Midwifery 36 (2016) 92–98

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Midwifery
journal homepage: www.elsevier.com/midw

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
Chan Man Yi DN, MSc, BN (Hon), RN, RM, Dra,
Ip Wan Yim PhD, RN, RM (Associate Professor)b,n,
Choi Kai Chow PhD, BSc (Assistant Professor)b
a
The School of Midwifery, Hospital Authority, Hong Kong
b
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong

art ic l e i nf o a b s t r a c t

Article history: Background: breast feeding has a number of well-documented benefits. Numerous studies have been
Received 16 April 2015 conducted to investigate an effective approach to increase the breast feeding rate, duration and exclusive
Received in revised form breast feeding rate, in which maternal breast feeding self-efficacy was determined as one of the major
19 January 2016
contributors. Although numerous breast feeding educational programmes have been developed to
Accepted 6 March 2016
enhance maternal breastfeeding self-efficacy, results on the effectiveness of these programmes remain
inconclusive.
Keywords: Objective: this study aims to investigate the effectiveness of a self-efficacy-based breast feeding educa-
Self-efficacy tional programme (SEBEP) in enhancing breast feeding self-efficacy, breast feeding duration and exclu-
Education
sive breast feeding rates among mothers in Hong Kong.
Hong Kong
Methods: eligible pregnant women were randomized to attend a 2.5-hour breast feeding workshop at
Breast feeding duration
Exclusive breast feeding 28–38 weeks of gestation and receive 30–60 minutes of telephone counselling at two weeks post par-
tum, whereas both intervention and control groups received usual care. At two weeks postpartum, the
Breast feeding Self-Efficacy Scale-Short Form (BSES-SF) and a self-developed post partum questionnaire
were completed via telephone interviews. The breast feeding duration, pattern of breast feeding and
exclusive breast feeding rates were recorded at two weeks, four weeks, eight weeks and six months post
partum.
Results: results of analyses based on an intention-to-treat (ITT) assumption showed a significant dif-
ference (po0.01) in the change in BSES-SF mean scores between the mothers who received SEBEP and
those who did not receive SEBEP at two weeks post partum. The exclusive breast feeding rate was 11.4%
for the intervention group and 5.6% for the control group at six months post partum.
Conclusion: the findings of this study highlight the feasibility of a major trial to implement breast feeding
education targeted at increasing breast feeding self-efficacy and exclusive breast feeding rates in
Hong Kong.
& 2016 Elsevier Ltd. All rights reserved.

Background et al., 2002). Extensive research has demonstrated overwhelming

Breast feeding benefits not only the infants but also the
mothers, families and society in terms of nutritional, develop-
mental, economic and environmental factors. The benefits of
breast feeding include a low incidence of pre-menopausal breast
and/or ovarian cancer among mothers who have breast fed (Beral
n at 14.8%, and artificial feeding at 31.3% in Hong Kong (Lau, 2010).
Correspondence to: The Chinese University of Hong Kong, Room 826, 8/F, Esther
Lee Building, Shatin, NT, Hong Kong.
E-mail address: ip2013@cuhk.edu.hk (W.Y. Ip).
advantages of breast feeding or the use of human milk for infant
feeding (Bachrach et al., 2003; Quigley et al., 2006; Ip et al., 2007).
Despite the promulgation of the benefits of breast feeding
worldwide, many mothers from various countries prematurely
discontinue breast feeding. The prevalence of breast feeding in
both developed and developing countries remains suboptimal. A
local study reported rates of breast feeding at 53.9%, mixed feeding
In examining factors that influence women's decisions on
sustained breast feeding, maternal age, education level, marital

