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A Literature Review of the Factors That Influence Breastfeeding: An

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 International Journal of Nursing and Health Science
2015; 2(3): 28-36
Published online June 10, 2015 (http://www.openscienceonline.com/journal/ijnhs)

A Literature Review of the Factors That Influence

Breastfeeding: An Application of the Health Belief
Model
Andy Emmanuel1, 2
1
Department of Nursing science, Faculty of Medical sciences University of Jos, Jos, Plateau State, Nigeria
2
Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa

Email address
[email protected]

To cite this article

Andy Emmanuel. A Literature Review of the Factors That Influence Breastfeeding: An Application of the Health Believe Model.
International Journal of Nursing and Health Science. Vol. 2, No. 3, 2015, pp. 28-36.

Abstract
Breastfeeding is beneficial for both mother and child. Exclusive breastfeeding rate and early initiation of breastfeeding has not
reached desirable level in many countries. Understanding the factors that influence infant feeding will help in promotion,
protecting and supporting breast feeding. This review identified the determinants of infant feeding practices and presented it
using the Health Belief Model as a frame work. Several data bases were searched with specific keywords and findings reveal
that maternal sociodemograhpic characteristic like age, education, parity, economic status, and employment may influence
breastfeeding. Other factors include, antenatal attendance, multiple births, type of delivery, previous breastfeeding experience,
breastfeeding support, Knowledge of individual’s feeding as babies, maternal prenatal feeding intention and infant birth weight.
Women will breastfeed as recommended if they are influenced to develop a positive perception about breastfeeding.
Keywords
Breastfeeding, Determinants, Health Belief Model, Breastfeeding Intention, Infant Feeding

& Erickson, 2010). Breastfeeding has a beneficial effect on

1. Introduction the health of women. Studies have shown that breastfeeding
helps in losing pregnancy weight faster (Kramer and Kakuma
Suboptimal breastfeeding is responsible for the death of 2012; Baker Gamborg, Heitmann, Lissner, et al 2008; Sanusi
1.4 million children and the disability of 44 million globally and Falana, 2013). A study revealed that women who
(Black et al, 2008). Therefore, it has been recommended that breastfed lost 4.4kg within a year, while those who did not
all women should breastfeed their infants exclusively in the breastfeed only lost 2.4 kg (P<0.05) (Dewey, Heinig and
first six months and subsequently with supplementary Nommsen, 1993).This underlines the effectiveness of
feeding for 2 years for optimal growth and development breastfeeding especially if practiced exclusively in the first
(UNICEF, 2013). The World Health Organization and six months, in reducing weight gain during pregnancy.
UNICEF had launched several programmes like the baby Breastfeeding promotes uterine contraction, thereby reducing
friendly hospital initiative and the International Code of blood loss after delivery and promotes uterine involution
Marketing of Breast Milk Substitutesin order to protect, (NRDC, 2005). Breastfeeding reduces the risk of type 2
promote and support breastfeeding in response to persistent diabetes and cardiovascular diseases (Davis, Stichler and
decline in the rate of breast feeding globally (Fairbank et al, Poeltler, 2012). It also lowers the risk of breast, endometrial
2000; UNICEF, 2013). The factors that influence infant and ovarian cancers (Labbok, 2001; NRDC, 2005; Centre for
feeding are complex and vary from one setting to another. Community Child Health, 2006; Huo, Adebamowo, et al
Understanding these factors is necessary in addressing the 2008; Sule, 2011; Davis, Stichler and Poeltler, 2012).
declining rate of breastfeeding. Absence of menstruation due to breastfeeding serves as
Exclusive Breastfeeding for six months is beneficial for temporary contraception for some women (Kuti, Adeyemi
women because it ensures better reproductive and and Owolabi, 2007).This is effective for some women who
postmenopausal health (NRDC, 2005; Murimi Dodge, Pope, breastfed exclusively for six months (Kuti, Adeyemi and
 International Journal of Nursing and Health Science 2015; 2(3): 28-36 29

