Objective: To present an overview of breastfeeding self-efficacy interventions to enhance the implementation of exclusive breastfeeding for mothers with low birth weight infants.
Method: The systematic review comprised search for randomised controlled trials and quasi-experimental studies published between January 2014 to January 2022 on Scopus, ScienceDirect, Sage journals, ProQuest, Google Scholar and PubMed databases using the Population-Intervention-Comparison-Outcome framework and in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The analytical quality of the studies was assessed using the Critical Appraisal Skills Programme checklist.
Results: Of the 339 studies initially identified, 10(2.94%) qualified for detailed analysis. Breastfeeding self-efficacy interventions could notably enhance the implementation of exclusive breastfeeding.
Conclusion: Breastfeeding self-efficacy interventions can be modified and effectively used by nurses to improve the implementation of exclusive breastfeeding for mothers with low birth weight infants.
Keywords: Breastfeeding, Milk, Infant, Low birth weight, Intervention. (JPMA 73: S-153 [Suppl. 2]; 2023)
Exclusive breastfeeding (EBF) has extraordinary advantages for optimising the growth, development and staying power of low birth weight (LBW) infants.1,2 Breastfeeding (BF) contributes to short- and long-term health results for both mother and infant.3 BF can reduce the incidence of pre-menopausal breast and/or ovarian cancers, in addition to type 2 diabetes mellitus (T2DM) for the mother.4,5 Infants who are exclusively breastfed can have a decreased risk of infections owing to immune protection.3,5 However, maintaining EBF can be a challenge for many mothers.6
The EBF prevalence is still low at 18% inside the first 48 hours of LBW life, and by the sixth month, one-third women continue to breastfeed, but effectively it is 1 in 20 in EBF terms.7 The BF rate of LBW mothers was found to be lower than that of mothers who gave birth at term8. Usually, early BF termination is based on mother’s notion that there is not sufficient milk.5 Mother’s perception related to BF behaviour is called breastfeeding self-efficacy (BSE), which is recognised as an essential modifiable factor for successful BF related to LBW neonates.4,9-11 BSE can have an effect, among other things, on the way a mother responds to various demanding situations in the BF procedure.9,12,13
The health belief model (HBM) is a principle that is broadly used to explain health behaviours, including BSE interventions. The 4 factors that determine the perceived level of confidence are; overall performance achievement, representative experience, verbal persuasion, and physiological and affective states.14 The current systematic review was planned to present BSE interventions used in literature to improve BSE implementation for LBW neonates.
Materials and Methods
The systematic review comprised randomised controlled trials (RCTs) and quasi-experimental studies published between January 2014 to January 2022 that were searched on Scopus, ScienceDirect, Sage journals, ProQuest, Google Scholar and PubMed databases in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA checklist.15
Key words and Boolean operators (AND, OR, and AND NOT) were used in line with the Population-Intervention-Comparison-Outcome (PICO) framework (Table 1).16 Studies included were RCTs or controlled clinical trials to decrease the risk of unknown factors, comprised mother or both parents with LBW/premature neonates, had interventions associated with BSE based on education, training and counselling, used smartphone applications for follow-ups.
The studies identified were imported into the Mendeley application, and duplicates were removed. Studies that did not meet the inclusion criteria were also excluded. The analytical quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist (Table 2).17
Data was noted to evaluate BSE interventions based on social learning theory to increase EBF in LBW cases.14,18
Of the 339 studies initially identified, 10 (2.94%) qualified for detailed analysis (Figure).1,10, 19–26,27 Of the total, 7(70%) studies examined BSE interventions primarily based on self-efficacy theory.10,19-23 BF performance is identified through an education/ knowledge provision and demonstration.
