The Association Between Breastfeeding Self-Efficacy and Mode of Infant Feeding

Abstract

Introduction:

It is well established that low breastfeeding self-efficacy is associated with early breastfeeding cessation. Over the past several decades, expressed human milk feeding has increased among parents of healthy infants. Researchers have hypothesized an association between maternal breastfeeding confidence and expressed human milk feeding, but it has not been empirically examined. Therefore, the primary objective of this study was to assess the associations between breastfeeding self-efficacy and human milk expression practices. The secondary objective was to assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity.

Methods:

This study used a prospective cohort design. From 2017 to 2018, we recruited 821 healthy mothers with term births in two public hospitals in Hong Kong. Participants completed a self-administered questionnaire in the immediate postpartum period, which gathered information about sociodemographic characteristics and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). Participants were followed up for 6 months or until infants were weaned. The proportion and type of infant feeding were assessed at telephone follow-up.

Results:

The overall mean BSES-SF score in our sample was 46.5 (standard deviation = 10.1). Every one-point increase in the BSES-SF score was associated with 4–5% lower risk of any expressed human milk feeding and 4–7% higher odds of breastfeeding continuation across the first 6 months postpartum.

Conclusion:

Higher breastfeeding self-efficacy is associated with a lower risk of expressed human milk feeding and a longer duration of any and exclusive breastfeeding. Further studies should explore how improving breastfeeding self-efficacy may affect the mode of human milk feeding.

Introduction

In many high-income countries, breastfeeding initiation rates are increasing, but breastfeeding duration is still suboptimal. In the United States, although 84.1% of mothers initiate breastfeeding, only 58.3% are still breastfeeding at 6 months postpartum.¹

Similarly, in Hong Kong, 86.8% of mothers initiate breastfeeding, but only 43.1% continue to breastfeed at 6 months postpartum.² Reasons for breastfeeding cessation are multifactorial, including sociodemographic factors^3,4 and hospital practices.^5,6 In addition, experiencing breastfeeding difficulties⁷ and the perception of not having enough milk⁴ are commonly reported reasons for early weaning.

Low breastfeeding self-efficacy is another factor associated with early breastfeeding cessation.⁸ Breastfeeding self-efficacy theory was first proposed by Dennis⁹ and is derived from Bandura's self-efficacy theory.¹⁰ According to Bandura, self-efficacy is the ability of a person to take action to deal with a situation and it can influence the thought patterns, actions, and emotions.¹¹ Breastfeeding self-efficacy is defined as the mother's confidence in her ability to breastfeed her infant.⁹

Breastfeeding self-efficacy was developed based on four important sources of information: performance accomplishments, vicarious experiences, verbal persuasion, and physiological and affective states.⁹ The theory posits that increased exposure to the four sources of information increases a mother's breastfeeding self-efficacy, further affecting the mother's breastfeeding behavior, such as persistence in breastfeeding. Therefore, increasing breastfeeding self-efficacy can increase breastfeeding duration and exclusivity.^12,13

Breastfeeding persons provide breast milk to their infants through direct breastfeeding, expressed human milk feeding, or a combination of both (i.e., mixed-mode feeding). When feeding expressed human milk, human milk is removed from the breast, either by hand expression or using a breast pump, which is subsequently fed to the infant using a bottle, cup, or syringe.¹⁴ Research has shown inconsistent findings in the association between expressed human milk feeding and breastfeeding duration. Some studies show that expressed human milk feeding is associated with prolonged breastfeeding duration,^15,16 others show that expressed human milk feeding is associated with early breastfeeding cessation.^17,18

