on the benefits of breastfeeding, supportive systems, and breastfeeding self-efficacy (15). Such factors as socioeconomic status cannot be easily changed. Therefore, healthcare providers should assess changeable factors including maternal knowledge on the benefits of breastfeeding, supportive systems, and breastfeeding self-efficacy to promote attitudes towards breastfeeding (20). Measuring attitudes and beliefs, setting social norms, and identifying barriers to breastfeeding can help understand breastfeeding behaviors. Since determining the factors affecting exclusive breastfeeding can be useful in identifying mothers who are at risk of early cessation of breastfeeding, and due to the modifiable factors affecting exclusive breastfeeding such as breastfeeding self-efficacy, it is necessary that descriptive and interventional studies be performed to find the way to increase the rate of exclusive breastfeeding. Due to the limited studies in the field of predictors of exclusive breastfeeding in Iran and the lack of such study in Tabriz, the present study was conducted to determine the predictors of exclusive breastfeeding.

Materials and Methods

This cross-sectional study was conducted on 183 lactating mothers with infant aged 4 months visiting the health-treatment centers of Tabriz, Iran in July to October 2017. Inclusion criteria were singleton pregnancy, no history of chronic physical (high blood pressure, lupus, heart disease, diabetes, depression) or mental diseases which may interfere the breastfeeding, no maternal breast disease to prevent breastfeeding, access to a phone line, literacy to fill out the questionnaires, physical ability to breastfeed, good mental health. Exclusion criteria were having an abnormal infant, taking drugs by mother, and divorced women.

Ethical approval was obtained from the Medical Research Ethics Committee (Code: ir.tbzmed.rec.21/12/93). A letter of introduction was also obtained from the Student Research Committee and presented to the respected authorities of the health centers. Necessary arrangements were made. The sampling permission was also obtained. Clustering sampling was used. A quarter of health centers and clinics was randomly selected (simple randomization) from 45 health centers and 41 health clinics in Tabriz using the website (www.random.org). The number of sample in each health center or clinic was calculated and determined using quota sampling according to the original sample size and demographic data available in each health center and clinic (the number of mothers visiting the health centers and clinics). The researcher visited the selected centers and clinics and gave the information to the eligible mothers who had four-month old infants and invited them to participate in the study. The objectives of the study were explained to the mothers and they were ensured of voluntary participation in the study. Written consent forms were collected. Data collection tools were demographic questionnaire (including data of both mother and infant), the infant feeding checklist, the Iowa Infant Feeding Attitude Scale (IIFAS) and the breastfeeding self-efficacy scale that were completed by the mothers.

Demographic questionnaire collected the information on mother and infant, including maternal age, mother's occupation, education of mother and father, economic status, body mass index, place of residence, ethnicity, and whether mother and father of the participants were alive. The infant feeding checklist collected the information on feeding method.

 IIFAS is a reliable and valid scale that measures attitudes towards different methods of feeding. It contains 17 items. Nine items measure attitudes toward formula feeding and eight items measure attitudes toward breastfeeding. A Likert scale is used to score the items ranging from strongly disagree (score 1) to strongly agree (score 5). Total score varies from 17 to 85. Higher scores indicate positive attitude towards breastfeeding. 70<score<85 indicates positive attitude toward breastfeeding, 49<score<69 indicates neutral attitude towards breastfeeding and 17<score<48 indicates positive attitude towards formula-feeding (8). Validity and reliability of the scale were confirmed in the study by Mirghafourvand et al. in Iran (2018) (21).

The breastfeeding self-efficacy scale contains 33 items with positive values. It was developed by Faux and Dennis and scored based on a five-point Likert scale ranging from strongly agree (5) to strongly disagree (1). Sum of the scores assigned to each item represents the breastfeeding self-efficacy score. Scores are ranging from 33 and 165. 33<score<76 indicates low self-efficacy, 77<score<120 shows moderate self-efficacy, and 121<score<165 represents high self-efficacy (22). Validity and reliability of the scale were confirmed in the study by Hassanpour et al. and Varei et al. in Iran (23, 24).

Sample size was calculated as 94 women using the formulae of

and given the prevalence of exclusive breastfeeding during the first 4 months in Iran = 58% (P) (7), d = 0.1, 95% confidence interval (Z=1.96), and 90% test power. The sample size was calculated as 141 given the cluster sampling and design effect = 1.5. The sample size was determined as 161 given the 20% sample loss. Finally, 183 mothers were studied.                                         

Data were analyzed using SPSS (software 21). Descriptive statistics including frequencies and percentages, mean and standard deviation (SD), were used for describing the socio-demographic characteristics, pregnancy and breastfeeding characteristic, breastfeeding attitude, breastfeeding self-efficacy, and frequency of exclusive breastfeeding. Normality of the quantitative data was measured by skewness and kurtosis and data distribution were normal. Then, to determine the effect of the independent variables (breastfeeding self-efficacy, breastfeeding attitude and socio-demographic characteristics) on the dependent variable (exclusive breastfeeding), those variables that confirmed significance (p < 0.05) were entered into the adjusted logistic regression. P< 0.05 was considered statistically significant.

