The Effect of Motivational Interviewing on Self-Efficacy and Continuation of Exclusive Breastfeeding Rates: A Quasi-Experimental Study

Abstract

Background:

Self-efficacy is a decisive psychological and motivational factor in maintaining exclusive breastfeeding (EBF). The aim of this study was to explore the impact of motivational interviewing (MI) on EBF self-efficacy and EBF in primiparous women.

Materials and Methods:

This quasi-experimental study was conducted on 140 primiparous women admitted to a number of comprehensive health centers in Zahedan in 2019. The health centers were determined through multistage random sampling, and the subjects were selected from each center using convenience sampling. The selected women were equally divided into the intervention and control groups. The two groups took the pretest by filling out a demographic questionnaire and a breastfeeding self-efficacy questionnaire. The intervention group attended four 45- to 60-minute MI sessions on breastfeeding. The EBF continuation sheet and the breastfeeding self-efficacy questionnaire were filled out 6 months postpartum. Data were analyzed in SPSS 22 using paired t-test, independent t-test, chi-square test, and covariance analysis.

Results:

Based on the results, the mean and standard deviation of the number of EBF days were significantly higher in the intervention group (137.68 ± 65.50) compared with that of the control group (99.51 ± 80.62). In addition, the mean score of breastfeeding self-efficacy after MI was significantly different between the two groups (p = 0.0001).

Conclusion:

Because of the significantly positive impact of MI on enhancing EBF self-efficacy and continuation, it is recommended to integrate this counseling strategy into the care programs designed for women in pregnancy and even postpartum period.

Introduction

Exclusive breastfeeding (EBF) refers to the practice of feeding an infant on breast milk alone for the first 6 months of life without addition of other food or water with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals, or medicines.¹ Despite the benefits of EBF in the first 6 months of birth, many Iranian mothers stop breastfeeding earlier than recommended or use supplements alongside breastfeeding. The prevalence of EBF varies from 28% among employed women living in urban areas to 55% among unemployed women.

Some of the more recurrent causes of EBF discontinuation in Iranian women include others' advice, being employed, feeling restricted because of EBF, caring for and feeding the baby by a person other than the mother, mother's low self-efficacy, advanced maternal age, low birth weight, misconceptions such as mother's impression that her milk is not sufficient as indicated by the infant's crying, and using traditional foods and liquids to alleviate infantile colic.^2–4

Considering the importance that global nutrition policies put on increasing EBF rates and conducting breastfeeding promotion programs, it is essential to address various factors affecting breastfeeding.⁵

Breastfeeding is influenced by mother's various physiological and psychological characteristics. Altering physiological factors is extremely difficult and in some cases impossible; hence, interventions aimed at improving breastfeeding should take psychological and motivational variables into account.⁶ In this context, self-efficacy is an important and modifiable factor for sustaining breastfeeding.⁷ It refers to the mother's perceived ability or confidence in breastfeeding and influences her decisions about this activity.⁸

Studies have indicated that as the mother's self-efficacy in breastfeeding improves, continuing this behavior is facilitated so does the rate of EBF.⁹ O'Campo et al. demonstrated that women with low self-efficacy stopped breastfeeding 3.1 times earlier than did women with high self-efficacy.¹⁰ Therefore, interventions that emphasize strengthening one's commitment and self-efficacy are more helpful than simply providing educational information and giving advice.¹¹

Motivational interviewing (MI) is one of the counseling methods used to enhance self-efficacy and change behaviors. It is a client-oriented approach to reinforcing intrinsic motivation for behavior change through exploring and resolving ambivalence.¹² MI underscores principles such as express empathy, developing discrepancy, and roll with resistance, support self-efficacy and clients' sense of autonomy.¹³ Motivation is a function of the discrepancy between the client's present behaviors and values. Awareness of these discrepancies can increase motivation to change. In MI, resistance to change is a normal and expected part of the change process. When faced with resistance it becomes important to let the resistance be expressed instead of trying to fight against it. The therapist strives to understand and respect both sides of the ambivalence from the client's perspective.^14,15 The spirit, principles, and techniques of MI are given in Table 1.

Table 1.

