Maternal Infant-Feeding Attitudes,Infant Eating Behaviors,and Maternal Feeding Choice at 3 and 6 Months Postpartum: A Comparative Multicenter International Study

Abstract

Objective:

The aim of this study was to compare mothers' attitudes toward infant feeding and infant eating behavior in different countries, and their associations with infant feeding at 3 and 6 months.

Methods:

Data from 164 mothers with healthy term infants recruited for a randomized trial comparing breast pumps from the UK (n = 68), Russia (n = 51), and China (n = 45) were included in this analysis. Feeding practices were assessed using questionnaires at 3 and 6 months. Maternal attitudes toward infant feeding and infant eating behaviors were measured by Iowa Infant Feeding Attitudes Scale (IIFAS) and Baby Eating Behavior Questionnaire (BEBQ) at 5–6 weeks postpartum; scores were compared between countries and associations with infant feeding at 3 and 6 months were examined.

Results:

IIFAS score was significantly different between countries; mean scores in Chinese and Russian mothers (China 64.6 ± 4.88 and Russia 61.5 ± 6.15) lay in the range of “neutral breastfeeding attitudes,” while British mothers had more positive attitudes (70.6 ± 6.47, post hoc p < 0.001). Russian infants had higher scores for “general appetite” (mean = 4.8 ± 0.41, p < 0.05) and “satiety responsiveness” (mean = 8.7 ± 1.08, p < 0.01) than Chinese or British infants. Longer duration of full-time education was associated with more positive attitudes toward breastfeeding in the whole sample (p < 0.001) and in the United Kingdom (p < 0.05). The majority of mothers were exclusively breastfeeding (EBF) at 3 months. Total IIFAS and BEBQ scores were not significant predictors of EBF at 3 and 6 months (p > 0.05), although greater agreement with the IIFAS statement “Formula feeding is more convenient than breastfeeding” was associated with lower EBF at 3 months (OR = 0.47, 95% CI: 0.29–0.78, p < 0.01).

Conclusions:

Maternal attitudes toward infant feeding and perceptions of infant eating behavior differed between countries, but were not associated with EBF at 6 months. Mothers with a greater baseline perception that formula feeding is more convenient than breastfeeding were less likely to EBF at 3 months; this could be a potential target for education.

Introduction

The importance of breastfeeding for maternal and infant health has been well documented.^1,2 The World Health Organization (WHO) recommends infants should be exclusively breastfed for the first 6 months of life.³ The WHO and United Nations Children's Fund have set a goal that at least 50% of infants be breastfed exclusively for 6 months in 2025.⁴ However, according to the 2013 report of WHO, the global rate of exclusively breastfeeding (EBF) at 6 months was 38%.⁴ While some countries have reported relatively high breastfeeding rates, including Russia, where the exclusive breastfeeding rate was 49.1% in Moscow in 2015,⁵ other countries have disappointingly low rates of breastfeeding. As shown in a national nutritional survey in China, the exclusive breastfeeding rate under 6 months was 20.8%.⁶ In the United Kingdom, the rate of exclusive breastfeeding and any breastfeeding at 6 weeks postpartum were 23% and 55%, respectively, in 2010.⁷ Low breastfeeding rates are associated with increased health care costs.²

Studies have investigated mothers' perspectives, experiences, and decision-making associated with breastfeeding. Early studies concentrated on demographics such as marital status, education, race/ethnicity, employment status, age, and socioeconomic factors. However, more recently, measurement of maternal infant feeding attitudes has been the subject of extensive research. The Iowa Infant Feeding Attitudes Scale (IIFAS)⁸ is one tool that has been reliably replicated in a number of settings to determine the strength of infant feeding attitudes.^9–11

