Effect of Stress Management Counseling on Self-Efficacy and Continuity of Exclusive Breastfeeding

Abstract

Background:

Self-efficacy is an important motivational factor that can be affected by physiological responses such as stress.

Objective:

The study aimed to determine the effect of stress management counseling on self-efficacy and continuity of exclusive breastfeeding in mothers.

Materials and Methods:

This randomized controlled trial was carried out on 46 pregnant women recruited at three Childbirth Preparation Centers of Zanjan (Iran) in 2018. The eligible women were allocated into two intervention and control groups according to the block design. Stress management counseling was carried out individually in four sessions, twice a week at 35 and 36 weeks of gestation. The control group only received routine cares. The self-efficacy and continuity of exclusive breastfeeding were measured monthly up to 4 months after childbirth.

Results:

Breastfeeding self-efficacy showed a statistically significant difference between the two study groups at 1 and 4 months after childbirth (p = 0.001). More women in the control group terminated exclusive breastfeeding compared to those in the intervention group (16 (72.7%) versus 8 (34.8%), p = 0.013).

Conclusion:

The results showed that integration of stress management counseling in breastfeeding education package can improve the self-efficacy and continuation of breastfeeding in mothers.

Introduction

Breastfeeding is the healthiest method to feed a newborn and contributes to improved short- and long-term health outcomes for both mothers and infants.¹ The World Health Organization (WHO) recommends that infants should be exclusively breastfed from birth to 6 months of age.² Concern over declining breastfeeding rates is universal. In low-income and middle-income countries, only 37% of children younger than 6 months of age are exclusively breastfed; so the importance of breastfeeding in these countries is well recognized.¹ Despite global strategy targets, ∼53% of Iranian babies have exclusive breastfeeding up to 6 months.³ Although the duration of exclusive breastfeeding in Iran is within the limits of WHO-recommendation (4 to 6 months), it seems that early cessation of exclusive breastfeeding has increased in recent years.⁴ Several factors have been found to be associated with mothers' compliance with exclusive breastfeeding, including low breastfeeding self-efficacy, mothers' perception of breast milk inadequacy and breast concerns, parental education, maternal smoking, marital status, parity, geographical region, family income, maternal age, body mass index, and birth weight.^5,6 Substantial resources have been allocated to improve breastfeeding rates, often through addressing modifiable factors that may contribute to breastfeeding success.^6–8

Self-efficacy is an important psychological and motivational factor in breastfeeding.⁹ It is also a valuable framework that predicts breastfeeding behavior and demonstrates maternal confidence and ability to practice breastfeeding.¹⁰ Being a mother is one of the most stressful events in women's life. Sixty-four percent and 46.5% of women experience high level of stress during pregnancy and postpartum period, respectively.^11,12 Furthermore, primiparous women endure higher levels of stress than multiparous mothers due to their lack of previous breastfeeding experience. As a result, they may have low level of breastfeeding self-efficacy comparing to multiparous mothers.^12,13 The role of stress in breastfeeding is well established. For example, women having higher level of stress in postpartum period are at higher risk for early cessation of breastfeeding. Dewey, studying the role of stressors in lactogenesis, found that acute stress can disrupt milk ejection reflex by reducing oxytocin release.^14,15 Some supportive or educational methods have been developed to evaluate the effect of these interventions on mothers' breastfeeding self-efficacy, but they have not focused on emotional factors.^16,17 Moreover, there is little evidence concerning the applicability of structured counseling programs using psycho-educational methods on mothers' breastfeeding self-efficacy.^7,8,18 It seems that counseling programs designed based on stress management can be effective in mothers' breastfeeding self-efficacy through modifying stressful factors. Therefore, the current study aimed at investigating the effect of stress management counseling on self-efficacy and continuity of exclusive breastfeeding in mothers.

Materials and Methods

Study aim and design

This randomized controlled trial aimed at determining the effect of stress management counseling on continuation and self-efficacy of breastfeeding up to 4 months after childbirth among 46 mothers in Zanjan, Iran in 2018.