The Spirit, Principles and Techniques in Motivational Interviewing

The “Spirit” of MI	Collaborative
	Evocative
	Honoring patient autonomy
Core principles of MI	Express empathy
	Developing discrepancy
	Roll with resistance
	Support self-efficacy
Basic skills of MI	Ask open-ended questions
	Reflection statements
	Listen reflectively
	Affirm
	Summarize
	Elicit change talk
	Give feedback
Strategies of MI	Fostering a collaborative relationship/autonomy
	Effectively engage clients and avoid arguments
	Guide them into a discussion regarding breastfeeding
	Use open-ended questions to solicit thoughts, feelings, beliefs, opinions about EBF—do not start giving advice
	Evoke reasons to EBF
	Evoke responses from them that will help identify resistance and resolve ambivalence by use pros and cons chart, use the decisional balance to actually increase motivation
	To help them develop a custom plan that will work for them
	Elicit cultural health beliefs of clients about EBF
	Affirmations of strengths and self-efficacy (established and supported EBF)
	Coping with tempting situations of discontinuation of EBF
Main questions	What are your thoughts and ideas about breastfeeding?
	Why might you choose non-EBF?
	What do you like/don't like about non-EBF or EBF?
	Write the short- and long-term pros and cons of formula feeding or non-EBF.
	How confident are you that you can properly position and latch your baby?
	What are the barriers and concern you have about EBF?
	Would you know what to do if you encounter difficulties or problems with EBF?

Adapted from Arkowitz et al.¹⁵ and Rollnick et al.¹⁴

EBF, exclusive breastfeeding; MI, motivational interviewing.

Numerous studies have reported that MI is effective in promoting positive healthy behaviors and reducing unhealthy behaviors.¹⁶ Elliott-Rudder et al. and Salehi et al. showed that MI had a positive effect on breastfeeding and increasing EBF self-efficacy in primiparous women.^17,18 Meanwhile, the study of Wilhelm et al. reported no significant difference between the intervention and control groups in terms of breastfeeding.¹⁹

Considering the importance of EBF on the health of babies and mothers and also the empirical evidence on the effectiveness of MI, this study explores the impact of this counseling method on EBF self-efficacy and continuation in primiparous women.

Materials and Methods

This is a quasi-experimental study conducted on 140 primiparous women who had presented to a number of comprehensive health centers in Zahedan in 2019. For all age groups, these centers offer outpatient health services. All pregnant women voluntarily present to these centers for monitoring, examinations, and receiving prenatal care (usually eight times during pregnancy).

This study was conducted to test this hypothesis “can the motivational interviewing at the end of pregnancy increase the motivation for postpartum exclusive breastfeeding rates and self-efficacy in women?” The eligibility criteria were minimum age of 20 years, first pregnancy, 32–34 weeks of gestation, no pregnancy complications, telephone accessibility, and no speech or hearing problems. Infant's hospitalization at the neonatal intensive care unit, any condition in the mother or infant discouraging breastfeeding such as mothers being treated with radioactive iodine, chemotherapy, radiotherapy, infant cleft lip and cleft palate, and failure to attend at least one educational session constituted the exclusion criteria.

Based on the EBF formula proposed by Parsa et al., a 95% confidence interval, and an 80% power, the sample size was estimated at 63 individuals for each group.²⁰ To account for possible attrition and ensure the adequacy of the sample size, the researchers finally enrolled 70 women in each group (total = 140).

Data collection tools included a demographic questionnaire, the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF), and EBF continuation sheet. The demographic questionnaire covered age, education, ethnicity, mother's occupation, husband's occupation, economic status, and infant's gender.

The EBF continuation sheet included two important questions about EBF designed by the researchers: (1) How many days have you exclusively breastfed your newborn since birth until the end of 6-month-old baby? (2) Have you ever (at end of 6 months) started supplemental or extra feeding for your baby? If the answer was positive, when have you begun the supplemental nutritional support?

BSES-SF was developed by Dennis, and it consists of 13 questions. All items begin with the phrase “I can always.” The responses are scored on a 5-point Likert scale (with 1 indicating “never or I'm not sure at all” and 5 suggesting “always or I'm quite sure”); in addition, following Bandura's theory of self-efficacy, they are designed as positive statements. The scores of breastfeeding self-efficacy range from 13 to 65, with higher scores representing higher levels of self-efficacy.²¹ In Iran, the reliability of this questionnaire was evaluated and validated by Araban et al..²² In this study, the reliability of this instrument was confirmed by Cronbach's alpha (0.80).

