This article explores and clarifies the concept of maternal attitude as related to breastfeeding by exploring the literature and undertaking a concept analysis using Walker and Avant's (2011) eight-step framework for concept analysis.
The nutritional, immunological, physical, psychosocial, economic and environmental benefits of breastfeeding for infants, postpartum women and communities have been well proven (Cornall, 2011). Breastfeeding can be described as ‘exclusive breastfeeding’, where no artificial milk substitutes or other fluids are given to the infant, or as ‘partial or mixed breastfeeding’, where the infant is given some breast milk supplemented by formula milk and/or other fluids. The World Health Organization (WHO) and UNICEF (2003) recommends exclusive breastfeeding for a minimum of 6 months post-birth and partial breastfeeding for up to 2 years and beyond for optimal health in children and to promote healthy growth and development of the infant. Children who are breastfed are less likely to develop infections during infancy and chronic diseases later in childhood, and have improved cognition and IQ (Horta et al, 2015). Maternal benefits include faster return to postpartum uterine tone, postpartum weight loss, and delayed resumption of menses (Chowdhury et al, 2015). In addition, breastfeeding reduces the risk of a woman developing invasive breast cancer by 4.3% and ovarian cancer by 30% (Victora et al, 2016).
Despite the WHO recommendations, the duration of breastfeeding in many countries falls short of this. Globally, 37% of infants less than 6 months old are exclusively breastfed (WHO, 2012), and 75% of mothers do not meet the UNICEF recommendation for optimal breastfeeding (Stuebe and Bonuck, 2011). In Hong Kong, more than 80% of postpartum women initiate breastfeeding (Baby Friendly Hospital Initiative Hong Kong Association and UNICEF, 2011), but only 6% exclusively breastfeed when the infant is 3 months old (Tarrant et al, 2010). In the UK, 81% of women initiate breastfeeding and 17% are exclusively breastfeeding at 3 months post-birth, dropping to 1% when the infant is 6 months old (Victora et al, 2016).
Breastfeeding is a complex phenomenon, the duration of which may be influenced by a combination of demographic, physical, social, and psychological factors. There is increasing evidence that knowledge of infant feeding, and psychosocial factors such as maternal attitude, self-efficacy, and influence of family and friends are significant predictors of initiation and duration of breastfeeding (Scharfe, 2012). Other factors associated with a reduced duration include lack of breastfeeding knowledge and practical skills. Targeted support can be helpful to overcome some barriers (Dykes et al, 2003).
It is recognised that women are influenced by female friends' or relatives' breastfeeding experiences, and that this influences attitude and behaviour (Oakley et al, 2014). Attitude towards breastfeeding is important and a predictor for breastfeeding initiation, duration, and exclusivity (Shaker et al, 2004). Women's attitudes and practices are also influenced by the availability and perception of social support from their partner, other postpartum women, close friends, and health professionals (Meedya et al, 2010). Maternal breastfeeding self-efficacy is associated with women's breastfeeding behaviour and can be described as the mother's perceived ability and/or confidence to breastfeed (Ku and Chow, 2010).
There are several factors that contribute to mothers' choices to use formula as opposed to breast milk. One factor relates to the use of formula milk in hospital, which may cause women to assume that it is equivalent to breast milk and endorsed by health professionals (Philipp et al, 2001). The introduction of the UNICEF global baby-friendly initiative has substantially reduced the availability of formula milk in maternity units.
Maternal attitude towards breastfeeding intent and duration is a frequently-used concept in clinical practice and research. The term is based on a number of assumptions and would benefit from further exploration and clarity to aid understanding and meaning. This article therefore aims to explore and clarify the concept of maternal attitude in relation to breastfeeding.
Method
Walker and Avant's (2011) eight step framework (Table 1) was used to explore and further understand the concept.
| Step 1. Identify concept |
| Step 2: Aims and purpose |
| Step 3: Identify all uses |
| