ABSTRACT
Aim
The purpose of this study was to determine the association between mothers’ breastfeeding self-efficacy for infants aged 0-6 months and their attitudes toward infant feeding.
Materials and Methods
This descriptive, cross-sectional study was conducted with mothers of infants aged 0-6 months. Data were collected using a questionnaire assessing sociodemographic characteristics and breastfeeding status, as well as the Breastfeeding Self-Efficacy Scale and the Infant Feeding Attitude Scale. For the statistical analysis of the data, mean, standard deviation, percentage distributions, and linear regression analysis were employed.
Results
This study found that the mothers had high levels of breastfeeding self-efficacy (57.66±8.49) and positive infant feeding attitudes (56.99±7.09). According to the results of the regression analysis, it was determined that the mothers’ breastfeeding self-efficacy scores positively and statistically significantly predicted their infant feeding attitude scores (β=0.208; p=0.001).
Conclusion
This study showed that mothers’ perceptions of their breastfeeding self-efficacy positively influence their attitudes toward infant feeding. Accordingly, the development of clinical interventions focused on breastfeeding self-efficacy, particularly during the critical first six months after birth, may play an important role in increasing breastfeeding success.
Introduction
Breastfeeding is recognized as the gold standard for infant nutrition, offering significant health benefits for both the mother and the infant. Consistent evidence from diverse global settings indicates that breastfeeding reduces the incidence and severity of various conditions in both populations (1). Guidelines from the World Health Organization and United Nations Children’s Fund recommend exclusive breastfeeding for the first 6 months, followed by continued breastfeeding alongside appropriate and safe complementary foods from 6 months of age until 2 years of age or beyond (2). Breastfeeding is one of the most effective strategies to protect children’s health and ensure their survival. However, contrary to recommendations, less than half (44%) of infants aged 0-6 months are exclusively breastfed. If all children aged 0-23 months were breastfed optimally, the lives of more than 820,000 children under the age of 5 could be saved each year (3). Breast milk offers optimal and balanced nutrition. Breastfeeding provides numerous benefits for both the mother and the baby and it is fundamental for infants’ health and their long-term well-being. Evidence indicates that breastfeeding significantly promotes healthy growth and immune system development. Those infants who are fed breast milk have a lower risk of asthma, obesity, diabetes, and severe lower respiratory tract infections. Concurrently, it has been reported that breastfeeding mothers have a lower risk of breast cancer, hypertension, diabetes, endometrial cancer, and ovarian cancer (4).
Breastfeeding self-efficacy is widely utilized in breastfeeding research, as defined by Dennis (7) in 1999, who adapted Bandura’s self-efficacy theory to breastfeeding as being a mother’s perceived confidence and belief in her ability to breastfeed (5, 6). Breastfeeding self-efficacy theory posits that a mother’s breastfeeding self-efficacy influences her response (effort and thought patterns) to breastfeeding, which subsequently affects the initiation and continuation of breastfeeding behaviours (7). Breastfeeding self-efficacy is a woman’s belief and confidence in her perceived ability to breastfeed. Knowledge, attitudes, and intentions regarding breastfeeding also provide an indication of breastfeeding confidence and they are associated with improved breastfeeding outcomes (5).
The feeding method for infants aged 0-6 months is of critical importance for both the infant’s and the mother’s health. The literature frequently emphasizes the importance of breastfeeding self-efficacy in initiating and maintaining breastfeeding behaviour. However, there have been few studies examining the relationship between mothers’ perceptions of their breastfeeding self-efficacy and their attitudes toward infant feeding, particularly during the first six months, which is the most critical period of development. In this context, this study aimed to determine the association between mothers’ breastfeeding self-efficacy and their attitudes toward infant feeding for infants aged 0-6 months. In order to achieve this primary objective, this study examined mothers’ levels of breastfeeding self-efficacy and their attitudes toward infant feeding. In addition, this study examined associations between the sociodemographic and the clinical characteristics of the mother and infant (e.g., the mother’s age, infant’s age, gestational age, etc.) and the mothers’ breastfeeding self-efficacy and their attitudes toward infant feeding. This study hypothesized that the mothers’ levels of breastfeeding self-efficacy would positively and significantly predict their infant feeding attitudes (H1) and that the mothers’ educational levels would show a significant association with their infant feeding attitude scores (H2).
Materials and Methods
Study Design
This descriptive and cross-sectional study was conducted in order to determine the association between mothers’ breastfeeding self-efficacy for infants aged 0-6 months and their attitudes toward infant feeding.
