CHAPTER 2: LITERATURE REVIEW

2.1 Introduction

"Breastfeeding saves lives" and "Breast is best" are well-known slogans that
emphasize the critical importance of breastfeeding for both infant and maternal
health (Dieterich et al., 2013). These messages are widely recognized by physicians
and women, underscoring the life-saving potential and health benefits of
breastfeeding. According to Dieterich et al. (2013), in the United States, initiating
breastfeeding is now considered "normative," with approximately 75% of women
starting to breastfeed their newborns. However, the continuation of breastfeeding for
the recommended duration is less common. Many women do not breastfeed as long
as advised by health experts and government guidelines, leading to missed
opportunities for improving infant and maternal health (Dieterich et al., 2013). This
chapter will review the evidence supporting the benefits of prolonged breastfeeding
and the potential health improvements it offers. Basically, the chapter will be
focusing on a comprehensive review of the literature related to the influence of
breastfeeding promotion strategies on infant health, maternal welfare, and
healthcare expenditure. The review is organized into several sections: the benefits of
breastfeeding for both infants and mothers, the economic implications of
breastfeeding, the determinants of breastfeeding practices, the various breastfeeding
promotion strategies, and the overall impact of these strategies on healthcare
expenditure. By examining these areas, the chapter aims to provide a solid
foundation for understanding the multifaceted factors that influence breastfeeding
practices and the effectiveness of different promotional approaches.

2.2 Benefits of Breastfeeding

Breast milk is a complex, living substance and a nutritionally complete food for
babies until they reach six months of age. Unlike formula products, which cannot
replicate its composition, breast milk is a dynamic and interactive "bioactive fluid"
that adjusts its physical properties and nutrient concentrations in response to various
factors (Camacho-Morales et al., 2021). Its composition varies among individuals
based on their diet and stages of lactation, making it uniquely tailored to each infant's
needs. As per World Health Organization (2009), the biochemistry of breast milk
changes throughout the day and even during a single feeding session. Initially, the
milk has a lower fat content, which gradually increases until the baby feels satiated.
This intricate adaptability ensures that breast milk provides optimal nutrition and
health benefits, supporting the infant's growth and development in ways that no
artificial substitute can match. The benefits of breastfeeding extend far beyond
immediate nourishment, fostering long-term health and well-being for both the child
and the mother. This section delves into the specific benefits of breastfeeding for
children and mothers, highlighting its comprehensive impact on health.

2.2.1 Infant Health Benefits

Breast milk has evolved to provide the best nutrition, immune protection, and
regulation of growth, development, and metabolism for human infants (Gregory &
Walker, 2013). It plays a crucial role in compensating for developmental delays in the
neonatal immune system and reduces intestinal permeability, preparing the gut for
extrauterine life. The unique composition of breast milk, which includes proteins, fats,
vitamins, and minerals, is specifically tailored to meet the nutritional needs of infants.
In their study, Gregory & Walker (2013) assert that the immunological components of
breast milk, particularly secretory IgA (sIgA), inhibit the adherence and penetration of
pathogens in the gastrointestinal tract and support phagocytosis and cytotoxicity of
harmful microorganisms. Colostrum, the early milk produced postpartum, is
especially rich in sIgA, providing key immunoprotection during the initial days of life.
Additional acquired secretory antibodies like IgM and IgG, which depend on maternal
exposure to pathogens, offer environment-specific immunoprotection, further
enhancing the infant’s immune defense (Gregory & Walker, 2013).

A significant benefit of breastfeeding is the establishment of a favorable gut

microbiome, which protects against pathogenic bacteria and is associated with
reduced rates of asthma and obesity in children. The interaction between breast
milk’s microbiota, such as Bifidobacteria and Lactobacilli, and oligosaccharides fuels
these beneficial bacteria, promoting antimicrobial activity and maintaining the
integrity of the intestinal barrier (M’Rabet et al., 2008). A study by Nolan et al. (2019)
found that this interaction prevents inflammatory responses and contributes to the
regulation of genes affecting fat metabolism and deposition. The healthy gut
microbiota synthesized by breast milk also produces essential micronutrients,
including vitamins B12, B6, folate, and vitamin K, which are crucial for the infant’s
overall health and development (Nolan et al., 2019). According to a recent study by
Alotiby (2023), infants who are breastfed for at least six months are 19% less likely
to be obese by age seven compared to those who were never breastfed.

Breastfeeding provides significant immunological benefits, reducing the incidence of

infections and illnesses. As per Stuebe (2009), infants who are not breastfed or are
breastfed for short periods are at higher risk of infections. In a study done by
Dieterich (2013) for instance, the PROmotion of Breastfeeding Intervention Trial
(PROBIT) revealed that infants in the standard-care group experienced more
gastrointestinal infections compared to those in the intervention group. In the U.S.,
where daycare usage is widespread, breastfed infants are significantly less likely to
contract gastrointestinal and respiratory infections. Meta-analyses have shown that
breastfed infants have a 72% lower risk of hospitalization for respiratory infections
and are 64% less likely to contract gastrointestinal infections (Branger et al., 2023).
Additionally, breastfeeding has been associated with a reduced risk of Sudden Infant
Death Syndrome (SIDS), with studies indicating that breastfed infants have a 45%
lower SIDS risk compared to formula-fed infants. Infants exclusively breastfed for at
least six months are particularly protected, with their risk of SIDS reduced by up to
73% (Branger et al., 2023).