Setting

Sampling was performed in three childbirth preparation centers of Zanjan, Iran. The study population consisted of women who participated in the childbirth preparation classes of these centers. These classes provide information to expectant mothers and their partners about pregnancy, labor, childbirth, and postpartum.

Participants

The sample size per group was 23 (total = 46) according to a study by Karbandi et al.¹⁹ at the confidence level of 95%, power of 80%, and attrition rate of 15%. The inclusion criteria were as follows: (1) willingness to participate in the study, (2) reading and writing skills, (3) being married, (4) gestational age above 20 weeks, (5) natural pregnancy, (6) single wanted pregnancy, (7) absence of any known systemic or psychological diseases in the last pregnancy, and (8) a score above average on the Cohen's Perceived Stress Questionnaire. The exclusion criteria were as follows: (1) birth of a newborn weighing <2,500 g, (2) known congenital abnormalities in the newborn, (3) intrauterine or prenatal death, (4) prenatal or postpartum complications such as preterm childbirth, prenatal or postpartum hemorrhage, and complicated childbirth, (5) lack of breastfeeding as recommended by the physician in the postpartum period, (6) absence from the classes for more than two counseling sessions, (7) unexpected events such as divorce or death of close relatives in the postpartum period, and (8) withdrawal from the study.

Procedure

Among the 115 pregnant women admitted to Zanjan pregnancy centers, overall, 46 eligible women were selected to participate in this study based on convenience sampling and after obtaining a written consent. Given a block size of four, the participants were assigned into two groups of intervention (n = 23) and control (n = 23) in a random manner. Flowchart of the research process is shown in Figure 1.

FIG. 1.

Flowchart of the research process.

Intervention

According to the guidelines of Iran's Ministry of Health, routine childbirth preparation classes were run from the 20th week of gestation every 2 weeks until the 32nd week of gestation for both groups. The sessions focused on the mothers' familiarity with different stages of pregnancy from fertilization to childbirth, personal hygiene, prenatal nutrition, mental and physical changes during pregnancy, pregnancy risks, childbirth planning, postpartum health, breastfeeding, and child care. In addition, four face-to-face sessions of stress management counseling were held weekly (two 2-hour sessions per week) for each participant from the intervention group at the 35th and 36th weeks of gestation. At the end of the sessions, the mothers were asked to do some assignments at home, and their performance was examined at the beginning of the next session. The content of the meetings is presented in Table 1. Routine care, including eight sessions of childbirth preparation classes according to the Ministry of Health guidelines, was provided for the control group.

Table 1.

Description of the Content of Stress Management Counseling Sessions

First session	Welcome Aims and objectives Pretest with the Breastfeeding Self-Efficacy Scale of Dennis Definition of stress and preparing a list of stressful situations Discussing the relationship between stress and performance and the effect of stress on the body and breastfeeding Homework: Express important postpartum stressors
Second session	The source of stress and potentially stressful resources, different strategies of people in coping with stressful situations, and expression of experiences of mothers from their coping strategies against stressful situations Homework: Explain the difficult and stressful moments and feelings experienced by mothers in that situation and how they had handled the situation
Third session	Adaptation resources, skills necessary for better management of stress at different individual, family, environmental, and social levels, measures to improve physical and mental statuses, ways of increasing maternal tolerance threshold, and individual strategies for coping with stress as long-term strategies Homework: Write some long-term strategies to cope with stress
Fourth Session	Short-term strategies for coping with stress, designing a play of a stressful situation, charting a table of tensions experienced during the last week, notes on the severity of tension, behavior and attitudes, satisfaction with the coping method used in those situations, and simple suggestions to cope with stress Homework: Provide a check list and record the stressful situations and activities within a month

Data collection instruments

The evaluated outcomes of this study included breastfeeding self-efficacy and continuation of breastfeeding. The Breastfeeding Self-Efficacy Scale (BSES) of Dennis was used to evaluate self-efficacy before counseling, 1 month, and then 4 months after childbirth. Also the breastfeeding status was determined using a three-option question, (i.e., exclusive breastfeeding, combined feeding (breastfeeding with formula), and formula feeding without breastfeeding) using phone calls on a monthly basis up to 4 months postpartum.