http://dx.doi.org/10.1016/j.midw.2016.03.003
0266-6138/& 2016 Elsevier Ltd. All rights reserved.
 M.Y. Chan et al. / Midwifery 36 (2016) 92–98
status, family income and socio-economic status are regarded as
non-modifiable (Scott and Binns, 1999; Taveras et al., 2003). In
contrast, factors that are closely related to breast feeding pre-
valence and duration, such as maternal attitudes, timing of the
decision to breast feed, timing of first feeding, breast feeding
knowledge and breast feeding self-efficacy, are regarded as mod-
ifiable. Among these, maternal breast feeding self-efficacy has
increasingly been identified as an important modifiable factor for
successful breast feeding.
Maternal breast feeding self-efficacy is derived from the self-
efficacy concept of Bandura (1977). According to Dennis (1999),
maternal breast feeding self-efficacy is defined as a mother's
perceived ability to breast feed her child, which influences her
decision on breast feeding, such as whether to breast feed or not,
how much effort to exert on breast feeding, and how to respond to
challenges during breast feeding. Mothers with high self-efficacy
are more likely to choose breast feeding, persist when confronted
with difficulties, employ self-encouraging thoughts, and react
positively to challenges (Dennis, 1999).
Breast feeding self-efficacy is influenced by four sources of
information: (a) performance accomplishments (e.g., past breast
feeding experiences), (b) vicarious experiences (e.g., watching
other women breast feed), (c) verbal persuasion (e.g., encourage-
ment from others, such as friends, family and lactation con-
sultants), and (d) physiological responses (e.g., somatic reactions
due to autonomic stimulation during an experience or in antici-
pation of a potentially stressful event) (Bandura, 1986; Dennis,
1999).
A positive correlation between maternal self-efficacy and
breast feeding duration has been demonstrated in many studies
(Dennis and Faux, 1999; Chezem et al., 2003; Blyth et al., 2004;
Dunn et al., 2006; Gregory et al., 2008). Thus, many health care
researchers and breast feeding educators have integrated the
theoretical framework of self-efficacy into breast feeding educa-
tional programmes.
Although many breast feeding educational programmes are
aimed to promote and encourage a longer duration of breast
feeding, the findings on their effectiveness remain inconclusive.
Furthermore, local data on the effect of breastfeeding education on
maternal breast feeding self-efficacy and breast feeding duration
are lacking.
A study was therefore designed and implemented locally to
investigate the effectiveness of a self-efficacy-based breast feeding
educational programme (SEBEP) in increasing breast feeding self-
efficacy, breast feeding duration and exclusive breast feeding rates
among Hong Kong mothers.
Methods
This research was conducted in the obstetric unit of a
university-affiliated public hospital in Hong Kong. The majority of
women served by this hospital were Chinese (95%). Only 5% of the
pregnant women came from other countries, including Indonesia,
Pakistan and Thailand. This hospital has the highest birth rate
among Hong Kong public hospitals. More than 7000 mothers give
birth at this hospital every year. The sample size was determined
to give the study 80% power to detect a large effect size of the
intervention group over control group with cohen's d¼ 0.8 (Cohen,
1988) at 5% level of significance. Using the power analysis software
PASS 12.0 (NCSS, Kaysville, Utah, US), it was estimated that a
sample size of n¼ 26 per group would be required. Further
allowing for attrition rate up to 25% (Hatamleh, 2006), it was
targeted to recruit at least 35 participants per group into the study.
Those eligible for inclusion were primigravidas who were 18
years of age or older, married, with normal breast and nipple
93
examination results as recorded at the antenatal assessment,
without anticipated medical or pregnancy complications that
inhibit breast feeding, able to understand and communicate in
Chinese and willing to participate in the study.
Pregnant women were excluded from the study if 1) they
developed health complications after birth, such as acute uterine
inversion, post partum haemorrhage or post partum depression;
2) their infants were admitted to the neonatal intensive care unit
or their infants were diagnosed with cleft palate, had low birth
weight (o 2500 g), or were born prematurely (o37 weeks of
gestation); 3) they were non-Hong Kong Chinese residents; and 4)
they had no access to a telephone for follow-up.
The group allocation of each participant was assigned
sequentially according to her sequence of enrolment in the study
by opening the corresponding serially numbered opaque sealed
envelope to ensure concealment. The serially numbered envelopes
containing the grouping identifier (either I [intervention] or C
[control]) were prepared by an independent researcher not
involved in the trail, using computer-generated random codes
prior to subject recruitment. The participants in the intervention
group were invited to attend the SEBEP, whereas both the inter-
vention and control group continued to receive usual care. The
usual care provided by the study hospital includes breast feeding
support that was provided by midwives in the hospital, seeking
help from a lactation consultant, and post partum follow-up by
midwives or doctors. Blinding of the participants was not possible
due to the nature of the intervention.
The SEBEP comprised a 2.5 hour breast feeding workshop
provided between 28 and 38 weeks of gestation, with small
groups of six–eight mothers at each interactive session. A com-
fortable lecture room facilitated the group discussion and the
sharing of experience with multimedia equipment, including a
computer, LCD projector and a DVD player. Life-like dolls and
blankets were provided to each participant for practice. The
interaction motivated the participant to acquire more information
about breast feeding. At home, the participants were encouraged
to practice what they learned from the breast feeding workshop.
The breast feeding workshop protocol is shown in Table 1.
Telephone counselling was provided to the participants at two
weeks post partum, focusing on evaluating their emotional/phy-
siological condition and breast feeding status. Each call lasted for
30–60 minutes. The researcher addressed problems, such as fear
and pain, with the aim of correcting misconceptions. Coping
strategies were reinforced and emotional support was provided to
the participants. The researcher evaluated the participants based
on their description of positioning, infant cues of hunger, and
frequency of breast feeding. Appropriate advice was given and
breast feeding practices were encouraged. The telephone coun-
selling protocol is shown in Table 2.
Data were obtained at five time points, namely 20–38 weeks of
gestation/baseline at pregnancy, and two weeks, four weeks, eight
weeks and six months post partum. Socio-demographic data were
collected. The items of the questionnaire comprised age, marital
status, gestational age, education level, occupation, economic
status, whether living with family, intention to breast feed and
experience of breast feeding. In addition, the Breast feeding Self-
Efficacy Scale-Short Form (Chinese Hong Kong version) was used
to measure breast feeding self-efficacy (Ip et al., 2012). The content
validity and reliability of BSES-SF (Chinese Hong Kong version)
was well validated among Chinese pregnant women (Cronbach's
Alpha¼0.95). Thus, in this study, the BSES-SF was appropriate for
measuring the same concept among Hong Kong mothers. A post
partum questionnaire was developed to collect information about
the infant's condition after birth, including infant birth weight,
method of birth, infant gender, history of admission to neonatal
unit, timing of initial breast feeding after birth, and the duration
94 M.Y. Chan et al. / Midwifery 36 (2016) 92–98

