670645

research-article2016
WJNXXX10.1177/0193945916670645Western Journal of Nursing ResearchLiu et al.

Intervention Study
Western Journal of Nursing Research
2017, Vol. 39(7) 906­–923
The Effect of a © The Author(s) 2016
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DOI: 10.1177/0193945916670645
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Breastfeeding Outcomes
in Primiparous Mothers

Lingying Liu1, Jiemin Zhu1, Jinqiu Yang1,

Min Wu1, and Benlan Ye1

Abstract
The purpose of this study was to examine the effect of a self-efficacy
intervention on primiparous mothers’ breastfeeding behaviors. Participants
were recruited from an antenatal clinic at a university-affiliated hospital.
Seventy-five primiparous mothers were recruited from November 2013
to February 2014 for the control group, and 75 primiparous mothers
were recruited from March to June 2014 for the intervention group. The
intervention group participated in a 1-hr prenatal breastfeeding workshop
and a 1-hr breastfeeding counseling session within 24 hr after delivery.
The Breastfeeding Self-Efficacy Scale–Short Form and the infant feeding
method were assessed at hospital discharge, as well as 4 and 8 weeks
postpartum. The breastfeeding support program was found to be effective
and beneficial to mothers. Nurses should incorporate breastfeeding self-
efficacy interventions into their routine care to support new mothers
and to increase their breastfeeding self-efficacy and the duration of their
breastfeeding exclusivity.

1Xiamen University, Fujian, China

Corresponding Author:
Benlan Ye, Department of Nursing, School of Medicine, Xiamen University, Xiamen, Fujian
361102, P.R. China.
Email: [email protected]
Liu et al. 907

Keywords
breastfeeding self-efficacy, breastfeeding confidence, exclusive breastfeeding,
nursing intervention

The diverse and compelling advantages of breastfeeding for infants, mothers,

and communities have been well established, with studies documenting clear
links between breastfeeding and nutritional, immunological, social, and envi-
ronmental benefits (American Academy of Pediatrics, 2012; Kramer &
Kakuma, 2002). Recognition of the importance of breastfeeding has led to
the promotion of breastfeeding as a primary goal by the World Health
Organization (WHO; 2015). The Chinese government also promulgated “The
National Program of Action for Child Development in China” (2012) with
the aim of exceeding an exclusive breastfeeding rate of 50% for infants below
6 months.
Although concerted efforts to publicly promote breastfeeding have
increased, 40% of babies below 6 months are currently exclusively breastfed
worldwide (WHO, 2015). In China, 85.1% of mothers initiated breastfeed-
ing, but only 41.8% of them continued to exclusively breastfeed for 3 months,
with 1.4% of mothers breastfeeding exclusively and 58% of mothers breast-
feeding partially at 6 months postpartum (Y. Q. Zhang, Li, & Xia, 2008).
Thus, the duration of exclusive breastfeeding in China is well below the
WHO recommendations.
Breastfeeding self-efficacy, a mother’s confidence in her ability to breast-
feed her new baby, plays an important role in mothers’ breastfeeding behav-
iors (Dennis, 1999). Breastfeeding self-efficacy predicts whether a mother
will choose to breastfeed, how much effort she will need to achieve breast-
feeding success, whether she will have self-enhancing or self-defeating
thought patterns, and how she will respond to the emotional difficulties of
breastfeeding (Dennis & Faux, 1999). In general, the higher the breastfeeding
self-efficacy that mothers have, the greater the likelihood of breastfeeding
initiation and the longer the duration of breastfeeding (Meedya, Fahy, &
Kable, 2010)
Dennis (1999) identified four major influential factors that construct or
enhance breastfeeding self-efficacy: (a) performance accomplishments, (b)
vicarious experiences, (c) verbal persuasion, and (d) physiological response.
Performance accomplishments lead to the expectation of repeated good
future outcomes. Vicarious experiences that involve the successful breast-
feeding experiences of others, conveyed live, printed, or recorded, can also
lead to the expectation of good future outcomes, especially for a first-time
mother. Verbal persuasion or encouragement from friends, family, and health
908 Western Journal of Nursing Research 39(7)

