Maternal and Child Health Journal

, Volume 19, Issue 1, pp 49–57 | Cite as

Maternal Knowledge, Attitudes and Self-efficacy in Relation to Intention to Exclusively Breastfeed Among Pregnant Women in Rural Bangladesh

  • Joan S. Thomas
  • Elaine A. Yu
  • Noor Tirmizi
  • Aatekah Owais
  • Sumon K. Das
  • Shahed Rahman
  • A. S. G. Faruque
  • Benjamin Schwartz
  • Aryeh D. SteinEmail author


Achieving optimal exclusive breastfeeding (EBF) remains a challenge. Because intention is a precursor of practice, we examined factors associated with EBF intention during pregnancy in two rural sub-districts of Kishoreganj district, Bangladesh. We studied 2,400 pregnant women in their third trimester (26–32 weeks gestation). We assessed knowledge (6 items, scale range 0–6), attitudes (15 items, scale range 15–75) and self-efficacy (6 items, scale range 6–30) by interview using a standardized questionnaire. 83.9 % of pregnant women reported EBF intention. Mean breastfeeding knowledge was 3.5 (SD 1.3), mean attitude was 55.8 (SD 8.1) and mean self-efficacy was 25.6 (SD 3.4). Knowledge was associated with EBF intention (OR 2.47, 95 % CI 1.74, 3.51), attitudes toward EBF (OR 1.68, 95 % CI 1.31, 2.16) and self-efficacy (OR 1.72, 95 % CI 1.23, 2.40) were independently associated with EBF intention in the model in which all three constructs were entered simultaneously. Receipt of breastfeeding counseling during pregnancy and being literate were each associated with EBF knowledge and EBF intention (all p < 0.05). Increasing maternal knowledge, positive attitudes, and self-efficacy regarding EBF were associated with prenatal EBF intention. These results reinforce the importance of appropriate counseling to increase EBF prevalence .


Exclusive breastfeeding Knowledge Attitude Self-efficacy Intention Time management Privacy 



This study was embedded in CARE’s community based initiative to improve infant and young child feeding and nutritional outcomes, known as “Akhoni Shomay” or Window of Opportunity, in Bangladesh. We would like to thank the field staff and team leads in Bangladesh. We thank the staff of the International Center for Diarrhoeal Disease, Bangladesh and CARE Bangladesh. We thank the women for their participation. This study was supported by a grant from CARE USA.