Neurological outcomes also favor breastfed infants. Lee et al. (2016) found
breastfeeding to be linked to better cognitive development, higher IQ scores, and
improved academic performance. A study published in JAMA Pediatrics found that
children who were breastfed for at least one year scored higher on IQ tests and had
better academic performance at age 7-8 compared to their non-breastfed peers
(Kramer, 2008). These benefits are partly attributed to the fatty acids in breast milk,
such as DHA, which are essential for brain development. According to a study by
Victora et al. (2015), the differences in appetite-regulating hormones found in breast
milk, like leptin and ghrelin, may contribute to better self-regulation of food intake in
breastfed infants, reducing the likelihood of obesity. Furthermore, breastfeeding
behaviors foster stronger mother-infant bonds, promoting emotional and
psychological development (Kramer, 2008). This comprehensive range of benefits
underscores the importance of breastfeeding as a critical practice for enhancing
infant health and development.
Source: Lyons et al. (2020)

The protective effects of breastfeeding extend beyond infancy, with lasting health
benefits into childhood and beyond. Breastfed children have lower rates of allergies,
asthma, and type 2 diabetes. A study by Lyons et al. (2020) has shown that
breastfeeding for at least six months can reduce the risk of type 2 diabetes in
children by up to 30%. Additionally, as revealed by Davis (2018), breastfed infants
have a lower incidence of pediatric cancers such as acute lymphoblastic leukemia.
Meta-analyses done by Stordal (2023) indicates that children breastfed for more than
six months have a 24% lower risk of developing this type of cancer compared to
those who were not breastfed. Moreover, breastfeeding contributes to better dental
health, with lower risks of malocclusions and dental caries (Stuebe, 2009). The act of
breastfeeding promotes proper development of the oral cavity, reducing the need for
orthodontic treatments in later years.
Source: Davis (2018)

2.2.2 Benefits for Mothers

Breastfeeding is often hailed as one of the most important practices for promoting
infant health, but its benefits extend beyond babies to include numerous advantages
for mothers as well. While public health messaging frequently emphasizes the
benefits of breastfeeding for infants, it's essential to recognize that mothers also reap
substantial rewards from this natural process. Immediate and early benefits for
mothers encompass postpartum weight loss, enhanced bonding with the newborn,
and lactational amenorrhea, which serves as a natural form of birth control for up to
six months postpartum. Breastfeeding promotes postpartum weight loss by
stimulating calorie expenditure, with greater intensity and duration of breastfeeding
associated with more significant weight loss in women across all BMI categories
(Jarlenski et al., 2014). Moreover, breastfeeding facilitates the release of oxytocin,
often referred to as the "love hormone," fostering maternal-infant bonding despite
limited empirical evidence confirming the biological link between breastfeeding and
bonding (Tarsha & Narvaez, 2023). Besides, the oxytocin hormone also helps
mother's uterus to contract after delivery. This helps it return to its normal size and
reduces the amount of vaginal bleeding after delivery. Additionally, lactational
amenorrhea, resulting from exclusive breastfeeding, suppresses ovulation, serving
as a natural contraceptive method for mothers during the early postpartum period
(Tarsha & Narvaez, 2023).

In the long term, breastfeeding confers enduring maternal benefits, including a

reduced risk of diabetes, metabolic disorders, and cardiovascular diseases.
Pregnancy induces metabolic changes that can predispose women to gestational
diabetes and increase the risk of type 2 diabetes later in life (Gunderson, 2014).
However, breastfeeding promotes favorable metabolic alterations, enhancing insulin
sensitivity and reducing the risk of type 2 diabetes, with each 12 months of lifetime
lactation associated with a 4–12% reduction in diabetes risk (Stuebe, 2015).
Furthermore, lactation exerts beneficial effects on blood lipid profiles, lowering the
risk of hyperlipidemia and cardiovascular diseases among breastfeeding mothers
(Stuebe, 2015). Research suggests that women who breastfed their children are less
likely to develop hypertension, diabetes, and hyperlipidemia compared to non-
breastfeeding counterparts, highlighting the long-term protective effects of
breastfeeding on maternal health (Stuebe, 2015).

Breastfeeding also offers significant protection against reproductive cancers, with

longer breastfeeding durations associated with reduced risks of breast and ovarian
cancers. Women who breastfed exhibit decreased lifetime exposure to hormones
such as estrogen, contributing to a lower risk of hormone receptor-negative breast
cancers, which are more common in younger women (Gunderson, 2014). Meta-
analyses have demonstrated a 4.3% reduction in breast cancer risk for each year of
breastfeeding, underscoring the protective role of breastfeeding against breast
cancer (Gunderson, 2014). Similarly, breastfeeding for at least 12 months is
associated with a 28% lower risk of ovarian cancer compared to women who never
breastfed, highlighting the significant benefits of breastfeeding in reducing the
incidence of reproductive cancers among mothers (Stuebe, 2015).
Moreover, breastfeeding may have positive implications for maternal mental health,
contributing to reduced risks of postpartum depression and promoting overall
psychological well-being. Oxytocin, released during breastfeeding, facilitates
maternal-infant bonding and generates feelings of warmth and affection toward the
newborn, potentially mitigating postpartum depressive symptoms (Gunderson,
2014). Research indicates that longer breastfeeding durations are associated with
lower risks of postpartum depression, suggesting a protective effect of breastfeeding
on maternal mental health (Gunderson, 2014). Overall, breastfeeding not only
nurtures infants but also serves as a cornerstone of maternal health, offering a
myriad of physical, emotional, and psychological benefits for mothers throughout the
postpartum period and beyond.

Source: Gunderson (2014)

2.3 Economic Implications of Breastfeeding

Breastfeeding has profound economic implications on a global scale, encompassing

direct healthcare cost savings, indirect economic benefits, and environmental
sustainability. Increasing breastfeeding rates significantly reduces healthcare costs
by lowering the incidence of various infant and maternal illnesses such as
gastrointestinal infections, respiratory infections, otitis media, necrotizing
enterocolitis, and chronic diseases like type 1 diabetes and childhood obesity. For
instance, in Australia, Quesada et al. (2020) estimated a saving of US$6.2 million on
treatments if exclusive breastfeeding (EBF) rates at three months increased to 80%.
In the United States, Weimer (2001) projected that achieving recommended
breastfeeding rates could save US$3.6 billion annually, a figure updated by Bartick
and Reinhold (2009) to US$13 billion annually and the prevention of 911 infant
deaths per year if 90% of babies were breastfed for the first six months. Similar
savings are seen in Italy, where Cattaneo et al. (2006) found that non-breastfed
children incurred an additional US$178 in treatment costs per year compared to
those exclusively breastfed for the first three months. In the Netherlands, Fl et al.
(2007) estimated savings of US$279 per child born if EBF rates at six months
increased to 100%. Moreover, Otter et al. (2024) reported potential savings of over
GBP17 million per year in the UK by reducing treatment costs for various infant
diseases through increased breastfeeding rates.

Indirect economic benefits of breastfeeding are substantial, contributing significantly

to human capital development. Breastfeeding promotes optimal infant growth and
cognitive development, leading to healthier and more productive individuals, which in
turn results in improved educational outcomes and workforce productivity.
Additionally, breastfeeding facilitates quicker postpartum recovery for mothers,
reducing absenteeism and enhancing workforce participation. A study by Rollins et
al. (2016) highlighted that a 10% increase in EBF at six months could save US$312
million in the US, US$7.8 million in the UK, US$30 million in China, and US$1.8
million in Brazil annually. These savings can be reinvested in other critical areas,
further stimulating economic growth and development.

In addition to its health and productivity benefits, breastfeeding is environmentally

friendly, requiring minimal resources compared to formula feeding. Formula
production involves significant use of water, energy, and raw materials, and it
generates considerable greenhouse gas emissions due to manufacturing and
transportation processes. By contrast, breastfeeding is a natural, sustainable feeding
method that helps conserve resources and reduce environmental impact. Studies
have shown that promoting breastfeeding can contribute to environmental
sustainability goals, aligning with global efforts to combat climate change and
resource depletion. For instance, in Indonesia, it was estimated that the healthcare
system would incur an additional US$118 million annually if breastfeeding rates
declined, highlighting the importance of maintaining high breastfeeding rates not only
for health but also for environmental sustainability (Rollins et al., 2016).

While there are opportunity costs associated with breastfeeding, such as the
potential loss of productivity and economic contribution from mothers due to the time
commitment required, these are often outweighed by the substantial savings from
reduced healthcare expenses and the economic value of human milk. Dr. Julie
Smith's research indicated that the economic value of breast milk produced by
Australian women is around US$2 billion annually, far exceeding the retail value of
formula at US$135 million. This significant economic output, if all mothers were to
breastfeed as recommended by the World Health Organization, would result in an
additional US$3 billion in economic value. Moreover, breastfeeding promotion
campaigns, though associated with certain costs, have been shown to be highly
cost-effective. For example, in Indonesia, a 25% decline in breastfeeding prevalence
would require an additional US$40 million annually for diarrhea treatment (Smith,
2016). These examples illustrate that the long-term economic benefits of
breastfeeding, including cost savings in healthcare and enhanced productivity, far
surpass the immediate costs of promoting and supporting breastfeeding practices.

2.4 Determinants of Breastfeeding Practices

Breastfeeding practices refer to the behaviors and routines associated with feeding
an infant breast milk directly from the mother or expressed breast milk. These
practices encompass the initiation, duration, and exclusivity of breastfeeding, as well
as the methods and frequency of feeding. Understanding the determinants of
breastfeeding practices is essential for promoting and supporting optimal infant
nutrition globally. Several factors influence these practices globally, including socio-
demographic, psychological, biological, and healthcare-related determinants.

2.4.1 Socio-Demographic Determinants

Socio-demographic factors play a significant role in breastfeeding practices.

Maternal age, occupation, and education levels are critical determinants. Research
shows that older mothers tend to have more positive attitudes toward breastfeeding,
as indicated by higher scores on the Iowa Infant Feeding Attitude Scale (IIFAS),
suggesting a stronger intention to breastfeed. For instance, Di Mattei et al. (2016)
found that older mothers (ages 19-45) had significantly higher IIFAS scores,
indicating a more positive attitude towards breastfeeding. Studies have found that
while younger women are as likely to initiate breastfeeding as older women, they are
almost twice as likely to stop breastfeeding by six months. Additionally, Lutsiv et al.
(2013) revealed that older mothers had a higher intention to exclusively breastfeed
their infants compared to younger ones. Occupational status also significantly affects
breastfeeding duration. Attanasio et al. (2013) revealed that full-time employment is
associated with early cessation of breastfeeding, while self-employed mothers tend
to breastfeed for longer periods. Skafida (2012) found that part-time working women
were more inclined to continue exclusive breastfeeding for six or more months
compared to full-time employed mothers. These findings highlight the need for
supportive workplace policies and flexible maternity leave options to promote
sustained breastfeeding.

2.4.2 Psychological Factors

Psychological determinants, including self-efficacy, maternal personality, and prior

feeding experiences, are crucial in influencing breastfeeding practices. De Jager et
al. (2014) developed a model correlating psychological factors with the duration of
exclusive breastfeeding, finding that higher levels of maternal self-efficacy were
strongly linked to longer breastfeeding durations. Iliadou et al. (2020) also reported
that higher self-efficacy levels three days postpartum were strongly related to
exclusive breastfeeding at six months. Women who were breastfed as infants are
more likely to breastfeed their children, as indicated by Di Mattei et al. (2016),
suggesting the influence of personal feeding history. Maternal personality traits such
as emotional stability, extraversion, and conscientiousness also play a role. Brown
(2014) found that mothers with high emotional stability and conscientiousness were
less likely to cease breastfeeding early. Support from healthcare professionals,
family, and peer groups significantly enhances breastfeeding success, emphasizing
the importance of comprehensive lactation support and encouragement.

2.4.3 Biological Factors

Biological factors significantly impact breastfeeding practices. Conditions such as
maternal obesity, smoking, and cesarean delivery are linked to shorter breastfeeding
durations. Verret-Chalifour et al. (2015) found that obese women were less likely to
initiate breastfeeding compared to women of normal weight. Mäkelä et al. (2013)
suggested that overweight or obese women breastfed for shorter durations. Liu et al.
(2010) reported that smoking during the breastfeeding period is associated with early
cessation, as nicotine negatively affects milk production and infant sleep patterns.
Clifford et al. (2006) found that only 23% of mothers who smoked breastfed
exclusively for six months postpartum. Cesarean deliveries also pose challenges,
with Hauck et al. (2011) indicating that mothers who undergo cesarean sections are
less likely to breastfeed exclusively for extended periods. Ayton et al. (2012) found
that over 50% of mothers who had cesarean sections breastfed exclusively for only
two months postpartum. Addressing these biological barriers through targeted
interventions and support is crucial for improving breastfeeding rates.

2.4.4 Healthcare Practices and Policies

Healthcare practices and policies significantly influence breastfeeding practices. The

Baby-Friendly Hospital Initiative (BFHI) promotes practices conducive to successful
breastfeeding, such as immediate skin-to-skin contact and rooming-in. Hospitals
adhering to BFHI protocols have higher rates of breastfeeding initiation and
continuation. For example, BFHI-accredited hospitals in the UK have shown a 10%
increase in exclusive breastfeeding rates at six weeks postpartum (UNICEF, 2020).
The training and attitudes of healthcare professionals are also vital. Supportive
healthcare providers who actively encourage and assist with breastfeeding can
significantly impact a mother's confidence and ability to breastfeed. Oakley et al.
(2020) reported that consistent support from midwives was crucial for sustained
breastfeeding. Implementing comprehensive breastfeeding support in healthcare
settings and promoting policies that facilitate breastfeeding was attributed to improve
global breastfeeding rates and outcomes.

Overall, it is evident that breastfeeding practices are shaped by a complex interplay

of socio-demographic, psychological, biological, and healthcare-related factors.
Addressing these determinants through tailored interventions and supportive policies
is essential for promoting and sustaining breastfeeding globally. By understanding
and mitigating the barriers to breastfeeding, societies can create a more supportive
environment for mothers, ensuring better health outcomes for both infants and
mothers worldwide.

2.5 Breastfeeding Promotion Strategies

Breastfeeding promotion strategies are essential for improving breastfeeding rates

and supporting optimal infant health outcomes. These strategies encompass a range
of interventions aimed at creating a supportive environment for breastfeeding
mothers, raising awareness about the benefits of breastfeeding, and addressing
barriers to breastfeeding initiation and continuation. Effective promotion strategies
are evidence-based and tailored to the unique needs of diverse communities.
Several key strategies have been implemented globally to promote breastfeeding,
supported by data demonstrating their impact on breastfeeding practices and infant
health.

2.5.1 Healthcare Provider Training and Support

Training healthcare providers to support breastfeeding mothers is a cornerstone of

breastfeeding promotion efforts. Evidence suggests that supportive and
knowledgeable healthcare providers play a crucial role in helping mothers initiate
and sustain breastfeeding. A study by Schmied et al. (2017) found that mothers who
received consistent support from healthcare professionals were more likely to
breastfeed exclusively at six months postpartum. Training programs for healthcare
providers should include education on breastfeeding physiology, counseling
techniques, and strategies for addressing common breastfeeding challenges. The
Baby-Friendly Hospital Initiative (BFHI), launched by WHO and UNICEF, promotes
breastfeeding-friendly practices in healthcare facilities, leading to higher rates of
breastfeeding initiation and duration. Data from BFHI-accredited hospitals
consistently show increased rates of breastfeeding initiation and exclusive
breastfeeding at discharge compared to non-accredited facilities (Pérez-Escamilla et
al., 2016).

2.5.2 Community-Based Support Programs

Community-based support programs provide invaluable assistance to breastfeeding

mothers, particularly in underserved and marginalized communities. These programs
offer peer support, counseling, and educational resources to help mothers overcome
breastfeeding challenges and build confidence in their breastfeeding journey. A
meta-analysis by McFadden et al. (2017) demonstrated that peer support
interventions significantly increased breastfeeding initiation and duration.
Community-based support programs leverage the power of social networks and
culturally relevant approaches to promote breastfeeding within communities. Data
from programs like La Leche League International and the WIC Breastfeeding Peer
Counseling Program show positive outcomes, including higher rates of breastfeeding
initiation and longer duration of exclusive breastfeeding (Tuthill et al., 2018).

2.5.3 Workplace Support Policies

Workplace support policies are critical for enabling breastfeeding mothers to

continue breastfeeding after returning to work. Maternity leave, lactation
accommodations, and breastfeeding breaks allow mothers to maintain breastfeeding
while balancing work responsibilities. Research indicates that supportive workplace
policies are associated with longer breastfeeding durations and higher rates of
exclusive breastfeeding. A systematic review by Bai et al. (2019) found that longer
maternity leave durations were positively correlated with increased breastfeeding
duration and exclusivity. Similarly, workplace lactation support programs, such as
designated lactation rooms and flexible work schedules, have been shown to
facilitate continued breastfeeding upon return to work. Data from countries with
comprehensive workplace support policies, such as Sweden and Norway,
demonstrate higher rates of breastfeeding continuation among working mothers
compared to countries with less supportive policies (Heymann et al., 2019).

2.5.4 Public Health Campaigns and Education

Public health campaigns and educational initiatives play a vital role in raising
awareness about the benefits of breastfeeding and dispelling myths and
misconceptions. These campaigns utilize various media channels, including
television, radio, social media, and print materials, to reach diverse audiences.
Evidence suggests that well-designed breastfeeding promotion campaigns can
positively influence breastfeeding attitudes and practices. A systematic review by
Sinha et al. (2015) found that mass media campaigns were associated with
increased rates of breastfeeding initiation and duration. Educational interventions
targeting healthcare providers, parents, and the general public can also contribute to
improved breastfeeding outcomes. Data from campaigns like the "Breastfeeding: A
Great Start" campaign in the United States show increased breastfeeding initiation
rates and higher rates of exclusive breastfeeding at hospital discharge (Grummer-
Strawn et al., 2010).

2.5.5 Policy Interventions

Policy interventions are pivotal in shaping breastfeeding practices, with maternity

leave policies and adherence to the International Code of Marketing of Breast Milk
Substitutes (BMS) playing significant roles. Research by Smith et al. (2013)
underscores this, highlighting that countries with robust maternity protection and
strict regulations on BMS marketing tend to exhibit higher rates of breastfeeding
initiation and duration. For instance, a study comparing breastfeeding rates across
36 countries found that those with longer paid maternity leave policies, such as
Sweden and Norway, had higher exclusive breastfeeding rates at 4 months
postpartum (Huang et al., 2018). Similarly, adherence to the International Code of
Marketing of BMS has been shown to have a positive impact on breastfeeding
practices. A study analyzing breastfeeding rates in 11 European countries, including
France, Germany, and the United Kingdom, found that countries with stronger
adherence to the Code had higher rates of exclusive breastfeeding at 6 months
(Munn et al., 2016). By implementing and enforcing policies that prioritize
breastfeeding support and protection, governments can create an enabling
environment that empowers mothers to make informed choices about infant feeding,
leading to healthier populations and reduced healthcare costs in the long term.
Therefore, investing in comprehensive policy interventions is essential for promoting
and safeguarding breastfeeding as the optimal feeding choice for infants.
2.6 Barriers to Breastfeeding Promotion Strategies

Breastfeeding promotion strategies face numerous barriers that undermine their

effectiveness, as identified by a substantial body of research. One major barrier is
the lack of adequate maternity leave policies, which significantly impacts
breastfeeding rates. Nguyen et al. (2021) found that countries with longer maternity
leave policies, such as Norway and Sweden, have higher rates of breastfeeding
initiation and duration compared to countries with shorter leave, such as the United
States. Similarly, a study by Kinshella et al. (2021) revealed that part-time working
women were more inclined to continue exclusive breastfeeding for six or more
months compared to their full-time counterparts. This highlights the importance of
flexible work arrangements in supporting breastfeeding. Additionally, Tomori (2022)
evaluated the correlation between returning to work and the early cessation of
breastfeeding, finding that mothers who returned to work within three months
postpartum were more likely to stop breastfeeding earlier than those who took longer
leaves. Research by Ahluwalia et al. (2012) further indicated that women who had
induced labor or cesarean deliveries were less likely to initiate and continue
breastfeeding compared to those who had spontaneous vaginal deliveries.
Another significant barrier is the influence of social and cultural factors on
breastfeeding practices. Cole et al. (2024) used the Iowa Infant Feeding Attitude
Scale (IIFAS) to assess mothers’ intentions and attitudes towards breastfeeding,
finding that positive attitudes were significantly associated with older maternal age
and prior breastfeeding experience. However, younger mothers and those with
negative family or community attitudes towards breastfeeding faced greater
challenges. Asimaki et al. (2022) supported this, showing that younger mothers had
lower intentions to exclusively breastfeed compared to older mothers. Mohamed et
al. (2018) further determined that positive maternal attitudes towards breastfeeding
were crucial for its duration, with younger mothers more likely to cease breastfeeding
earlier. Studies by Li et al. (2008) identified self-reported factors for early
discontinuation, such as trouble with suckling and latching (54%), sore and cracked
nipples (37%), and the perception of insufficient milk supply. These studies
underscore the need for culturally sensitive education and support programs to
address misconceptions and promote positive attitudes towards breastfeeding. In
Vietnam, despite multiple breastfeeding promotion programs, only 24% of infants are
breastfed exclusively for the first six months (Nguyen et al., 2021).

Psychological factors and maternal self-efficacy also play critical roles in

breastfeeding practices. De Jager et al. (2014) developed a model correlating
psychological factors with the duration of exclusive breastfeeding, finding that higher
self-efficacy was a strong predictor of longer breastfeeding durations. Asimaki et al.
(2020) reinforced this by demonstrating that higher levels of maternal self-efficacy
three days postpartum were strongly related to exclusive breastfeeding at six
months. Conversely, low self-efficacy and lack of support were found to be
significant barriers, with Teich et al. (2014) reporting that women without adequate
breastfeeding advice or support were more likely to stop breastfeeding within the first
ten days postpartum. Additionally, Brown (2013) examined the relationship between
maternal personality and breastfeeding, finding that traits such as emotional stability,
extraversion, and conscientiousness were inversely associated with early cessation
of breastfeeding. Biological and health-related factors also contribute to barriers in
breastfeeding promotion. Peprah et al. (2022) reported that smoking during the
breastfeeding period was correlated with elevated rates of early cessation due to the
negative impact of nicotine on milk production and infant sleep patterns. Similarly,
obesity has been linked to lower breastfeeding initiation and shorter durations, with
Han & Brewis (2018) showing that obese women were less likely to initiate and
continue breastfeeding compared to those of normal weight. Studies by Kavle et al.
(2017) also highlighted physical challenges such as mastitis, breast engorgement,
sore nipples, and cracked or inverted nipples as significant barriers to exclusive
breastfeeding.

2.7 Conceptual Framework

The Theory of Planned Behavior (TPB), introduced by Ajzen in 1991, is a prominent

framework in health psychology used to understand and predict human behaviors,
especially in health-related contexts. TPB posits that the most immediate predictor of
behavior is an individual's intention to engage in that behavior. This intention is
influenced by three core components: attitudes, subjective norms, and perceived
behavioral control. Attitudes refer to the individual's positive or negative evaluations
of performing the behavior, shaped by beliefs about the outcomes and the value
placed on these outcomes. For instance, if a person believes that engaging in a
particular behavior will lead to beneficial results, they are more likely to have a
favorable attitude toward performing it (Ajzen, 1991).

Subjective norms involve the perceived social pressure to perform or not perform a
behavior, based on the individual's perceptions of whether significant others think
they should engage in the behavior. This social influence can be substantial,
especially if the individual values the opinions of these significant others (Ajzen,
1991). Perceived behavioral control (PBC) relates to the individual's perception of
the ease or difficulty of performing the behavior, influenced by past experiences and
anticipated obstacles. PBC reflects the individual's confidence in their ability to
execute the behavior, affecting both their intentions and actual behavior. TPB
suggests that even if an individual has a positive attitude toward a behavior and
perceives strong social support for it, they are less likely to follow through if they
doubt their ability to perform the behavior.

The Theory of Planned Behavior

Source: Ajzen (1991)

Applying the Theory of Planned Behavior to breastfeeding provides a structured

approach to understanding the factors influencing mothers' decisions about infant
feeding. Attitudes towards breastfeeding can be significantly shaped by beliefs about
its health benefits for both the infant and the mother, as well as the perceived
convenience and bonding opportunities it offers. Studies have shown that mothers
who believe breastfeeding will lead to positive health outcomes are more likely to
have a favorable attitude towards it, thereby increasing their intention to breastfeed
(Bai et al., 2011). Subjective norms play a critical role in breastfeeding decisions,
influenced by the expectations of family members, friends, healthcare providers, and
cultural norms. For example, if a mother perceives that her partner, family, and social
circle support breastfeeding, she is more likely to intend to and actually engage in
breastfeeding (Sheehan et al., 2010). Support from healthcare providers, through
positive reinforcement and practical advice, also strengthens the subjective norms
favoring breastfeeding.

PBC in the context of breastfeeding involves a mother’s confidence in her ability to

successfully breastfeed and manage any challenges that arise. This control can be
bolstered by previous breastfeeding experience, access to breastfeeding support
groups, and education on breastfeeding techniques. Mothers who feel well-prepared
and supported are more likely to believe they can overcome potential difficulties such
as latching problems or milk supply issues (Scott et al., 2001). As TPB suggests,
higher perceived behavioral control increases the likelihood that a mother will intend
to breastfeed and follow through with it.

Evidence shows that culture and individual characteristics significantly impact

breastfeeding behaviors postpartum (Bai et al., 2011; Dyson, Green, Renfrew,
McMillan, & Woolridge, 2010). Significant predictors of breastfeeding intention
among low-income women in the southern United States include self-efficacy,
perceived social support, attitudes, and previous breastfeeding experience (Mitra et
al., 2003; Kloeblen-Tarver et al., 2002). Understanding these predictors through the
TPB framework can help identify why certain mothers may not be interested in
breastfeeding, thus aiding in the development of effective promotion strategies to
improve exclusive breastfeeding rates (Bai et al., 2011). The fundamental premise of
TPB is that the immediate antecedent of a behavior is the intention to perform it,
which is shaped by positive attitudes towards the behavior (behavioral beliefs).
Research by Thome et al. (2006) indicated that the attitudes of breastfeeding women
towards breastfeeding intention can be measured through these beliefs, further
supporting the application of TPB in understanding and promoting breastfeeding
behaviors.

References

Ahluwalia, I. B., Li, R., & Morrow, B. (2012). Breastfeeding practices: Does method
of delivery matter? Maternal and Child Health Journal, 16(S2), 231–237.
https://doi.org/10.1007/s10995-012-1093-9
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and
Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-
5978(91)90020-t
Alotiby, A. A. (2023). The role of breastfeeding as a protective factor against the
development of the immune-mediated diseases: A systematic review.
Frontiers in Pediatrics, 11. https://doi.org/10.3389/fped.2023.1086999
Asimaki, E., Dagla, M., Sarantaki, A., & Iliadou, M. (2022). Main biopsychosocial
factors influencing breastfeeding: A systematic review. Maedica, 17(4), 955–
962. https://doi.org/10.26574/maedica.2022.17.4.955
Bai, Y., Wunderlich, S. M., & Fly, A. D. (2011). Predicting intentions to continue
exclusive breastfeeding for 6 months: A comparison among racial/ethnic
groups. Maternal and Child Health Journal, 15(8), 1257–1264.
https://doi.org/10.1007/s10995-010-0703-7
Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the
United States: A pediatric cost analysis. Pediatrics, 125(5), e1048-56.
https://doi.org/10.1542/peds.2009-1616
Branger, B., Bainier, A., Martin, L., Darviot, E., Forgeron, A., Sarthou, L., Wagner,
A.-C., Blanchais, T., Brigly, T., & Troussier, F. (2023). Breastfeeding and
respiratory, ear and gastro-intestinal infections, in children, under the age of
one year, admitted through the paediatric emergency departments of five
hospitals. Frontiers in Pediatrics, 10, 1053473.
https://doi.org/10.3389/fped.2022.1053473
Brown, A. (2013). Maternal trait personality and breastfeeding duration: the
importance of confidence and social support. Journal of Advanced Nursing,
70(3), 587–598. https://doi.org/10.1111/jan.12219
Camacho-Morales, A., Caba, M., García-Juárez, M., Caba-Flores, M. D., Viveros-
Contreras, R., & Martínez-Valenzuela, C. (2021). Breastfeeding contributes to
physiological immune programming in the newborn. Frontiers in Pediatrics, 9,
744104. https://doi.org/10.3389/fped.2021.744104
Cattaneo, A., Ronfani, L., Burmaz, T., Quintero-Romero, S., Macaluso, A., & Di
Mario, S. (2006). Infant feeding and cost of health care: A cohort study. Acta
Pædiatrica, 95(5), 540–546. https://doi.org/10.1080/08035250500447936
Cole, J., Bhatt, A., Chapple, A. G., Buzhardt, S., & Sutton, E. F. (2024). Attitudes and
barriers to breastfeeding among women at high-risk for not breastfeeding: A
prospective observational study. BMC Pregnancy and Childbirth, 24(1), 81.
https://doi.org/10.1186/s12884-024-06264-x
Davis, T. (2018). Benefits of breastfeeding and struggles with latch - Tyler Davis.
Medium. https://medium.com/@tyler.davis313/benefits-of-breastfeeding-and-
struggles-with-latch-8d85bbaa456e
De Jager, E., Broadbent, J., Fuller-Tyszkiewicz, M., & Skouteris, H. (2014). The role
of psychosocial factors in exclusive breastfeeding to six months postpartum.
Midwifery, 30(6), 657–666. https://doi.org/10.1016/j.midw.2013.07.008
Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013).
Breastfeeding and health outcomes for the mother-infant dyad. Pediatric
Clinics of North America, 60(1), 31–48.
https://doi.org/10.1016/j.pcl.2012.09.010
Fl, B., Hoekstra, J., Van, R. C., & Cvg. (2007). Health gain and economic evaluation
of breastfeeding policies : Model simulation.
https://www.semanticscholar.org/paper/Health-gain-and-economic-evaluation-
of-policies-%3A-Fl-Hoekstra/9aa1d6c0433448c0558f1a5b0acfa81ec5fbc282
Gregory, K. E., & Walker, W. A. (2013). Immunologic factors in human milk and
disease prevention in the preterm infant. Current Pediatrics Reports, 1(4),
10.1007/s40124-013-0028–2. https://doi.org/10.1007/s40124-013-0028-2
Gunderson, E. P. (2014). Impact of breastfeeding on maternal metabolism:
Implications for women with gestational diabetes. Current Diabetes Reports,
14(2), 460. https://doi.org/10.1007/s11892-013-0460-2
Han, S.-Y., & Brewis, A. A. (2018). Influence of weight concerns on breastfeeding:
Evidence from the Norwegian mother and child cohort study. American
Journal of Human Biology : The Official Journal of the Human Biology Council,
30(2), e23086. https://doi.org/10.1002/ajhb.23086
Jarlenski, M. P., Bennett, W. L., Bleich, S. N., Barry, C. L., & Stuart, E. A. (2014).
Effects of breastfeeding on postpartum weight loss among U.S. women.
Preventive Medicine, 69, 146–150.
https://doi.org/10.1016/j.ypmed.2014.09.018
Kavle, J. A., LaCroix, E., Dau, H., & Engmann, C. (2017). Addressing barriers to
exclusive breast-feeding in low- and middle-income countries: A systematic
review and programmatic implications. Public Health Nutrition, 20(17), 3120–
3134. https://doi.org/10.1017/S1368980017002531
Kinshella, M. L. W., Prasad, S., Hiwa, T., Vidler, M., Nyondo-Mipando, A. L., Dube,
Q., Goldfarb, D., & Kawaza, K. (2021). Barriers and facilitators for early and
exclusive breastfeeding in health facilities in Sub-Saharan Africa: a systematic
review. Global Health Research and Policy, 6(1).
https://doi.org/10.1186/s41256-021-00206-2
Kloeblen-Tarver, A. S., Thompson, N. J., & Miner, K. R. (2002). Intent to breast-
feed: The impact of attitudes, norms, parity, and experience. American
 Journal of Health Behavior, 26(3), 182–187.
https://doi.org/10.5993/ajhb.26.3.3
Kramer, M. S. (2008). Breastfeeding and child cognitive development. Archives of
General Psychiatry, 65(5), 578. https://doi.org/10.1001/archpsyc.65.5.578
Lee, H., Park, H., Ha, E., Hong, Y.-C., Ha, M., Park, H., Kim, B.-N., Lee, B., Lee, S.-
J., Lee, K. Y., Kim, J. H., Jeong, K. S., & Kim, Y. (2016). Effect of
breastfeeding duration on cognitive development in infants: 3-Year follow-up
study. Journal of Korean Medical Science, 31(4), 579–584.
https://doi.org/10.3346/jkms.2016.31.4.579
Li, R., Fein, S. B., Chen, J., & Grummer-Strawn, L. M. (2008). Why mothers stop
