Académique Documents
Professionnel Documents
Culture Documents
Aims and objectives. The purpose of this article is to explore the relationships between breastfeeding knowledge, self-efficacy
and demographic factors on breastfeeding patterns among Hong Kong Chinese primiparous women.
Background. There is substantial evidence showing that maternal education, social class, ethnic background and religion are
related to the decision to initiate as well as continue breastfeeding. Nevertheless, not much is known about how the controllable
factors are able to influence the practice with the Hong Kong Chinese population.
Design. A cross-sectional and correlational design.
Methods. A convenience sample of 82 subjects who had normal vaginal delivery in the maternity unit of a regional hospital in
Hong Kong was recruited.
Results. Linear regression analysis showed that subjects who lived with their mothers-in-law, had higher household income and
higher gravida would be associated with a higher score in the Breastfeeding Self-Efficacy Scale. On the other hand, decisions to
breastfeed made later in the pregnancy, father-in-law to pei-yue (the Chinese practice whereby the new mother is expected to
stay at home and to avoid all household chores and social activities during the first month after giving birth) and older in age
would be associated with a lower score. Pei-yue is Chinese ritual of which the woman who has delivered should stay at home for
one month and being taken care by others (this Chinese term is used throughout the article to indicate the time period
described). Generalised estimating equations model revealed that women who had searched through the Internet for breastfeeding information, who had husbands to pei yue, lived in private housing, were married, had a domestic helper to pei yue
and who had attained higher education were more likely to practice exclusive breastfeeding.
Conclusion. The social support from the family and breastfeeding self-efficacy have implications for continuing the practice of
breastfeeding for primiparous women.
Relevance to clinical practice. Future efforts aimed at promoting exclusive breastfeeding could include the modifiable factors
into consideration to better tailor interventions for successful, exclusive breastfeeding.
Key words: exclusive breastfeeding, knowledge, self-efficacy
Accepted for publication: 26 February 2010
Introduction
Breastfeeding has been recognised worldwide as being beneficial for both the mother and child, as breast milk is
considered the best source of nutrition for an infant.
Breastfeeding provides economic and social benefits to the
family, the health care system and the employer, as breastfed
Authors: Ching-Man Ku, MSc, RN, Registered Midwife, United
Christian Hospital, Kwun Tong, Kowloon, Hong Kong; Susan KY
Chow, PhD, RN, Assistant Professor, School of Nursing, The Hong
Kong Polytechnic University, Hunghom, Kowloon, Hong Kong,
China
2434
Breastfeeding practices
Despite the known benefits of exclusive breastfeeding, a study
conducted in Argentina revealed that the exclusive breastfeeding rate at four months postdelivery was 56% and at
six months it was 19% (Cernadas et al. 2003). While in
Georgia, Russia, the breastfeeding in maternity wards was at
about 97%, the exclusive breastfeeding rate was 18% at
four months (UNICEF 2006). In a study of feeding practices
in 105 counties of rural China, 9822% of the 20,914 babies
in the study were breastfed. While the percentage of exclusive
breastfeeding in the first four months after birth in the urban
areas was 52% and in the rural areas was 2435% (Wang
et al. 2005). The situation among Hong Kong Chinese is not
optimistic. Surveys conducted by the government showed
that breastfeeding is very common, with 70% of the new
mothers practicing breastfeeding in 2006. However, early
weaning persisted and the exclusive breastfeeding rate at four
to six months after delivery was only 135% (Hong Kong
Government, 2007). Another Asian country, Singapore, also
shared a similar trend. The National Breastfeeding Survey
2001 demonstrated an encouraging breastfeeding initiation
rate of 945%, only 211% of mothers continued to breastfeed after six months, with fewer than 5% breastfeeding
exclusively (Foo et al. 2005).
There is substantial evidence showing that maternal
education, social class, mothers comfort in breastfeeding,
fathers occupation and religion are related to the decision to
initiate and continue breastfeeding (Venancio & Monteiro
2006, Kelly & Watt 2005, Duong et al. 2005). Other aspects,
such as the desires or attitudes of mothers regarding
breastfeeding, mother-infant bonding, family support, mode
of delivery and history of smoking, are important in initiation
and sustaining breastfeeding (Beck & Watson 2008, Chandrashekhar et al. 2007, Scott & Binns 1999).