Table 1
Breast feeding workshop protocol.

Time allocated Content Teaching method Teaching aids

5 minutes  Welcome Briefing

 Introduction: aims and objectives PowerPoint
15 minutes Knowledge of lactation Exposition  PowerPoint
 Benefits of breast feeding  DVD
 Anatomy and physiology of lactating breasts
 Cues to start feeding and the signs of infant satisfaction
35 minutes Positioning and attachment skills Demonstration and return demonstration Life-like dolls and blankets
10 minutes Tea break
25 minutes DVD on breast-feeding mothers sharing their experiences Watching the DVD for 20 minutes
20 minutes Common misunderstandings about breast feeding Discussion
15 minutes Expressing milk technique (by hand and pump) Demonstration and return demonstration Breast model
15 minutes Summary Conclusion and reinforcement PowerPoint
10 minutes Questions and answers Evaluation
Total: 150 minutes

Table 2 and pattern of breast feeding. In this study, exclusive breast

Telephone counselling protocol. feeding referred to infants receiving only breast milk, such that no
other liquid or solid food was given to the infant. Expressed breast
Telephone counselling protocol
milk was included. Partial breast feeding referred to an infant
Duration: 30–60 minutes receiving at least one bottle of artificial milk each day. Fig. 1 shows
A. Emotional/physiological condition the study protocol.
 Do you feel tired/stressed after the delivery?
 Address possible misconceptions
 Reinforce taught coping strategies Data analysis
 Offer emotional support
B. Breast feeding status All data were entered and analysed using SPSS 20. Katz (1999)
 How many times per day do you breast feed? pointed out that ITT analysis can protect against treatments
 Can you describe the breast feeding position you normally use?
 What are the infant cues of hunger? appearing to be more favourable than they are. In view of the non-
 Give appropriate advice and feedback harmful educational intervention, missing data were imputed
 Encourage breast feeding practices using the last observation carried forward method, where more
conservative efficacy results would generally be obtained for the
outcome measures.
Study
Protocol Ethical considerations
Identification of eligible participants
Ethical approval for the study was obtained from the Clinical
Recruitment of participants Research Ethics Committee of the hospital cluster. Data collection
was conducted from July 2013 to June 2014. The purpose and
20-28 weeks of • Obtain consent details of the study were clearly outlined to the participants before
• Complete BSES-SF
gestation gaining their consent. Maintenance of confidentiality and anon-
• Complete socio-demographic data
sheet ymity of data gained were also assured. Participants were
informed that the quality of care would not be affected by their
Randomization participation in the study.