Setting and Sample
This descriptive/cross-sectional study was conducted between June and December 2025 at the outpatient clinics of Ege University Children’s Hospital in the province of İzmir, Türkiye. With its numerous outpatient clinics, this hospital is one of the region’s major centres, providing comprehensive pediatric diagnosis, treatment, and care services.
In the study’s main hypotheses, it was planned to examine the relationships between the independent variables using correlation coefficients and regression models. The calculation yielding the highest number according to the main hypothesis was taken into account. Using the G*Power (version 3.1.9.2) program (8), at a 95% confidence level (α=0.05), the standardized effect size was taken as 0.15 (medium level for the Linear Regression Model and number of independent variables: 10), as proposed by Cohen (9) (2013) due to the originality of the study, and the minimum sample size was calculated as 172 with 95% theoretical power (8). Considering potential data losses and the risks of incomplete form filling, this study was completed with 180 participants. Those mothers who visited the Social Pediatrics (Healthy Child) Outpatient Clinic and had infants aged 0-6 months, who were literate in Turkish and had no communication barriers, and who volunteered to participate in this study were included in the research. Those mothers who had acute or chronic health problems themselves or in their infants, as well as those who did not complete the data collection forms in full, were excluded from this study.
Data Collection Tool
The data for this study were collected using the “Case Report Form”, the “Breastfeeding Self-Efficacy Scale,” and the “Infant Feeding Attitude Scale”.
Case Report Form: This form was developed by the researchers in order to collect demographic information regarding the mothers and infants. It includes questions concerning the mother’s age, educational background, occupation, parity, whether she has received breastfeeding education, and the duration of breastfeeding as well as the infant’s postnatal age, gestational age at birth, and birth weight (1, 4-6).
Breast-feeding Self-Efficacy Scale-Short Form: Developed by Dennis in 2003 and adapted into Turkish by Aluş Tokat et al. (10) (2008), this scale consists of 14 items. The “Breast-feeding Self-Efficacy Scale-Short Form” is a 5-point Likert-type scale ranging from 1 (Not at all confident) to 5 (Always confident). The Cronbach’s alpha value was found to be 0.94. The total score range for this scale is between 14 and 70. A high score indicates high breastfeeding self-efficacy (10).
Infant Feeding Attitude Scale (Iowa): This scale, developed by De La Mora and Russel in 1999, was adapted into Turkish by Ekşioğlu et al. (11) (2016). This scale aims to assess women’s attitudes toward breastfeeding. It consists of 17 items and uses a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Eight items on the scale contain positive statements regarding breastfeeding, while nine items contain positive statements regarding formula feeding. The total scale score ranges from 17 (indicating a positive attitude toward bottle-feeding) to 85 (reflecting a positive attitude toward breastfeeding). The scale has no cut-off value; a high score on this scale indicates a positive attitude toward breastfeeding. The scale’s Cronbach’s alpha internal consistency coefficient is 0.71 (11).
Data Collection
The data were collected by the researchers between June and December 2025 at the Social Pediatrics (Healthy Child) Outpatient Clinic using face-to-face interviews. The interviews were conducted in the outpatient clinic setting in a quiet area where the mothers could feel at ease and where confidentiality was ensured. The data collection instruments were completed by the mothers under the supervision of the researchers. The questionnaires were handed to the mothers, who were allowed to complete them independently in a quiet area. The researchers remained on-site throughout the process in order to explain the questions as needed and to check the returned forms for any missing items. The administration of the data collection tools took an average of 15 minutes. The questionnaire forms were completed either during the infants’ pre-examination waiting period or at an appropriate time following the examination in order to avoid any external influences.
Ethical Considerations
Written institutional approval was obtained from the Medical Research Ethics Committee of Ege University (approval no.: 25-6T/25, date 20.06.2025) and from the hospital where this study was conducted (date/ref. no.: 03.06.2025-E.2470168) before carrying out this study. During the data collection phase, in accordance with the principles of the Declaration of Helsinki, the mothers were informed about the purpose and scope of the study; an “Informed Consent Form” was obtained from those who agreed to participate. Participants were informed that they had the right to withdraw from this study at any time, that the data collected would be used solely for scientific purposes, and that their personal identifying information would not be used.