Research has demonstrated that the IIFAS not only predicts maternal infant feeding attitude but is also an accurate measure of paternal attitudes.^9,10,12,13 Maternal attitudes toward breastfeeding as the choice of infant feeding have been demonstrated to be associated with intent, initiation, and duration of breastfeeding.^14–16 Chen et al.¹⁴ compared the data of Chinese mothers based in Perth, Australia, and Beijing, China, and showed that higher IIFAS scores were significantly associated with the likelihood of both breastfeeding initiation (OR: 3.85, CI: 2.49–5.96, p < 0.001) and longer breastfeeding duration (≥8 months) (OR: 2.52, CI: 1.87–3.40, p < 0.001). However, since the study population was mothers of children younger than 5 years, these associations could be influenced by when the attitudes are measured. Evidence also indicates that maternal attitudes could be a better predictor of breastfeeding than sociodemographic factors such as age, marital status, level of education, and lifestyle factors.^15–17

Infant eating behavior may also be associated with feeding mode during the early months.¹⁸ Mallan et al.¹⁹ investigated 467 Australian mothers at 4 months postpartum. Infant eating behavior, measured using the Baby Eating Behavior Questionnaire (BEBQ), was consistently associated with feeding mode; breastfed infants displayed greater enjoyment of food, fed more slowly, but were reportedly less satiety responsive than formula-fed infants. However, this study did not demonstrate whether infant eating behavior can predict feeding practices.

Few studies have investigated the influence of maternal feeding attitudes and infant eating behavior on infant feeding practices, and most have been conducted in a single setting. The aim of this study was (1) to compare maternal attitudes toward infant feeding and infant eating behavior in three different countries; (2) to investigate whether these factors predict infant feeding at 3 and 6 months; and (3) to investigate whether any associations differed between countries.

Methods

Study participants

Data collected as part of a multicenter experimental study²⁰ were used for these analyses. EBF mothers were recruited 3–4 weeks postpartum from London (United Kingdom), Moscow (Russia), and Beijing (China). Mothers were eligible if they (1) had a healthy, term singleton infant (birth weight >2.5 kg, ≥37 weeks gestation); (2) were EBF and willing to be randomized to receive a pump or to continue breastfeeding without using a pump; (3) were not using a pump regularly; (4) could speak and write in English, Russian, or Mandarin.

Data and variables

Baseline data were collected on socioeconomic status, pregnancy and delivery, infant health, and feeding. Mothers completed questionnaires reporting their personal goals for EBF and any breastfeeding in months, using questions from the Infant Feeding Practices Study.²¹

Predictors

Maternal attitudes toward infant feeding and infant eating behaviors were measured using the IIFAS and BEBQ, respectively, at 5–6 weeks postpartum. The IIFAS is a 17-item questionnaire with a five-point scale ranging from “strongly disagree” to “strongly agree” for each item. Total scores range from 17 to 85 with higher scores reflecting more positive attitudes toward breastfeeding. The total scores were also grouped into three groups: positive to breastfeeding (70–85), neutral (49–69), and positive to formula feeding (17–48).²² The BEBQ is a reliable tool with 18 items designed to measure 4 aspects of infant feeding behavior (enjoyment of food, food responsiveness, slowness in eating, and satiety responsiveness) of both breastfed and formula-fed infants.¹⁸ An independent indicator of “general appetite” was assessed by an additional item in the questionnaire (“My baby has a big appetite”), which is cross-loaded on all four factors. The internal reliability estimates of the four factors in the original developed article were acceptable (Cronbach's α = 0.73–0.81).¹⁸ Scoring requires calculation of mean scores for each subscale with higher mean scores indicating greater reported expression of the feeding behavior. A full list of the items, including two reverse scored items, appears in Table 1. Questionnaires were translated into local languages.

Table 1.

