The Influence of Psychological Factors on Breastfeeding Duration

The influence of psychological factors on breastfeeding duration

Maxine O’Brien, Elizabeth Buikstra & Desley Hegney

Accepted for publication 1 April 2008

Correspondence to M. O’Brien:

e-mail: [email protected]

Maxine O’Brien BSc PhD

Postdoctoral Research Fellow

Centre for Rural and Remote Area Health,

University of Southern Queensland,

Toowoomba, Queensland, Australia

Elizabeth Buikstra BSc PhD

Statewide Project Officer

Centre for Rural and Remote Mental Health

Queensland, Cairns, Queensland, Australia

Desley Hegney BA PhD RN

Professor of Nursing, Director,

Research and Practice Development Centre,

University of Queensland and Blue Care,

Brisbane, Queensland, Australia

O’BRIEN M., BUIKSTRA E. & HEGNEY D.O’BRIEN M., BUIKSTRA E. & HEGNEY D. (20082008) The influence of psychological

factors on breastfeeding duration. Journal of Advanced Nursing 63(4), 397–408

doi: 10.1111/j.1365-2648.2008.04722.x

AbstractTitle. The influence of psychological factors on breastfeeding duration.

Aim. This paper reports on a study examining the relationship between women’s

psychological characteristics and breastfeeding duration, after controlling for socio-

demographic factors.

Background. The literature suggests that psychological factors may influence

breastfeeding behaviour, but studies are few. Existing evidence and the results of

phase 1 of our study were used to construct a list of psychological factors, which

were tested for their association with breastfeeding duration in the current design.

Method. Participants were postnatal inpatients in one of two regional hospitals

between October and December 2005 and they completed the initial questionnaire

within 14 days of giving birth (n = 375). Infant feeding method at 6 months and the

timing of introduction of other food(s), where relevant, were ascertained by tele-

phone interview.

Findings. Forty-four per cent of the sample showed signs of postnatal distress in the

14 days following the birth. Breastfeeding duration was statistically significantly

associated with psychological factors including dispositional optimism, breastfeed-

ing self-efficacy, faith in breastmilk, breastfeeding expectations, anxiety, planned

duration of breastfeeding and the time of the infant feeding decision. As a set, these

psychological factors were more predictive of breastfeeding duration than was the

set of socio-demographic characteristics. The duration of any breastfeeding was

uniquely predicted by faith in breastmilk, planned breastfeeding duration and

breastfeeding self-efficacy.

Conclusion. This increased knowledge of the factors influencing breastfeeding will

assist in identifying women at risk of early weaning and in constructing programmes

capable of increasing the length of time for which women breastfeed.

Keywords: breastfeeding duration, empirical research report, midwifery, psycho-

logical factors, questionnaire

Introduction

The numerous adverse consequences of replacing breastfeed-

ing with artificial baby formulas are well known (Horta et al.

2007, Ip et al. 2007). However, many mothers wean from

the breast well before the initial 6 months of exclusive

breastfeeding recommended by national and international

authorities (WHO 2001, Australian Bureau of Statistics

2003, Callen & Pinelli 2004). Previous research has demon-

strated the influence of socio-demographic factors on breast-

feeding duration (Callen & Pinelli 2004); however, these

factors are not easily modified and therefore offer little

ORIGINAL RESEARCHJAN

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 397

opportunity to increase the duration of breastfeeding. This

has led to calls for breastfeeding researchers to focus on

identifying factors which may be open to modification (e.g.

Blyth et al. 2002).

One research area with the potential to identify modifiable

factors involves the study of psychological differences

between women and the effect of these differences on

breastfeeding behaviour. Breastfeeding research conducted

to date has demonstrated the effect of many factors associ-

ated with the human mind and its functions, including the

woman’s attitudes and plans regarding breastfeeding (Forster

et al. 2006, Scott 2006) and her confidence in her ability to

breastfeed (O’Brien & Fallon 2005), in addition to factors

such as depression (Henderson et al. 2003) and self-esteem

(Damato 2005). However, to date little research has been

performed to explore more fully the psychological charac-

teristics of women that may influence breastfeeding duration,

or just how predictive these characteristics are.

Background

The data reported in this paper were gathered during the

second phase of a two-phase study designed to identify and

explore individual psychological differences between women

and their influence on breastfeeding duration. In phase 1, we

gathered the opinions of mothers and breastfeeding clini-

cians, asking them to draw on their intimate knowledge of

breastfeeding to decide which psychological factors they

believed influence breastfeeding duration. In an attempt to

draw on all available sources of evidence, this information

was considered along with a careful review of the literature.

Taken as a whole, the literature and the phase 1 data support

a theoretical framework (Shields & Tajalli 2006) summarized

by the working hypothesis that individual psychological

differences exist between women which explain breastfeeding

duration, over and above the influence of socio-demographic

characteristics.