Statistical Analysis
In this study, descriptive statistics for the data (frequency, percentage, mean, standard deviation, median, minimum, maximum, and the 25th and 75th percentiles) are presented. The assumption of normal distribution was tested using the Shapiro-Wilk test. When the normality assumption was not met, the Mann-Whitney U test was used to compare two independent groups, and the Kruskal-Wallis test was used to compare three groups. Post-hoc Bonferroni-corrected tests were used to identify the group or groups responsible for the difference. Spearman correlations were performed in order to examine relationships between continuous measurements which did not follow a normal distribution. Linear regression analysis using the stepwise approach was employed to mathematically model relationships between dependent continuous variables and independent variables. Analyses were conducted using the IBM Statistical Package for the Social Sciences (SPSS) Windows version 27 (SPSS Inc., Chicago, IL, USA).
Results
The distributions of the demographic and clinical characteristics of the mothers and infants participating in this study were examined and the data obtained are summarized in Table I. When the educational backgrounds of the participating mothers were examined, it was found that the vast majority of the participants held a bachelor’s degree (33.3%) or high school diploma (30.0%). Regarding the mothers’ occupational distribution, 40.6% (n=73) were not employed in any job, while the total proportion of mothers working in healthcare (doctors, nurses, and other healthcare personnel) was determined to be 14.4%.
It was determined that 57.8% of the mothers had only one child and 97.8% had had a singleton pregnancy. In terms of the mode of delivery, 73.3% of the mothers (n=132) had had a caesarean section, while 26.7% (n=48) had given birth vaginally. When evaluating the mothers’ educational status regarding breastfeeding, 58.9% (n=106) of the participants had received prior education. Among those who had received education, 66.0% (n=70) had been educated by nurses and 34.0% (n=36) by midwives. The mean age of the mothers included in this study was found to be 30.51±5.04 years. The average postnatal age of the infants was 3.79±2.12 months, and the average gestational age at birth was recorded as 37.59±2.12 weeks. The mothers’ average daily breastfeeding duration was 185.83±101.49 minutes, and the frequency of breastfeeding was determined to be 9.94±3.2 times per day (Table I).
The descriptive statistics and internal consistency coefficients for the scales used in this study are presented in Table II. Analysis of the data from the Breastfeeding Self-Efficacy Scale revealed that the mothers’ self-efficacy score was 57.66±8.49. This result indicates that the mothers included in this study had high self-efficacy regarding breastfeeding. The reliability analysis of the scale showed that the Cronbach’s alpha coefficient was 0.829, indicating a high level of reliability. Upon examining the scores obtained from the Infant Feeding Attitude Scale, it was determined that the mothers’ mean score was 56.99±7.09 and that their attitudes toward infant feeding were at a moderate level. The scale’s internal consistency coefficient in this study fell below the thresholds generally accepted in the literature, indicating limited consistency. It is noted that while the Cronbach’s alpha value should be higher than 0.70, a level of 0.60 is also considered acceptable in exploratory studies (12). Since the reliability of the scale’s original form (Cronbach’s alpha=0.71) has been established in the literature, this scale was included in the analyses despite the low reliability observed in our study.
The distributions of scores on the Infant Feeding Attitude Scale and the Breast-feeding Self-Efficacy Scale according to mothers’ demographic characteristics are presented in Table III. When examining the distribution of infant feeding attitude scale scores according to the mothers’ demographic characteristics, a statistically significant difference was found between the mothers’ educational status and their attitude scores (p=0.008). A numerical downward trend in attitude scores was observed as the mothers’ educational level increased. It was found that the number of children the mothers had (p=0.717) and whether they had received education on breastfeeding (p=0.543) did not create statistically significant differences in the total scores of the infant feeding attitude scale (p>0.05).
When the distribution of breast-feeding self-efficacy scale scores was examined according to the mothers’ demographic characteristics, no statistically significant difference was found between the mothers’ educational status (p=0.102), the total number of children in the family (p=0.362), and whether they had received education on breast-feeding (p=0.907) in relation to their breast-feeding self-efficacy scores (p>0.05) (Table III).
Spearman’s correlation coefficients were used to examine the relationships between the participants’ demographic characteristics and their total scores on the Infant Feeding Attitude Scale and the Breastfeeding Self-Efficacy Scale, with these findings being presented in Table IV. The analysis revealed a positive, weak, and statistically significant relationship between the total scores of the two scales (r=0.242; p=0.001). Accordingly, it was determined that as the mothers’ infant feeding attitudes increased in a positive direction, their perceptions of breastfeeding self-efficacy also increased. When other variables were examined, a negative, weak, and statistically significant relationship was found between the infant’s postnatal age and the scores on the Infant Feeding Attitude Scale (r=-0.181; p=0.015). However, no statistically significant relationship was found between the mothers’ age, the gestational age at birth, the birth weight, and the duration of breastfeeding and the total scores on either scale (p>0.05).