breastfeeding: Mothers’ self-reported reasons for stopping during the first
year. Pediatrics, 122(Supplement_2), S69–S76.
https://doi.org/10.1542/peds.2008-1315i
Lyons, K. E., Ryan, C. A., Dempsey, E. M., Ross, R. P., & Stanton, C. (2020). Breast
milk, a source of beneficial microbes and associated benefits for infant health.
Nutrients, 12(4), 1039. https://doi.org/10.3390/nu12041039
M’Rabet, L., Vos, A. P., Boehm, G., & Garssen, J. (2008). Breast-Feeding and its
role in early development of the immune system in infants: Consequences for
health Later in life1,. ˜the œJournal of Nutrition/˜the œJournal of Nutrition ,
138(9), 1782S-1790S. https://doi.org/10.1093/jn/138.9.1782s
Mitra, A. K., Khoury, A. J., Carothers, C., & Foretich, C. (2003). Evaluation of a
comprehensive loving support program among state women, infants, and
children (WIC) program breast-feeding coordinators. Southern Medical
Journal, 96(2), 168–171.
https://doi.org/10.1097/01.smj.0000053675.41623.15
Mohamed, M. J., Ochola, S., & Owino, V. O. (2018). Comparison of knowledge,
attitudes and practices on exclusive breastfeeding between primiparous and
multiparous mothers attending Wajir District hospital, Wajir County, Kenya: A
cross-sectional analytical study. International Breastfeeding Journal, 13, 11.
https://doi.org/10.1186/s13006-018-0151-3
Nguyen, N. T., Do, H. T., & Pham, N. T. V. (2021). Barriers to exclusive
breastfeeding: A cross-sectional study among mothers in Ho Chi Minh City,
Vietnam. Belitung Nursing Journal, 7(3), 171–178.
https://doi.org/10.33546/bnj.1382
Nolan, L. S., Parks, O. B., & Good, M. (2019). A review of the immunomodulating
components of maternal breast milk and protection against necrotizing
enterocolitis. Nutrients, 12(1), 14. https://doi.org/10.3390/nu12010014
Otter, G., Davis, D., Kurz, E., Hooper, M., Shield, A., Samarawickrema, I., Spiller, S.,
& Atchan, M. (2024). Promoting breastfeeding in women with gestational
diabetes mellitus in high-income settings: an integrative review. International
Breastfeeding Journal - Electronic Edition -, 19(1).
https://doi.org/10.1186/s13006-023-00603-y
Peprah, P., Agyemang-Duah, W., Gyamfi, N., Asare, B. Y.-A., Boateng, D., Appiah,
J. O., & Adu, C. (2022). Cigarette smoking during breastfeeding in Papua
New Guinea: Prevalence and demographic and socio-economic predictors.
PloS One, 17(12), e0278373. https://doi.org/10.1371/journal.pone.0278373
Quesada, J. A., Méndez, I., & Martín-Gil, R. (2020). The economic benefits of
increasing breastfeeding rates in Spain. International Breastfeeding Journal,
15(1), 1–7. https://doi.org/10.1186/s13006-020-00277-w
Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C.,
Piwoz, E. G., Richter, L. M., & Victora, C. G. (2016). Why invest, and what it
will take to improve breastfeeding practices? Lancet, 387(10017), 491–504.
https://doi.org/10.1016/s0140-6736(15)01044-2
Scott, J., Landers, M., Hughes, R., & Binns, C. (2001). Factors associated with
breastfeeding at discharge and duration of breastfeeding. Journal of
Paediatrics and Child Health, 37(3), 254–261. https://doi.org/10.1046/j.1440-
1754.2001.00646.x
Sheehan, A., Schmied, V., & Barclay, L. (2010). Complex decisions: theorizing
women’s infant feeding decisions in the first 6 weeks after birth. Journal of
Advanced Nursing, 66(2), 371–380. https://doi.org/10.1111/j.1365-
2648.2009.05194.x
Smith, J. P. (2016). Markets in mothers’ milk: Virtue or vice, promise or problem?
Making Milk, 117–138. https://doi.org/10.5040/9781350029996.ch-007
Stordal, B. (2023). Breastfeeding reduces the risk of breast cancer: A call for action
in high-income countries with low rates of breastfeeding. Cancer Medicine,
12(4), 4616–4625. https://doi.org/10.1002/cam4.5288
Stuebe, A. (2009). The risks of not breastfeeding for mothers and infants. Reviews in
Obstetrics & Gynecology, 2(4), 222–231.
Stuebe, A. (2015). Associations among lactation, maternal carbohydrate metabolism,
and cardiovascular health. Clinical Obstetrics and Gynecology, 58(4), 827–
839. https://doi.org/10.1097/GRF.0000000000000155
Tarsha, M. S., & Narvaez, D. (2023). The evolved nest, oxytocin functioning, and
prosocial development. Frontiers in Psychology, 14, 1113944.
https://doi.org/10.3389/fpsyg.2023.1113944
Teich, A. S., Barnett, J., & Bonuck, K. (2014). Women’s perceptions of breastfeeding
barriers in early postpartum period: A qualitative analysis nested in two
randomized controlled trials. Breastfeeding Medicine : The Official Journal of
the Academy of Breastfeeding Medicine, 9(1), 9–15.
https://doi.org/10.1089/bfm.2013.0063
Thome, M., Alder, E. M., & Ramel, A. (2006). A population-based study of exclusive
breastfeeding in Icelandic women: Is there a relationship with depressive
symptoms and parenting stress? International Journal of Nursing Studies,
43(1), 11–20. https://doi.org/10.1016/j.ijnurstu.2004.10.009
Tomori, C. (2022). Overcoming barriers to breastfeeding. Baillière’s Best Practice &
Research. Clinical Obstetrics & Gynaecology/Baillière’s Best Practice and
Research in Clinical Obstetrics and Gynaecology, 83, 60–71.
https://doi.org/10.1016/j.bpobgyn.2022.01.010
Victora, C. G., Horta, B. L., Loret de Mola, C., Quevedo, L., Pinheiro, R. T., Gigante,
D. P., Gonçalves, H., & Barros, F. C. (2015). Association between
breastfeeding and intelligence, educational attainment, and income at 30
years of age: A prospective birth cohort study from Brazil. The Lancet. Global
Health, 3(4), e199-205. https://doi.org/10.1016/S2214-109X(15)70002-1
Weimer, J. P. (2001). The Economic Benefits of Breastfeeding: A Review and
analysis. ideas.repec.org. https://ideas.repec.org/p/ags/uersfa/33813.html
World Health Organization. (2009). The physiological basis of breastfeeding. Infant
and Young Child Feeding - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK148970/#:~:text=The%20fat%20is
%20secreted%20in,somewhat%20bluish%2Dgrey%20in%20colour.