Results

Mean age of the participants was 28.04±5.24 years and mean BMI was 26.3±4.9 kg/m².

Almost half of the participants (45.3%) had a high school diploma and the majority of the participants (91.8%) were housewives. Half of the spouses (51.4%) were self-employed and had a high school diploma (43.7%). 68.3% of the participants had sufficient monthly income. 55.7% of the participants lived in a private home and 74.3% lived independently. Majority of the participants (98.4%) were Turks (An ethnic group in Iran) and 81.6% of the families consisted of four members (Table 1).

Two-thirds of the participants (74.3%) had planned pregnancies and 76.6% of them were pregnant for their first or second baby. About two-thirds of the participants (63.9%) were highly supported by their spouse, more than half of them (66.1%) were negligibly supported by their friends and about one-third of them (33.9%) were moderately supported by their families. About half of them (45.4%) had cesarean section and 7.1% had a history of infertility.

The majority of them (89.1%) received pregnancy care in the physician office and 57.9% of them received breastfeeding training. Majority of the participants (68.3%) were greatly encouraged by their spouses, friends,

and families and few (4.4%) were encouraged by a private physician to breastfeed. The health center was the most important source of breastfeeding education. The majority of mothers (71.6%) and fathers (74.3%) were interested to know their baby’s gender. The majority of mothers (84.6%) received antenatal education and most of them (90.2%) initiated breastfeeding immediately after delivery. 11.5% of mothers reported cessation of growth and 13.1% reported decline in growth according to growth chart for infants during the first month. In addition to breast milk, 20.1% of the infants feed with formula milk and complementary food (10.4%) (Formula milk was more used than complementary food). Few infants (12%) generally refused to breastfeed. The majority of the infant (72%) were exclusively breastfed (Table 2).

Mean of attitude toward breastfeeding was 55.13±5.5 (ranging 17 to 85). Mean of breastfeeding self-efficacy was 131.8±15.5 (ranging 33 to 165). The independent t-test results showed a significant difference between self-efficacy and exclusive breastfeeding scores (P=0.004). There was also a statistically significant relationship between exclusive breastfeeding and attitude towards breastfeeding (P=0.005) (Table 3).

Logistic regression model showed that the variables of breastfeeding attitude, type of delivery, breastfeeding immediately after delivery, mother’s personal experience and refusal to breastfeed were the predictors of exclusive breastfeeding. Exclusive breastfeeding rates were higher in women who had a neutral attitude toward breastfeeding compared to those who had a positive attitude toward formula feeding (P<0.001, OR= 16.6); women with vaginal delivery compared to those with cesarean section (P<0.001, OR= 9.3); women who initiated breastfeeding immediately after delivery compared to those who delayed breastfeeding (P=0.006, OR= 6.8); women with a personal experience of exclusive breastfeeding compared to those with no personal experience of exclusive breastfeeding (P=0.008, OR=11); women whose infants did not refuse to breastfeed compared to those women whose infants refused to breastfeed (P=0.003, OR= 8.7)  (Table 4).

Discussion

The results of the present study showed positive attitude and strong self-efficacy of mothers with exclusive breastfeeding during the first 4 months. There was statistically significant relationship between exclusive breastfeeding with attitude toward breastfeeding and breastfeeding self-efficacy. The variables of attitude toward breastfeeding, type of delivery, breastfeeding immediately after delivery, maternal personal experience and refusal of infants to breastfeed were the predictors of exclusive breastfeeding in the mothers.

Assessment of different aspects and challenges to breastfeeding was prioritized in most countries. Several studies addressed this issue in various countries. Some studies assessed mothers’ knowledge and attitudes toward breastfeeding and the factors affecting breastfeeding. Taveras et al. (2003) (25) in the United States, Graham et al. (26) in Australia (two case studies in developed countries), DeOliveira et al. (27) in Brazil and Egbuoxu et al. (28) in Nigeria (two case studies in developing countries) raised concerns that the mothers had less tendency to breastfeed. These results were not consistent with the results of the present study, because more than two-thirds of mothers in the present study chose exclusive breastfeeding. These confounding results might be due to cultural differences since in the culture of Iran, Hadiths and the twelve Imams recommended breastfeeding. Therefore, Iranian people and Muslims are more willing to breastfeed.

The Ministry of Health, Treatment and Medical Education promoted breastfeeding as one of the most important strategies to improve infant's growth and survival. The ministry took effective steps to promote this strategy in Iran. The prevalence of exclusive breastfeeding was 72.0% in the current study. Another study reported the prevalence of continuous breastfeeding was less than 28% in Iran (29). These results were not consistent with the results of the present study. Another study in Canada also showed that one-third of Canadian women stopped early breastfeeding before eight weeks postpartum, and the most common reason was a perception of insufficient milk supply (30). These results were also inconsistent with the results of the present study regarding the poor performance of mothers in exclusive breastfeeding, since more than two thirds of mothers had exclusive breastfeeding in the present study. These confounding results might be due to poor socioeconomic status of Canadian women, while women with different socioeconomic states were assessed in the present study.

