Exclusive breastfeeding, breastfeeding self-efficacy and perception of milk supply among mothers in Singapore: A longitudinal study
Section snippets
Key conclusions
Breastfeeding self-efficacy and perceptions of milk supply are modifiable factors that predict exclusive breastfeeding at 6 months.
Implications for practice
BSES-SF and PIM questionnaire may be used to identify mothers at risk of discontinuing exclusive breastfeeding for targeted interventions. Interventions to increase exclusive breastfeeding up to 6 months should focus on increasing breastfeeding self-efficacy and addressing misconceptions about milk supply. Training for primary care nurses should be enhanced to ensure incorporation of effective breastfeeding counselling into current maternal and child health services and continuity of support
Aim & objectives
The aim of the study was to examine the factors that affect exclusive breastfeeding among mothers in Singapore.
The specific objectives were to
- 1)
Determine rates of any breastfeeding and exclusive breastfeeding at among infants aged 3 and 6 months old in Singapore.
- 2)
Determine the relationship between maternal breastfeeding self-efficacy and exclusive breastfeeding among infants aged 3 and 6 months old.
- 3)
Determine the relationship between maternal perceived milk supply and exclusive breastfeeding among
Definitions
In this study, we adopted the World Health Organization definition of `exclusive breastfeeding’ that the infant receives only breast milk (including expressed breast milk) and may include drop and syrup forms of vitamins, minerals and medicines and oral rehydration salts (ORS) solution (WHO, 2008). The same definition was used in the local National Breastfeeding Survey by the Singapore Health Promotion Board (Chua and Win, 2013).
`Any breastfeeding’ was defined by the National Breastfeeding
Study design
This was a longitudinal study. Participants were breastfeeding mothers recruited postnatally from primary care clinics in Singapore who were followed up until their infants reached the age of 6 months.
Ethical considerations
Ethical approval was obtained from SingHealth. The researchers explained the study to potential participants and fully informed written consent was obtained from all who agreed to participate in the study. Participants were informed that their data would be kept confidential. All participants’ data were kept in locked cabinets or password protected computers, which were accessible only to study personnel.
Setting and participants
We recruited 400 participants from 6 public primary care clinics (polyclinics) in Singapore. These clinics were chosen as they have higher maternal and infant attendances. All consecutive and eligible mothers were invited to participate in this study to reduce selection bias. Consecutive sampling provides some structure and additional rigor as it includes all accessible participants within the study time frame, thus the resulting sample is more representative of the target population than
Data collection
400 mothers completed a self-administered baseline questionnaire which included sociodemographic information, breastfeeding practices, prior breastfeeding experience, the Breastfeeding Self-Efficacy Scale (Short form) (BSES-SF) and the Perception of Insufficient Milk (PIM) questionnaire.
Mothers subsequently completed follow-up questionnaires on breastfeeding practices when their infants were 3 and 6 months old when attending the clinics for routine immunization.
The Breastfeeding Self-Efficacy
Data analysis
Descriptive statistics were used to report baseline characteristics and breastfeeding practices. Independent t-test was used to assess Breastfeeding Self Efficacy and Perception of Milk Supply and Exclusive Breastfeeding at 3 and 6 months in Table 4 and Fisher's exact test and Chi-square test were used to assess the Breastfeeding experience and Exclusive Breastfeeding at 3 and 6 months in Table 5. The factors associated with exclusive breastfeeding versus any breastfeeding or not breastfeeding
Participant characteristics
A total of 400 mother-infant dyads were recruited at baseline. Three hundred and twenty-three mothers completed the questionnaires at infant age 3 months and 258 mothers completed the questionnaires at infant age 6 months with retention rates of 80.1% and 64.5% respectively. The main reasons for drop out was transfer of care to other clinics and mothers declining to complete follow up questionnaires via phone call after other caregivers brought infants for routine immunizations. See Fig. 1.
The
Breastfeeding rates
Our study found higher any and exclusive breastfeeding rates at 6 months as compared to the National Breastfeeding Survey (NBFS) in 2011. Notably, 71.3% of mothers in our study were still breastfeeding at 6 months, while only 42% of infants were still breastfed at 6 months in the National Breastfeeding Survey (Chua and Win, 2013). In our study, 38.2% of mothers were exclusively breastfeeding at 6 months, while the NBFS in 2011 found an exclusive breastfeeding rate of only 1% (Chua and Win, 2013
Strengths
This was the first study in Singapore to explore breastfeeding self-efficacy and perception of milk supply. This study recruited mothers from an urban Asian setting and findings may be applicable in other countries with a similar population. Findings of this study are likely reflective of mothers who birthed at public BFHI certified hospitals as a high proportion of these mothers and infants are followed up at our public primary care clinics for government subsidized care. Thus, our findings
Limitations
Only English-speaking participants were recruited leading to a predominantly educated sample, thus findings may be limited to this specific demographic profile. Only mothers who were breastfeeding at baseline were included. These mothers had high median and range of breastfeeding self-efficacy and perceived milk supply at baseline. The number of multiparous mothers with no breastfeeding experience was very small, which limited comparison between groups.
Implications for practice
While our study findings showed increase in exclusive breastfeeding rate at 6 months, it still does not meet the recommendations set by the Singapore Health Promotion Board (HPB, 2012) or the Global Target of 50% suggested in the WHO/UNICEF Breast Feeding Collective (WHO/UNICEF, 2014). Thus, greater effort is needed locally, particularly in the primary care setting, to develop evidence-based interventions to increase exclusive breastfeeding rates.
BSES-SF and PIM questionnaire may be used to
Implications for research
Misconceptions about milk supply may be explored in depth in a qualitative study. Mothers’ knowledge of physiological breastmilk production and expression and their association with perceived and actual milk supply may be explored to determine reasons for perception of low milk supply or inability to express sufficient breastmilk. The needs of multiparous mothers with no breastfeeding experience may also be further explored in a qualitative study, as this group had an even lower breastfeeding
Conclusion
Our study found higher rates of any and exclusive breastfeeding at 6 months as compared to National Breastfeeding Survey in 2011. Our study also revealed that baseline maternal breastfeeding self-efficacy, perception of milk supply, breastfeeding intention and breastfeeding experience predicted exclusive breastfeeding rates at 6 months. The modifiable factors for breastfeeding self-efficacy and perceived milk supply provide opportunity for focused interventions on these areas, particularly in
Ethical approval
Ethical approval was obtained from the SingHealth Centralized Institutional Review Board (CIRB Ref: 2015/2464).
Funding source
The study received Seed Funding from SingHealth Polyclinics no (SHP-SEED29-2015[4]).
CRediT authorship contribution statement
Jacqueline Giovanna De Roza: Conceptualization, Funding acquisition, Methodology, Project administration. Mew Keng Fong: Project administration. Bee Leng Ang: Project administration, Writing - review & editing. Roslinda Bte Sadon: Project administration, Writing - review & editing. Eileen Yi Ling Koh: Formal analysis, Writing - review & editing. Stephanie Swee Hong Teo: Conceptualization, Writing - review & editing.
Declaration of Competing Interest
All authors wish to declare that there was no conflict of interest.
Acknowledgements
The authors wish to acknowledge the support of Dr. Tan Ngiap Chuan, Ms Patricia Kin and Ms Tan Yan Thong from SingHealth Polyclinics Research Department and nurses who helped to screen suitable participants for the study.
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