After approval of the research, necessary coordination was made with the targeted health centers. Initially, Zahedan health centers were divided into five areas including North, South, East, West, and Center. Then two centers were randomly selected from each of the areas and allocated into the intervention group and control group. Convenience sampling was subsequently used to choose the subjects from each center. Using the electronic medical records, primiparous women in 32–34 weeks of gestation were identified and contacted. The objectives of the study were briefly explained for these women, and if willing to participate in the study, they were invited to come to the health center. The subjects were included in the study after they submitted their written consent. A total of 156 eligible mothers were assessed and 140 subjects continued to participate.

The pretest was performed by means of a demographic questionnaire and a breastfeeding self-efficacy questionnaire at 32–34 weeks of gestation at the beginning of the study. The intervention and control groups received routine breastfeeding training in the form of prenatal care based on the latest guidelines. Then, the intervention group took part in four 45- to 60-minute sessions of MI. The sessions were held twice a week at the health centers for subgroups of six to eight members. MI and pretests of breastfeeding self-efficacy was performed in the last weeks of pregnancy upon entering the study, but the effect of the intervention on self-efficacy and the continuation of EBF was measured in the postpartum period.

The initial format and content of the MI sessions were designed according to the model developed by Fields.²³ The content was finalized after studying relevant books and other materials on MI. This structure of group MI has been frequently tested and used in Iran (Table 2).^24,25 Issues such as the importance, advantages, and disadvantages of breastfeeding; frequency and duration of breastfeeding and EBF; breastfeeding problems and concerns; and how to store milk for working mothers are discussed in the context of MI. The MI intervention was presented by an experienced postgraduate in Midwifery Counseling under the supervision of a PhD in Counseling.

Table 2.

Structure and Content of Group Motivational Counseling Sessions

Session	Educational content
First	Orientation: Introducing motivational approaches, group norms and processes, stages of change and EBF, practicing dimensions affected by one's behavior (discontinuation BF and EBF), and Elicit mother's information about EBF (implementation with adherence to the principles and techniques of MI)
Second	Emotions: Identifying of feeling, practicing emotional aspects of the EBF and discontinuation EBF, breastfeeding problems and concerns (implementation with adherence to the principles and techniques of MI)
Third	Positive and negative aspects of EBF: Predicting pros and cons of EBF (short-term and long-term) and decisional balance via brainstorming, supporting EBF self-efficacy (implementation with adherence to the principles and techniques of MI)
Fourth	Values and prospective: Identifying and prioritizing values, developing discrepancy between values and discontinuation of EBF, tempting situations of discontinuation EBF, summary and practice of starting a EBF Program Vision

Adapted from Fields²³; Mojahed and Navidian²⁴; and Navidian et al.²⁵

EBF, exclusive breastfeeding; MI, motivational interviewing.

Data analysis

Data were analyzed in SPSS 22. Kolmogorov–Smirnov test was used to examine normality of data. Frequency, percentage, mean, and standard deviation were determined by descriptive statistics. The main hypotheses were analyzed using paired t-test, independent t-test, chi-square test, and covariance analysis. p < 0.05 was considered statistically significant.

Ethical considerations

This study was approved by the Ethics Committee of Zahedan University of Medical Sciences (IR.ZAUMS.REC.1397.354). Providing information on the research process and scheduling as well as the type of intervention, obtaining written informed consent, ensuring confidentiality of what happens in the sessions, and the freedom to withdraw from the study at any stage were among ethical considerations observed in this study.

Results

Two women in the intervention group were excluded: one owing to neonatal death and another because of a change of residence out of the service area. Furthermore, one person was excluded from the control group because of skipping the posttest. Consequently, the final analysis was performed based on the data obtained from 137 individuals. The mean and standard deviation of mothers' age in the intervention and control groups were 22.41 ± 3.86 and 23.37 ± 5.04, respectively. Other demographic information of the study subjects is given in Table 3.

Table 3.