In order to include categorical variables in the regression models, dummy variables were created, and certain groups were selected as references. For educational status, the elementary school group was taken as the reference. Linear regression analysis using the stepwise approach was applied in order to investigate the effect of participants’ Breastfeeding Self-Efficacy Scale scores, as well as their age and educational status, on the total scores of the Infant Feeding Attitude Scale. An ANOVA test was conducted in order to test the significance of the model, and the established regression model was found to be significant (F=11.776 and p<0.001). The proportion of the dependent variable explained by the independent variables in the model was 5.7% (R2=0.057). Upon examining the VIF values of the variables in the model, it was determined that all values were less than 5, indicating no multicollinearity issues, and there was no autocorrelation problem (Durbin-Watson statistic: 1.897). The Shapiro-Wilk test was used to check the standardized residuals, and it was found that the assumption of normal distribution was met (p>0.05). The standardized regression coefficient (β) for the Breastfeeding Self-Efficacy Scale was calculated as 0.208 and this was found to be statistically significant (p=0.001) (Table V).
Discussion
This study was conducted in order to determine the association between mothers’ breastfeeding self-efficacy for infants aged 0-6 months and their attitudes toward infant feeding. The main findings of this study indicated that mothers’ breastfeeding self-efficacy scores were positive and statistically significant predictors of their infant feeding attitude scores (β=0.208; p<0.05). This result demonstrates that the mothers’ perceived sense of competence regarding their breastfeeding abilities serves as a determinant in shaping their attitudes toward infant feeding.
Discussion of Findings Regarding Mothers’ Breastfeeding Self-Efficacy and Attitudes Toward Infant Feeding
In this study, the mean breastfeeding self-efficacy score for the mothers was found to be 57.66±8.49. This finding indicates that the mothers’ perceptions of their self-efficacy regarding the breastfeeding process are high. A review of the literature revealed that a study conducted by Akça and Yıldız (13) similarly found that mothers’ breastfeeding self-efficacy scores were 54.0±7.1, indicating a high level of self-efficacy. In this regard, our research findings are consistent with the literature. However, Akça and Yıldız (13) reported that those mothers who received prenatal breastfeeding education (p=0.008) and those with higher education levels (p<0,001) had higher breastfeeding self-efficacy scores, which contradicts our findings. The findings of this study are consistent with those reported by Konukoğlu and Pasinlioğlu (14), who found that pregnant women’s perceptions of breastfeeding self-efficacy were above average. They also noted that participants with undergraduate and graduate education levels, as well as those experiencing their second pregnancy, had significantly higher levels of breastfeeding self-efficacy compared to the other groups (14). However, these findings differ from our results, as we found no statistically significant relationship between breastfeeding self-efficacy and the mothers’ educational status (p=0.102) or their number of children (p=0.362). The literature highlights the lasting effects of breastfeeding education on self-efficacy. For instance, a study conducted by Golnam et al. (15) demonstrated that self-efficacy scores, which were at an intermediate level prior to the intervention, increased significantly at the 3- and 6-month follow-ups, whereas the control group experienced a decline over time. Additionally, other studies have indicated that breastfeeding education enhances mothers’ breastfeeding self-efficacy (16, 17). These findings suggest that the high average self-efficacy scores observed in our study may be related to the fact that more than half (58.9%) of the mothers in the sample had received breastfeeding education.
In this study, the mean score on the infant feeding attitude scale for mothers was found to be 56.99±7.09. This finding suggests that mothers possess a positive attitude toward infant feeding, which supports breastfeeding and prioritizes breast milk. A positive maternal attitude toward breastfeeding during the 0-6-month period, which is crucial for the protection and promotion of infant health, is consistent with the prior literature (18-22). Similarly, Kurtbeyoglu and Caferoğlu (23) determined that mothers exhibited a positive attitude toward infant feeding, reporting a mean score of 65.08±6.8. Our study found an inverse relationship between the mothers’ education levels and their infant feeding attitude scores; specifically, as the mothers’ education levels increased, their attitude scores decreased. Additionally, we observed that the mothers’ number of children (p=0.717) and their prenatal breastfeeding education status (p=0.543) had no statistically significant effects on their infant feeding attitudes. However, contrary to our findings, several studies in the literature have indicated that infant feeding attitudes improve as the mothers’ education levels rise (23, 24). Factors such as highly educated mothers returning to work early during the postpartum period due to employment and career goals, working conditions, the amount of time spent at work, and greater financial resources may lead to the use of formula. This suggests that there may be an indirect relationship between higher levels of education and a tendency to use formula.