professionals can bolster a mother’s self-efficacy. Finally, physiological

response (e.g., fatigue, stress, and anxiety) can influence the perception of
self-efficacy, and the reduction or reinterpretation of such states can lead to
higher perceived breastfeeding self-efficacy. Strategies targeted at these fac-
tors may enhance breastfeeding self-efficacy.
Although evidence suggests the importance of self-efficacy in the decision
of mothers to breastfeed (Meedya et al., 2010; Semenic, Loiselle, & Gottlieb,
2008; Thulier & Mercer, 2009), only a few studies to date have investigated
whether breastfeeding self-efficacy can be enhanced to increase breastfeed-
ing duration and exclusivity. Prenatal breastfeeding self-efficacy interven-
tions that involve educational workshops or workbooks increased mothers’
self-efficacy and exclusively of breastfeeding at 4 weeks postpartum (Nichols,
Schutte, Brown, Dennis, & Price, 2009; Noel-Weiss, Rupp, Cragg, Bassett, &
Woodend, 2006). Postnatal breastfeeding self-efficacy interventions included
peer support and individualized breastfeeding counseling and were reported
to promote breastfeeding exclusivity and duration (Dennis, Hodnett, Gallopp,
& Chalmers, 2002; McQueen, Dennis, Stremler, & Norman, 2011).
Chinese mothers experience a low level of breastfeeding self-efficacy
(Ding & Li, 2010; Yang, Yong, & Yang, 2011; Zhao, 2008). Despite evidence
suggesting that breastfeeding self-efficacy interventions are beneficial, few
of these self-efficacy interventions are carried out. In addition, Chinese moth-
ers do not receive enough breastfeeding information and support from the
health care professionals (Zhu et al., 2012).
A combination of pre- and postnatal interventions has been recommended
by many studies to support and promote breastfeeding practice (Meedya
et al., 2010; Semenic et al., 2008). A postnatal intervention to increase pri-
miparous mothers’ breastfeeding self-efficacy has been conducted in China
(Wu, Hu, McCoy, & Efird, 2014). However, to the best of our knowledge, no
breastfeeding self-efficacy intervention that combines both prenatal and post-
natal support has been tested in China.
The aims of this study were to examine the effectiveness of a perinatal
breastfeeding support program on breastfeeding self-efficacy and breastfeed-
ing exclusivity in Chinese primiparous mothers.

Conceptual Framework
The conceptual framework was based on Bandura’s (1977) self-efficacy the-
ory and Dennis’s breastfeeding self-efficacy framework. Self-efficacy was
defined by Bandura (1977) as a dynamic cognitive process in which an indi-
vidual evaluates his or her ability to perform a given task. Bandura (1977)
suggested four major influential factors that determine one’s confidence to
Liu et al. 909

master a given task: (a) performance accomplishment, (b) vicarious experi-

ences, (c) verbal persuasion, and (d) physiological response. Bandura (1977)
advocated a behavior-specific approach to conceptualize and measure self-
efficacy. Dennis’s (1999) breastfeeding self-efficacy framework fulfilled this
requirement and focused specifically on breastfeeding. Breastfeeding self-
efficacy refers to a mother’s perceived ability to breastfeed her new infant
(Dennis & Faux, 1999). These four factors may influence a mother’s breast-
feeding self-efficacy.

Method
Design
This study utilized a quantitative, comparative, and quasi-experimental research
design.

Setting and Participants

A convenient, non-probability sample was recruited from the antenatal clinic
between November 2013 and June 2014 at the Xiamen University First
Affiliated Hospital that averages 400 births per month. Seventy-five partici-
pants recruited from November 2013 to February 2014 were assigned to the
control group, and 75 participants recruited from March to June 2014 were
assigned to the intervention group. Eligible women were nulliparous women
who were expecting a single, healthy, term birth child, and who were plan-
ning to breastfeed. Participants had to be competent in Mandarin and have
access to a telephone. Mothers with any conditions (e.g., Hepatitis B) that
could significantly interfere with breastfeeding (J. Zhang, 2009), or infants
who were expected to require special care that would delay discharge from
the hospital, were excluded from the study.