Frequency Distribution and Comparison of Mothers in the Two Groups of Test and Control According to Demographic Variables

Variable	Group		p
Variable	Intervention, n (%)	Control, n (%)	p
Mother's job
Employee	2 (2.9)	4 (5.7)	0.68
Unemployed	68 (97.1)	66 (94.3)
Total	70 (100)	70 (100)
Mother's education
Elementary School	12 (17.1)	14 (20)	0.65
Secondary School	17 (24.3)	15 (21.4)
High School	24 (34.3)	29 (41.4)
Academic	17 (24.3)	12 (17.2)
Total	70 (100)	70 (100)
Mother's age, mean ± SD	22.41 ± 3.86	23.37 ± 5.04	0.21
Husband's job
Self-employed	55 (78.6)	50 (71.4)	0.28
Unemployed	3 (4.3)	8 (11.5)
Employee	12 (17.1)	12 (17.1)
Total	70 (100)	70 (100)
Nationality
Fars	31 (44.3)	37 (52.9)	0.31
Baluch	39 (55.7)	33 (47.1)
Total	70 (100)	70 (100)
Economy
<$300	13 (18.6)	11 (15.7)	0.77
$300–600	44 (62.8)	48 (68.6)
Over $600	13 (18.6)	11 (5.7)
Total	70 (100)	70 (100)
Delivery
Natural	55 (78.6)	57 (81.4)	0.67
Cesarean section	15 (21.4)	13 (18.6)
Total	55 (78.6)	57 (81.4)
Gender
Girl	31 (44.3)	32 (45.7)	0.86
Boy	39 (55.7)	38 (54.3)
Total	70 (100)	70 (100)
Gestation age
Term	70 (100)	68 (97.1)	0.49
<37 weeks	0 (0)	2 (2.9)
Total	70 (100)	70 (100)
Breastfeeding the first hour
Yes	62 (88.6)	63 (90)	0.78
No	8 (11.4)	7 (10)
Total	70 (100)	70 (100)

SD, standard deviation.

The mean score of breastfeeding self-efficacy was 46.42 ± 7.40 and 41.48 ± 6.75 before MI and increased to 52.16 ± 7.72 and 43.71 ± 7.29 after MI in the intervention and control groups, respectively (Table 4). Based on the results of independent t-test, the mean score of breastfeeding self-efficacy before and after MI differed significantly between the two groups (p = 0.0001).

Table 4.

Comparison of Mean and Standard Deviation of Breastfeeding Self-Efficacy Score Before and After Motivational Interview in Intervention and Control Group

Time	Before	After	Changes	Paired t-test
Group	Mean ± SD	Mean ± SD	Mean ± SD	p
Intervention	46.42 ± 7.40	52.16 ± 7.72	5.76 ± 7.99	0.0001
Control	41.48 ± 6.75	43.71 ± 7.29	2.08 ± 8.01	0.03
Independent t-test	p = 0.0001	p = 0.0001	p = 0.008

SD, standard deviation.

The analysis of covariance (ANCOVA) test was used to adjust for preexisting differences in nonequivalent groups. This application aimed at correcting initial group differences (before intervention) that existed on dependent variable among groups. In this study the mean score of breastfeeding self-efficacy before MI differed significantly between the two groups (p = 0.0001).

In this situation, participants could not be made equal through random assignment, so covariates were used to adjust scores and make participants more similar in pretest than without the covariates. Given the established normality and homogeneity of variances, the results of ANCOVA test (Table 5) showed that the mean score of breastfeeding self-efficacy in the two groups after MI was significantly different (p = 0.0001).

Table 5.

Results of Analysis of Covariance Test on Women's Breastfeeding Self-Efficacy Score After Motivational Interviewing While Controlling the Pretest Effect

Source of changes	Sum squares	Degrees of freedom	Mean squares	F	Significance level	Impact size	Power
Pretest	1216.80	1	1216.80	25.48	0.0001	0.16	0.99
Group	1296.07	1	1296.07	26.57	0.0001	0.16	0.99
Error	6397.62	134	47.75
Total	324,463	137

Concerning the number of EBF days after 6 months, the results of independent t-test suggested a significantly higher mean and standard deviation in the intervention group (137.68 ± 65.50) than in the control group (99.51 ± 80.62) (p = 0.003).