Characteristics of the Participants

	All	United Kingdom	China	Russia
Number of participants	164	68	45	51
Gender of the infant
Male	85	24	31	30
Female	77	21	37	19
Parity
Primip	102	45	35	22
Multip	62	0	33	29
Delivery
Vaginal	131	34	53	44
Caesarean	31	11	15	7
Skin-to-skin contact after birth, n
Not within first hour	19	1	3	15
<20 minutes	74	18	27	29
>20 minutes	71	26	38	7
Maternal age, years	31.9 ± 4.5	33.8 ± 4.5^a,b	30.8 ± 3.2^a	30.6 ± 4.8^b
Maternal education, years	16.2 ± 3.4	18.1 ± 2.8^a	16.9 ± 1.9^a	13.1 ± 3.0^a
Marital status, n
Married	142	45	50	47
Cohabiting	19	0	16	3
Lone parent	2	0	1	1
Living with parents	1	0	1	0
Family income^*
Low	39	23	9	7
Medium-low	43	17	7	19
Medium-high	32	2	9	21
High	50	3	43	4
EBF at 3 months, n (%)	121 (87.3)	36 (83.7)	38 (84.4)	42 (82.4)
EBF at 6 months, n (%)	26 (19.3)	11 (29.7)	7 (15.9)	9 (18.4)

a,b

Significant differences detected by post hoc test (Bonferroni) at the 0.05 level. Between pairs with the same letter.

Family income grade refers to local incomes.

EBF, exclusive breastfeeding.

Outcome: breastfeeding at 3 and 6 months

At 3 and 6 months postpartum, mothers completed questionnaires either online (the United Kingdom) or sent by post (China, Russia). They were asked to indicate infant feeding in the last 7 days. Categories of infant feeding at 3 months included the following: EBF, mainly BF with <1 formula feed (FF) per day, mainly BF with at least 1 FF per day, mainly FF with at least 1 BF per day, mainly FF with <1 BF per day, and exclusively FF. At 6 months, two categories for BF or FF with solid foods or other drinks were added.

Statistical analysis

Analyses were performed using SPSS version 24. Descriptive statistics were reported as means and standard deviations or proportions. One-way analysis of variance (ANOVA) was used to compare scores between countries, with post hoc pairwise testing (Bonferroni) if the ANOVA was significant. Binary logistic regression was performed to examine predictors of breastfeeding at 3 and 6 months. We adjusted for covariates: maternal age, marital state, socioeconomic status (family income), maternal education (duration of full-time education), duration of hospital stay, and early hospital experience (time for skin-to-skin contact). Inclusion of these potential confounders was based on previous studies that reported associations between each covariate separately with both psychosocial factors and breastfeeding behaviors.^17,23

The original study was approved by the research ethics committee in each site (UK—UCL Research Ethics Committee, Ref: 5645/001 12.8.14; Russia—Local Ethics Committee, Ref: 35–04/15.04.14; China: Local Institutional Approval). All participants gave written informed consent.

Results

One hundred fifty nine of the 164 participants completed the questionnaire and were included in the analyses (Table 1). Around 41.5% of the mothers were from the United Kingdom (n = 66), 30.2% from Russia (n = 48), and 28.3% from China (n = 45). Approximately 81.7% of the participants had more than 12 years of full-time education, while 66.4% mothers had 13–19 years of full-time education (n = 113). Significant differences were observed in family income, marital status, and maternal education between countries.

Maternal feeding attitudes at 5–6 weeks postpartum

One hundred fifty-nine participants provided data on IIFAS at 5–6 weeks postpartum. Total IIFAS score was significantly different between countries (Table 2). Mean scores in Chinese and Russian mothers (China 64.58 ± 4.88 and Russia 61.52 ± 6.15) lay in the range of “neutral breastfeeding attitudes,” while British mothers had more positive attitudes (70.58 ± 6.47, post hoc p < 0.001). No significant differences were found in IIFAS between mothers of male and female infants (65.95 ± 6.73 versus 66.00 ± 7.48, p > 0.05). Parity, birth weight, and family income were not significantly associated with IIFAS scores. However, the number of years of full-time education was significantly positively correlated with mean IIFAS score in the whole sample (r = 0.41, p < 0.001) and in the United Kingdom (r = 0.28, p < 0.05).

Table 2.