Interventions
Both groups received standard care and were not limited to the types of
breastfeeding support they sought before and after their infants’ birth.
Standard care included their choice of physician or midwife, prenatal visits,
and prenatal classes. In addition to standard care, participants in the interven-
tion group participated in a 1-hr prenatal breastfeeding workshop and a 1-hr
postnatal, one-on-one breastfeeding counseling session provided by the
researcher of this study in the hospital.
910 Western Journal of Nursing Research 39(7)

The design of the breastfeeding intervention was based on the four influ-
ential factors of breastfeeding self-efficacy (Dennis, 1999). In the prenatal
breastfeeding workshop, participants were invited to explore their thoughts
and feelings that were related to previous accomplishments in various realms
and were prompted to incorporate identified skills (e.g., providing positive
suggestions about how to improve future breastfeeding performance and how
to express breast milk after delivery) into anticipated breastfeeding behavior
(performance accomplishments). Expectant mothers watched a video and
used a life-like doll to practice the skills and perseverance needed when
encountering common problems (vicarious experience). Their husbands or
significant others were invited into the workshop. This invitation emphasized
the importance of their encouragement and support to the expectant mothers
and to the success of breastfeeding (verbal persuasion). The mothers were
additionally provided with visual and written examples about how negative
physiological response can affect breastfeeding mothers, and with alternative
skills (e.g., self-talking, problem solving) to alter perception and to gain con-
trol (physiological responses).
Based on an initial assessment of breastfeeding self-efficacy using the
Hong Kong Chinese version of the Breastfeeding Self-Efficacy Scale–Short
Form (BSES-SF), strategies were implemented in an effort to increase moth-
ers’ breastfeeding self-efficacy during the one-on-one postnatal breastfeeding
counseling session. For example, if a mother indicated low self-efficacy on
the Hong Kong Chinese version of BSES-SF item, “I can always recognize
the signs of a good latch,” specific strategies were implemented such as (a)
giving attention to the successful or improved aspects of the latch, such as an
audible swallow and painless nursing (performance accomplishment); (b)
using visual materials to make unobservable breastfeeding skills apparent to
the mother, such as what a proper latch looks like (vicarious experience); (c)
providing encouragement, such as infant weight gain and infant contented
after the mother’s perseverance with feeding (verbal persuasion); and (d) pro-
viding anticipatory guidance, explicitly acknowledging and normalizing the
tendency to experience anxiety and fatigue during the postpartum period,
such as “It is normal for new mothers to experience fatigue and anxiety. Do
not hesitate to ask for help and give yourself a short break” (physiological
responses).

Outcome measurements
Baseline demographic variables.  The baseline questionnaire included demo-
graphic variables that may influence breastfeeding outcomes. Data such as
age, marital status, education, family income, and employment were col-
lected prenatally at registration. Data on birth weight, type of birth, labor
Liu et al. 911

and delivery complications, and any free formula received were gathered
postpartum.

Breastfeeding self-efficacy.  The Hong Kong Chinese version of the BSES-

SF was used to assess breastfeeding self-efficacy. It was completed at regis-
tration, hospital discharged, and 4 and 8 weeks postpartum. Dennis (2003)
revised the original tool and deleted items that were deemed redundant,
which resulted in the 14-item BSES-SF (Cronbach’s α = .94). Ip, Yeung,
Choi, Chair, and Dennis (2012) translated the BSES-SF into Hong Kong Chi-
nese and tested the Hong Kong Chinese version of the BSES-SF in 185 Hong
Kong Chinese breastfeeding mothers reporting a Cronbach’s alpha coeffi-
cient of .95. The Hong Kong Chinese version of the BSES-SF is a 14-item,
unidimensional, self-report instrument that was developed to measure a
mother’s confidence in her ability to breastfeed. All the items are presented
positively and answered on a 5-point Likert-type scale, where 1 indicates not
at all confident and 5 indicates always confident. High scores indicate that
the mother has greater confidence in breastfeeding (Dennis, 2003; Polit &
Beck, 2004). However, the languages and cultures of Hong Kong and Main-
land China are different (Gao, Ip, & Sun, 2011). We performed a preliminary
experiment to determine the Cronbach’s alpha coefficient of the translated
short form and found that it was .927 and .941 before delivery and at hospital
discharge, respectively, which is in accordance with the recommended alpha
for established instruments (Nunnally & Bernstein, 1994).