Educating mothers can significantly reduce scheduled BF and improve on-demand BF.28 Demonstration activities based on previous BF experiences can be done using a doll1,28 on days 2-3 when the babies are cared for in the nursery.10,25,28 Building confidence by learning from others was identified through counselling activities carried out by nurses to explore the experience of mothers learning BF skills.29 The primary counselling consultation was carried out face-to-face, and subsequent sessions continued via smartphones.10 Counselling was carried out flexibly according to the mother’s condition.1
Verbal persuasion through encouragement from friends and family as well as by nurses helped maintain EBF.1,7 Encouraging mothers to begin pumping on day one post-delivery also helped.20
It was found to be crucial to apply BSE interventions to reduce postpartum distress and to increase BSE21. Stress counselling management could also be used as an intervention as it has been shown30 that the combination of stress control counselling in BF education programmes can enhance self-efficacy and BF duration in mothers.
In the current review, 5(50%) studies involved face-to-face and telephone contact with mothers in providing BSE interventions.1,10,21,24
BSE is a variable that can be modified through nursing interventions.12,14 It is an important component underlying sustainable BF practices.31 The first few weeks post-delivery are very crucial in this regard.10
BSE interventions increased EBF at six months postpartum. Overall, a BSE intervention with focus on the HBM theory14 is recommended as an appropriate strategy to increase the initiation or duration of BF. The most effective HBM-based BSE interventions consist of 4 sessions to produce a significant effect, especially for the first one month postpartum, including a performance of BF behaviour, representative experience (seeing other people breastfeeding), verbal persuasion (encouraging and praise), and physiological reactions that may affect breastfeeding practice.14 A study3 reported that BSE ratings had been higher at 4-6 weeks postpartum.
Six of the studies reviewed used a combination of hospital and community settings. A study3 has reported that combined hospital and community settings showed better outcomes. Presenting education during hospitalisation and follow-up at home reduces BF-associated issues, strengthens present BF information, and encourages mothers to practise EBF for up to 6 months.32
Interventions involving face-to-face and telephone contact with mothers significantly maintain EBF.33 Such interventions are recommended as they are feasible, low-cost and may reduce early weaning.
BSE interventions can be modified and effectively used by nurses to improve the implementation of EBF for mothers with LBW infants.
Limitation: The current literature review was not registered with the Prospective Register of Systematic Reviews (PROSPERO), which is a limitation.
Acknowledgment: We are grateful to the Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia, Faculty of Medicine, Universitas Airlangga, Surabaya, and to the Faculty of Nursing and Midwifery, Nahdlatul Ulama University, Surabaya, Indonesia.
Disclaimer: The study was presented at the 13th International Nursing Conference, 2022, at Universitas Airlangga, Indonesia.
Conflict of Interest: None.
Source of Funding: None.
1. Küçükoğlu S, Çelebioğlu A. Effect of natural-feeding education on successful exclusive breast-feeding and breast-feeding self-efficacy of low-birth-weight infants. Iran J Pediatr 2014;24:49-56.
2. Nisa F, Damayanti N, Suhariadi F, Anggasari Y, Dewi FE, Arini D, et al. Breastfeeding based on Breastfeeding Self-efficacy and Social Support in Wonokromo Surabaya. Open Access Maced J Med. Sci 2021;9:1026-31. Doi: 10.3889/oamjms.2021.6381.
3. Brockway M, Benzies K, Hayden KA. Interventions to Improve Breastfeeding Self-Efficacy and Resultant Breastfeeding Rates: A Systematic Review and Meta-Analysis. J Hum Lact 2017;33:486-99. doi: 10.1177/0890334417707957.
4. Chan MY, Ip WY, Choi KC. The effect of a self-efficacy-based educational programme on maternal breast feeding self-efficacy, breast feeding duration and exclusive breast feeding rates: A longitudinal study. Midwifery 2016;36:92-8. doi: 10.1016/j.midw. 2016.03.003.
5. Wong MS, Mou H, Chien WT. Effectiveness of educational and supportive intervention for primiparous women on breastfeeding related outcomes and breastfeeding self-efficacy: A systematic review and meta-analysis. Int J Nurs Stud 2021;117:103874. doi: 10.1016/j.ijnurstu.2021.103874.