Outcomes of the Iowa Infant Feeding Attitude Scale (Mean ± Standard Deviation)

Scale items	United Kingdom (n = 66)	China (n = 45)	Russia (n = 48)	F
1. The benefits of breastfeeding last only as long as the baby is breastfed^†	4.27 ± 0.97^a	4.13 ± 1.06^b	3.38 ± 0.96^a,b	12.310^**
2. Formula feeding is more convenient than breastfeeding^†	4.09 ± 1.08	3.91 ± 0.87	3.70 ± 1.18	1.936
3. Breastfeeding increases mother-infant bonding	4.76 ± 0.61	4.78 ± 0.42	4.72 ± 0.45	0.156
4. Breast milk is lacking in iron^†	3.79 ± 0.98^a,b	3.00 ± 0.95^a	3.20 ± 0.95^b	10.041^**
5. Formula-fed babies are more likely to be overfed than breastfed babies	3.88 ± 0.84^a	3.47 ± 0.69	3.24 ± 1.02^a	8.055^**
6. Formula feeding is the better choice if the mother plans to go back to work^†	3.50 ± 1.00^a	3.09 ± 1.04^b	2.14 ± 0.81^a,b	29.379^**
7. Mothers who formula feed miss one of the great joys of motherhood	3.61 ± 1.04^a	4.20 ± 0.66^a	4.02 ± 1.05	5.663^**
8. Women should not breastfeed in public places such as restaurants^†	4.74 ± 0.47^a,b	2.87 ± 1.08^a	2.88 ± 1.39^b	66.693^**
9. Breastfed babies are healthier than formula-fed babies	4.20 ± 0.85	4.56 ± 0.69^a	3.98 ± 0.87^a	6.021^**
10. Breastfed babies are more likely to be overfed than formula-fed babies^†	4.26 ± 0.69^a	3.02 ± 1.03^a	3.62 ± 1.12^a	23.364^**
11. Fathers feel left out if a mother breastfeeds^†	3.59 ± 0.99^a	3.89 ± 0.83	4.06 ± 0.87^a	3.948^*
12. Breast milk is the ideal food for babies	4.79 ± 0.41	4.78 ± 0.42	4.82 ± 0.44	0.134
13. Breast milk is more easily digested than formula	4.50 ± 0.69	4.53 ± 0.63	4.20 ± 0.88	3.151^*
14. Formula is as healthy for an infant as breast milk^†	4.15 ± 0.73^a	3.62 ± 0.86^a	2.74 ± 0.80^a	45.537^**
15. Breastfeeding is more convenient than formula	4.06 ± 0.93	4.18 ± 0.78	4.42 ± 0.84	2.523
16. Breast milk is cheaper than formula	4.82 ± 0.58	4.53 ± 0.51	4.70 ± 0.54	3.610^*
17. A mother who occasionally drinks alcohol should not breastfeed her baby^†	3.36 ± 1.20^a,b	2.02 ± 0.62^a	1.50 ± 0.89^b	57.461^**
Total score	70.58 ± 6.47^a,b	64.58 ± 4.88^a	61.52 ± 6.15^b	32.766^**

The Iowa Infant Feeding Attitude Scale is a 17-item questionnaire with a 5-point scale ranging from “strongly disagree” (1 mark) to “strongly agree” (5 marks) for each item. Total scores range from 17 to 85 with higher scores reflecting more positive attitudes toward breastfeeding. The total scores were grouped into three categories: positive to breastfeeding (70–85), neutral (49–69), and positive to formula feeding (17–48). Higher score means more agreement.

a,b

Significant differences detected by post hoc test (Bonferroni) at the 0.05 level. Between pairs with the same letter.

†

Reverse scored items; ^*p < 0.05, ^**p < 0.01, significant differences between groups using ANOVA.

ANOVA, analysis of variance.