The results of this study showed a statistically significant relationship between the positive attitude of pregnant women toward breastfeed and exclusive breastfeeding. These results were consistent with the results of the study which was performed by Persad et al. (2008) (31) and Dungy et al. (2008) (32) who also found out a positive relationship of maternal attitude and knowledge with maternal intention to breastfeed. One of the most important factors affecting the rate of breastfeeding is the awareness and attitude of mothers and their spouses. So that mothers' performance in choosing exclusive breastfeeding improves with increasing the level of awareness (33).

Although most women received breastfeeding education during pregnancy and later in the hospital in the present study, the prevalence of continuous exclusive breastfeeding was average. These results were consistent with the results of the study in the United States; they also reported 32.2% exclusive breastfeeding rate in 70% of mothers who started breastfeeding immediately after delivery (34). Low rate of exclusive breastfeeding in these studies might be due to insufficient training of breastfeeding and neglecting feedback on breastfeeding training. As Yahyavi et al. (2017) (35) showed that there is a significant relationship between the number of sessions participating in childbirth preparation classes and exclusive breastfeeding.\ Necessary information is not transmitted to mothers with few training sessions.

Varaei et al. (24) (2009) also reported that mothers with low self-efficacy discontinue exclusive breastfeeding earlier than expected. These results were consistent with the results of the present study in which greater self-efficacy increased the rate of exclusive breastfeeding. Nevertheless, Varaei et al. showed that more than 80% of mothers did not attend prenatal breastfeeding training sessions, which negatively changed their attitudes towards breastfeeding and reduced their breastfeeding self-efficacy.

Various factors are involved in the rate of breastfeeding including duration of pregnancy, type of delivery, mother's occupation, support of family and relatives, a suitable room for infants in the workplace, and proper education of health personnel (36, 37). Mother’s intention to breastfeed depends on various factors including social norms, support from health center experts, and husband's support (38). One of the predictors of exclusive breastfeeding in the present study was vaginal delivery. This result was consistent with the results of the study by Islami et al. (39). In both studies, exclusive breastfeeding was more seen in mothers who had vaginal delivery. Spontaneous vaginal delivery without medical interventions and mother and newborn skin-to-skin contact immediately after the delivery increase the rate of breastfeeding, which contribute to continuous breastfeeding (40).

Cesarean section medications affect newborns’ nervous system and behavior as well as it will affect early breastfeeding. These medications either delay or inhibit lactogen production which increases the risk of excessive weight loss in infants. Intravenous injection of opioids during delivery may alter newborns’ normal reflexes to find their mothers’ breasts (41). Cernadas et al. (2003) (42) found that early breastfeeding within the first hours of life increased the likelihood of exclusive breastfeeding during the first 4 months of life. These results were consistent with the results of this study in which early initiation of breastfeeding immediately after birth was one of the predictors of exclusive breastfeeding.

Another predictor of exclusive nutrition is the mother's personal experience, which is in line with the studies that have shown exclusive nutrition will increase with increasing awareness and attitude (31, 32). The personal experience will probably increase the breastfeeding mother's awareness and attitude about early starting and continuing breastfeeding and how to cope and solve the problems.

Other predictor of exclusive breastfeeding in the present study was refusal of infant to breastfeed. These results were consistent with the results of the study by Mohammadi et al. (2004) (37) who found that infant's problems, fussing and crying were associated with exclusive breastfeeding.

According to the available literature, this study is the first study which examined the impact of socio-individual and obstetrics factors, attitude towards breastfeeding, and breastfeeding self-efficacy as possible predictors of success in exclusive breastfeeding in Iranian women. The other strengths of the present study were using of standard and valid questionnaires, as well as random sampling among the women visiting Tabriz health centers that increase the generalizability of the study findings. One of the limitations of the present study was that the participants had no special disease or problem. Therefore, it is suggested to perform more similar studies on lactating women in rural areas or lactating women with different medical problems. Also, cross-sectional study does not reflect the causal relationship between the studied variables (e.g. exclusive nutrition and some socioeconomic factors).

Conclusion

The results of this study showed positive attitude and strong self-efficacy of lactating mothers in the first 4 months after delivery. Since attitude towards breastfeeding, type of delivery, breastfeeding immediately after delivery, mother’s personal experience and refusal to breastfeed were the predictors of exclusive breastfeeding, it is recommended to promote practical management of breastfeeding problems and refusal of infants to breastfeed, and encourage vaginal delivery and early breastfeeding.

Acknowledgements

This article is a part of a research project approved by the Ethical Committee of Tabriz University of Medical Sciences. We would like to thank the authorities of Tabriz University of Medical Sciences for the scientific and ethical approval and financial support of this research. We also sincerely thank all personnel of the health care centers/posts of Tabriz for their cooperation, and all women who participated in this study.

Conflicts of interest

Authors declared no conflicts of interest.