Several studies have focused on evaluating the factors
related to breastfeeding practices, but there are few that
focus on evaluating the practice of exclusive breastfeeding.
Moreover, there is a lack of research investigating the
Aim
The aim of this study is to explore the relationships between
breastfeeding knowledge, self-efficacy and demographic factors on breastfeeding patterns among Hong Kong Chinese
primiparous women.
Objectives
1 To examine the breastfeeding patterns of primiparous
women.
2 To examine the relationships between demographic factors, breastfeeding self-efficacy and breastfeeding knowledge.
3 To delineate factors that are independent predictors of
exclusive breastfeeding.
Research method
Design
This study was a non-experimental, cross-sectional design.
The data were collected during hospitalisation with telephone
follow-up interviews conducted at six weeks postpartum.
The study setting was the maternity unit of a regional general
public hospital, the subjects were recruited from the 40bedded postnatal ward.
Sampling
Subject recruitment took place between AprilJuly 2007. To
meet the inclusion criteria, subjects were primiparas who
intended to breastfeed or exclusively breastfeed; able to read
and communicate in Chinese; maternal age older than 18;
singleton pregnancy; no major obstetrical complications and
baby was healthy with no congenital abnormalities. A
convenience sample of women who met the inclusion
criteria was generated. Participants were excluded if their
babies were born before 37 weeks of gestation (prematurity).
Based on the previous study of Blyth et al. (2002),
Breastfeeding Self-Efficacy is one of the predictors of
breastfeeding practice at four months after delivery. The
2435
Instruments
The Breastfeeding Knowledge Questionnaire (BKQ) and
Breastfeeding Self-Efficacy Scale (BSES) were chosen to
measure the knowledge and self-report efficacy of the
subjects. The BKQ was developed by Gulick (1982) and
was used to assess participants knowledge on exclusive
breastfeeding. The 26-multiple-choice questionnaire assesses
clients knowledge about the advantages of exclusive
breastfeeding, simple physiology of breastfeeding and
breastfeeding management. The scale was translated into
Chinese and back translated following the techniques
described by Bracken and Barona (1991). To investigate
its validity and reliability, content validity of the translated
instrument was examined by a panel of experts experienced
in breastfeeding. The content validity index (CVI) was 092
and considered satisfactory, as the acceptable index is
above 075 (Portney & Watkins 2009). The reliability of
the instrument was assessed by the testretest method.
Intraclass correlation coefficient (ICC) was 081 which
showed significant agreement and correlation among the
two tests.
The BSES was developed by Dennis and Faux (1999). It is
a 33-item, self-report instrument to measure self-perceived
confidence in breastfeeding. The scores are summed to
produce a range from 33165, with higher scores indicating
higher levels of breastfeeding self-efficacy. The scale has
been translated into Mandarin Chinese (Dai & Dennis
2003) and Spanish (Torres et al. 2003) and is commonly
used in overseas studies (Blyth et al. 2002, Dunn et al.
2006, Hauck et al. 2007). The CVI of the translated
instrument was 094, and ICC was shown very satisfactory
at 094.
Ethical considerations
Ethical approvals were obtained from The Hong Kong
Polytechnic University and the research ethics committee of
the study hospital before commencement of data collection.
An information sheet regarding the details of the study was
provided to the participants, informed consent was obtained
from all participants before data collection.
2436
Data collection
The recruited subjects completed the BKQ and BSES within
one to two days after delivery. The demographic and medical
information were obtained from the subjects and through
retrieval of medical records. Telephone follow-up interviews
were conducted at six weeks postpartum to obtain the
information on exclusive breastfeeding practice in week 1,
2, 4 and 6.
Data analysis
Data were coded and analysed using the Statistical Package
for the Social Sciences (SPSS ) version 15.0 (SPSS Inc., Chicago,
IL, USA). Descriptive statistics were used to describe the
sample characteristics and breastfeeding duration. Linear
regression was used to examine the predictors of breastfeeding self-efficacy. The generalised estimating equation (GEE)
methods logistic regression was used to estimate the multiple
predictors of practicing exclusive breastfeeding. This is
considered an appropriate method to identify predictors in
the repeated measures studies or longitudinal designs
(Ballinger 2004, Hanley et al. 2003). The statistical significance was set at p < 005.