Some have found no association between human milk expression practices and breastfeeding duration.^19,20 Women express human milk for various reasons, such as problems with direct breastfeeding,²⁰ to allow others to feed the infant,²¹ and perceived insufficient milk.²² The increase in human milk expression has also been associated with a lack of maternal self-confidence in their ability to breastfeed successfully,²¹ especially among new parents for whom the ability to express and store milk may provide reassurance of their ability to breastfeed their infants. However, it has been argued that the use of breast pumps for human milk expression could potentially create a dependency on the pump and thus diminish women's confidence in breastfeeding.²³ This reliance on a breast pump could further reduce maternal breastfeeding confidence.²²

Researchers have hypothesized an association between maternal breastfeeding confidence and expressed human milk feeding, but it has not been empirically examined. One study examined the association between breastfeeding self-efficacy and the use of second-line strategies that helped to breastfeed, such as nipple shields, syringes, and cups. However, the study did not differentiate between different modes of expressed human milk feeding nor report the timing of use.²⁴ To our knowledge, no study has examined the association between breastfeeding self-efficacy and breast milk expression practices.

Understanding the association between breastfeeding self-efficacy in the immediate postpartum period and expressed human milk feeding may help early detection of breastfeeding problems and facilitate timely breastfeeding support. Therefore, the primary objective of this study was to assess the associations between breastfeeding self-efficacy and breast milk expression practices. The secondary objective was to assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity.

Methods

Design, setting, and participants

We conducted a prospective cohort study in Hong Kong from 2017 to 2018. The study methods are described in detail elsewhere.^25,26 A trained research nurse recruited participants from the postnatal obstetric units of two public hospitals in Hong Kong. At the time of this study, Hong Kong had 8 public and 10 private hospitals that provide obstetric services. In 2017, two-thirds (67%) of all births in Hong Kong were in public hospitals.²⁷ The two study hospitals were not designated as baby-friendly hospitals at the time of data collection.

Study inclusion criteria were as follows: women who had (1) a singleton pregnancy, (2) intention to breastfeed, (3) Cantonese speaking, (4) no serious medical or obstetric complications, and (5) term birth (≥37 weeks' gestation). Women were excluded if their infants had (1) a 5-minute Apgar score <8, (2) birth weight <2,500 g, (3) severe medical conditions or congenital malformations, (4) admission to the special care baby unit for 48 hours or more after birth, or (5) ever admitted to the neonatal intensive care unit.

Data collection and measurements

Participants self-completed a questionnaire immediately after recruitment. The questionnaire collected information on sociodemographic characteristics, family members' breastfeeding preferences, and participants' intention to feed expressed human milk and to exclusively breastfeed. The research nurse retrieved the maternal and neonatal birth data and in-hospital infant feeding data from the health records for the first 48 hours after birth from the health records. Participants received telephone follow-up at 1.5, 3, and 6 months postpartum or until breastfeeding ceased. The frequencies of the different modes of human milk feeding and the type of infant feeding in the 24-hour period preceding each telephone follow-up were collected according to standard practices.²⁸

Study definitions and variable descriptions

The primary exposure variable was breastfeeding self-efficacy, which was measured using the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF).²⁹ BSES-SF is the revised short form of the original BSES.³⁰ It consists of 14 items with a 5-point Likert scale. On the scale, “1” indicates “not at all confident” and “5” indicates “always confident.” The total score ranges from 14 to 70, with a higher total item score indicating a higher level of breastfeeding self-efficacy. The BSES-SF has been translated into multiple languages^31,32 and is a valid scale to measure breastfeeding self-efficacy worldwide.^33,34 A validated Chinese version of the BSES-SF was used.³¹ Its Cronbach's alpha coefficient in this sample was 0.94 (Supplementary Table S1).

The secondary outcomes assessed were the mode of breastfeeding and the continuation of any and exclusive breastfeeding at 1.5, 3, and 6 months postpartum. The operational definitions of the mode of human milk feeding and infant feeding categories are summarized in Supplementary Table S2. The mode of breastfeeding was classified based on the proportion of expressed human milk feeding: (i) direct breastfeeding only (0%), (ii) mixed-mode feeding (>0% to <100%), and (iii) expressed human milk feeding only (100%). We combined participants into one mixed-mode feeding group as the data were highly skewed, and there were no significant differences in the findings between participants with different levels of expressed human milk feeding.