In selecting psychological factors to be measured in the

current study, factors thought to be of most importance by

phase 1 participants were given priority over those thought to

be of less importance. Preference was also given to factors

signalling individual psychological differences between

women, as opposed to factors of a more social nature which

may pose problems with modification as our ultimate goal.

The decision process resulted in the selection of 15 psycho-

logical factors for measurement: the woman’s self-esteem,

current life priorities, psychological reactance (motivation to

regain lost or threatened personal freedoms), adaptability,

optimism, breastfeeding self-efficacy, achievement striving,

faith in breastmilk, breastfeeding expectations, depression,

anxiety, stress, time of decision, planned breastfeeding dura-

tion and mothering self-efficacy. An association between

breastfeeding duration and five of these factors is supported

by the results of several previous studies, while four other

factors are less well established, and the remainder have

attracted little or no known research support in the past. A list

of the psychological factors included in our design and a

selection of the published research are shown in Table 1.

Socio-demographic influences previously identified in the

literature were measured and controlled during the analysis.

This list of factors included the woman’s age, education,

occupation, marital status, socio-economic status, parity,

previous breastfeeding experience, hospital where the birth

occurred, rural/remote or regional dwelling and planned

return to employment, in addition to her partner’s prefer-

ences and occupation (Fitzpatrick et al. 1994, Bourgoin et al.

1997, Bulk-Bunschoten et al. 2001, Nagy et al. 2001, Callen

& Pinelli 2004, Arora et al. 2005, Stamp & Casanova 2006,

Bolling et al. 2007).

The study

Aim

The aim of this study was to examine the relationship between

women’s psychological characteristics and breastfeeding

duration, after controlling for socio-demographic factors.

Design

A prospective survey-based design was used as the final phase

of a triangulated, mixed-method research programme, as

described above (Denzin & Lincoln 2005).

Participants

The study was conducted in a large regional centre of

Queensland, Australia, which has two hospitals with mater-

nity units, one publicly funded and one privately funded.

Women who gave birth in either of these hospitals and were

inpatients between October 2005 and December 2005 were

invited to participate in the project. Eligibility criteria

excluded 26 women who were under 18 years of age; had

insufficient English language skills to complete the question-

naire; were too ill; or whose baby was too ill, had died or was

not in their care. Of the 657 women who gave birth during

the study period, 375 completed the questionnaire within the

14 day cut-off period and returned it to the researcher,

leaving an overall participation rate of 59Æ4% (private

hospital = 75Æ7%, public hospital = 45Æ2%). The rate of

M. O’Brien et al.

398 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd

attrition at follow-up was relatively low (15%), and the use

of survival analysis and Cox regression techniques allowed all

data collected at the first interview to be included in the

major analyses.

Data collection

Questionnaires

Data for the initial interview were collected using a 123-item

self-report questionnaire arranged in three sections. The first

two sections were based on previous research (O’Brien &

Fallon 2005) and contained items designed to cover the socio-

demographic information indicated in the literature as being

relevant to breastfeeding duration and the participant’s cur-

rent feeding method (Webb et al. 2001). The third section

contained measures of the woman’s psychological charac-

teristics and space for additional qualitative comments where

desired.

Prevalidated psychometric scales were used where available.

Where such scales were not available, researcher-designed

scales were employed. These included scales measuring the

planned duration of breastfeeding and the time of the infant

feeding decision, both of which had been validated in an earlier

study (O’Brien & Fallon 2005). Additional measures of the

woman’s faith in breastmilk (relative to faith in formula),

breastfeeding expectations and maternal priorities were

constructed for use in the current study.

Faith in breastmilk was measured using a two-item scale.

The first item measured faith in breastmilk (‘If I feed my baby

breastmilk, I can relax and be sure he/she is getting everything

he/she needs’); and a second, similarly worded item, mea-

sured faith in formula. Participants were asked to respond to

the items on a six-point scale from (1) ‘strongly disagree’ to

(6) ‘strongly agree’. Scores on the two items were combined

to produce an overall score, where high scores indicated high

faith in breastmilk and low faith in formula. While Cron-

bach’s alpha is inappropriate for use with brief scales such as

this, the inter-item correlation of 0Æ33 suggested satisfactory

internal consistency for this two-item scale (Briggs & Cheek

1986).

Similarly, the woman’s expectations regarding breastfeed-

ing were measured with two items representing opposing

views of the level of difficulty they expected to encounter (e.g.

‘I don’t expect to experience any real trouble with breast-

feeding, I think it will be easy for me’). Participants

responded on a six-point scale from (1) ‘strongly disagree’

to (6) ‘strongly agree’. Responses on the two items were

combined to form a single score, with high scores indicating

more expected difficulty with breastfeeding (inter-item cor-

relation = 0Æ50).

The placement of the new baby at the top of the mother’s

priorities was considered by phase 1 participants to be

important for breastfeeding success. To measure this novel

factor, participants were asked to rate nine potentially

Table 1 Exemplars of previous research support for psychological factors selected for inclusion in the phase 2 quantitative enquiry

Factors previously established in the literature

Self-esteem Damato (2005), Papinczak and Turner (2000), Whelan and Lupton (1998)

Depression Dunn et al. (2006), Forster et al. (2006), Hatton et al. (2005), Henderson et al. (2003),

McLearn (2006)

Time of infant feeding decision O’Brien and Fallon (2005), Boulton and Landers (1999), Scott et al. (2001a, 2001b)

Planned duration of breastfeeding Blyth et al. (2004), Forster et al. (2006), Donath et al. (2004), Kronborg and Vaeth (2004),

Whaley et al. (2002)

Breastfeeding self-efficacy O’Brien and Fallon (2005), Blyth et al. (2002, 2004), Creedy et al. (2003),

Dennis and Faux (1999)

Factors with only tentative research support

Mothering self-efficacy Tarkka et al. (1999)

Achievement striving Rentschler (1991)

Stress Ueda et al. (1994)

Anxiety Papinczak and Turner (2000), Cooke et al. (2007) NB. Cooke = statistically nonsignificant result

Factors raised in previous qualitative enquiries (no known previous quantitative support)

Need for freedom Bulk-Bunschoten et al. (2001), Kirkland and Fein (2003), Kieffer et al. (1997)

Adaptability Hegney et al. (2007), Hewat and Ellis (1986), Vandiver (1997)

Breastfeeding expectations Hegney et al. (2007), Mozingo et al. (2000)

Faith in breastmilk Bottorff (1990), Hegney et al. (2007)

Novel factors included

Optimism Effect on infant feeding choice supported by Wagner et al. (2006)

Current life priorities Raised in phase 1 of the current study only

JAN: ORIGINAL RESEARCH Influence of psychological factors


competing priorities on a scale of 1–10, with 1 being the

lowest priority and 10 being the highest. Scale items included

priorities such as this baby, husband/partner, other children,

paid work and time for myself. The scale also included an

‘other’ category. A single dichotomous variable was then

created for the analysis. This identified participants who had

assigned this baby a higher priority than any other and those

who had assigned one or more competing priorities the same

or higher priority rating compared with this baby. A list of all

instruments used to measure psychological factors is pre-

sented as Table 2.

At the 6-month follow-up, two to five items were admin-

istered during a telephone interview, depending on the

woman’s feeding method at that time. This instrument was

based on earlier research (O’Brien & Fallon 2005) and

gathered information on the woman’s feeding method at that

time and the time of introduction of other foods or the

cessation of breastfeeding where appropriate.

Procedure

The questionnaire was piloted with a small group of mothers

and subject-matter experts (n = 11) and changes made as

required. Eligible women were approached by the researcher

during their postnatal hospital stay and invited to participate

in the research by completing the initial questionnaire within

14 days and accepting a brief follow-up telephone call at

6 months postpartum. After explaining the study and

receiving signed consent, consenting participants were left

with the coded self-report questionnaire, a copy of the plain

language statement describing the study and a postage-paid

envelope. The participant was asked to place the completed

questionnaire in a locked box near the nurses’ station or

return it through the postal system.

Participants were telephoned for follow-up when their

baby was 6 months old. Participants were considered lost to

follow-up if the telephone numbers supplied were discon-

nected, or if the researcher was unable to contact them after a

minimum of five attempts.

Ethical considerations

Ethics approval was gained from the appropriate university

and health service committees. Informed consent was

obtained from all participants. Data were stored securely

according to Australian National Health and Medical

Research Council guidelines (NHMRC 2007) and all data

were kept separately from any information which could

identify participants.

Data analysis

The aim of the statistical analysis was to assess the relation-

ship between time of cessation of breastfeeding and the set of

influencing factors and to determine whether the psycholog-

ical factors under investigation made a unique contribution to

the prediction after controlling for the remaining variables

(working hypothesis). An alpha level of P < 0Æ05 was used

for all analyses, which were performed using the Windows

version of the Statistical Package for Social Sciences (SPSS

2005).