Breastfeeding exclusivity.  Based on Labbok and Krasovec’s (1990) classifica-

tion, the infant feeding questionnaire was used to assess the type of infants feed-
ing at hospital discharged and 4 and 8 weeks postpartum. Breastfeeding was
classified into the following six categories: (a) exclusive breastfeeding (breast
milk only), (b) almost exclusive breastfeeding (breast milk and other fluids, but
not formula), (c) high breastfeeding (<one bottle of formula/day), (d) partial
breastfeeding (at least one bottle of formula/day), (e) token breastfeeding (breast
given to comfort the baby but not for nutrition), and (f) bottle-feeding (no breast
milk at all). Breastfeeding was defined as providing any amount of breast milk,
either by breast or expressed breast milk, via a bottle or tube. If the mother no
longer practiced any breastfeeding, the date of discontinuation was recorded,
and she was classified into the bottle-feeding or formula category.

Data Collection Procedure

The eligible mothers were approached by the researcher in the antenatal
clinic while they were waiting for an appointment. The researcher explained
912 Western Journal of Nursing Research 39(7)

the purpose and the rationale of the study clearly so that the eligible mothers
understood the nature of the research. Consent forms were signed by the
mothers who agreed to participate. The recruited mothers completed the
Hong Kong Chinese version of the BSES-SF and a demographic question-
naire at registration. At hospital discharge, the researcher came to the ward to
collect the postpartum demographic questionnaire, the Hong Kong Chinese
version of the BSES-SF, and the infant feeding questionnaire. The researcher
called the participating mothers at 4 and 8 weeks postpartum to collect data
related to the Hong Kong Chinese version of the BSES-SF and the infant
feeding questionnaire. The details of the study work flow are provided in the
consolidated standards of reporting trial (CONSORT) flowchart (Figure 1).

Ethical Considerations
The study received approval from the health research ethics committee of the
university and hospital. The participants’ rights were protected by ensuring
that their participation in the study was entirely voluntary, that they could
refuse to answer questions on any sensitive topics, and that they could with-
draw at any time during the study without penalty or loss of benefits with
regard to maternal infant care in the unit.

Data Analysis
The data analyses were performed using SPSS Version 19.0. Descriptive sta-
tistics were used to analyze the socio-demographics, breastfeeding catego-
ries, and scores of the Hong Kong Chinese Version of the BSES-SF. The
difference in demographic characteristics between the two groups was
assessed by the chi-square and Fisher’s exact tests. For the breastfeeding
exclusivity categories, the chi-square test was used to assess differences
between groups. The differences in scores on the Hong Kong Chinese Version
of the BSES-SF between the two groups were assessed using repeated mea-
sures ANOVA. Repeated measures ANOVA with a least square difference
(LSD) post hoc analysis was used to examine the significance of differences
in the mean scores of the Hong Kong Chinese version of the BSES-SF over
time (at registration, hospital discharge, 4 weeks postpartum, and 8 weeks
postpartum) in the 2 groups. This statistical test was also used to determine
the effect of the prenatal and postnatal breastfeeding intervention on the
mean scores of the BSES-SF. The t test was used to compare the mean scores
of the Hong Kong Chinese Version of the BSES-SF between groups at the
same time point.
Liu et al. 913

Assessed for eligibility (n = 180)

Excluded (n = 0)
Not meeting inclusion criteria (n = 10)
Enrollment Baseline Data Collection: Refused to participate (n = 15)
Demographic & Newborn data(After Other reasons (n = 5)
Delivery),Hong KongCV-BSES-SF

n = 150

Intervention Group (n = 75) Did not receive

Control Group (n = 75)
Receive Prenatal and postnatal intervention
Routine Care Only
Postnatal Intervention (n = 4)

Loss to follow up
at hospital discharged (n = 2) Loss to follow up
2 withdrawal at hospital discharged
(n = 0)