Owolabi, 2007).Breastfeeding is cost effective as finances do times greater chance of survival in the early months than
not have to be set aside for infant formula (NRDC, 2005 non-breastfed children (UNICEF, 2013). Early breastfeeding
Centre for Community Child Health, 2006).Breastfeeding reduce infant morbidity and mortality as a result of the
gives women a sense of bonding with their babies (NRDC, preventive benefits of breastfeeding in reducing long term
2005 Centre for Community Child Health, 2006) and diseases (WHO, 2007).
promotes mental health of women (Davis, Stichler and The aim of this review is to utilise the Health Believe
Poeltler, 2012). Model to highlight the factors that influence breastfeeding
Breastfeeding is also beneficial for the infant. Adequately practices globally. Understanding these factors and how they
breastfed infants grow more rapidly and are healthier than influence various infant feeding practices is important in
those who were not (Ukegbu, Ebenebe and Ukegbu, 2010, improving breastfeeding practice through appropriately
Gale, Logan, et al, 2012). Breast milk confers a child with targeted and designed promotion programs.
significant protection against many infectious diseases
because it containsantibodies (immuno globulins) that 2. Literature Search
strengthen the Childs immunity (Ukegbu, 2010; Murimi et al,
2012; Lamberti, Zakarija-Grković, et al, 2013). Breastfeeding CINAHL, GOOGLE SCHOLAR, MEDLINE through
reduces the incidence of meningitis, malaria, asthma, PUBMED and EBSCO were searched using the following
respiratory diseases (such as pneumonia), ear infection, key words; exclusive breastfeeding or formula feeding or
diarrhoea, and urinary tract infection (Ukegbu, 2010; mixed feeding and Health Belief Model, benefit of
Murimiet al, 2012; Ibadin et al, 2012; Lamberti et al 2013). breastfeeding, breastfeeding and infant feeding practices.
Kramer and Kakuma (2012) posited that in the first six Articles published from 2005 to date were included. Articles
months of life, exclusive breastfed infants are six times less with information about factors that influence infant feeding
likely to die from diarrhoea and 2.5 times less likely to die with regards to initiation, mixed feeding, formula feeding,
from acute respiratory infection. Breastfeeding lowers the exclusive breastfeeding and duration of feeding were also
risk of allergy and food intolerance and improve brain included.
development (Centre for Community Child Health, 2006: 7). Articles without key words related to the search terms
Infants exclusively breastfed for six months have higher IQ, were excluded. Additional literature was sourced from WHO
lower risk of childhood obesity, diabetes and lower risk of and UNICEF websites, reference checking, and text books.
mental health problems, as they enter their teenage (UNICEF,
2010, Davis, et al 2012). Breastfed children have at least six

Figure 1. The Health Belief Model (Adapted from Kabiru, Beguy, Crichton, and Zulu, 2011)1.

1The Health Belief Model depicted in Figure1 was originally used by Kabiru et al (2011) in a study of HIV/AIDS among youths in Kenya. For this study the topic has
been changed from HIV/AIDS to breastfeeding.
30 Andy Emmanuel: A Literature Review of the Factors That Influence Breastfeeding: an Application of the Health Believe Model