Any expressed human milk feeding indicated that infants received some amount of expressed human milk among all human milk feedings. Expressed human milk feeding only means that infants received expressed human milk feeding only and did not receive any human milk directly from the breast. The proportion of expressed human milk feeding was measured using only the human milk feedings, irrespective of the overall exclusivity of breastfeeding.

Any breastfeeding was defined as the infant receiving any human milk and exclusive breastfeeding is defined as feeding only human milk and no other liquids or solids, except for vitamin and mineral supplements or medicines.²⁸ The continuation of any and exclusive breastfeeding were recorded as yes or no and did not differentiate between the modes of breastfeeding. The proportion of participants providing any and exclusive breastfeeding exclusivity was assessed at 1.5, 3, and 6 months postpartum and categorized into three groups: exclusive breastfeeding, any or partial breastfeeding, and exclusive formula feeding.

Several confounding variables were also measured.^4,35–37 These confounders were maternal age, maternal education level, monthly family income, length of residence in Hong Kong, intention to return to work postpartum, previous breastfeeding experience, intention to breastfeed exclusively, partner's infant feeding preference, and attendance at a breastfeeding class.

Statistical analysis

Descriptive statistics were used to describe the characteristics of the participants. Analysis of variance was conducted to compare the mean BSES-SF scores among participants with different breastfeeding exclusivity and mode of breastfeeding at 1.5, 3, and 6 months. We used multinomial logistic regression to examine the association between breastfeeding self-efficacy and breast milk expression practices. Models were built based on the proportion of expressed breast milk feeding, that is, any expressed human milk feeding and expressed human milk feeding only.

To understand the association between breastfeeding self-efficacy, the proportion of expressed human milk feeding, and the mode of infant feeding, we included infants who received exclusive formula feeding in the analysis. Previous research has also shown that mode of breastfeeding is associated with breastfeeding exclusivity.^17,25 Therefore, the participants were stratified by breastfeeding exclusivity, that is, partial breastfeeding and exclusive breastfeeding.

To assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity, bivariable and multivariable logistic regression was used to compute the odds of any and exclusive breastfeeding at 1.5, 3, and 6 months postpartum. Hosmer–Lemeshow test was used to assess the goodness of fit of all the logistic models.³⁸ Variance inflation factor (VIF) was used to assess the presence of multicollinearity problem.³⁹ All analyses were carried out using Stata version 14.0 (Stata Corp, College Station, TX). A 95% confidence interval (CI) and 0.05 level of significance were used throughout the analyses.

Ethical approval

This study was approved by institutional review boards of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 16-2045) and the participating hospitals [KW/EX-17-050(109–15); KC/KE-16-0261/ER-1]. The study was conducted in accordance with the principles of the Helsinki Declaration. In addition, we obtained informed written consent from all participants at recruitment. Patient confidentiality was preserved at all times.

Results

The flow of participant recruitment and follow-up is shown in Figure 1. All study participants self-identified as female. Among the 821 recruited participants, 64 participants were excluded for the following reasons: not meeting the inclusion criteria (n = 16), no demographic data provided (n = 5), withdrawn from study (n = 1), and not completing the BSES-SF questionnaire (n = 4). Another 38 participants were completely lost to follow-up after recruitment, leaving 757 participants in the analysis. There were 747, 725, and 684 participants with complete data at 1.5, 3, and 6 months, respectively.

FIG. 1.

Flow diagram of participant recruitment and follow-up. NICU, neonatal intensive care unit.

The characteristics of the study participants are presented in Table 1. The majority were born in Hong Kong (56.7%) and intended to return to paid employment (60.6%). Approximately one-half of participants reported no previous breastfeeding experience (48.8%) and no partner preference of infant feeding method (50.5%). More than half of participants intended to exclusively breastfeed their infants (56.3%).