Demographic data checklist

This checklist included the participant's age, educational level, occupation, place of residence, spouse's educational and occupational status, first day of the last menstrual period, estimated date of childbirth, and family's economic status. Data related to the newborn's sex and birth weight, as well as the mode of childbirth, were self-reported.

Perceived Stress Scale-14 Items

This scale, which was used to determine the inclusion criteria of the study, measures perceived stress in the past month and contains seven negative items, revealing the person's stress-coping inability, and seven positive items, which are indicative of the person's suitable coping. The items are graded on a five-point Likert scale, ranging from “never” (0) to “very often” (4). The maximum total score is 56, and the minimum total score is zero, with higher scores indicating higher perceived stress. Accordingly, women who scored above average were included in this study.²⁰ The translation and psychometric characteristics of the questionnaire were studied by Maroufizadeh et al. in 2018.²¹ The Cronbach's alpha coefficient of the scale was obtained as 0.79.

Breastfeeding Self-Efficacy Scale of Dennis (13 items)

This questionnaire contains 13 questions, rated on a five-point Likert scale. The questions begin with the affirmative phrase “I always can” and are scored from one (I'm not sure at all) to five (I'm completely sure). The range of scores is 13 to 65, with higher scores suggesting a higher self-efficacy.²² The Persian version of BSES has been shown to have adequate reliability and validity in Iranian mothers.²³ In this study, the Cronbach's alpha coefficient of the scale was 0.94.

Breastfeeding status

Breastfeeding status was assessed with a three-choice question at three levels. The question was extracted from a questionnaire developed by Parsa et al. with confirmed reliability (Cronbach's alpha coefficient, 0.81).²⁴ This type of grading has been also used in some domestic and foreign studies.^25,26

Data analysis

Statistical analysis was performed using the SPSS 16.0 software (SPSS, Inc., Chicago, IL). The chi-square and Fisher's exact tests were used for comparing the categorical variables. For comparison of quantitative variables, independent t-test and analysis of covariance were performed at a significant level of p < 0.05. In addition, to estimate the breastfeeding continuity, Kaplan–Meier's method was applied, and the log-rank test was used to compare the survival distribution of the intervention and control groups.

Results

Demographic characteristics

The intervention and control groups were not significantly different in demographic characteristics, newborn's sex, and mode of childbirth (p > 0.050) (Table 2).

Table 2.

Comparison of the Frequency Distribution of Demographic Characteristics Between the Two Study Groups

Social and Midwifery characteristics	Intervention		Control		p
Social and Midwifery characteristics	n	%	n	%	p
Mother's job
Housekeeper	19	82.6	18	78.3	0.500^**
Employee	4	17.4	5	21.7	0.500^**
Mother's education
Elementary	0	0	1	4.3	0.816^*
Guidance	2	8.7	2	8.7
High school	7	30.4	9	39.1
Academic	14	60.9	11	47.8
Wife's job
Employed	9	39.1	8	34.8	0.953^**
Self-employed	13	56.5	14	60.9
Unemployed	1	4.3	1	4.3
Wife's education
Elementary	0	0	3	13	0.269^*
Guidance	2	8.7	4	17.4
High school	9	39.1	7	30.4
Academic	12	52.2	9	39.1
Abortion history
Yes	5	21.7	1	4.3	0.093^**
No	18	78.3	22	95.7	0.093^**
Gravid
First	18	78.3	22	95.7	0.093^**
Second	5	21.7	1	4.3	0.093^**
Type of childbirth
NVD	17	73.9	13	56.5	0.216^**
C/S	6	26.1	10	43.5	0.216^**
Sex of newborn
Girl	12	52.2	10	43.5	0.768^**
Boy	11	47.8	13	56.5	0.768^**
Family monthly income
Not enough	4	17.4	7	30.4	0.318^*
To some degree enough	19	82.6	15	65.2
Sufficient	0	0	1	4.3
Mother's age (year)^****	25.26 ± 4.08		26.87 ± 4.45		0.208^***
Gestational age^****	27.935 ± 3.98		26.630 ± 3.97		0.273^***
Birth weight (g)^****	3,202.39 ± 325.86		3,182.39 ± 454.51		0.865^***