Allocation
Findings
Allocate to intervention group Allocate to control group
• Self-efficacy based breastfeeding • Usual care
educational programe (SEBEP)
The research assistant assessed the eligibility of 223 pregnant
• Usual care women to participate in the study during the recruitment period.
Only 118 of the 223 pregnant women met the inclusion criteria.
Seventy-one (60.2%) of the eligible pregnant women agreed to
• Complete BSES-SF participate and signed the consent form. Of the 47 pregnant
2 weeks postpartum • Complete postpartum questionnaire women who refused to participate, 31 mothers indicated that they
had no time to participate in the study, eight refused to fill out the
questionnaire, five planned to give birth in private hospitals, two
4 weeks postpartum • Complete postpartum questionnaire were leaving Hong Kong after giving birth, and one could not
communicate in Chinese or English.
A total of 71 participants, who were primigravidas, were
8 weeks postpartum • Complete postpartum questionnaire entered into the study and randomized into the intervention and
control groups. The intervention group consisted of 35 pregnant
women, whereas the control group consisted of 36 pregnant
6 months postpartum • Complete postpartum questionnaire women. Informed consent was obtained from all participants.
During the post partum period, two and four mothers in the
Fig. 1. Self-Efficacy-based Breast feeding Educational Programme (SEBEP) protocol. intervention and control groups, respectively, discontinued the
 M.Y. Chan et al. / Midwifery 36 (2016) 92–98 95

Assessed for eligibility (n= 223) Table 3

Baseline socio-demographic characteristics of participants and outcome measures
in comparison groups (n¼ 71).
Excluded (n= 152)
¨ Did not meet inclusion criteria (n= 105 ) Intervention group Control group p Value
¨ Declined to participate (n=47 )
(n ¼35) (n¼ 36)

Randomized (n= 71) N (%) N (%)