Loss to follow up Loss to follow up at 4

at 4 weeks (n = 4) weeks (n = 4)
2 no response 2 no response
2 withdrawal 2 telephone disconnected
1 withdrawal

Loss to follow up Loss to follow up (n = 2)

at 8 weeks (n = 4) at 8 weeks
3 no response 1 no response
1 withdrawal 1 telephone disconnected

Outcome Measures: the Hong Kong Chinese Outcome Measures: the Hong Kong
Version of BSES-SF, breastfeeding exclusivity Chinese Version of BSES -SF, breastfeeding
(by telephone) exclusivity (by telephone)
hospital discharged hospital discharged
4 weeks postpartum 4 weeks postpartum
8 weeks postpartum 8 weeks postpartum

Figure 1.  CONSORT flowchart.

Note. CONSORT = consolidated standards of reporting trial; CV-BSES-SF = Chinese version
of Breastfeeding Self-Efficacy Scale–Short Form.

Results
A total of 150 eligible mothers were assigned to the control group and the inter-
vention group with 75 mothers in each group. In the control group, two (2.7%)
mothers withdrew at hospital discharged, four (5.3%) mothers were lost to fol-
low-up at 4 weeks postpartum (two mothers did not respond to the telephone call,
and two mothers withdrew from the study), and four (5.3%) mothers were lost to
follow-up at 8 weeks postpartum (three mothers did not respond to the telephone
call, and one mother withdrew from the study), leaving a total of 65 (87%)
914 Western Journal of Nursing Research 39(7)

mothers in this study. In the intervention group, four (5.3%) mothers gave birth at
other hospitals and did not receive the postpartum intervention, four (5.3%)
mothers were lost to follow-up at 4 weeks postpartum (two mothers did not
respond to the telephone call, and two mothers’ telephones were disconnected),
and two (2.7%) mothers were lost to follow-up at 8 weeks postpartum (one
mother did not respond to the telephone call, and one mother’s telephone was
disconnected), leaving a total of 65 (87%) expectant mothers in the study.

Socio-Demographic Data
The socio-demographic characteristics in terms of marital status, education,
family income, employment, type of birth, birth weight, labor and delivery
complication, and free formula received were not statistically different
between the two groups. Table 1 shows the socio-demographic characteris-
tics of both groups.

Comparison of the Mean Change in Breastfeeding Self-Efficacy

by Group Over Time
Repeated measures ANOVA was used to assess differences in the mean
scores of the Hong Kong Chinese Version of the BSES-SF within and between
groups. The result of the repeated measures ANOVA showed that the mean
scores of the Hong Kong Chinese Version of the BSES-SF were significantly
different between groups (F = 26.39, p < .0001). There was a significant
change in the mean scores of the Hong Kong Chinese Version of the BSES-SF
between groups across the four time points (F = 4.468, p = .004). There was
a significant interaction effect (F = 33.21, p < .0001). The results are shown
in Table 2. The LSD comparison post hoc analysis revealed that the mean
scores of the BSES-SF at registration was significantly different from the
mean scores of the BSES-SF at hospital discharge, 4 weeks postpartum, and
8 weeks postpartum. This result showed that both the time at which breast-
feeding interventions were assessed and the intervention itself had effects on
the mean score of the Hong Kong Chinese Version of the BSES-SF over time.

Comparison of the Mean Scores of the Hong Kong Chinese

Version of the BSES-SF Between Groups at the Same Time Point
The mean scores of the Hong Kong Chinese Version of the BSES-SF were
not significantly different at registration between the intervention group and
control group (44.85 ± 8.897 vs. 46.34 ± 9.188; t = 0.94, p = .3486). However,
Liu et al. 915

Table 1.  Demographic Characteristics of Subjects (N = 130).