Table 1.

The Characteristics of the Study Participants (n = 757)

Demographic variable	Total, N = 757 (%)
Maternal age (years)
18–29	236 (31.2)
30–34	324 (42.8)
≥35	197 (26.0)
Maternal education
≤Secondary	367 (48.5)
Postsecondary	152 (20.1)
University degree or above	238 (31.4)
Monthly family income (HKD)^a
<$15,000	48 (6.3)
$15,000–$34,999	389 (51.4)
≥$30,000	320 (42.3)
Length of residence in Hong Kong
<5 years	66 (8.7)
≥5 years	262 (34.6)
Since birth	429 (56.7)
Intention to return to work postpartum
No	298 (39.4)
Yes	459 (60.6)
Previous breastfeeding experience
No	388 (51.3)
Yes	369 (48.8)
Intention to exclusively breastfeed
No	331 (43.7)
Yes	426 (56.3)
Partner's infant feeding preference
Breastfeeding	289 (38.2)
No preference	382 (50.5)
Infant formula and mixed feeding	86 (11.4)
Attended antenatal breastfeeding class(es)
No	425 (56.1)
Yes	332 (43.9)

1 USD = 7.78 HKD.

HKD, Hong Kong dollars.

The overall mean BSES-SF score was 46.5 (standard deviation = 10.1), with a range from 17 to 70. The mean baseline BSES-SF scores by the mode of infant feeding and exclusivity of breastfeeding at different time points are shown in Figure 2. Participants who were exclusively breastfeeding generally had higher baseline BSES-SF scores than partially breastfeeding participants. When compared with participants who had mixed-mode feeding and expressed human milk feeding only, participants who had direct breastfeeding only had higher baseline BSES-SF scores (p < 0.001).

FIG. 2.

Mean baseline BSES-SF scores by infant feeding method and mode of infant feeding at (A) 1.5, (B) 3, and (C) 6 months postpartum. BF, breastfeeding; BSES-SF, Breastfeeding Self-Efficacy Scale-Short Form; DBF, direct breastfeeding; EHM, expressed human milk; FF, formula feeding.

At 1.5 months postpartum, among participants who were exclusively breastfeeding, participants who fed breast milk directly had 5.0 and 3.8 points higher BSES-SF scores than participants who had mixed-mode feeding and expressed human milk feeding only, respectively.

Table 2 presents the unadjusted and adjusted relative risk ratios (aRRs) of BSES-SF scores on any expressed human milk feeding. Higher baseline breastfeeding self-efficacy scores were associated with a decreased risk of expressed human milk feeding and exclusive formula feeding at the three time points. At 1.5 months postpartum, every one unit increase in the baseline BSES-SF score was associated with a 4% (aRR = 0.96; 95% CI: 0.94–0.98) and 8% (aRR = 0.92; 95% CI: 0.89–0.94) decrease in the risk of any expressed human milk feeding and exclusive formula feeding, respectively.

Table 2.

Unadjusted and Adjusted Relative Risk Ratios of Breastfeeding Self-Efficacy Short Form Scores on Any Expressed Human Milk Feeding and Exclusive Infant Formula Feeding at 1.5, 3, and 6 Months Postpartum