The majority of the participants from all three countries agreed that “breast milk is the ideal food for babies” (Q3) and “breastfeeding increases mother-infant bonding” (Q12), with no significant differences between countries. While most mothers agreed that “Breast milk is the ideal food for babies,” significant differences were found between countries. Compared to Chinese and Russian mothers, British mothers had the lowest agreement with the statement “The benefits of breastfeeding last only as long as the baby is breastfed”(Q1), “Breast milk is lacking in iron”(Q4), “Formula feeding is the better choice if the mother plans to go back to work” (Q6), “Women should not breastfeed in public places such as restaurants”(Q8), and “Formula is as healthy for an infant as breast milk” (Q14). Chinese mothers had significantly higher scores for the statements “Mothers who formula feed miss one of the great joys of motherhood” (Q7) and “Breastfed babies are healthier than formula-fed babies” (Q9), and a lower score for “Breastfed babies are more likely to be overfed than formula-fed babies” (10). Russian mothers had higher agreement with the statement “Fathers feel left out if a mother breastfeeds” (Q11), but strongly disagreed with the statement “A mother who occasionally drinks alcohol should not breastfeed her baby” (Q17) compared to mothers from the United Kingdom (1.50 ± 0.89 versus 3.36 ± 1.20, p < 0.001).

Infant eating behavior at 5–6 weeks postpartum

One hundred forty six of the 164 mothers completed the BEBQ (Table 3). The number of completers was not significantly different between countries. Significant differences were found in “general appetite,” “satiety responsiveness,” and “enjoyment of food” among countries. Russian infants had higher scores for “general appetite” (mean = 4.79 ± 0.41) than British (mean = 4.02 ± 0.91, p < 0.01) and Chinese infants (mean = 4.36 ± 0.48, p < 0.01) and higher “satiety responsiveness” (mean = 1.73 ± 0.22, p < 0.01) than British infants (mean = 1.46 ± 0.48, p < 0.01). Russian infants also had the highest score for “enjoyment of food” (mean = 4.43 ± 0.48, p < 0.001) compared to Chinese and British babies. No significant association was found between family income, marital status, and infant eating behavior. Mothers with male infants reported bigger appetites and higher slowness in eating than those with female infants (4.5 versus 4.2 and 11.0 versus 10.1, respectively, p < 0.05).

Table 3.

Outcomes of the Baby Eating Behavior Questionnaire

	N	Mean	SD	95% Confidence interval for mean
	N	Mean	SD	Lower bound	Upper bound
Food responsiveness
China	44	3.44	0.52	3.28	3.60
United Kingdom	53	3.15	0.91	2.90	3.40
Russia	48	3.15	0.98	2.86	3.44
Total	151	3.24	0.85	3.10	3.38
Satiety responsiveness^**
China	45	1.69	0.24	1.62	1.76
United Kingdom	53	1.46	0.48	1.33	1.59
Russia	46	1.73	0.22	1.67	1.79
Total	150	1.62	0.36	1.56	1.68
General appetite^**
China	45	4.36^a	0.48	4.21	4.50
United Kingdom	53	4.02^b	0.91	3.77	4.27
Russia	48	4.79^a,b	0.41	4.67	4.91
Total	152	4.36	0.73	4.24	4.48
Enjoyment of food^*
China	45	4.18	0.38	4.07	4.30
United Kingdom	52	4.38	0.54	4.23	4.53
Russia	48	4.43	0.48	4.29	4.57
Total	151	4.33	0.48	4.26	4.41
Slowness eating
China	45	2.49	0.39	2.37	2.61
United Kingdom	51	2.64	0.76	2.43	2.85
Russia	48	2.80	0.71	2.59	3.01
Total	150	2.65	0.66	2.54	2.76

The Baby Eating Behavior Questionnaire is an 18-item questionnaire with a 5-point scale ranging from “never” (1 mark) to “always” (5 marks) for each item. Scoring requires calculation of mean scores for each subscale with higher mean scores indicating greater reported expression of the feeding behavior.

a,b

Significant differences detected by post hoc test (Bonferroni). Between pairs with the same letter.

p < 0.05, ^**p < 0.01, significant differences between groups using ANOVA.

ANOVA, analysis of variance; SD, standard deviation.