Results
Sample characteristics
There were subjects (n = 82) recruited for the study. The mean
age of the mothers was 284 (SD 51, range 1840). The
majority (n = 71, 866%) were born in Hong Kong and were
married (n = 77, 97%). Of all recruits, 659% (n = 54) had
completed secondary school and 171% (n = 14) had completed tertiary education. Fifty-six subjects (683%) stated
that the pregnancies were planned. Fifty-four per cent
(n = 45) of the subjects were pregnant for the first time. The
subjects having higher gravida were because of either previous
spontaneous abortions or terminations of pregnancies.
Table 1 shows the demographic characteristics of the subjects.
There was less than half of the mothers who had decided to
breastfeed their babies before conception (n = 36, 439%),
while a further 329% (n = 27) made the same decision during
the first trimester. Decisions made in second (n = 8, 98%) and
third (n = 9, 11%) trimester share similar proportions and
only two mothers (24%) decided to breastfeed their babies
after delivery. The mean of planned duration of breastfeeding
their babies was 6806 days (SD 6287, range 0365).
Only a minority (85%) of the mothers expressed that they
received no information regarding breastfeeding. Over half of
Characteristics
Total
(n = 82)
866
134
183
817
939
61
24
659
146
171
195
476
37
37
37
207
12
159
341
293
207
61
268
232
37
61
24
256
61
11
146
244
159
98
244
354
232
415
2437
45
37
76
39
24
22
15
67
56
45
45
65
53
11
63
9
28
29
69
36
56
34
74
4
(5488)
(4512)
(9268)
(4756)
(2927)
(2683)
(1829)
(8171)
(6829)
(5488)
(5488)
(7927)
(6463)
(1341)
(7683)
(1098)
(3415)
(3537)
(8415)
(4390)
(6829)
(4146)
(9024)
(488)
Discussion
Some of these findings are similar to those reported
internationally, while a few results reflect the unique social
and cultural environment in Hong Kong and the special
characteristics of Chinese women in Hong Kong society. The
rate of exclusive breastfeeding in our study sample was
persistently low, and breastfeeding knowledge was neither
significantly correlated to breastfeeding self-efficacy nor the
duration of exclusive breastfeeding. However, breastfeeding
self-efficacy provided a statistically significant explanation
for exclusive breastfeeding prevalence. The duration after
BSES items
Internal thought
Continue to breastfeed my baby for every feeding
Determine that my baby is getting enough milk
Manage the breastfeeding situation to my satisfaction
Focus on getting through one feed at a time
Breastfeed my baby without using formula as a supplement
Successfully cope with breastfeeding like I have with
other challenging tasks
Feed my baby with breast milk only
Refrain from bottle feeding for the first 4 weeks
Keep feeling that I really want to breastfeed my baby
for at least 6 weeks
Manage to keep up with my babys breastfeeding demands
Keep wanting to breastfeed
Stay motivated to breastfeed my baby
Be satisfied with my breastfeeding experience
Motivate myself to breastfeed successfully
Maintain my milk supply by using the supply and demand rule
Monitor breast milk by keeping track of my babys
urine and bowel movement
Accept the fact that breastfeeding may temporarily limit
my freedom
Deal with the fact that breastfeeding can be
time-consuming
Technique
Tell when my baby is finished breastfeeding
Position my baby correctly at my breast
Feel if my baby is sucking properly at my breast
Recognise the signs of a good latch
Count on my friends to support my decision
to breastfeed
Ensure that my baby is properly latched on for
the whole feeding
Manage to breastfeed even if my baby is crying
Keep my baby awake at my breast during a feeding
Feed my baby every 23 hours
Finish feeding my baby on one breast before
switching to the other breast
Take my baby off the breast without pain to myself
Comfortably breastfeed in public places
Comfortably breastfeed with my family members present
Hold my baby comfortably during breastfeeding
Depend on my family to support my decision to breastfeed
b (95% CI)
p-value
5329
1678
12223
4159
6376
0713
*<0001
*<0001
*0009
*<0001
*<0001
*0017
( 7553 to 3105)
(1023523325)
( 21328 to 3118)
(23225997)
(31289624)
( 1297 to 0129)
Mean (SD)
Range
371
309
390
405
315
355
(068)
(071)
(066)
(066)
(074)
(067)
25
25
25
25
25
25
312 (076)
370 (081)
360 (091)
15
25
15
390
380
367
293
354
356
361
(064)
(078)
(072)
(068)
(076)
(063)
(073)
35
25
25
14
25
25
25
363 (064)
25
344 (079)
15
345
365
384
367
378