Prior to analysis, data were inspected for accuracy of entry,

missing values and the fit between their distributions and the

assumptions of the various analyses to be undertaken. The

three Depression, Anxiety and Stress Scales (DASS) sub-scales

were statistically significantly positively skewed and dis-

played statistically significant positive kurtosis. Scores on

Table 2 Instruments used to measure psychological factors

Factor Instrument used

Self-esteem Rosenberg’s Self-Esteem Scale Rosenberg (1989)

Psychological reactance Hong’s Psychological Reactance Scale – Refined Hong and Faedda (1996)

Adaptability Adaptability Scale from the International Personality Item Pool Goldberg et al. (2006)

Dispositional optimism Life Orientation Test-Revised Scheier et al. (1994))

Breastfeeding self-efficacy Breastfeeding Self-Efficacy Scale – Short Form Dennis (2003)

Depression Depression, Anxiety Stress Scale-21 Lovibond and Lovibond (1995)

Anxiety Depression, Anxiety Stress Scale-21 Lovibond and Lovibond (1995)

Stress Depression, Anxiety Stress Scale-21 Lovibond and Lovibond (1995)

Achievement striving Achievement Strivings Scale [adapted] Spence et al. (1987)

Mothering self-efficacy Self-efficacy subscale from the Parenting Sense of Competence Scale Gibaud-Wallston (1977)

Time of decision Single Likert-scale item validated during an earlier study O’Brien and Fallon (2005)

Planned duration Single item validated during an earlier study O’Brien and Fallon (2005)

Faith in breastmilk Novel scale (properties described in text)

Breastfeeding expectations Novel scale (properties described in text)

Maternal priorities Novel scale (properties described in text)

M. O’Brien et al.


these variables were normalized using log (Depression and

Anxiety) and square root (Stress) transformations. Analyses

were run first with the transformed scores and again with the

untransformed scores and the results compared. As no

meaningful differences existed in these results, the original

scores were retained to aid interpretation. Inspection of

correlations and tolerance scores revealed no evidence of

multicollinearity in the multivariate data set and no multi-

variate outliers existed [Mahalanobis Distance v2(5 = 20Æ52,

P < 0Æ001)]. The proportionality of hazards assumption was

tested by examination of the interactions of each covariate

with a variable representing the natural logarithm of time

(using a = 0Æ004 to account for familywise error) and no

statistically significant interactions were observed.

The accuracy and precision of Cox regression survival

analysis becomes untrustworthy when the number of events

per variable becomes too low. In the case of this study,

cessation of breastfeeding/fully breastfeeding represented

such an ‘event’. Conservative guidelines calling for a mini-

mum of 10 events per variable were followed to ensure

sufficient power for the Cox regressions (Peduzzi et al. 1995).

Of the 342 participants who initiated fully breastfeeding and

provided complete data sets, 302 had ceased fully breast-

feeding (event occurred) at 26 weeks, allowing for the

inclusion of up to 30 covariates and ample power to test

the current model for the cessation of fully breastfeeding (12

covariates). Of the 351 women who initiated any breastfeed-

ing and provided complete data sets, 137 had ceased any

breastfeeding at 26 weeks (event occurred), allowing up to 13

covariates in the model. Power for the 12 covariates utilized

in this analysis was therefore adequate.

Spearman’s rho correlations and Wilcoxon (Gehan) statis-

tics were employed to test the bivariate relationship between

variables of interest and the duration of fully or any

breastfeeding. Variables statistically significantly related to

breastfeeding duration in these analyses were entered into a

sequential Cox regression equation in two steps, with all

statistically significant socio-demographic factors entered at

step 1 and statistically significant psychological factors

entered at step 2. All analyses were performed twice, first

using the data measuring the duration of fully breastfeeding

and second using data measuring the duration of any

breastfeeding.

Validity and reliability

With the exception of the three researcher-designed scales

described above, the validity and reliability of scales used to

measure psychological constructs in this study were estab-

lished during psychometric testing, with the results published

by the scale authors. Tabachnick and Fidell (2001) recom-

mend a Cronbach’s alpha coefficient of 0Æ70 or above as

signalling satisfactory internal consistency for these tests and

this statistic was exceeded with the current sample (range

a = 0Æ74–0Æ95) for all but two of these instruments.

One of the two problematic instruments was the Adapt-

ability Scale from the International Personality Item Pool

(Goldberg 1999, Goldberg et al. 2006), which achieved

a = 0Æ69 with the present sample following the deletion of

two items with inter-item correlations below 0Æ3. The second

problematic scale was the Achievement Strivings Scale

(Spence et al. 1987), which also achieved a Cronbach’s alpha

of 0Æ69 after the deletion of one item with an inter-item

correlation below 0Æ3. However, no statistically significant

association was found between scores on either of these scales

and breastfeeding duration, thereby automatically excluding

these data from the multivariate analysis.

Results

At the time of the first interview the average age of

participants’ babies was 3Æ5 days (range = 0–14). The typical

participant was married or in a cohabiting relationship (92%)

and believed that their partner preferred breast over artificial

feeding (72%). Most participants had already had at least

one baby (61%) and had no current plans regarding when

they may return to full- (88%) or part- time (63%) work. The

average participant was approximately 30 years of age

(range = 18–45 years) and had completed 13Æ6 years of

education (range = 9–22 years). Breastfeeding was defined

according to current Australian guidelines (Webb et al. 2001)

and the breastfeeding rates observed were similar to those

seen in previous Australian studies (e.g. Hegney et al. 2003).