The Determining Role of Breastfeeding Self-Efficacy on Infant Feeding Attitudes
The most striking finding of this study was that the mothers’ breastfeeding self-efficacy scores positively and statistically significantly predicted their infant feeding attitude scores (β=0.208; p<0.05). This finding supports the notion that a mother’s belief in her ability to breastfeed directly influences her cognitive attitude toward breastfeeding. This finding aligns with Bandura’s Self-Efficacy Theory. While previous studies in the literature have sought to explain mothers’ attitudes toward infant feeding using demographic variables, our study contributes a unique perspective to the literature by highlighting the impact of a psychosocial factor, namely self-efficacy, on these attitudes. Specifically, Selvi et al. (25) reported that breastfeeding education significantly increased self-efficacy perceptions during both the antenatal and postnatal periods. However, they noted that high levels of breastfeeding self-efficacy among mothers did not influence breastfeeding attitudes during the postnatal period. This particular finding contrasts with both Bandura’s Self-Efficacy Theory and the current study (25). The literature indicates that high levels of breastfeeding self-efficacy among mothers are directly associated with the tendency to feed their infants exclusively with breast milk and with prolonged breastfeeding durations (6, 26, 27). Furthermore, this phenomenon is not limited to healthy pregnancies; even among mothers who had experienced high-risk pregnancies or delivered premature infants, high self-efficacy perceptions were positively associated with breastfeeding success, prolonged breastfeeding, and increased milk production (28, 29). By contrast, Ergezen et al. (30) found no association between breastfeeding self-efficacy and breastfeeding success, reporting instead that as the number of children increased, both mothers’ breastfeeding self-efficacy and breastfeeding success increased. Additionally, Awaliyah et al. (31) demonstrated that breastfeeding self-efficacy is positively correlated with breastfeeding satisfaction (31).
The findings of this study indicate that postpartum mothers’ levels of breastfeeding self-efficacy have a direct and decisive effect on their infant feeding attitudes. This clinical picture redefines the role of nurses who provide breastfeeding counselling, maternal education, and postpartum care services. In particular, nurses working in primary care settings and in areas such as neonatal clinics and well-baby clinics should assess breastfeeding self-efficacy using validated scales during routine infant follow-ups. Interventions which strengthen the mother’s breastfeeding self-efficacy (such as peer support, positive feedback, hands-on demonstrations of breastfeeding techniques, and anxiety management) should be incorporated into the focus of care. It is anticipated that as the mother’s perception of self-efficacy increases, her attitudes toward infant feeding will also improve positively, thereby ensuring the sustainability of breastfeeding and thus support mother-infant health.
Study Limitations
The strengths of this study include its focus on mothers during the first six months which is a critical postpartum period, the use of validated measurement tools, and the examination of breastfeeding self-efficacy as a psychosocial predictor of infant feeding attitudes. This study had some limitations. This study was conducted at a single centre; this may limit the generalizability of our findings. Additionally, in this study, the internal consistency of the Infant Feeding Attitudes Scale was lower than the value reported in the original validity study (Cronbach’s α=0.637 versus 0.71). This relatively low reliability may be related to the homogeneity of the study sample, cultural differences, or the narrow age range of the infants (0-6 months).
Conclusion
In conclusion, this study has demonstrated that the mothers’ perceptions of breastfeeding self-efficacy are a significant psychosocial factor in determining their infant feeding attitudes. It is believed that self-efficacy-focused clinical interventions and nursing counselling aimed at enhancing mothers’ confidence in their own breastfeeding skills, particularly during the first six months postpartum, may contribute to an increase in breastfeeding success rates. In this context, it is recommended that healthcare professionals working in primary care, obstetrics, and neonatology clinics integrate psychosocial approaches grounded in theory (such as Bandura’s Self-Efficacy Theory) into routine breastfeeding education in order to strengthen mothers’ perceptions of self-efficacy.