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129, e827–e841.CrossRefGoogle Scholar
  2. 2.
    American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496–506.CrossRefGoogle Scholar
  3. 3.
    American Academy of Pediatrics. (1997). Breastfeeding and the use of human milk. Pediatrics, 100(6), 1035–1039.CrossRefGoogle Scholar
  4. 4.
    Arifeen, S., Black, R. E., Antelman, G., et al. (2001). Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics, 108(4), E67.PubMedCrossRefGoogle Scholar
  5. 5.
    Lamberti, L. M., Fischer Walker, C. L., Noiman, A., et al. (2011). Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health, 11(Suppl 3), S15.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Ip S., Chung M., Raman G. et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Rockville: Agency for Healthcare Research and Quality Contract No.: 153.Google Scholar
  7. 7.
    Berry, N., & Gribble, K. (2008). Breast is no longer best: Promoting normal infant feeding. Maternal Child Nutrition, 4(1), 74–79. doi: 10.1111/j.1740-8709.2007.00100.x.PubMedCrossRefGoogle Scholar
  8. 8.
    Kramer, M. S., & Kakuma, R. (2004). The optimal duration of exclusive breastfeeding: A systematic review. Advances in Experimental Medicine and Biology, 554, 63–77.PubMedCrossRefGoogle Scholar
  9. 9.
    World Health Organization. (2011). Exclusive breastfeeding for six months best for babies everywhere. Geneva: WHO.Google Scholar
  10. 10.
    World Health Organization. (2010). WHO Global Data Bank on Infant and Young Child Feeding (IYCF): Bangladesh. Geneva: WHO.Google Scholar
  11. 11.
    Labbok, M., & Krasovec, K. (1990). Toward consistency in breastfeeding definitions. Studies in Family Planning, 21(4), 226–230.PubMedCrossRefGoogle Scholar
  12. 12.
    Kramer, M., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database Systematic Review, 15(8), CD003517. doi: 10.1002/14651858.CD003517.pub2.Google Scholar
  13. 13.
    World Health Organization. Exclusive Breastfeeding.Google Scholar
  14. 14.
    Lawson, K., & Tulloch, M. I. (1995). Breastfeeding duration: Prenatal intentions and postnatal practices. Journal of Advanced Nursing, 22, 841–849.PubMedCrossRefGoogle Scholar
  15. 15.
    Dodgson, J. E., Henly, S. J., Duckett, L., et al. (2003). Theory of planned behavior-based models for breastfeeding duration among Hong Kong mothers. Nursing Research, 52(3), 148–158.PubMedCrossRefGoogle Scholar
  16. 16.
    Wambach, K. (1997). Breastfeeding intention and outcome: A test of the theory of planned behavior. Research in Nursing & Health, 20, 51.CrossRefGoogle Scholar
  17. 17.
    Janke, J. R. (1994). Development of the breast-feeding attrition prediction tool. Nursing Research, 43(2), 100–104.PubMedCrossRefGoogle Scholar
  18. 18.
    Piper, S., & Parks, P. L. (1996). Predicting the duration of lactation: Evidence from a national survey. Birth, 23, 7–12.PubMedCrossRefGoogle Scholar
  19. 19.
    Scott, J. A., Binns, C. W., Oddy, W. H., et al. (2006). Predictors of breastfeeding duration: Evidence from a cohort study. Pediatrics, 117, e646.PubMedCrossRefGoogle Scholar
  20. 20.
    Stuebe, A., & Bonuck, K. (2011). What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes and beliefs in a diverse urban population. Breastfeeding Medicine, 6, 413–420.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Nommsen-Rivers, L., Chantry, C., Cohen, R., et al. (2010). Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeeding Medicine, 5(1), 25–33. doi: 10.1089/bfm.2009.0052.PubMedCrossRefGoogle Scholar
  22. 22.
    Bai, Y., Middlestadt, S., Peng, C., et al. (2010). Predictors of continuation of exclusive breastfeeding for the first six months of life. Journal of Human Lactation, 26(1), 26–34. doi: 10.1177/0890334409350168.PubMedCrossRefGoogle Scholar
  23. 23.
    World Health Organization. (2011). World Health Statistics 2011. Geneva: WHO.Google Scholar
  24. 24.
    Hood, L., Faed, J., Silva, P., et al. (1978). Breast feeding and some reasons for electing to wean the infant: A report from the Dunedin multidisciplinary child development study. New Zealand Medical Journal, 88(621), 273–276.PubMedGoogle Scholar
  25. 25.
    Buxton, K., Gielen, A., Faden, R., et al. (1991). Women intending to breastfeed: Predictors of early infant feeding experiences. American Journal of Preventive Medicine, 7(2), 101–106.PubMedGoogle Scholar
  26. 26.
    Houston, M. (1981). Breast feeding: Success or failure. Journal of Advanced Nursing, 6(6), 447–454. doi: 10.1111/j.1365-2648.1981.tb03248.x.PubMedCrossRefGoogle Scholar
  27. 27.
    Armitage, C., & Conner, M. (2001). Efficacy of the theory of planned behavior: A meta-analytic review. British Journal of Social Psychology, 40, 471–499.PubMedCrossRefGoogle Scholar
  28. 28.
    Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211.CrossRefGoogle Scholar
  29. 29.
    Ajzen, I. (2002). Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. Journal of Applied Social Psychology, 32, 665–683.CrossRefGoogle Scholar