Fisher's exact test.

Chi-squared test.

***

Independent t-test.

****

Mean ± SD.

Breastfeeding self-efficacy

The results showed that before the intervention, the mean difference of breastfeeding self-efficacy was not statistically significant between the two groups (p = 0.452) (Table 3).

Table 3.

Comparison of the Mean Score of Perceived Stress and Breastfeeding Self-Efficacy Before Intervention Between the Two Groups

Variable	Intervention	Control	p ^*
Variable	Mean ± SD	Mean ± SD	p ^*
Perceived stress score	23.57 ± 3.81	23.09 ± 4.29	0.692
Breastfeeding self-efficacy score	47.17 ± 8.96	48.74 ± 4.20	0.452

Independent t-test.

A mixed between-within subjects' analysis of variance was conducted to assess the impact of stress management intervention on self-efficacy scores across three periods (preintervention, 1 month, and 4 months after childbirth). There was a significant effect for time (Wilks' lambda = 0.73, F (2, 42) = 7.49, p = 0.002, Partial Eta Squared = 0.26). After adjusting the preintervention self-efficacy scores, there was a significant group-time interaction (Wilks' lambda = 0.519, F (2, 41) = 18.99, p = 0.001, Partial Eta Squared = 0.48).

The means and standard deviations of breastfeeding self-efficacy are presented in Table 4. The intervention group showed significantly higher breastfeeding self-efficacy in the first and fourth months after childbirth compared with the controls (p = 0.001) (Table 4).

Table 4.

Comparison of the Mean Self-Efficacy Score Across Three Times (Preintervention and 1 and 4 Months After Childbirth) Between the Two Groups

Variable		Intervention	Control	Error	p ^*
Variable		Mean ± SD	Mean ± SD	Error	p ^*
Breastfeeding self-efficacy score before intervention	Breastfeeding self-efficacy score 1 month postpartum	54.35 ± 6.05	46.82 ± 6.45	—	0.001
	Breastfeeding self-efficacy score 4 months postpartum	57.48 ± 6.07	49.59 ± 13.49	—	0.005
Group	Breastfeeding self-efficacy score 1 month postpartum	54.35 ± 6.05	46.82 ± 6.45	887.10	0.001
	Breastfeeding self-efficacy score 4 months postpartum	57.48 ± 6.07	49.59 ± 13.49	3,837.47	0.003

Analysis of covariance.

Breastfeeding status

There was a significant difference between the two groups regarding the breastfeeding status in the first month after childbirth. Eighty-two percent of mothers in the intervention group and 50% of mothers in the control group exclusively breastfed their newborns (p = 0.020). In the intervention group, the rate of exclusive breastfeeding was found to be higher in the second, third, and fourth months after childbirth in comparison with the controls; nevertheless, the differences were not significant (Table 5).

Table 5.

Comparison of the Frequency Distribution of Breastfeeding Level Between the Intervention and Control Groups

Variable		Intervention		Control		p ^*
Variable		n	%	n	%	p ^*
Breastfeeding level 1 month postpartum	Exclusive breastfeeding	19	82.6	11	50	0.020
Breastfeeding level 1 month postpartum	Combined breastfeeding	4	17.4	11	50	0.020
Breastfeeding level 2 months postpartum	Exclusive breastfeeding	17	73.9	14	63.6	0.510
	Combined breastfeeding	6	26.1	7	31.8
	Bottle (formula) feeding	0	0	1	4.5
Breastfeeding level 3 months postpartum	Exclusive breastfeeding	17	73.9	12	54.5	0.141
	Combined breastfeeding	6	26.1	7	31.8
	Bottle (formula) feeding	0	0	3	13.6
Breastfeeding level 4 months postpartum	Exclusive breastfeeding	17	73.9	11	50	0.086
	Combined breastfeeding	6	26.1	8	36.4
	Bottle (formula) feeding	0	0	3	13.6

Chi-squared test.