(065)
(078)
(071)
(074)
(067)
25
25
25
25
25
367 (075)
25
333
329
380
390
(080)
(075)
(076)
(073)
25
15
25
25
352
231
266
384
401
(072)
(078)
(088)
(074)
(062)
25
15
15
25
35
delivery, living conditions, maternal education level, searching through Internet for breastfeeding information, marital
status, husband to pei yue, having a domestic helper to pei
yue, household income and information from friends all
influenced the mothers wishes and decisions to exclusively
breastfeed. In traditional Chinese culture, pei yue refers to
the practice whereby the new mother is expected to stay at
home and to avoid all household chores and social activities
during the first month after delivery. Hong Kong is a
2439
Factors
p-value
0506 (03150812)
0178 (00910349)
0044 (00210094)
002 (00090045)
9303 (268532239)
5793 (180818565)
8733 (227933466)
*0005
*<0001
*<0001
*<0001
*<0001
*0003
*0002
643658 (35111803376)
6984 (134236351)
2369 (115104)
1104 (10611149)
0492 (03210755)
0182 (00450736)
0388 (00911661)
0232 (00421273)
31 (062215446)
075 (0426132)
*<0001
*0021
*0028
*<0001
*0001
*0017
0202
0093
0167
0319
3639 (056823315)
0322 (01011034)
0173
0057
0203
0246
1737
0272
1481
(00251637)
(0057107)
(06224852)
(00362033)
(07412961)
0134
0062
0292
0205
0267
0501 (01212079)
0341
three months was 54% and at six months was 32%. While
in Brazil, the exclusive breastfeeding rate at six months was
29% (La Leche League International, 2006). The breastfeeding rate in Hong Kong is even less than some of the
developing countries, such as India, having an exclusive
breastfeeding rate of 43% at six months and Indonesia, with
a rate of 42% at six months (La Leche League International,
2006).
Our result shows consistency with a local study by
Dodgson et al. (2003) who revealed short exclusive breastfeeding duration among the samples. The necessity of
returning to work for postpartum women was one of the
factors affecting the rate of exclusive breastfeeding. Paid
maternity leave in Hong Kong is six weeks postdelivery; this
externally enforced condition explains the cessation of
exclusive breastfeeding in mothers who return to work. The
phenomenon could further be explained by Chinese culture as
parents or grandparents have traditionally fed infants with
congee at an early stage of life, considering congee to be
nutritious, as Asian people consume rice daily as the major
source for carbohydrate. This could explain the marked
Breastfeeding knowledge
Although the correlation coefficients between breastfeeding
knowledge and breastfeeding self-efficacy were statistically
significant in this study, the correlation was small. The
result corroborated the evidence in a previous study by
Chezem et al. (2003). Despite a positive and significant
correlation on breastfeeding self-efficacy and knowledge, a
small value of correlation coefficient has little relation to
exclusive breastfeeding duration or breastfeeding self-efficacy. Although information on the benefits of breastfeeding
has been widely promoted in antennal classes and should
impact the initiation of the health behaviours, nonetheless, it
does not significantly affect the duration of exclusive
breastfeeding. As resources for promoting breastfeeding
are limited, we could consider re-directing these resources
and efforts to other factors such as breastfeeding selfefficacy, which contributes significantly to the duration of
exclusive breastfeeding.
Breastfeeding self-efficacy
From the GEE model, breastfeeding self-efficacy is a statistically significant factor associated with exclusive breastfeeding. The more confidence the mothers had in their
breastfeeding performance, the more likely (OR 1104,
p < 0001) they were to breastfeed their babies exclusively
at different time points. Previous studies have revealed that
skills are needed to realise the desired behaviour self-efficacy
on breastfeeding duration (Etrem et al. 2001, OBrien et al.
2008).
For most mothers, breastfeeding is not a simple, nutritional decision as related knowledge has been imparted
during pregnancy (Greene et al. 2003). Although all subjects
in the study were committed to breastfeeding, most reported
that they nonetheless found it embarrassing and felt uncomfortable to breastfeed in front of others. This was not a
unique phenomenon among the mothers, but also for local
university students. Tarrant and Dodgson (2007) studied 400
university students on their views on breastfeeding in public.