Age (years) *
32.6 (3.5) 31.4 (4.2) 0.19†
Marital status§ –
Married 35 (100%) 36 (100%)
Education level 0.84¶
Secondary school 5 (14.3%) 7 (19.4%)
Allocated to intervention group (n= 35) Allocated to control group (n= 36) Undergraduate 16 (45.7%) 16 (44.4%)
¨ Self-efficacy-based breastfeeding ¨ Usual care Post-graduate 14 (40%) 13 (36.2%)
educational programme (SEBEP) Allocation
Monthly family 0.47**
¨ Usual care
income (HK$)
o $15,000 8 (22.9%) 13 (36.1%)
$15,001–$25,000 16 (45.7%) 15 (41.7%)
$25,001 or above 11 (31.4%) 8 (22.2%)
Occupation 0.15**
• Discontinued intervention (n=2) • Discontinued intervention (n=4)
Reason: infants were admitted
Postpartum Reason: infants were admitted
Clerk 12 (34.3%) 11 (30.6%)
to neonatal intensive care unit follow-up to neonatal intensive care unit Professional/ 19 (54.3%) 13 (36.1%)
immediately after birth immediately after birth managerial
Housewife 3 (8.6%) 7 (19.4%)
• Lost to follow-up (n=1) • Lost to follow-up (n=2)
Reason: moved to China Reason: moved to China (n=1), Others 1 (2.8%) 5 (13.9%)
unknown reason (n=1) Living with family 0.93¶
Yes 22 (62.9%) 23 (63.9%)
Fig. 2. Number of participants from study entry to analysis. No 13 (37.1%) 13 (36.1%)
Antenatal plan to 0.33**
breast feed
intervention according to the exclusion criteria of the study: their
r 12 weeks 11 (31.4%) 6 (16.6%)
infants were admitted to the neonatal intensive care unit imme- 13 to 24 weeks 14 (40%) 19 (52.8%)
diately after birth because of birth complications. In addition, one 4 24 weeks 10 (28.6%) 11 (30.6%)
woman in the intervention group and two women in the control Medical/obstetrical –
problem§
group did not complete data collection (i.e., lost to follow-up) at
No 35 (100%) 36 (100%)
two weeks post partum. The participant who was lost to follow-up Antenatal BSES-SF 42.51 (8.36) 44.36 (7.53) 0.33†
from the intervention group and one of the two from the control score††
group were reported by phone contacts to have moved to China,
but could not be reached. The other participant who was lost to *
Age is mean (standard deviation).
follow-up from the control group could not be contacted by tele- †
Age and BSES-SF score were calculated using a t-test.
phone or post for data collection during the post partum period for §
p Value is inapplicable.
¶
unknown reasons. The post partum questionnaire and BSES-SF Education level and living conditions were calculated using Pearson’s chi-
were mailed to three participants who could not be contacted by squared test.
**
Monthly family income, occupation and antenatal plan to breast feed were
phone, but they did not reply. Finally, 32 and 30 women in the
calculated using Fisher’s exact test.
intervention and control group, respectively, participated in all ††
BSES-SF score is mean (standard deviation).
data collection. This is summarised in the flow diagram in Fig. 2.
Those who were recruited to participate in the intervention and intervention and control groups. Table 4 shows the obstetrical and
control groups showed no significant difference in their baseline breast feeding outcomes in the intervention and control groups.
socio-demographic characteristics, which comprised age, marital Independent t-tests were performed to assess the group effect on
status, education level, occupation, income, living conditions and breast feeding self-efficacy as the outcome variable. The intervention
intention to breast feed. The mean age of the participants in the and control groups showed no statistically significant difference in
intervention and control groups was 32.6 and 31.4 years, respec-
BSES scores (t¼  0.98, p¼0.33, mean difference (MD)¼ 1.85, 95% Cl
tively. All participants were married. Most of the participants
[ 5.61 to 1.92]) during the Antenatal period as baseline. However,
(n ¼71, 83.1%) attained an undergraduate education or higher.
the women in the intervention group reported a significantly higher
Approximately 70% of the participants had a monthly family
BSES score than those in the control group at two weeks post par-
income of at least HK$15,001. Approximately 45% of the partici-
tum; hence, a statistically significant difference (t¼5.73, po0.01,
pants were professionals and 32% of the participants had clerical
MD¼11.91, 95% Cl [7.76–16.07]) was found between the intervention
jobs. More than 60% of the participants lived with family. All
and control groups. In addition, a statistically significant difference
participants planned to breast feed their babies and more than 65%
intended to breast feed their babies for more than 12 weeks. The (t¼ 4.80, po0.01, MD¼ 13.76, 95% Cl [8.03–19.49]) was found in the
intervention and control groups showed no significant difference change in BSES scores of the intervention and control groups from
in baseline breast feeding self-efficacy. Table 3 shows the baseline antenatal to two weeks post partum (see Table 5).
socio-demographic characteristics of the participants and outcome Fig. 3 shows the mean and 95% confidence intervals for the
measures in comparison groups. breast feeding self-efficacy scores of the two comparative groups
All participants had a full-term birth, and the participants in across the two study time points. Similar mean scores for breast
the intervention and control groups had similar birth outcomes in feeding self-efficacy at the baseline measurement were found
terms of birth weight and mode of birth. 82.9% and 83.3% of par- between the two groups. An inspection of the mean scores at two
ticipants in the intervention group and control group started weeks post partum indicated that the intervention group had
breast feeding after birth respectively, however the time of breast significantly higher breast feeding self-efficacy scores than the
feeding initiation showed a significant difference between the control group.
96 M.Y. Chan et al. / Midwifery 36 (2016) 92–98

Table 4
Obstetrical and breast feeding outcomes in the intervention and control groups
(n¼71).