Breastfeeding rates observed in the current study are pre-

sented in Table 3.

Results on the Depression, Anxiety and Stress Scales DASS-

21 showed that, at the time of the first interview, >44% of

the sample reported symptoms of postnatal distress in the

form of mild to extremely severe stress, anxiety and/or

depression. Without taking co-morbidity into account,

Table 3 Breastfeeding rates

Feeding method Time 1 (0–14 days) 6 months

Fully breastfeeding 82Æ8 10Æ1Complementary breastfeeding 7Æ8 44Æ2Breastfeeding (any) 90Æ6 54Æ3Artificially feeding 9Æ4 45Æ7

Feeding methods classified according to current Australian guidelines

Webb et al. (2003).

Values are expressed as %(n).



symptoms of stress were reported by approximately 26% of

the sample, 15% reported symptoms of depression and 34%

reported symptoms of anxiety. Of these, co-morbid anxiety

and depression were experienced by 12Æ1% of women in the

study.

Spearman’s Rho correlations revealed that the duration of

both any breastfeeding (BF) and fully breastfeeding (FBF) was

statistically significantly related to continuous measures of

the mother’s age (FBF and BF rs = 0Æ2), education (FBF

rs = 0Æ19, BF = 0Æ24), dispositional optimism (FBF rs = 0Æ12,

BF rs = 0Æ18), breastfeeding self-efficacy (FBF rs = 0Æ48, BF

rs = 0Æ46), faith in breastmilk (FBF rs = 0Æ49, BF rs = 0Æ39),

breastfeeding expectations (FBF rs = �0Æ36, BF rs = �0Æ30)

and anxiety (FBF rs = �0Æ12, BF rs = �0Æ16). For the

categorical variables, Wilcoxon (Gehan) statistics from actu-

arial life tables revealed statistically significant associations

(a = 0Æ05, df = 1) between the duration of breastfeeding and

the mother’s usual occupation (FBF v2 = 6Æ7, BF v2 = 6Æ5),

previous breastfeeding experience (FBF v2 = 13Æ4, BF

v2 = 15Æ7), partner’s infant feeding preference (FBF

v2 = 22Æ1, BF v2 = 28Æ9), the time of the infant feeding

decision (FBF v2 = 15Æ7, BF v2 = 20Æ6) and planned duration

of breastfeeding (FBF v2 = 38Æ5, BF v2 = 57Æ1).

To determine whether the psychological variables would

predict breastfeeding duration over and above the influence

of other related variables, thereby supporting our working

hypothesis, variables statistically significantly associated with

breastfeeding duration were entered into Cox regression

equations in two blocks for both BF and FBF. The five socio-

demographic variables entered at step 1 statistically signifi-

cantly predicted the duration of both BF [v2 (5) = 49Æ51,

P £ 0Æ001, R2 = 0Æ15] and fully breastfeeding [v2 (5) = 26Æ98,

P £ 0Æ001, R2 = 0Æ08]. The subsequent inclusion of the five

statistically significant psychological variables at step 2

significantly increased the model’s ability to predict the

premature cessation of both BF [v2 (7) = 90Æ62, P £ 0Æ001, R2

Change = 0Æ29] and fully FBF [v2 (7) = 54Æ78, P £ 0Æ001, R2

Change = 0Æ17]. Overall, the model with all variables

included moderately predicted the premature cessation of

FBF [v2 (12) = 83Æ74, P £ 0Æ001, R2 = 0Æ27] and more

strongly predicted the duration of BF [v2 (12) = 148Æ62,

P £ 0Æ001, R2 = 0Æ49] in this sample.

Alpha for the statistical significance of covariates was set at

a conservative level of P < 0Æ004 to adjust for familywise

error for 12 covariates (Tabachnick & Fidell 2001). After

controlling for all variables in the model (step 2), the

woman’s faith in breastmilk and her planned duration of

breastfeeding were reliable unique predictors of the duration

of fully breastfeeding. The working hypothesis was therefore

supported. The probability of continuing to fully breastfeed

increased by 36% (1Æ36 times) for every one-point increase in

the faith in breastmilk score (score range 1–5), and partic-

ipants were 1Æ72 times more likely to cease fully breastfeeding

prematurely if they had planned to breastfeed for 6 months

or less.