Control Group Intervention

Characteristics (n = 65) Group (n = 65) p
Age, n (%) .588a
  19-24 years 13 (20) 9 (13.85)  
  25-30 years 44 (67.69) 49 (75.38)  
  30 years above 8 (12.31) 7 (10.77)  
Marital status, n (%) .476a
 Married 63 (96.9) 65 (100)  
 Unmarried 2 (3.1) 0 (0)  
Education, n (%) .924a
  Junior middle school 7 (10.8) 6 (9.2)  
  High school or vocational school 27 (41.5) 26 (40.0)  
or junior college
  University degree and above 31 (47.7) 33 (50.8)  
Family income (RMB), n (%) .91a
  ≤2,999 5 (7.7) 4 (6.2)  
 3,000-4,999 26 (40.0) 25 (38.5)  
  ≥5,000 34 (52.3) 36 (55.3)  
Employment, n (%) .862a
 Employed 44 (67.7) 42 (64.6)  
 Self-employed 7 (10.8) 9 (13.9)  
 Unemployed 14 (21.5) 14 (21.5)  
Type of birth, n (%) .380a
  Vaginal delivery 50 (76.9) 54 (83.1)  
 C-section 15 (23.1) 11 (16.9)  
Birth weight (kg), n (%) .592a
 2.40-3.0 17 (26.15) 18 (27.69)  
 3.1-3.7 41 (63.08) 43 (66.15)  
 >3.7 7 (10.77) 4 (6.15)  
Labor and delivery complication, 1.000b
n (%)
 No 63 (96.9) 64 (98.5)  
 Yes 2 (3.1) 1 (1.50)  
Free formula received, n (%) .238a
 No 64 (98.5) 65 (100.0)  
 Yes 1 (1.5) 0 (0)  

a. Person chi-square test.

b. Fisher’s exact test.
Note. RMB = unit of Chinese currency
916 Western Journal of Nursing Research 39(7)

Table 2.  Comparison of the Mean Scores of the Hong Kong CV-BSES-SF in Two
Groups Over Time.

Control Group Intervention

(n = 65) Group (n = 65)
M (SD) M (SD) t p
At registration 46.34 (9.188) 44.85 (8.897) 0.94 .3486
Hospital discharge 47.22 (10.508) 50.86 (10.124) −2.01 .0460
4 weeks postpartum 42.17 (11.285) 52.32 (9.066) −5.66 <.0001
8 weeks postpartum 38.95 (12.244) 55.15 (10.617) −8.06 <.0001

Note. Group effect: F = 26.39 (p < .0001); Time effect: F = 4.47 (p = .0103); Intervention effect
(Time × Group): F = 33.21 (p < .0001). CV-BSES-SF = Chinese Version of Breastfeeding-
Efficacy Scale–Short Form.

Table 3.  Comparison of Exclusive Breastfeeding Rates Between Groups at

Hospital Discharged, 4, and 8 Weeks Postpartum.

Control Group Intervention Group

(n = 65) (n = 65)

Exclusive Other Exclusive Other

Breastfeeding Feeding Breastfeeding Feeding
  n (%) n (%) n (%) n (%) χ2 p
At hospital 2 (3.1) 63 (96.9) 3 (4.6) 62 (95.4) 0.000 1.000
discharge
4 weeks 2 (3.1) 63 (96.9) 18 (27.7) 47 (72.3) 15.127 <.0001
postpartum
8 weeks 1 (1.5) 64 (98.5) 16 (24.6) 49 (75.4) 15.226 <.0001
postpartum

the mean scores were significantly different between the intervention group
and control group at hospital discharge (50.86 ± 10.124 vs. 47.22 ± 10.508; t
= −2.01, p = .0460), at 4 weeks postpartum (52.32 ± 9.066 vs. 42.17 ± 11.285;
t = −5.66, p < .0001), and at 8 weeks postpartum (55.15 ± 10.617 vs. 38.95 ±
12.244; t = −8.06, p < .0001).

Comparison of the Exclusivity Breastfeeding Rate

The results showed that there was a higher percentage of mothers who fed
their infants exclusively by breastfeeding in the intervention group than in the
control group at 4 and 8 weeks postpartum (Table 3). At hospital discharge,
Liu et al. 917

three (4.6%) mothers in the intervention group fed their infants exclusively
breastfeeding, and two (3.1%) mothers in the control group fed their infants
with breast milk only (χ2 = 0.000, p = 1.000). At 4 weeks postpartum, the
number of mothers in the intervention group who exclusively breastfed was
18 (27.7%) compared with two (3.1%) in the control group (χ2 = 15.127, p <
.0001). At 8 weeks postpartum, there was a higher rate of exclusive breast-
feeding in the intervention group (24.6%) compared with the control group
(1.5%; χ2 = 15.226, p < .0001).