According to Kaplan–Meier's method, the rate of exclusive breastfeeding termination was higher in the controls comparing to the intervention group (16 [72.7%] versus 8 [34.8%], p = 0.013) (Table 6).

Table 6.

Comparison of the Exclusive Breastfeeding Continuation and Exclusive Breastfeeding Termination Between the Intervention and Control Groups

Group	N	Event of exclusive breastfeeding termination	Exclusive breastfeeding continuation^*		p
Group	N	Event of exclusive breastfeeding termination	n	%	p
Intervention	23	8	15	65.2	0.013^{^**}
Control	22	16	6	27.3
Total	45	24	21	46.7

Kaplan–Meier's method.

Log rank test.

Also more than 90% and 70% in the intervention and control groups, respectively, had started exclusive breastfeeding from the first day after childbirth. Although there was a decline in exclusive breastfeeding in several intervals, including the first day, first month, and second month after childbirth, the greatest reduction in exclusive breastfeeding was observed after 100 days in the intervention group and after 90–120 days in the control group. During the follow-up, the percentage of exclusive breastfeeding continuation was 65.25% and 27.3% in the intervention and control groups, respectively (Fig. 2).

FIG. 2.

Survival functions of continuity of exclusive breastfeeding.

Discussion

According to the current research findings, stress management counseling effectively improved breastfeeding self-efficacy in the intervention group comparing to the controls, which is consistent with the other studies that used theory-based intervention.^27,28 In the present study, the mean breastfeeding self-efficacy score also increased in the control group at 4 months after childbirth; however, the increase was not significant; this finding shows that consideration of time and integration of direct experiences can increase self-efficacy through improving performance accomplishments.²⁹

Self-efficacy is described as an individual's belief in his/her ability to accomplish goals. According to Bandura theory, four sources of information, including physiological responses (e.g., stress), can influence self-efficacy.²⁹ Therefore, it can be stated that stress management counseling improves one's self-efficacy by improving physiological responses.³⁰ In Ertem's study, it was 12 times more likely for mothers without adequate self-efficacy to terminate breastfeeding before 2 months after childbirth³¹; the higher breastfeeding self-efficacy, the longer the breastfeeding continuity!³² In a controversial study by Henderson et al., the intervention group had lower mean score of self-efficacy than the control group.³³

In a study by Joshi et al., although Hispanic American women demonstrated an increase in breastfeeding knowledge, intention to breastfeed, and breastfeeding self-efficacy after implementation of a breastfeeding training program, the difference was not statistically significant.³⁴ The discrepancy between the findings can be attributed to the difference in the evaluated time intervals or the content of the interventional programs. In the above study, the educational program was implemented in the first 24 hours after birth; therefore, it is not logical to expect a significant improvement in breastfeeding self-efficacy within this short period. However, in the present study, stress management was conducted with a counseling approach during pregnancy, and the outcome was examined within more reasonable intervals.

The present research results indicated that continuation of exclusive breastfeeding during the follow-up period was 65.2% and 27.3% in the intervention and control groups, respectively. In terms of breastfeeding level, although the percentage of exclusive breastfeeding was higher in the intervention group in different postpartum periods, the difference compared to controls was only significant in the first month after childbirth. The findings showed that 82.6% of mothers in the intervention group and 50% of mothers in the control group had exclusive breastfeeding in the first month after childbirth. The main reason for this finding can be due to the high self-efficacy of mothers in the intervention group in comparison with the controls in the first month after childbirth, whereas the mean breastfeeding self-efficacy was reduced in the control group in the first month after childbirth.