After controlling for the effect of socio-demographic

factors in the model, three psychological variables were

found to be reliable unique predictors of the duration of any

breastfeeding, providing further support for our working

hypothesis. Every one-point increase in the breastfeeding

Table 4 Results of the cox regression

predicting duration of fully breastfeedingCovariate B SESE Odds ratio 95% CI P value

Step 1 – Socio-demographic variables

Years of education �0Æ05 0Æ03 0Æ96 0Æ91–1Æ01 0Æ084

Mother’s occupation 0Æ06 0Æ17 1Æ06 0Æ77–1Æ47 0Æ720

Breastfeeding experience �0Æ24 0Æ13 0Æ79 0Æ62–1Æ01 0Æ060

Partner’s preference �0Æ49 0Æ14 0Æ61 0Æ46–0Æ81 0Æ001

Mother’s age �0Æ03 0Æ01 0Æ97 0Æ95–1Æ00 0Æ036

Step 2 – Addition of psychological variables


Mother’s occupation 0Æ03 0Æ17 1Æ03 0Æ74–1Æ44 0Æ868

Breastfeeding experience 0Æ02 0Æ13 1Æ02 0Æ78–1Æ32 0Æ903



Breastfeeding self-efficacy �0Æ02 0Æ01 0Æ98 0Æ96–0Æ99 0Æ008

Optimism 0Æ01 0Æ02 1Æ01 0Æ98–1Æ05 0Æ544

Anxiety �0Æ02 0Æ01 0Æ99 0Æ97–1Æ01 0Æ144

Faith in breastmilk 0Æ31 0Æ09 1Æ36 1Æ14–1Æ62 0Æ001

Breastfeeding expectations 0Æ01 0Æ07 1Æ01 0Æ88–1Æ17 0Æ853

Planned duration 0Æ55 0Æ14 1Æ72 1Æ31–2Æ27 <0Æ001

Time of decision �0Æ26 0Æ14 0Æ77 0Æ58–1Æ02 0Æ065

M. O’Brien et al.


self-efficacy score resulted in a 5% increase in the likelihood

of continuing any breastfeeding to 6 months (Breastfeeding

Self-Efficacy Scale – Short Form, score range 14–70). Also,

participants were 1Æ70 times more likely to continue any

breastfeeding for each one-point increase in faith in breast-

milk score (score range 1–5) and were more than twice as

likely to cease breastfeeding prematurely if they had planned

to breastfeed for 6 months or less (odds ratio = 2Æ19). The

results of these Cox regression equations are presented in

Tables 4 and 5.

Discussion

There are several limitations to the study that should be

taken into account when attempting to draw conclusions

from its results. Firstly, while the participation rate com-

pared well with other postnatal research, previous research

suggests that important differences in the demographic

characteristics of participants and non-participants may

exist, such that younger and unmarried women are less

likely to participate (Hegney et al. 2003). The current

sample was certainly relatively homogeneous with regard to

marital status (92% married/cohabiting). It should also be

noted that women <18 years of age or with insufficient

English language skills were excluded from participating.

Particular caution in generalizing these results to young,

unmarried or non-English-speaking women is therefore

warranted. However, in acknowledging this, it should also

be noted that while most hospital-based breastfeeding

studies gather data from a single maternity unit, we included

data from two maternity units, one public and one private,

thus increasing generalizability across the Australian hospi-

tal system.

There were some measurement issues which may also have

influenced the study results. In addition to the concerns about

using the three novel scales employed in this study (i.e. Faith

in Breastmilk, breastfeeding expectations and current life

priorities), two of the previously validated instruments

displayed less than optimal reliability. These were the

International Personality Item Pool Adaptability scale (Gold-

berg et al. 2006) and the Achievement Strivings scale (Spence

et al. 1987). These factors were not statistically significantly

associated with breastfeeding duration and were excluded

from the multivariate analysis. However, further research to

establish the relationship between adaptability, achievement

striving and breastfeeding duration is warranted. Despite

these limitations, the results offer several new insights which

may be of utility to those with an interest in breastfeeding.

First, while a clinical interview is necessary to diagnose

stress, anxiety or depression accurately in individuals (Lovi-

bond & Lovibond 1995), use of the DASS-21 in this study

revealed a somewhat alarming level of potential postnatal

distress among participants, with 44Æ1% of the sample

reporting symptoms of these states. Also, while the literature

appears to focus on the incidence and effects of depression in

the postpartum period, the most common form of postnatal

distress reported in this sample was anxiety. Only 3% of the

sample revealed symptoms of depression alone, while 21Æ8%

reported symptoms of anxiety alone and a further 12Æ1% were

anxious–depressed. This is particularly important given that

Table 5 Results of the cox regression

predicting duration of any breastfeedingCovariate B SESE Odds ratio 95% CI P value

Step 1 – Socio-demographic variables


Mother’s occupation �0Æ15 0Æ27 0Æ86 0Æ51–1Æ47 0Æ586


Partner’s preference �0Æ99 0Æ18 0Æ37 0Æ26–0Æ53 <0Æ001


Step 2 – Addition of psychological variables


Mother’s occupation �0Æ18 0Æ28 0Æ83 0Æ49–1Æ43 0Æ508




Breastfeeding self-efficacy �0Æ05 0Æ01 0Æ95 0Æ93–0Æ97 <0Æ001

Optimism 0Æ03 0Æ03 1Æ03 0Æ98–1Æ08 0Æ296

Anxiety �0Æ01 0Æ02 0Æ99 0Æ97–1Æ02 0Æ620

Faith in breastmilk 0Æ53 0Æ15 1Æ70 1Æ26–2Æ29 0Æ001

Breastfeeding expectations 0Æ04 0Æ12 1Æ04 0Æ82–1Æ31 0Æ759

Planned duration 0Æ79 0Æ19 2Æ19 1Æ52–3Æ16 <0Æ001

Time of decision �0Æ14 0Æ20 0Æ87 0Æ60–1Æ28 0Æ487



higher anxiety was associated with earlier weaning, while

depression had no statistical relationship to breastfeeding

duration in this sample. The lower incidence of depression

found in this study may be because of the widespread use of the

Edinburgh Postnatal Depression Scale (Cox & Sagovsky

1987). This instrument is thought to measure both depression

and anxiety, without adequately distinguishing between these

two distinct psychological states (Brouwers et al. 2001).

In addition to depression, seven other psychological factors

included in the design revealed no statistical relationship to

breastfeeding duration in this sample. These unrelated factors

were psychological reactance (the motivation to regain lost or

threatened personal freedoms), adaptability, mothering self-

efficacy, the mother’s current life priorities, achievement

striving, self-esteem and stress. This result is surprising, given

the evidence suggesting a link between many of these factors

and breastfeeding behaviour (see Table 1). It is also worth

noting that two of these factors (the mother’s life priorities

and mothering self-efficacy) were together ranked as the most

important factor influencing breastfeeding duration by phase

1 participants.

In total, the results revealed seven psychological factors

which were statistically associated with the duration of

breastfeeding: anxiety, dispositional optimism, the timing of

the infant feeding decision, breastfeeding expectations,

planned breastfeeding duration, faith in breastmilk and

breastfeeding self-efficacy. Three of these factors have been

identified as predictors of breastfeeding duration in previous

studies, namely the time of the infant feeding decision,

breastfeeding self-efficacy (O’Brien & Fallon 2005) and

planned breastfeeding duration (Blyth et al. 2004). A

relationship between breastfeeding duration and anxiety has

also been found (Papinczak & Turner 2000). However,

measures used have often been less than ideal (Clifford et al.

2006, Forster et al. 2006), making the current results the

most decisive indication to date of a relationship between

maternal anxiety and early weaning. In the case of breast-

feeding expectations, previous qualitative research suggests

that women may experience a clash between highly idealized

antenatal expectations of breastfeeding and early problems,

leading to disillusionment and early weaning (Mozingo et al.

2000). However, we measured expectations postnatally and

found the opposite to be true. In this study, women who

believed that breastfeeding would be difficult for them

when asked in the 14 days following the birth were more

likely to wean early than those who believed it would be easy,

perhaps because of the experience of early breastfeeding

problems.

Two novel factors associated with breastfeeding duration

were also identified in this study: dispositional optimism and

faith in breastmilk. Optimism has recently been linked to

choice of infant feeding method (Wagner et al. 2006).

However, we found a statistically significant relationship

between optimism and breastfeeding duration, such that the

higher the score on dispositional optimism, the longer the

woman breastfed for. This fits well with what is known about

other, related psychological influences on breastfeeding and

the theories underlying dispositional optimism (Scheier &

Carver 1992) and supports the inclusion of this factor in

future research designs.

The second novel factor was faith in breastmilk. Score on

the Faith in Breastmilk measure was identified as one of two

reliable, unique predictors of both fully and any breastfeeding

duration in this sample. The results for fully breastfeeding

showed that the probability of continuing to fully breastfeed

increased by 36% for every one point increase in faith in

breastmilk score (score range 1–5). The relationship between

this measure and continuing any breastfeeding was even more

strongly predictive, showing that women in the sample were

70% more likely to wean prematurely for each one-point

increase in this scale score. It is possible that this measure

may tap into infant feeding attitudes measured by instru-

ments such as the 17-item Iowa Infant Feeding Attitudes

Scale (De La Mora et al. 1999). However, the brevity, self-

report format and predictive ability of the Faith in Breastmilk

scale will increase its usefulness in clinical settings. Further

research to confirm the psychometric properties of this scale

is therefore warranted.

The second reliable unique predictor of both any and fully

breastfeeding identified was the woman’s planned breast-

feeding duration. As mentioned previously, this factor has

been confirmed as an important predictor of breastfeeding

duration in the past (e.g. Blyth et al. 2004, Forster et al.

2006). When compared with women who planned to

breastfeed for >6 months, women in the current study

who planned to breastfeed for 6 months or less were 1Æ72

times more likely to cease fully breastfeeding and 2Æ19 times

more likely to cease any breastfeeding before 6 months.

While it can be argued that these findings may indicate that

women in this group are merely exercising their right to set

and adhere to their personal goals for breastfeeding, the data

suggest that the majority of these women actually fell well

short of their stated breastfeeding goals. The mean planned

breastfeeding duration for this group was approximately

23 weeks; however, they actually breastfed for an average of

only 12 weeks (10 weeks fully), almost half the originally

planned duration for the group. This suggests that planning

to breastfeed for a relatively short time may be associated

with other risk factors, such as a lack of commitment to

breastfeeding goals.

M. O’Brien et al.


Finally, breastfeeding self-efficacy, or the mother’s confi-

dence in her ability to breastfeed, was identified as a reliable

unique predictor of the duration of any (but not fully)

breastfeeding in this sample. Every one-point increase in

breastfeeding self-efficacy score (score range = 14–70) was

associated with a 5% increase in the participant’s likelihood

of continuing any breastfeeding to 6 months. However, in

previous research which included fewer psychological factors

and a 6-week outcome measure a 6% increase per score point

was found for both any and fully breastfeeding duration

(O’Brien & Fallon 2005). This raises questions as to why

fully breastfeeding was not uniquely predicted by breastfeed-

ing self-efficacy in the current study, while any breastfeeding

was. It seems likely that this differing result may be because

of the inclusion of additional psychological factors such as

optimism, anxiety and faith in breastmilk. These factors may

have influenced the mother’s decision to introduce supple-

mental foods to the infant prematurely and thus cease fully

(but not any) breastfeeding; however, further research in this

area is warranted.

Implications for practice and research

Our data reveal that breastfeeding rates (particularly at

6 months) remain well below national targets and interna-

tional breastfeeding guidelines (WHO 2001). This means that

further efforts to increase breastfeeding duration by breast-

feeding clinicians, researchers and governments are needed.

These efforts should include further research into the

incidence and effect of anxiety on postnatal women. Clini-

cians may also find it helpful to address the issue of anxiety

with breastfeeding women. Discussing the woman’s fears and

worries, providing education on the anxiety response, and

offering help with structured problem solving and relaxation

techniques may help to alleviate the symptoms of many

women, while those with more severe symptoms should be

referred to a suitable mental health professional (WHO

2000).

The results also revealed that several psychological factors

were statistically significantly associated with the duration of

both fully and any breastfeeding. As a set, these psychological

factors were more important to the prediction of breastfeed-

ing duration than were the socio-demographic factors. These

data suggest that women who possess the right psychological

make-up for breastfeeding may be capable of overcoming the

disadvantages posed by socio-demographic factors, a finding

that may give hope to many breastfeeding advocates strug-

gling in difficult socio-demographic environments.

Finally, the importance of faith in breastmilk and planned

breastfeeding duration over and above other potential risks to

breastfeeding suggests that an increased focus on these three

distinct psychological factors by both researchers and clini-

cians is warranted.

Conclusion

The results of this research confirm that psychological factors

are important predictors of breastfeeding duration. This

knowledge has implications for both clinical practice and

future research and represents an increase in our ability to

identify women at risk of early weaning and to construct

programmes capable of increasing the length of time for

which women breastfeed.

Acknowledgements

We would like to thank the management and staff of the

Toowoomba Health Service and St Vincent’s Private Hospi-

tal, Toowoomba for their generous assistance and support.

Thanks also to the study participants, who gave up their

valuable time to discuss and subsequently participate in this

What is already known about this topic

• Only a minority of women continue to breastfeed for

long enough to meet World Health Organization

guidelines for breastfeeding duration, which recom-

mend exclusive breastfeeding for the first six months.

• Several individual psychological differences appear to

influence the duration of breastfeeding, but little

exploratory research has been performed in this area.

What this paper adds

• Duration of breastfeeding is statistically significantly

associated with levels of optimism, breastfeeding self-

efficacy, faith in breastmilk, breastfeeding expecta-

tions, anxiety, planned duration of breastfeeding and

the time of the infant feeding decision.

• As a set, individual psychological differences are more

predictive of breastfeeding duration than the known

socio-demographic determinants.

• After controlling for socio-demographic characteris-

tics, measures of individual psychological factors can

uniquely predict the duration of both fully and any

breastfeeding.

• Knowledge of the factors influencing breastfeeding will

assist in identifying women at risk of early weaning

and in constructing programmes capable of increasing

the length of time for which women breastfeed.



project. We would also like to express our gratitude to Dr

Tony Fallon for the valuable early contributions he made to

this work.

Author contributions

MOB and DH were responsible for the study conception and

design. MOB performed the data collection. MOB and EB

performed the data analysis. MOB was responsible for the

drafting of the manuscript. MOB, EB and DH made critical

revisions to the paper for important intellectual content.

MOB and EB provided statistical expertise. EB and DH

supervised the study.

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