	RR ratio (95% CI)
	1.5 months (N = 747)		3 months (N = 725)		6 months (N = 684)
	RR	aRR^a	RR	aRR^a	RR	aRR^a
Total
Breastfeeding women
No EHM feeding	1.0	1.0	1.0	1.0	1.0	1.0
Any EHM feeding	0.95 (0.93–0.96)	0.96 (0.94–0.98)	0.93 (0.91–0.95)	0.95 (0.93–0.98)	0.94 (0.92–0.96)	0.96 (0.94–0.99)
Exclusive formula feeding	0.90 (0.87–0.92)	0.92 (0.89–0.94)	0.89 (0.87–0.91)	0.92 (0.89–0.95)	0.91 (0.89–0.93)	0.93 (0.91–0.96)
Participants who had exclusive breastfeeding
Breastfeeding women
No EHM feeding	1.0	1.0	1.0	1.0	1.0	1.0
Any EHM feeding	0.95 (0.93–0.97)	0.97 (0.94–0.996)	0.92 (0.89–0.95)	0.94 (0.91–0.98)	0.94 (0.91–0.96)	0.97 (0.93–1.00)
Exclusive formula feeding	0.89 (0.87–0.91)	0.91 (0.88–0.94)	0.87 (0.84–0.89)	0.90 (0.86–0.93)	0.89 (0.86–0.91)	0.92 (0.90–0.95)
Participants who had partial breastfeeding
Breastfeeding women
No EHM feeding	1.0	1.0	1.0	1.0	1.0	1.0
Any EHM feeding	0.95 (0.92–0.98)	0.96 (0.93–0.99)	0.94 (0.91–0.98)	0.96 (0.92–1.00)	0.94 (0.91–0.98)	0.96 (0.92–1.00)
Exclusive formula feeding	0.91 (0.88–0.94)	0.92 (0.89–0.95)	0.93 (0.90–0.96)	0.94 (0.91–0.98)	0.93 (0.90–0.96)	0.95 (0.91–0.98)

Adjusted for the following variables: maternal age, educational level, family income, length of residence in Hong Kong, intention to return to work postpartum, previous breastfeeding experience, intention to exclusively breastfeed, husband's infant feeding preference, and breastfeeding class attendance.

aRR, adjusted relative risk ratio; CI, confidence interval; EHM, expressed human milk; RR, relative risk.

Furthermore, Table 3 shows that a higher BSES-SF score is associated with a lower risk of expressed human milk feeding only at 6 months postpartum (aRR = 0.94; 95% CI: 0.91–0.98). There was no association between BSES-SF scores and expressed human milk feeding only at 1.5 and 3 months postpartum. After stratification for the exclusivity of breastfeeding, the BSES-SF score was associated with 6% decreased risk of expressed human milk feeding only among participants who were exclusively breastfeeding, whereas there was no association between BSES-SF score and expressed human milk feeding only among participants who were partially breastfeeding.

Table 3.

Unadjusted and Adjusted Relative Risk Ratios of Breastfeeding Self-Efficacy Short Form Scores on Expressed Human Milk Feeding Only and Exclusive Infant Formula Feeding at 1.5, 3, and 6 Months Postpartum

	RR ratio (95% CI)
	1.5 months (N = 747)		3 months (N = 725)		6 months (N = 684)
	RR	aRR^a	RR	aRR^a	RR	aRR^a
Total
Breastfeeding women
Any DBF	1.0	1.0	1.0	1.0	1.0	1.0
EHM feeding only	0.97 (0.95–0.996)	0.99 (0.97–1.02)	0.96 (0.94–0.98)	0.98 (0.95–1.00)	0.93 (0.90–0.96)	0.94 (0.91–0.98)
Exclusive formula feeding	0.92 (0.90–0.94)	0.94 (0.91–0.96)	0.93 (0.91–0.95)	0.95 (0.93–0.97)	0.93 (0.91–0.94)	0.94 (0.92–0.96)
Participants who had exclusive breastfeeding
Breastfeeding women
Any DBF	1.0	1.0	1.0	1.0	1.0	1.0
EHM feeding only	0.98 (0.94–1.02)	0.98 (0.94–1.03)	0.97 (0.94–0.998)	0.97 (0.94–1.01)	0.92 (0.88–0.96)	0.94 (0.89–0.99)
Exclusive formula feeding	0.91 (0.89–0.93)	0.92 (0.90–0.95)	0.91 (0.89–0.93)	0.93 (0.90–0.95)	0.91 (0.89–0.93)	0.93 (0.91–0.95)
Participants who had partial breastfeeding
Breastfeeding women
Any DBF	1.0	1.0	1.0	1.0	1.0	1.0
EHM feeding only	0.98 (0.95–1.02)	1.00 (0.96–1.03)	0.97 (0.94–1.01)	0.99 (0.95–1.03)	0.95 (0.91–0.99)	0.95 (0.91–1.00)
Exclusive formula feeding	0.94 (0.91–0.96)	0.94 (0.91–0.97)	0.96 (0.94–0.98)	0.97 (0.94–0.99)	0.95 (0.93–0.98)	0.96 (0.93–0.99)