Students found it an acceptable practice but embarrassing
and restrictive of the mothers freedom. Moreover, breastfeeding is also strongly influenced by social beliefs. In the
United States, the overall population appears to approve of
breastfeeding in public, but less educated or older persons are
less likely to do so (Li et al. 2004). On the contrary, it was a
criminal offence to prevent a mother to breastfeeding her
2441
Limitations
The sample size, non-random sampling and use of only one
study site for data collection limited the generalisability of
this study. Subjects with a more diverse socio-economic
background could provide a comprehensive picture on the
phenomenon of exclusive breastfeeding. Another limitation
included some factors not measured in this study, such as the
mothers breastfeeding attitude, individuals breast conditions (flat nipples or inverted nipples) and the presence of
postpartum depression. These confounders could affect the
breastfeeding practices and behaviour of the mothers. As this
study collected breastfeeding patterns at six weeks postpartum, recall bias was another limitation of the study.
Acknowledgements
The authors thank Mr Edward Choi for his advices on
statistical analysis.
Contributions
Study design: SC, C-MK; data collection and analysis: C-MK
and manuscript preparation: SC, C-MK.
2443
Conflict of interest
None.
References
American Academy of Pediatrics (2005) Policy statement section on
breastfeeding and the use of human milk. Pediatrics 115, 496506.
Australian Bureau of Statistics (2003) Breastfeeding in Australia,
2001. Available at: http://www.abs.gov.au/Ausstats/abs@.nsf/0/
8E65D6253E10F802CA256DA40003A07C?Open (accessed 15
October 2007).
Avery M, Duckett L, Dodgson J, Savik K & Henly S (1998) Factors
associated with very early weaning among primiparas intending to
breastfeed. Maternal & Child Health Journal 2, 167179.
Ball TM & Wright AL (1999) Health care costs of formula-feeding in
the first year of life. Pediatrics 103, 870876.
Ballinger GA (2004) Using generalized estimating equations for
longitudinal data analysis. Organizational Research Methods 7,
127150.
Barber CM, Abernathy T, Steinmetz B & Charlebois J (1997) Using
a breastfeeding prevalence survey to identify a population for
targeted programs. Canadian Journal of Public Health 88, 242
245.
Beck CT & Watson S (2008) Impact of birth trauma on breastfeeding: a tale of two pathways. Nursing Research 57, 228236.
Blyth R, Creedy DK, Dennis CL, Moyle W, Pratt J & De Vries SM
(2002) Effect of maternal confidence on breastfeeding duration: an
application of breastfeeding self-efficacy theory. Birth 29, 278
284.
Bourgoin G, Lahaie N, Rheaume B, Berger M, Dovigi C, Picard L &
Sahai V (1997) Factors influencing the duration of breastfeeding in
the Sudbury region. Canadian Journal of Public Health 88, 238
241.
Bracken BA & Barona A (1991) State of the art procedures for
translating, validating and using psychoeduational tests in crosscultural assessment. School Psychology International 2, 119132.
Cernadas JMC, Noceda G, Barrera L, Martinez AM & Garsd A
(2003) Maternal and perinatal factors influencing the duration of
exclusive breastfeeding during the first 6 months of life. Journal of
Human Lactation 19, 136144.
Chan SM, Nelson AS, Leung SSF & Li CY (2000) Breastfeeding
failure in a longitudinal post-partum maternal nutrition study in
Hong Kong. Journal of Paediatrics and Child Health 36, 466471.
Chandrashekhar TS, Joshi HS, Binu VS, Shankar PP, Rana MS &
Ramachandran U (2007) Breast-feeding initiation and determinants of exclusive breast-feeding a questionnaire survey in an
urban population of western Nepal. Public Health Nutrition 10,
192197.
Chezem J, Friesen C & Boettcher J (2003) Breastfeeding knowledge,
breastfeeding confidence and infant feeding plans: effects on actual
feeding practices. Journal of Obstetric, Gynecologic and Neonatal
Nursing 32, 4047.
Cox S (2004) Breastfeeding with Confidence. Finch Publishing,
Australia.
Dai X & Dennis CL (2003) Translation and validation of the
breastfeeding self-efficacy scale into Chinese. Journal of Midwifery
& Womens Health 48, 350356.
2444
2445
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.