2009). If women are aware of the benefits of adequate

3. Discussion breastfeeding for them and their infants, they may likely
practice it. Most women do not practice breastfeeding as
The Health Belief Model was developed in the 1950s to recommended probably because they are ignorant of the
explain why medical screening programs in the US were not benefit of associated with such practice. Adequate
successful (Hayden, 2009). Hayden (2009:1) concluded that enlightenment especially during antennal care is vital in
“The underlying concept of the original Health Belief Model promotion breastfeeding.
is that, health behaviour is determined by personal beliefs or
perceptions about a disease and the strategies available to 3.4. Perceived Barrier
decrease its occurrence”. The main constructs of the model This is an individual’s own evaluation of the obstacles in
are: perceived susceptibility (individual’s perception of the way of him or her adopting a new behaviour. Women
exposure to danger and likelihood to contract a disease), have various experiences with breastfeeding (Schmied and
perceived severity or seriousness (individual’s perception of Barlay, 1999). Mothers commonly complain of painful / sore
the gravity of disease), perceived barriers and perceived nipple or breast (Lamontagne, Hamelin et al, 2008; Raffle,
benefits (Janz and Becker, 1984; Hayden, 2009). Three more Ware et al, 2011; Jager (2012), low milk
constructs were added later resulting in the expansion of the production(Lamontagne, Hamelin et al, 2008;Raffle, Ware et
Health Belief Model to include modifying variables, cues to al, 2011; Jager, 2012; Mutekanga and Atekyereza, 2007;
action and self-efficacy (Hayden, 2009). According to Muluye, 2012), Infants refusal to suck (Lamontagne,
Hayden (2009), the first four constructs are modified by Hamelin et al, 2008; Jager (2012), breast infection, maternal
variables such as culture, past experience, educational level, illness (Doherty, Sanders et al, 2012), and Stress(Ugbaoja,
skill and motivation to produce the individual perception. Berthrand, et al, 2013). Others include exclusive
The individual perception together with cues to action and breastfeeding not culturally acceptable (Ugbaoja, Berthrand,
self-efficacy determine the health behaviour or action (see et al 2013; Ajibade, Okunlade et al, 2013), husband refusal
Figure 1). (Ugbaoja, Berthrand et al, 2013) and delayed milk production
3.1. Personal Perception after delivery (Mutekanga and Atekyereza, 2007). Most
women can breastfeed as recommended if given the support
Perceived seriousness, Perceived susceptibility, Perceived they need to overcome barriers associated with breastfeeding
benefits, and Perceived barriers /cost of action are important (UNICEF, 2013).
determinants of health behaviour. The practice of
breastfeeding in a particular community depends on general 3.5. Modifying Variables
perception of the community about breastfeeding. The four major constructs of perception are modified by
3.2. Perceived Seriousness / Perceived other variables such as culture, educational level, past
Susceptibility experiences, skill, socio-demographic variables and
motivation.
The perception of seriousness is a function of medical
information or knowledge an individual has about a disease 3.6. Maternal Age
(Hayden, 2009). It may also come from beliefs a person has The relationship between maternal age and infant feeding
about the difficulties a disease would create or the effect it practices differs from place to place. Ogunlesi (2010) posited
would have on his or her life in general(Hayden, 2009).The that maternal age is not a significant determinant of
tendency of engaging in behaviour to reduce risk of a disease breastfeeding. On the other hand, other studies have
increases with increased perceived risk of the diseases. demonstrated that maternal age at the time of birth influenced
An adequate breastfeeding education will enable women to breastfeeding initiation and duration (Li, Zhang, et al 2004;
understand and appreciate the seriousness of health Centre for Community Child Health 2006). Studies have
challenges associated with suboptimal breastfeeding. If shown that older maternal age is associated with exclusive
women understood the degree of health challenges that may breastfeeding and longer duration of breastfeeding (Bolton,
arise due to inadequate infant feeding, it is likely that they Chow,et al 2009; Ukegbu, et al 2010), while others,
will change for the benefit of their health and that of their associated low rates of exclusive breastfeeding with younger
baby. Inadequate knowledge regarding breastfeeding maternal age (Qureshi, Oche, et al, 2011; Lawoyin et al, 2001;
negatively influence infant feeding. Brown, Raynor, et al, 2011). These findings suggest that the
3.3. Perceived Benefits relationship between maternal age and breastfeeding varies
from place to place, therefore, health workers should
This is a person’s view of usefulness of new behaviour in understand how maternal age influence breastfeeding
reducing the risk of developing a disease; people tend to practices in their locality in order to plan better promotion
adopt healthier behaviour when they believe a new behaviour intervention.
will decrease their chances of developing a disease (Hayden,
 International Journal of Nursing and Health Science 2015; 2(3): 28-36 31