aRR, adjusted relative risk ratio; CI, confidence interval; DBF, direct breastfeeding; EHM, expressed human milk; RR, relative risk.

Higher baseline BSES-SF scores were also significantly associated with the continuation of any breastfeeding (adjusted odds ratio [aOR] = 1.07; 95% CI: 1.04–1.09) and exclusive breastfeeding (aOR = 1.05; 95% CI: 1.03–1.07) at 1.5, 3, and 6 months postpartum (Table 4). Each one-point increase in the baseline BSES-SF score was associated with a 5% to 6% increased odds of continuation across the first 6 months postpartum. Similarly, each one-point increase in the baseline BSES-SF score was associated with a 7%, 6%, and 4% increased odds of continuation of any breastfeeding at 1.5, 3, and 6 months, respectively. The p-value of the Hosmer–Lemeshow goodness-of-fit test for the logistic regression models ranged from 0.09 to 0.92, indicating that the models fit the data well. VIF values showed no evidence of substantial multicollinearity.

Table 4.

Unadjusted and Adjusted Association Between Breastfeeding Self-Efficacy Short Form Scores and Any and Exclusive Breastfeeding Continuation (n = 757)

	Breastfeeding continuation at specific time points
	1.5 months		3 months		6 months
	OR (95% CI)	aOR^a	OR	aOR^a	OR	aOR^a
Any breastfeeding
BSES-SF scores	1.08 (1.06–1.10)	1.07 (1.04–1.09)	1.07 (1.05–1.09)	1.06 (1.04–1.08)	1.06 (1.04–1.07)	1.04 (1.02–1.06)
Exclusive breastfeeding
BSES-SF scores	1.07 (1.05–1.09)	1.05 (1.03–1.07)	1.08 (1.06–1.10)	1.06 (1.04–1.09)	1.07 (1.05–1.09)	1.05 (1.03–1.07)

aOR, adjusted odds ratio; BSES-SF, Breastfeeding Self-Efficacy Scale-Short Form; CI, confidence interval; OR, odds ratio.

Discussion

Higher breastfeeding self-efficacy measured in the immediate postpartum period was significantly associated with a lower risk of any expressed human milk feeding and continuation of any and exclusive breastfeeding across the first 6 months. This study also found lower baseline BSES-SF scores in participants who fed expressed human milk only at 6 months postpartum. These findings suggest that although some participants with lower breastfeeding self-efficacy continue to breastfeed, they are more likely to feed expressed human milk only, possibly to overcome breastfeeding problems or for other reasons.

Participants with lower breastfeeding self-efficacy have a higher risk of expressed human milk feeding and expressed human milk feeding itself is associated with shorter breastfeeding duration.^17,18,40 One of the possible explanations is that performance accomplishments are the main source of breastfeeding self-efficacy.⁹ Low breastfeeding self-efficacy is associated with breastfeeding problems⁴¹ and perceived insufficient milk.⁴² Perceived insufficient milk is one of the major reasons why women express human milk²² and stop breastfeeding.⁴ Therefore, expressed human milk feeding may further increase the risk of early breastfeeding cessation in people with low breastfeeding self-efficacy.

Furthermore, women who fed only expressed human milk are also more likely to supplement with infant formula,²⁵ and it has been well established that infant formula supplementation is highly detrimental to breastfeeding continuation.⁵ This may be one possible explanation for why persons with lower breastfeeding self-efficacy were more likely to feed expressed human milk only.