Infant feeding at 3 and 6 months postpartum

At 3 months, 116 of the 159 mothers who completed the questionnaire reported EBF (73%); this rate did not differ significantly by study center (80% China, 73% United Kingdom, and 78% Russia, p < 0.05). The proportion of mothers who were mainly BF at 3 months was 76.1% (121/159). At 6 months, 15.1% (24/159) and 18.9% (30/159) were EBF and mainly BF, respectively, while 68.0% (108/159) reported any BF.

At baseline, a total of 100 mothers (76%) aimed to EBF for 6 months. The goal for EBF was 5.5 months for Chinese mothers, 6.2 months for British mothers, and 6.3 months for Russian mothers. The proportion of mothers who attained their goal of EBF was 17%, 24%, and 27% for United Kingdom, China, and Russia, respectively. No significant differences were found between countries.

Predictors of infant feeding at 3 and 6 months

We assessed potential predictors of breastfeeding practice at 3 and 6 months, including years of full-time education, duration of skin-to-skin contact after birth, duration of hospital stay, individual and total IIFAS score, and the BEBQ scores by category. Since the data are from a randomized controlled trail comparing the effects of different breast pumps versus no pump, we also included the randomized group as a confounder. No significant predictors were identified for whether the mother met her own goal regarding EBF at 6 months. However, greater agreement with the IIFAS statement “Formula feeding is more convenient than breastfeeding” (item 2) was associated with lower EBF at 3 months (OR: 0.47, 95% CI: 0.29–0.78, p < 0.01).

Discussion

This study identified significant differences in infant feeding attitudes and infant eating behaviors between breastfeeding mothers in the United Kingdom, China, and Russia. The general attitude toward breastfeeding in China and Russia lay in the range of “neutral breastfeeding attitudes,” while mothers in the United Kingdom tended to report more positive attitudes toward breastfeeding. The number of years of full-time education was significantly positively correlated with maternal attitudes toward breastfeeding in the whole sample and in British mothers. For the assessment of infant eating behavior, infants from Russia received the highest score for “food responsiveness” and the lowest score for “enjoyment of food” at 5–6 weeks postpartum. Neither the total IIFAS score nor the BEBQ predicted EBF at 3 and 6 months postpartum. However, greater agreement with the IIFAS statement “Formula feeding is more convenient than breastfeeding” was associated with a lower EBF rate at 3 months.

Differences in both the total IIFAS scores and several individual IIFAS statements among the three countries may reflect cultural differences between these countries. In post hoc analyses, Chinese mothers had significantly higher scores for the statements “Mothers who formula feed miss one of the great joys of motherhood” (Q7) and “Breastfed babies are healthier than formula-fed babies” (Q9). This may originate from the traditional Chinese belief that breastfeeding is natural and a duty for a new mother. Moreover, Russian mothers strongly disagreed with the statement “A mother who occasionally drinks alcohol should not breastfeed her baby” (Q17) compared to those in the United Kingdom. This may be associated with cultural practices since Pridemore²⁴ reported that there is a long history of the integration of alcohol into Russian culture and daily routines. It could also reflect public health advice on alcohol consumption given to breastfeeding mothers in the different countries.

Result from our study also showed that breastfeeding attitudes at 5–6 weeks were not associated with EBF at 3 and 6 months. This differs from previous studies.^11,14,15,25 However, with the exception of Chen et al.,¹⁴ previous studies were not conducted in the same populations as our study. Although some of the participants in Chen et al.¹⁴ were Chinese, they were mothers of children younger than 5 years, which means most of them had finished breastfeeding some time before they were asked about their breastfeeding attitudes. Their attitudes may therefore have been influenced by their breastfeeding experiences. Also, some had taken part in a prenatal course that endorsed breastfeeding as the best feeding choice and this may have influenced the findings.