Intervention Control p Value

group group
(n ¼35) (n¼ 36)

N (%) N (%)

Mode of birth 0.87*

Normal vaginal birth 22 (62.9%) 25 (69.4%)
Forceps- or vacuum-assisted vaginal 3 (8.5%) 3 (8.3%)
birth
Caesarean birth 10 (28.6%) 8 (22.3%)
Infant's gender 0.71†
Male 21 (60%) 20 (55.6%)
Female 14 (40%) 16 (44.4%)
Infant's body weight at birth (g) 0.49*
o2500 0 0
2500–4000 34 (97.1%) 36 (100%)
44000 1 (2.9%) 0
Breast feeding after birth 0.96†
Yes 29 (82.9%) 30 (83.3%)
6 (16.7%)
Breast feeding starting time n¼ 29 n¼ 30 o 0.01*
Within 6 hours after birth 29 (100%) 21 (70%)
6–24 hours after birth 0 4 (13.3%) Fig. 3. Error bars of breast feeding self-efficacy scores of study groups across two
424 hours after birth 0 5 (16.7%) time points (Antenatal period and two weeks post partum).

*
Mode of birth, Infant’s body weight at birth, and the time for those mothers to
start breast feeding after birth were calculated using Fisher’s exact test.
†
Infant’s gender and start of breast feeding after birth were calculated using
Pearson’s chi-squared test.

To conclude, the SEBEP increased breast feeding self-efficacy, as

shown by the changes in the BSES-SF scores. Women in the inter-
vention group had higher BSES-SF scores at two weeks post partum.
The duration of breast feeding of all the participants was
recorded by follow-up telephone calls at two weeks, four weeks,
eight weeks and six months post partum. Each call was conducted
by the same research assistant and with the same script; the
research assistant was blinded to group allocation to assess the
duration of breast feeding and pattern of breast feeding. In this
study, a Kaplan–Meier plot and log-rank test were used to exam-
ine the effect of the SEBEP on breast feeding duration. The dura-
tion of breast feeding was assessed up to 182 days (six months)
among the participants. Time to cessation of breast feeding was
used as the failure endpoint for this analysis.
Fig. 4 shows the Kaplan–Meier survival curves for the inter-
vention and control groups. An estimated 31.4% of the women in
the intervention group and 16.7% in the control group were still
breast feeding by the 182nd day. However, the log-rank test
showed that there was no significant difference in breast feeding Fig. 4. Kaplan–Meier survival curves for breast feeding duration of intervention
survival time between the two groups (χ2 ¼2.03, p ¼0.07). and control groups.

Table 5
Mean breast feeding self-efficacy scores of study groups during antenatal period and two weeks post partum (n¼ 71).

Mean (SD) t Value Mean difference 95% Confidence interval of the p Value
difference

Intervention group Control group Lower Upper

(n¼ 35) (n ¼36)

Antenatal
BSES-SF score 42.51(8.36) 44.36(7.53)  0.98 1.85  5.61 1.92 0.33

Second week post partum

BSES-SF score 55.89(6.94) 43.97(10.31) 5.73 11.91 7.76 16.07 o 0.01*

Changes in BSES-SF scores, antenatal to second 13.37(11.13)  0.39(13.00) 4.80 13.76 8.03 19.49 o 0.01*
week post partum