3.7. Education 3.9. Economic Status

The influence of education on infant feeding practices Studies have shown that high socio-economic status was
varies from one setting to another (Centre for Community significantly related to low exclusive breastfeeding rate, and
Child Health, 2006; Ahmed, 2008; Sapna, Ameya 2009; short duration of overall breastfeeding (Lawoyin, Olawuyi, et
Okeh, 2010; Ajibade et al 2013).Maternal education below al, 2001; Okeh, 2010; Ekanem, Ekanem, et al 2012; Ajibade,
secondary level contributed to prelacteal feeding and failure Okunlade et al, 2013). This is not unconnected to the
to practice exclusive breastfeeding (Ogunlesi, 2010).Women employment status of women with high economic status
with low level of education are less likely to practice which has a negative impact on breast feeding. A contrary
exclusive breastfeeding (Li,Zhang et al, 2004; Uchendu, opinion was reported by Velpuri, (2004) in which women
Ikefuna, and Imodi, 2009; Qureshi,Oche et al,2011). On the with high income status were associated with a high
other hand, another study reported that lower maternal breastfeeding rate. Adelekan (2003) identified low economic
education attainment is related to increase in breastfeeding status as one of the most important determinants of
practices (Lawoyin, et al 2001).Highly educated women may suboptimal breastfeeding (non-exclusive and short duration)
be able to breastfeed exclusively as recommended because and concluded that significant improvement in the socio-
they are more likely to understand the benefits of economic status of women could help reduce childhood
breastfeeding when compared with less educated women malnutrition.
who may not see any need for that but may breastfeed longer
as a tradition. An enlightenment campaign in various 3.10. Marital Status
languages centered on the benefits of exclusive breastfeeding Marital status of a woman is an important determinant of
could help improve practice. infant feeding practices in some setting (Sika-Bright, 2010;
3.8. Occupation/Employment Ajibade, Okunlade et al 2013). Suboptimal infant feeding is
common with single mothers (Kimani-murage, Madise, et al,
Many scholars posited that maternal employment is in a 2011; Tampah-Naah and Kumi-Kyereme, 2013).Studes
continuous competition with breastfeeding (Okeh, 2010; concluded that single mothers are less likely to breastfeed
Raffle, Ware, et al, 2011;Muluye,) and may even be a barrier adequately and longer due to absence of partners’ support and
to breastfeeding (Velpuri, 2004; Ajibade, Okunlade et al 2013) confidence compared with married mothers (Lamontagne,
especially if there is no adequate planning for breastfeeding Hamelin, et al, 2008; Ajibade, Okunlade et al 2013). This
mothers in the workplace. Women’s work may have a conclusion was reached following a chi-square analysis that
negative impact on breastfeeding because of inadequate time indicated a significant relationship (P=0.01) between marital
to breastfeed (Ukwuani and Suchindran, 2003). Working status and exclusive breastfeeding and duration of
outside the home after birth was reported to have breastfeeding.
significantly reduce the likelihood of exclusive breastfeeding
at six months (Xu, Binns, et al, 2007; Qureshi, Oche, et al 3.11. Parity
2011; Chuang, Chang, et al, 2010;Matias, Nommsen-Rivers, The effect of parity on infant feeding and breastfeeding in
et al 2013).Jager, Hartley, et al (2012) identified return to particular is inconclusive because in some settings multi
work as an important factor that influence breastfeeding parity has a positive impact on breastfeeding (Ukegbu,
because of the challenges women face in trying to sustain Ukegbu et al, 2010;Qureshi, Oche et al, 2011) while in other
adequate infant feeding practices while working. Women settings, the impact is negative(Uchendu, Ikefuna et al,
who are unemployed are less likely to quit breastfeeding 2009).Some studies have shown that parity did not confer
early when compared with women working as administrators any advantage to breastfeeding practice (Ogunlesi, 2010;
and in manual jobs (Kimbro, 2006) and are more likely to Sapna, Ameya ,2009) meaning that breastfeeding behaviour
exclusively breastfeed (Tan, 2011). This implies that women of primiparous and multiparous women is the same
who work many hours are likely to mix feeding. Occupation (Amatayakul, Wongsawasdi et al, 1999).
of both parents affects breastfeeding (Lawoyin, Oche et al
2001). 3.12. Primiparity/Low Parity
A study by Scott, Landers, et al (2001) reported that
mothers who intended to return to full or part time work or Primiparous women are more likely to desire or plan to
study within 6 months of the birth were less likely to be breastfeed than multiparous women (Lee, Rubio, et al 2005;
breastfeeding at discharge (from hospital) than mothers who Leuung, Hung, et al, 2003). In some settings longer duration
intended to remain at home. Because of the challenges of breastfeeding has been associated with low parity
associated with breastfeeding by working mothers (poor suggesting that fewer children in the home incur less cost to
support for breastfeeding in the work place), WHO ( 2013) women’s time (Uchendu, Ikefuna et al, 2009). It has been
recommended that all women working should be supported demonstrated that primiparous women were twice as likely to
to sustain breastfeeding when they return to work by giving be breastfeeding at discharge when compared with
them a minimum of one break per day to breastfeed or multiparous women; however, there was no association
express breast milk. between parity and overall duration of breastfeeding (Scott,
32 Andy Emmanuel: A Literature Review of the Factors That Influence Breastfeeding: an Application of the Health Believe Model