Discussion

The first part of this study demonstrated that breastfeeding self-efficacy of mothers in the intervention group who had been exposed to MI boosted significantly both in the posttest and also compared with the control group. Adding the principles of MI to training programs designed for primiparous women increased the effectiveness of education. Salehi et al. also found that MI had a greater impact on promoting EBF self-efficacy in primiparous women than did lecture-based education.¹⁸ Similarly, Cangöl and Şahin reported that mothers exposed to the breastfeeding motivation program started breastfeeding earlier and had a higher perceived self-efficacy in this regard.²⁶ MI and its principles enhance one's intrinsic motivation for change and give rise to a favorable attitude that increases the likelihood of behavior change. Addick and McNeil stated that MI had a considerable effect on improving attitudes toward breastfeeding in primiparous women.²⁷

One of the pillars of MI is to foster self-efficacy. Navidian et al. observed such an impact in the context of patients with depression and heart failure.²⁵ Many of the MI techniques used in this study, including commitment and confidence assessment, behavior control in tempting situations, participation in decision-making, supporting client autonomy, resolving ambivalence, and change talk elicit, were directly aimed at promoting self-efficacy in the subjects.^14,15 Therefore, this research confirmed that MI could significantly improve this index of breastfeeding in primiparous women.

In line with the results of this study, Mirmohamadali et al. concluded that breastfeeding education during pregnancy using face-to-face method coupled with the direct involvement of the trainer can raise breastfeeding self-efficacy.⁹ These studies confirm that educational and counseling programs during pregnancy can be effective in modifying breastfeeding behaviors.

Another result of this study was that MI had a positive and significant effect on the duration of EBF in the intervention group. Whereas MI extended the mean duration of breastfeeding by 8 days in the study by Wilhelm et al., it increased this duration by 38 days within 6 months in this study.²⁸ Elliott-Rudder et al., aiming at maintaining breastfeeding continuation by improving primary care support through MI, reported that the duration of EBF within 4 months was significantly higher in the intervention group than in the control group.¹⁷ However, contrary to the results of this study, Wilhelm et al. proposed that MI could not significantly increase the mean duration of breastfeeding in primiparous mothers.¹⁹

It could be claimed that part of the extension in the duration of EBF in this study is because of the rise of self-efficacy in primiparous women who received the MI intervention inasmuch as increased self-efficacy raises the possibility of success (i.e., behavioral change). Compared with conventional education, MI could be effective through increased intrinsic motivation and readiness for change, increased engagement, persistence in the treatment programs, and adherence to advices. In addition, MI may exert its positive and effective impacts through enhancing positive behavior, increasing concerns about problematic behavior indirectly and without the pressure for change, weighing the pros and cons of change, supporting self-efficacy, and emphasizing autonomy and freedom.^14,15,25

In addition to education on EBF-related concepts, techniques such as solving ambivalence, developing discrepancy and support self-efficiency have led to motivation and increased continuation of EBF. In the control group, the pretest–posttest effect and effects of EBF monitoring (EBF continuation sheet) may also lead to maternal sensitivity and improved EBF behavior. Thus, in agreement with this research, Paranjothy et al. proposed that MI is a feasible and acceptable method for both mothers and breastfeeding service providers.²⁹

Limitations

Despite the clear definition of study population and application of ANCOVA test, because of the convenience sampling of pregnant women, selection bias in this study should be addressed as a limitation.

Conclusion

The findings of this study established that MI-based education exerts a significantly positive impact on strengthening breastfeeding self-efficacy and duration of EBF in primiparous women. Considering the ever-increasing usage of MI for diverse health/psychological problems around the world, it is strongly recommended that this counseling strategy be integrated in care programs developed for mothers, especially primiparous women. It is hoped that addressing the significance of EBF and extending its duration will yield favorable effects on the physical and psychological health of children.

Footnotes

Authors' Contributions

All the authors contributed to the conceptualization and development of the study and interpretation of data. Furthermore, they all reviewed and edited the article and approved the final draft. A.N. supervised the study.

Acknowledgments

The authors thank the Vice-President for Research and Information Technology and the staff of the Office of Vice-President for Health of the University, the personnel of the involved health centers, and all mothers who contributed to this project.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research is based on a Master's thesis in Midwifery Counseling (code: 9036) presented at the School of Nursing and Midwifery, and it was funded by the Office of Vice-President for Research and Information Technology in Zahedan University of Medical Sciences ().

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