Although the total IIFAS score did not predict infant feeding at 3 and 6 months in our sample, greater agreement with the individual statement “Formula feeding is more convenient than breastfeeding” predicted lower EBF at 3 months. While breastfeeding may be regarded as more convenient than formula feeding, since there is no need to prepare feeds, previous studies suggest several factors related to convenience could influence breastfeeding initiation and success, including the perceived lack of freedom and independence, and difficulties when the mother has to return to work.^26–28 Attitudes toward breastfeeding in public may also be relevant.^26,29 These factors may contribute to the perception of breastfeeding is less convenient than formula, and represent potential targets for intervention.

For the assessment of infant eating behavior, Russian mothers gave higher scores for “general appetite” and “enjoyment of food” compared to Chinese and British babies. However, none of the BEBQ traits predicted infant feeding mode at 3 and 6 months. Several studies have shown that infant feeding mode may be associated with scores on the BEBQ. Mallan et al.¹⁹ reported that breastfed infants were rated higher on enjoyment of food than both formula-fed and mixed-fed infants and were eating more slowly than formula-fed infants. Formula-fed infants displayed higher satiety responsiveness than breastfed infants. Similar findings were found in a secondary analysis of the UPBEAT trial in 353 U.K. mothers, where formula-fed infants had significantly lower enjoyment of food compared to breastfed infants, with no significant differences for satiety responsiveness and slowness in eating.³⁰ Mallan et al.¹⁹ and Rogers and Blissett³¹ suggested that mothers with greater breastfeeding concerns may perceive that their infants have lower enjoyment of food and food responsiveness, but higher satiety responsiveness. Hence, considering the BEBQ is a self-reported measure, this may lead to bias. Furthermore, previous studies have only examined the association between infant feeding mode and infant eating behavior; we found no studies that assessed whether infant eating behaviors could predict the infant feeding mode later on. This research gap merits further investigation.

Consistent with other studies, we found that a longer duration of full-time education was associated with more positive attitudes toward breastfeeding.^10,11,14, For example, a cross-sectional study in 866 pregnant women in the United Kingdom reported that women with a first degree had significantly higher mean IIFAS scores than all other groups.¹⁰ Dennis³² showed that mothers who believe breastfeeding is more convenient, healthier, and cheaper are less likely to introduce formula to their infant than those who find breastfeeding to be embarrassing, restrictive, or uncomfortable.³² These findings suggest that initiatives aimed at altering maternal perceptions and attitudes toward breastfeeding should focus on women with less formal education.

To our knowledge, this is the first study to investigate maternal feeding attitudes and baby eating behaviors and their associations with breastfeeding outcomes in different cultures. One of the limitations of this study is the relatively small sample size. Nevertheless, 79.3% of the participants completed the questionnaire at 6 months. Due to the inclusion criteria for the study, all participants were committed to breastfeeding and the IIFAS was conducted at 5–6 weeks postpartum when the breastfeeding was established. This might limit the generalizability of the findings to the general population. Furthermore, although the versions of the IIFAS used in each country are validated, it is possible that there might still be cultural differences in how the statements are understood.

In conclusion, maternal attitudes toward infant feeding and perceptions of infant eating behavior differed between countries, but were generally not associated with EBF at 6 months. However, mothers with a greater baseline perception that formula feeding is more convenient than breastfeeding were less likely to EBF at 3 months. If confirmed, this could be a potential target for education.

Footnotes

Authors' Contributions

M.F. and Z.W. were involved in the original study concept and design. All the authors designed the protocol, translated the document, and collected the data. J.Y. analyzed the data and drafted the article. All the authors contributed to the critical input and revision of article.

Acknowledgments

The authors would like to thank the mothers and infants who participated in the original study. All research at Great Ormond Street Hospital NHS Foundation Trust and UCL Great Ormond Street Institute of Child Health is made possible by the NIHR Great Ormond Street Hospital Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

Disclosure Statement

The data on which the article is based are from a trial funded by a grant from Philips. There was no commercial involvement in the design of this study, the analysis of the data, or in the writing or editing of the article. No competing financial interests exist.

Funding Information

No funding was received for the data analysis or preparation of this article.

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