Landers et al, 2001). Lopez-alatcon et al, 2002) and may be associated with the
belief that breast milk substitute is required to make up the
3.13. Multiparity/High Parity low weight (Matias, Nommsen-Rivers,2012).
Studies have shown that high breastfeeding rate is
associated with multiparity (Ukegbu, Ukegbu et al, 2010; 4. Cue to Action/ Self Efficacy
Qureshi, Oche et al, 2011). A study revealed that women with
fewer than five children are likely to record low exclusive Cues to action are events, people or things that move
breastfeeding duration. (Qureshi, Oche et al, 2011). Tan, people or things that move people to change their behaviour
(2011) opined that multiparity is associated with the practice e.g. illness of a family members, media report, mass media
of exclusive breastfeeding. This means that, primiparous campaign while self-efficacy is belief in one’s ability to do
mothers are less likely to breastfeed exclusively (Lawoyin, something. Self-efficacy is influenced by personal
Olawuyi et al, 2001). accomplishment (personal experience), vicarious experience
(individual performances whether live, recorded or printed),
3.14. Antenatal Care verbal persuasion from health care professionals, peer
counsellors, family members or personal friends,
Adequate counseling about breastfeeding during antenatal physiological and affective state (excitement or satisfaction,
care could significantly improve breastfeeding(Sapna, Ameya enhances self-efficacy while pain, fatigue, anxiety or stress
2009). Antenatal attendance is a potential determinant of reduces ones sense of self efficacy) (Danis, 1999).
infant feeding practice (Agho, et al 2009; Ghwass and
Ahmed, 2011). Antenatal care increases the likelihood of 4.1. Previous Experiences with
early breastfeeding initiation (Ogunlesi, 2010). Mothers who Breastfeeding
did not attend antenatal clinic during pregnancy may have a
poor initiation and exclusivity of breastfeeding (Ogunlesi, Breastfeeding experience helps in building confidence and
2010). confidence is a potential determinant of breastfeeding
(Brodribb, Fallon, et al 2008; Meedya, Fahy et al,
3.15. Multiple Births 2010).Women with little or no previous breastfeeding
experience require additional support to be able to breastfeed
Mothers of twins face more challenges than mothers of adequately (Kronborg, Væth,et al 2007) women with
singletons when it come exclusive breastfeeding. A study breastfeeding experience are more likely to intend
revealed that insufficient milk for the twins and time for tobreastfeed than those who never had any experience
breastfeeding are common causes of early cessation of (Mclnnes, Love,et al, 2001). Health beliefs, experience of
breastfeeding among mothers of twins (Damato, Dowling, et friends and family could encourage or discourage
al, 2005). Another study revealed that 89.4% of women with breastfeeding (Raffle, Ware et al, 2011).A study reported that
twins initiated breastfeeding and that support for mothers of less confident women are four to five times more likely to
twins to overcome breastfeeding problem over the first 6 experience breastfeeding failure (Dennis, 1999).Furthermore,
weeks may result in a longer duration of breastfeeding a longitudinal study of pregnant women in Australia to
(Damato, Dowling, et al, 2005). Mothers of twins can determine the influence of antenatal services on
breastfeed for the recommended duration if supported breastfeeding revealed that mothers with high breastfeeding
(Damato, Dowling et al2005). confidence were more likely to breastfeed compared with
3.16. Type of Delivery women with low breastfeeding confidence (79.3% versus
50.5%) (Blyth, Creedy et al, 2004).
Mothers who had a normal delivery tend to have a positive
attitude towards breastfeeding and had less stressful 4.2. Breastfeeding Support
experiences with breastfeeding than mothers who gave birth 4.2.1. Support from Family and Friends
through caesarean section (Imhonde, Shaibu, et al, 2012; Women who enjoyed support from family and friends are
Carlander, Edman, et al 2009). Caesarean delivery is likely to breastfeed longer (Wambach and Cohen, 2009).
associated with formula feeding and low milk production (Li, Presence of mother in-law in the home increased
Zhang et al, 2004). In a study of the effects of maternal care breastfeeding self efficacy and has implication for continuing
practice on breastfeeding, DiGirolamo, Grummer-Strawn et breastfeeding (Ku and Show, 2010). Social support by
al, (2008) concluded that type of delivery (vaginal versus women’s partners (husbands encouraging wives to breastfeed)
caesarean) had no influence on breastfeeding practices. Patel, may promote, and prolonged breastfeeding (Lamontagne,
Liebling et al (2003) also reported that type of delivery had Hamelin, 2008;Meedya, Fahy et al, 2010; Scott, Landers et al,
no impact on breastfeeding. 2001; Tan, 2011; Brown, Raynor et al, 2011). Grandmothers
3.17. Birth Weight/Infant Size are influential in infant feeding choices and can positively
influence breastfeeding, especially if they are aware of
Low birth weight infants are less likely to exclusively recommended practices (Kerr, Dakishoni, et al, 2008;
breastfeed (Matias, Nommsen-Rivers et al 2012; Butte, Grassley and Eschit, 2008).
 International Journal of Nursing and Health Science 2015; 2(3): 28-36 33