It is also increasingly common for women to procure a breast pump,⁴³ often before they give birth. The wide availability of effective breast pumps allows breastfeeding persons to continue to provide human milk when they encounter breastfeeding difficulties. One study reported that 97.5% of participants who experienced breastfeeding difficulties had ever fed expressed human milk.⁴⁴ The availability of a breast pump also provides a superior alternative to infant formula supplementation and enables people to continue human milk feeding when they encounter difficulties with direct breastfeeding.

Similar to the results of other studies,^12,13 this study found that higher breastfeeding self-efficacy is associated with a longer duration of any and exclusive breastfeeding. In this sample, the mean breastfeeding self-efficacy score was 46.5, similar to reports from other high-income countries that reported BSES-SF scores ranging from 44.7 to 52.0.^12,42,45,46 One study reported that a BSES-SF score of <50 indicated early cessation of exclusive breastfeeding and recommended that additional breastfeeding support be provided.⁴⁷

Interventions designed to improve breastfeeding self-efficacy are, therefore, recommended to increase the duration of exclusive breastfeeding. A meta-analysis of breastfeeding self-efficacy interventions found that each one-point increase in the BSES-SF scores between intervention and control groups increased the odds of exclusive breastfeeding by 10%.¹³

To our knowledge, this study is the first study that assessed the association between breastfeeding self-efficacy and the mode of breastfeeding. It is well established that BSES-SF is predictive of breastfeeding duration and exclusivity.³⁴ This study shows that it may also be predictive of the mode of breastfeeding. Breastfeeding self-efficacy was lower in participants who were partially breastfeeding and exclusively formula feeding. Increased support is needed for people who are feeding expressed human milk only. The experiences of participants who were feeding expressed human and how these experiences relate to breastfeeding self-efficacy need to be further explored.

Our study has some limitations. First, the study was not population based, and the generalizability of the findings may be limited to groups that are similar to the study participants. Only participants who were intending to breastfeed were recruited, and selection bias may occur. The study participants may have had more favorable perceptions of breastfeeding, they may have also had greater breastfeeding self-efficacy and thus scored higher on the BSES-SF when compared with the general population. However, the mean BSES-SF scores of study participants were lower than those reported in other studies.^12,34

Second, we used a prospective cohort study design wherein participants were asked to recall details about the mode of infant feeding and the amount of feeding. As such, the findings may be susceptible to some recall bias. However, we attempted to minimize recall bias by limiting the recollection of infant feeding details to the 24-hour period before the telephone follow-up as suggested by the World Health Organization.⁴⁸

Conclusion

Breastfeeding self-efficacy is associated with a lower risk of expressed human milk feeding and a longer duration of any and exclusive breastfeeding. As the mean self-efficacy level in the sample was low, interventions may be needed to increase breastfeeding self-efficacy in the early postpartum period. Interventions should be especially targeted toward pregnant people with lower breastfeeding self-efficacy. Further studies can explore the experiences of people with high levels of expressed human milk feeding and how improving breastfeeding self-efficacy can affect the mode of breastfeeding.

Footnotes

Acknowledgment

We thank the University of Hong Kong for supporting this study.

Authors' Contributions

H.S.L.F. contributed to formal analysis, investigation, data curation, writing—original draft, writing—review and editing, and visualization. D.Y.T.F. was involved in writing—review and editing. K.Y.W.L. was in charge of resources, writing—review and editing, project administration, and funding acquisition. M.T. carried out conceptualization, methodology, formal analysis, writing—review and editing, visualization, and supervision.

Disclosure Statement

We declare that we have no conflict of interest.

Funding Information

This study was supported by the University of Hong Kong (Grant No. 201702159003). The funder had no role in the study design, data collection or analysis, interpretation of the findings, or drafting of the article.

Supplementary Material

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