Discussion
The purpose of this study was to examine the effectiveness of a perinatal
nursing intervention to increase breastfeeding self-efficacy and the rates of
breastfeeding exclusivity. The findings suggested that this intervention was
effective. In the intervention group, mothers had higher mean scores on the
BSES-SF at hospital discharge, 4 weeks postpartum, and 8 weeks postpar-
tum. In addition, a higher rate of mothers in the intervention group breastfed
their infants exclusively compared with those in the control group at 4 and 8
weeks postpartum.
In this study, we found that time had an important effect on mothers’
breastfeeding self-efficacy and behavior. Blyth, Creedy, Dennis, Moyle, and
Veries (2002) suggested that mothers’ breastfeeding self-efficacy would
increase over time. Otsuka et al. (2014) also reported that if a mother began
to breastfeed her infant, her breastfeeding self-efficacy score would increase
with time. Many previous studies also showed that mothers’ breastfeeding
self-efficacy scores were associated with their breastfeeding behavior (Alus
Tokat, Oksmus, & Dennis, 2010; Blyth et al., 2002; Dennis, Heaman, &
Mossman, 2011; Oliver-Roig et al., 2012; Otsuka, Dennis, Tatsuoka, &
Jimba, 2008). Consistent with a previous study, our study showed that moth-
ers’ breastfeeding self-efficacy scores were significantly increased in the
intervention group. However, the scores of breastfeeding self-efficacy
decreased in the control group at 4 and 8 weeks postpartum. This result indi-
cated that time has an effect on mothers’ breastfeeding self-efficacy and
breastfeeding behavior in the intervention group.
Mothers had higher breastfeeding self-efficacy scores in the intervention
group than control group. Nichols et al. (2009) and McQueen et al. (2011) also
showed that mothers’ breastfeeding self-efficacy increased after a specialist’s
intervention. Mothers in the intervention group learned some techniques to
solve problems and role-played activities in the breastfeeding education work-
shop, which may have enhanced their confidence in feeding their infants with
breast milk. Bandura (2005) showed that problem-solving and role-playing
918 Western Journal of Nursing Research 39(7)

activities were effective techniques for increasing self-efficacy. Mothers in the

intervention group experienced performance accomplishments from the breast-
feeding education workshop class. Bandura (1986) also showed that perfor-
mance accomplishment may increase one’s self-efficacy beliefs.
Prenatal and postnatal breastfeeding self-efficacy intervention had a sig-
nificant effect on the scores of mothers’ breastfeeding self-efficacy. Ingram
(2013) showed that prenatal and postnatal breastfeeding interventions made
a greater difference in mothers’ breastfeeding than either a prenatal breast-
feeding intervention or a postnatal breastfeeding intervention alone. The par-
ticipants in our study were primiparous mothers, who did not have any
breastfeeding experience. In the breastfeeding education workshop, the
mothers may have learned some vicarious breastfeeding experiences from
the researcher. Mothers’ breastfeeding self-efficacy can be predicted by their
vicarious experience (Zhu, Chan, Zhou, Ye, & He, 2014). In the postpartum
period, mothers in the intervention group received individualized breastfeed-
ing self-efficacy counseling. Individualized breastfeeding self-efficacy coun-
seling would have been shown to increase a mother’s breastfeeding
self-efficacy (McQueen et al., 2011).
In this study, we found that few mothers in either the intervention or con-
trol group fed their infants with breast milk only at hospital discharge. The
mothers in this study were discharged from the hospital approximately 3 days
after delivery. During the hospital stay, the researcher found that most moth-
ers thought that there was not enough breast milk to feed their infants.
Previous studies (Blyth et al., 2002; Chatman et al., 2004; Glassman,
McKearney, Saslaw, & Sirota, 2014; Liu et al., 2011) also showed that if a
mother had the perception that she did not have enough milk to feed her
infants, she would give up exclusive breastfeeding. In addition, a mother may
experience anxiety, pain, loneliness, and restlessness after delivery (Tarkka,
Paunonen, & Laippala, 1998). These mental states may affect a mother’s
intention to feed her infant with breast milk only.
More mothers in the intervention group fed their infants with breast milk
exclusively than mothers in the control group at 4 and 8 weeks postpartum.
The reason for this result may be that mothers in the intervention group
received education about breastfeeding skills, the benefits of exclusive
breastfeeding, and breastfeeding support from family members. Santoro
Junior and Martinez (2007) showed that the mothers who received breast-
feeding education and support demonstrated longer exclusive breastfeeding
durations. After receiving breastfeeding education, mothers may have the
intention to feed their infants with breast milk only. Exclusive breastfeeding
intention has a strong effect on the duration of breastfeeding exclusivity (de
Jager, Skouteris, Broadbent, Amir, & Mellor, 2013).
Liu et al. 919