  30. 30.
    National Institute of Population Research and Training (NIPORT) (2009), Mitra and Associates, Macro International. Bangladesh Demographic and Health Survey 2007. Dhaka and Calverton: NIPORT, Mitra and Associates, and Macro International.Google Scholar
  31. 31.
    Dennis, C. L. (2002). Breastfeeding initiation and duration: A 1990—2000 literature review. Journal of Obstetrics, Gynecology & Neonatal Nursing., 32(6), 734–744.CrossRefGoogle Scholar
  32. 32.
    Li, R., Darling, N., Maurice, E., et al. (2005). Breastfeeding rates in the United States by characteristics of the child, mother, or family: The 2002 national immunization survey. Pediatrics, 115, e31.PubMedCrossRefGoogle Scholar
  33. 33.
    Thulier, D., & Mercer, J. (2009). Variables associated with breastfeeding duration. Journal of Obstetrics, Gynecology & Neonatal Nursing., 38, 259–268.CrossRefGoogle Scholar
  34. 34.
    Donath, S. M., & Amir, L. H. (2003). Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: A cohort study. Acta Paediatrica, 92(3), 352–356.PubMedCrossRefGoogle Scholar
  35. 35.
    Mitra, A. K., Khoury, A. J., Hinton, A. W., et al. (2004). Predictors of breastfeeding intention among low-income women. Maternal and Child Health Journal, 8(2), 65–70.PubMedCrossRefGoogle Scholar
  36. 36.
    Humphreys, A. S., Thompson, N. J., & Miner, K. R. (1998). Intention to breastfeed in low-income pregnant women: The role of social support and previous experience. Birth, 25(3), 169–174.PubMedCrossRefGoogle Scholar
  37. 37.
    Ahmed, T., Mahfuz, M., Ireen, S., et al. (2012). Nutrition of children and women in Bangladesh: Trends and directions for the future. Journal of Health, Population, and Nutrition, 30(1), 1–11.PubMedCentralPubMedGoogle Scholar
  38. 38.
    World Health Organization (2014). Infant and Young Child Feeding. In: Centre M, editor. Geneva: WHO.Google Scholar
  39. 39.
    DiGirolamo, A., Thompson, N., Martorell, R., et al. (2005). Intention or experience? Predictors of continued breastfeeding. Health Education & Behavior, 32(2), 208–226. doi: 10.1177/1090198104271971.CrossRefGoogle Scholar
  40. 40.
    Haider, R., Ashworth, A., Kabir, I., et al. (2000). Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. The Lancet, 356(9242), 1643–1647.CrossRefGoogle Scholar
  41. 41.
    Anderson, A., Damio, G., Young, S., et al. (2005). A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Archives of Pediatrics and Adolescent Medicine, 159(9), 836–841.PubMedCrossRefGoogle Scholar
  42. 42.
    Haque, M., Hussain, M., Sarkar, A., et al. (2002). Breast-feeding counselling and its effects on the prevalence of exclusive breast-feeding. Journal of Health, Population and Nutrition, 20(4), 312–316.Google Scholar
  43. 43.
    Aidman, B. A., Parez Escamilla, R., & Lartey, A. (2005). Lactation counseling increases exclusive breast-feeding rates in Ghana. The Journal of Nutrition, 135(7), 1691–1695.Google Scholar
  44. 44.
    Racine, E., Frick, F., Strobino, D., et al. (2009). How motivation influences breastfeeding duration among low-income women. Journal of Human Lactation, 25(2), 173–181. doi: 10.1177/0890334408328129.PubMedCrossRefGoogle Scholar
  45. 45.
    Wilhelm, S., Stepans, M., Hertzog, M., et al. (2006). Motivational interviewing to promote sustained breastfeeding. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(3), 340–348.PubMedCrossRefGoogle Scholar
  46. 46.
    Meedya, S., Fahy, K., & Kable, A. (2010). Factors that positively influence breastfeeding duration to 6 months: A literature review. Women and Birth, 23(4), 135–145. doi: 10.1016/j.wombi.2010.02.002.PubMedCrossRefGoogle Scholar
  47. 47.
    Uchenna, O. (2012). Problems encountered by breastfeeding mothers in their practice of exclusive breastfeeding in tertiary hospitals in Enugu State, South-east Nigeria. Journal of Nutrition and Metabolism, 4(8), 107–113.Google Scholar
  48. 48.
    Mihrshahi, S., Kabir, I., Roy, S., et al. (2010). Determinants of infant and young child feeding practices in Bangladesh: Secondary data analysis of Demographic and Health Survey 2004. Food & Nutrition Bulletin, 31(2), 295–313.Google Scholar
  49. 49.
    Das, D., Talukder, M., & Sella, G. (1992). Infant feeding practices in rural Bangladesh. Indian Journal of Pediatrics, 59(5), 573–577.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Joan S. Thomas
    • 1
    • 2
  • Elaine A. Yu
    • 1
  • Noor Tirmizi
    • 2
  • Aatekah Owais
    • 1
  • Sumon K. Das
    • 4
  • Shahed Rahman
    • 3
  • A. S. G. Faruque
    • 4
  • Benjamin Schwartz
    • 2
  • Aryeh D. Stein
    • 1
    Email author
  1. 1.Hubert Department of Global Health, Rollins School of Public HealthEmory UniversityAtlantaUSA
  2. 2.CARE USAAtlantaUSA
  3. 3.CARE BangladeshDhakaBangladesh
  4. 4.International Centre for Diarrhoeal Disease Research, BangladeshDhakaBangladesh

Personalised recommendations