Parsa et al. reported that breastfeeding counseling was effective in continuation of exclusive breastfeeding. In their study, 88.5% and 67.3% of mothers in the intervention and control groups exclusively breastfed their newborns in the 4-month follow-up, respectively. In addition, the prevalence of combined breastfeeding was 9.6% and 23%, and the prevalence of formula feeding was 1.9% and 6.9% in the intervention and control groups, respectively.²⁴ The findings of Parsa et al. are inconsistent with ours. This discrepancy may be attributed to differences in the type of intervention. In fact, in the study of Parsa et al., the intervention continued until the fourth month after childbirth, whereas in the present study, the counseling intervention did not continue in the postpartum period to maintain the high level of exclusive breastfeeding in mothers until the fourth month.

In the present study, the breastfeeding level decreased in the intervention group from the first month (82.6%) to the fourth month (73.9%), suggesting the need for continuous counseling support, including stress management to maintain exclusive breastfeeding. It is to be noted that physiological responses such as stress and integration of interventions are only some of the effective factors in improving breastfeeding self-efficacy, and other factors such as social support can also affect this phenomenon, which were discarded in this study. In addition, the prevalence of formula breastfeeding without breastfeeding showed an ascending trend in the control group, reaching 13.6% in the fourth month. Mothers in the intervention group maintained a steady status from the first month to the fourth month (none of the mothers from the intervention group had bottle feeding during this period).

In a similar study by Sikander et al. in 2015, cognitive-behavioral counseling improved the duration of exclusive breastfeeding and psychological distress in rural mothers of Pakistan; 59% of mothers in the intervention group and 28% of mothers in the control group exclusively breastfed their newborns up to 6 months postpartum.¹⁸ Chan et al. reported that the level of breastfeeding in the postpartum period was higher in the intervention group participating in a self-efficacy program compared with the controls,²⁵ which is in line with the current research findings. This indicates the positive effect of psychological counseling with an emphasis on stress management counseling on self-efficacy and continuation of breastfeeding; this finding needs to be considered by health care workers.

Limitations

The present study had several limitations. Data collection was performed using a self-report questionnaire, and sampling was done among the participants of Childbirth Preparation Centers, which should be considered in generalization of our findings. The long duration of sessions, which was exhausting for mothers, was another limitation of this study. For solving this problem, the mothers were allowed to walk for a while during recess; refreshments were also served during the sessions. Finally, the short follow-up period (4 months postpartum) was another limitation, which should be considered by researchers in future studies.

Conclusion

The present research results showed that integration of stress management counseling in childbirth preparation classes can improve self-efficacy and continuation of breastfeeding in mothers. Considering the low breastfeeding self-efficacy (especially in the first month after childbirth) and its effects on breastfeeding status, stress management counseling is suggested to continue for several months after childbirth.

Footnotes

Acknowledgments

The authors acknowledge the head of the Social Determinants of Health Research Center, Zanjan University of Medical Sciences, Zanjan, Iran, as well as the employees of Zanjan Childbirth Preparation Centers. The authors are also grateful to all the mothers who participated in the study.

Ethical Consideration

The Ethics Committee of Zanjan University of Medical Sciences approved this study (Ethics code: ). It was also registered in the Iranian Registry of Clinical Trials (IRCT20150731023423N10). The purpose of the study was outlined to the participants, and all participants gave informed consent before the study.

Ethical Approval

The Ethics Committee of Zanjan University of Medical Sciences approved this study (Ethics code: ).

Clinical Trial Registry and Registration Number

This study was registered in the Iranian Registry of Clinical Trials (IRCT20150731023423N10).

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was approved in Health and Biomedical Information with the code “A-11-344-7” and was funded by the Social Determinants of Health Research Center, Zanjan University of Medical Sciences, Zanjan, Iran.

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