6. Tseng JF, Chen SR, Au HK, Chipojola R, Lee GT, Lee PH, et al. Effectiveness of an integrated breastfeeding education program to improve self-efficacy and exclusive breastfeeding rate: A single-blind, randomised controlled study. Int J Nurs Stud 2020;111:103770. doi: 10.1016/j.ijnurstu.2020.103770.
7. Economou M, Kolokotroni O, Paphiti-Demetriou I, Kouta C, Lambrinou E, Hadjigeorgiou E, et al. The association of breastfeeding self-efficacy with breastfeeding duration and exclusivity: longitudinal assessment of the predictive validity of the Greek version of the BSES-SF tool. BMC Pregnancy Childbirth 2021;21:421. doi: 10.1186/s12884-021-03878-3.
8. Ryan AS, Wenjun Z, Acosta A. Breastfeeding continues to increase into the new millennium. Pediatrics 2002;110:1103-9. doi: 10.1542/peds.110.6.1103.
9. Wu DS, Hu J, McCoy TP, Efird JT. The effects of a breastfeeding self-efficacy intervention on short-term breastfeeding outcomes among primiparous mothers in Wuhan, China. J Adv Nurs 2014;70:1867-79. doi: 10.1111/jan.12349.
10. Mohammadian M, Maleki A, Badfar G. Effect of continuous supportive telephone counselling on improving breastfeeding self-efficacy in mothers with late preterm infants four months after discharge: A randomized, controlled study. J Mother Child 2021;25:44-50. doi: 10.34763/jmotherandchild.20212501.d-20-00017.
11. Naroee H, Rakhshkhorshid M, Shakiba M, Navidian A. The Effect of Motivational Interviewing on Self-Efficacy and Continuation of Exclusive Breastfeeding Rates: A Quasi-Experimental Study. Breastfeed Med 2020;15:522-7. doi: 10.1089/bfm.2019.0252.
12. Javorski M, Rodrigues AJ, Dodt RCM, Almeida PC, Leal LP, Ximenes LB. Effects of an educational technology on self-efficacy for breastfeeding and practice of exclusive breastfeeding. Rev Esc Enferm 2018;52:e03329. doi: 10.1590/S1980-220X2017031803329.
13. Li T, Guo N, Jiang H, Eldadah M. Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study. J Hum Lact 2019;35:583-91. doi: 10.1177/0890334418812044.
14. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215. doi: 10.1037//0033-295x.84.2. 191.
15. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/ bmj.n71.
16. Jin D, Szolovits P. Pico element detection in medical text via long short-term memory neural networks. InProceedings of the BioNLP 2018 workshop 2018:67-75.
17. Critical Appraisal Skills Programme (CASP). CASP Randomised Controlled Trial Checklist. [Online] 2020 [Cited 2022 February 02]. Available from URL: http://www.casp-uk.net
18. Lee YS, Garfield C, Kim HN. Self-efficacy theory as a framework for interventions that support parents of NICU infants. In: 2012 6th International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth) and Workshops. San Diego, CA: IEEE, 2012; pp 151-4. DOI: 10.4108/icst.pervasivehealth.2012.248710.
19. Brockway M, Benzies KM, Carr E, Aziz K. Breastfeeding self-efficacy and breastmilk feeding for moderate and late preterm infants in the Family Integrated Care trial: a mixed methods protocol. Int Breastfeed J 2018;13:29. doi: 10.1186/s13006-018-0168-7.
20. Fontana C, Menis C, Pesenti N, Passera S, Liotto N, Mosca F, et al. Effects of early intervention on feeding behavior in preterm infants: A randomized controlled trial. Early Hum Dev 2018;121:15-20. doi: 10.1016/j.earlhumdev.2018.04.016.