The number of exclusive breastfeeding mothers declined at 8 weeks post-

partum in both the intervention and control groups. In our study, mothers in
the intervention group did not receive an intervention from the researcher
beyond 24 hr after hospital discharge. Kucukoglu and Celebioglu (2014)
emphasized that mothers should receive breastfeeding support from a health
care professional 1 week after hospital discharge and breastfeeding education
6 months postpartum. Mesters, Gijsbers, Bartholomew, Knottnerus, and Van
Schayck (2013) also showed that breastfeeding booklets and prenatal and
postnatal home visits from a health care professional had a significant effect
on the rates of exclusive breastfeeding. The results suggested that health care
professionals should provide continuous breastfeeding support and education
to mothers who want to breastfeed after they go home.
There were some limitations of this study. The non-random sample, the
recruitment of expectant mothers from a university-affiliated hospital, and
the non-parallel recruitment of the control and intervention groups limit the
generalizability of this study. Furthermore, the intervention was only
offered for 1-hr prenatal and for 1-hr within 24 hr after delivery, mothers
did not receive breastfeeding after 24 hr delivery. Previous studies (de
Oliveria, Camacho, & Tedstone, 2001; Hannula, Kaunone, & Tarkka, 2008)
showed that breastfeeding support should need to continue after mothers’
hospital discharge. A longer intervention to support mothers to continue
breastfeeding their children should be considered in a future study. Despite
these limitations, the findings suggested that the perinatal breastfeeding
support program may be effective for mothers. To increase the rates of
breastfeeding, breastfeeding support from health care professionals should
be considered as a beneficial strategy (Yanikkerem, Tuncer, Yilmaz, Asian,
& Karadeniz, 2009).
In conclusion, this study has significant clinical utility for health care pro-
fessionals working with primiparous mothers in China. The study developed
a pre-and postnatal program to help Chinese mothers with breastfeeding.
Furthermore, the health care professionals can offer effective self-efficacy
strategies and provide valuable data with which to develop an appropriate
breastfeeding program to help prepare and support Chinese breastfeeding
mothers. During antenatal classes, health care professionals should demon-
strate the breastfeeding process and breastfeeding skills through videotapes
and pictures. In addition, health care professionals should invite mothers who
experienced breastfeeding to share their experiences. Health care profession-
als should offer breastfeeding counseling and support to mothers after deliv-
ery. After mothers are discharged from the hospital, health care professionals
should call them to follow-up postpartum visit, which may help them to solve
their breastfeeding problems.
920 Western Journal of Nursing Research 39(7)

Acknowledgments
We would like to acknowledge all the mothers for their participation in this study. In
addition, we would like to thank all the nurses from the antenatal visit and the study
wards for their great support during the data collection.

Author Contributions
L.L.Y., Z.J.M., and Y.B.L. were responsible for the study design. L.L.Y. and W.M.
performed the data collection. L.L.Y., Z.J.M., and Y.J.Q. performed data analysis.
L.L.Y., Z.J.M., Y.J.Q., W.M., and Y.B.L. were responsible for the manuscript prepa-
ration and critical revision of the article for important intellectual contents.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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