*
p o 0.05.
 M.Y. Chan et al. / Midwifery 36 (2016) 92–98 97

Table 6 exclusive breast feeding rates among postpartum women in the

Pattern of breast feeding at two Weeks, four weeks, eight weeks and six months first six months after birth.
post partum (n ¼71).
The results indicate that the intervention group demonstrated
Intervention group Control group p Value significantly higher BSES mean scores (t¼5.73, po 0.01,
(n ¼35) (n ¼36) MD¼11.91, 95% Cl [7.76–16.07]) than the control group at two
weeks post partum. The development of the SEBEP was based on
N (%) N (%) the breast feeding self-efficacy theory (Dennis, 1999). The theory
2 Weeks 0.14*
was successful in enhancing participants’ breast feeding self-effi-
Exclusive Breast 14 (40%) 8 (22.2%) cacy, which determined breast feeding behaviour by addressing
feeding the four influential sources of self-efficacy, namely, performance
Partial Breast 18 (51.4%) 20 (55.6%) accomplishments, vicarious learning, social/verbal persuasion and
feeding
emotional/physiological response These four influential sources
Bottle feeding 3 (8.6%) 8 (22.2%)
were attained by practicing the common breast feeding positions
4 Weeks 0.06* and attachments with a life-like doll during the breast feeding
Exclusive Breast 13 (37.2%) 5 (13.9%) workshop (performance accomplishments); enriched through the
feeding sharing sessions facilitated by the successful experiences of a
Partial Breast 18 (51.4%) 23 (63.9%)
feeding
lactating mother (vicarious learning); fulfilled by affirmation from
Bottle feeding 4 (11.4%) 8 (22.2%) the midwife educator during the breast feeding workshop (social/
verbal persuasion); and enhanced antenatally by providing
†
8 Weeks 0.02*, mothers with the knowledge and skills to cope with anxiety and
Exclusive Breast 11 (31.4%) 2 (5.5%)
breast feeding problems (emotional/physiological response.
feeding
Partial Breast 15 (42.9%) 20 (55.6%) Furthermore, the mothers in the intervention group demon-
feeding strated higher breast feeding self-efficacy levels and duration rates
Bottle feeding 9 (25.7%) 14 (38.9%) than the mothers in the control group. The findings show that
†
31.4% of the mothers in the intervention group breast fed their
6 Months 0.34*,
Exclusive Breast 4 (11.4%) 2 (5.6%)
babies at six months post partum compared with 16.7% of the
feeding mothers in the control group. Although the trend of survival
Partial Breast 7 (20%) 4 (11.1%) curves is favourable to the intervention group, the difference failed
feeding to reach statistical significance. The non-significant results of
Bottle feeding 24 (68.6%) 30 (83.3%)
breast feeding duration at six months post partum were not sur-
*
Infant feeding status at two weeks, four weeks and eight weeks post partum prising because of the small sample size of the comparison groups
was calculated using Pearson’s chi-squared test. in this study. Thus, a repeated study with a larger sample size is
†
p o0.05. recommended.
Mothers who received the SEBEP demonstrated higher exclu-
Pearson's chi-squared test was used to compare the proportions of
sive breast feeding rates than those who did not receive the
exclusive breast feeding at two weeks, four weeks, eight weeks and six
intervention. These rates were consistently high across the four
months post partum between the control and intervention groups.
data collection time points at two weeks, four weeks, eight weeks
Table 6 shows that the intervention group had higher rates of exclu-
and six months post partum. However, the differences only
sive breast feeding (40%) than the control group (22.2%) at two weeks
reached a significant value at eight weeks post partum. At eight
post partum. However, the differences in the rates of exclusive breast
weeks post partum, the number of mothers in the intervention
feeding of the two groups are not statistically significant (p¼ 0.14). At
group who exclusively breast fed was significantly higher (31.4%)
four weeks post partum, the intervention group demonstrated higher
than that in the control group (5.5%). This might be due to the
rates of exclusive breast feeding (37.2%) than the control group (13.9%).
effect of the telephone counselling provided at two weeks post
However, the difference is statistically insignificant (p¼0.06).
partum. The mothers had a higher level of self-efficacy and they
At eight weeks post partum, the intervention group demonstrated
were more willing to breast feed their babies for as long as pos-
higher rates of exclusive breast feeding (31.4%) than the control
sible. The data collected at eight weeks post partum may reflect
group (5.5%); the difference is statistically significant (x2 ¼7.17, df¼2, the ongoing impact of counselling.
p¼0.02). A total of 14 women in the control group and nine women Breast feeding initiation time was another contributor to the
in the intervention group stopped breast feeding at eight weeks post significant findings on exclusive breast feeding. During the breast
partum. Three mothers in the intervention group and six mothers in feeding workshop, the intervener always emphasised the impor-
the control group did not state the reason for weaning; five mothers tance of early initiation of breast feeding. Mothers in the inter-
in the intervention group and three mothers in the control group vention group demonstrated an earlier breast feeding initiation
indicated that they stopped breast feeding because they returned to time. Among the mothers who chose breast feeding, all those in