21. Mohammadi MM, Poursaberi R. The Effect of Stress Inoculation Training on Breastfeeding Self-Efficacy and Perceived Stress of Mothers With Low Birth Weight Infants: A Clinical Trial. J Family Reprod Health 2018;12:160-8.
22. Ghomi R, Vasli P, Hosseini M, Ahmadi F. Effect of an empowerment program on the caring behaviors of mothers with preterm infants: the health belief model approach. Int J Health Promot Educ 2019;57:55-66. Doi: 10.1080/14635240.2018.1549959.
23. Buhyun L, Kyung-Sook B. A Self-Efficacy Promotion Program for the Continuation of Breastfeeding for Mothers of Premature Infants. Perspect Nurs Sci 2020;17:90-8.
24. Hägi-Pedersen MB, Dessau RB, Norlyk A, Stanchev H, Kronborg H. Comparison of video and in-hospital consultations during early in-home care for premature infants and their families: A randomised trial. J Telemed Telecare 2022;28:24-36. doi: 10.1177/1357633X 20913411.
25. Askary Kachoosangy R, Shafaroodi N, Heidarzadeh M, Qorbani M, Bordbbr A, Hejazi Shirmard M, et al. Increasing Mothers’ Confidence and Ability by Creating Opportunities for Parent Empowerment (COPE): A Randomized, Controlled Trial. Iran J Child Neurol 2020;14:77-83.
26. Heidary S, Heidari H, Choopani R, Sedehi M. The effect of supportive care program based on Bandura self-efficacy on stress-exacerbating and stress-relieving factors of neonatal mothers admitted to neonatal intensive care unit. Health Monitor Journal of the Iranian Institute for Health Sciences Research 2021;20:451-60. Doi: 10.52547/payesh.20.4.451.
27. Otsuka K, Taguri M, Dennis CL, Wakutani K, Awano M, Yamaguchi T, et al. Effectiveness of a breastfeeding self-efficacy intervention: do hospital practices make a difference? Matern Child Health J 2014;18:296-306. doi: 10.1007/s10995-013-1265-2.
28. Oras P, Ljungberg T, Hellström-Westas L, Funkquist EL. A breastfeeding support program changed breastfeeding patterns but did not affect the mothers’ self-efficacy in breastfeeding at two months. Early Hum Dev 2020;151:105242. doi: 10.1016/j.earlhumdev. 2020.105242.
29. Karbandi S, Hosseini SM, Hosseini SA, Sadeghi F, Hesari M, Masoudi R. Evaluating the Effectiveness of Using a Progressive Muscle Relaxation Technique on the Self-Efficacy of Breastfeeding in Mothers With Preterm Infants. J Nurs Res 2017;25:283-8. doi: 10.1097/JNR.0000000000000217.
30. Azizi E, Maleki A, Mazloomzadeh S, Pirzeh R. Effect of Stress Management Counseling on Self-Efficacy and Continuity of Exclusive Breastfeeding. Breastfeed Med 2020;15:501-8. doi: 10.1089/bfm. 2019.0251.
31. Chipojola R, Chiu HY, Huda MH, Lin YM, Kuo SY. Effectiveness of theory-based educational interventions on breastfeeding selfefficacy and exclusive breastfeeding: A systematic review and metaanalysis. Int J Nurs Stud 2020;109:103675. doi: 10.1016/j.ijnurstu. 2020.103675.
32. Wan H, Tiansawad S,Yimyam S, Sriarporn P. Effects of a theory-based breastfeeding promotion intervention on exclusive breastfeeding in China. Chiang Mai Univ J Nat Sci 2016;15:49-66. Doi: 10.12982/ cmujns.2016.0005.
33. Dodou HD, Bezerra RA, Chaves AFL, Vasconcelos CTM, Barbosa LP, Oriá MOB. Telephone intervention to promote maternal breastfeeding self-efficacy: randomized clinical trial. Rev Esc Enferm 2021;55:e20200520. doi: 10.1590/1980-220X-REEUSP-2020-0520.