4.2.2. Support from Health Workers breastfeeding for mother and child should be done
Clinicians and health workers may have an influential role using various languages in order to accommodate
in breastfeeding initiation and continuation (Li, Laung et al, women who do not understand English and those with
2004). Professionals can sometimes have a negative low educational level.
influence when they provide women with breastfeeding 2. Breastfeeding counseling during antenatal care should
information and recommendations that are confusing be centered on solving problems associated with
(Lamontagne, 2008).Post natal support from experts increase breastfeeding.
breastfeeding duration (Brown, Raynor et al,2011). 3. Government should liaise with all employers of labour
Kronborg, Væth et al, (2007) reported that home visits in to ensure and improve breastfeeding support in the
the first 5 weeks following birth may prolong the duration of work place.
exclusive breastfeeding. This assertion was made after 4. Extending maternity leave to six months for all working
observing a significant increase in the duration of mothers could promote exclusive breastfeeding for six
breastfeeding of breastfeeding with an intervention which months. The six months leave could be limited to
focused on assisting women to overcome obstacle to maximum of three children.
breastfeeding. Ahmed (2008) identified support for mothers 5. Economic empowerment may improve breastfeeding in
immediately after delivery as a way of overcoming some settings.
breastfeeding problems and enhancing confidence. 6. Special support should be given to young mothers;
women who were formula or mixed fed as babies and
4.3. Knowledge of Individuals’ Feeding as mothers of twins during the postnatal period.
Babies

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