work; one mother in the intervention group and five mothers in the the intervention group breast fed their babies within six hours
control group stopped breast feeding because they perceived that after birth as compared with 70% of the mothers in the control
their milk supply was insufficient. At six months post partum, the group. Despite the usual practice for mother who had normal birth
intervention group demonstrated higher rates of exclusive breast would be encouraged to start skin to skin contact and breast
feeding (11.4%) than the control group (5.6%) but it could not reach feeding as soon as possible whereas it might not be feasible for
the statistically significance. mothers who had operative birth due to wound pain and residual
effects of anaesthesia, the proportion of participants had operative
deliveries were similar in both intervention and control group, and
Discussion all mothers in the intervention group able to follow the advise on
early breast feeding initiation that they learnt in the workshop.
This is the first study that reported the effectiveness of a self- In this study, the intervention group demonstrated higher rates
efficacy-based educational programme (Dennis, 1999) on enhan- of exclusive breast feeding (11.4%) than the control group (5.6%).
cing breast feeding self-efficacy, breast feeding duration and However, the exclusive breast feeding rates fall short of the
98 M.Y. Chan et al. / Midwifery 36 (2016) 92–98
recommendations of the WHO, which suggests breast feeding
exclusively for the first six months of life (World Health Organi-
zation, 2002).
The effects of returning to work as a factor can also contribute
to the exclusive breast feeding rate. The results indicate that 8 out
of 14 mothers reported a return to work as the reason for their
weaning. Although the purpose of this study was not to examine
this aspect, the effect of return to work on breast feeding may
indicate the need for improvements for the support and promo-
tion of breast feeding.
This study has certain limitations, including a small sample size
(n¼71), that limited the extent of generalisability of the findings. The
sample was drawn from only one public hospital in Hong Kong, and
other samples of pregnant women from different geographical areas
might be different in terms of variables such as family income, edu-
cation level and occupation. Moreover, a high refusal rate (39.2%) was
noted in this study. About two-thirds of the eligible women indicated
that they had no time to participate in the study. Furthermore, the
participants recruited in this study were those who voluntarily
attended the breast feeding class offered by the study hospital or the
school of midwifery. These mothers were probably highly motivated
to learn or to breast feed as compared with those who failed to attend
the class. In addition, the intervener was the researcher of this study.
Thus, preconceived expectations may have affected the interaction
with the participants.
In addition, response bias might have occurred because breast
feeding status was self-reported by the participants during the
data collection period. Participants may have tended to provide
favourable responses so that they would be perceived as successful
breast feeding mothers.
Finally, the baseline breast feeding self-efficacy scores of the par-
ticipants were collected from 20 weeks to 38 weeks of gestation, with
some variations among the participants. Furthermore, preventing the
participants in the two groups from speaking with each other seemed
to be difficult. Thus, contamination can still occur after undergoing an
effective randomisation process.
Conclusion
This study reported a preliminary investigation into a struc-
tured educational programme based on the breast feeding self-
efficacy theory to enhance maternal self-efficacy, prolong breast
feeding duration and increase the exclusive breast feeding rate
among mothers in Hong Kong.
Despite the methodological limitations of this study, the results
contributed uniquely and consistently to the literature on breast
feeding practices. The effects of the SEBEP were evident in terms of
enhancing maternal self-efficacy and increasing the exclusive
breast feeding rate. Mothers who received the intervention indi-
cated higher breast feeding self-efficacy than mothers who did not
receive the intervention.
In addition, the findings of this study have significant implications
for health care professionals, especially midwives and nurses. Breast
feeding self-efficacy was seen as a key factor influencing the promo-
tion of breast feeding. Therefore, theory-based interventions aimed at
enhancing breast feeding self-efficacy serve a crucial function as
strategies in promoting breast feeding.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/ or publication of this article.
Funding
This study was supported by a grant from the Association of Hong
Kong Nursing Staff (23/Reply/PD Fund/CEU).
Acknowledgements
The support of School of Midwifery, Prince of Wales Hospital was
appreciated. Sites and teaching materials supplies made the study
feasible. Specifically we would like to thank Miss Hau Wai Lei, School
Principal of School of Midwifery for her remarkable support
throughout the study.
I would like to acknowledge my research funding source. Asso-
ciation of Hong Kong Nursing Staff (AHKNS) generously awarded a
grant to help defray the costs of my study.
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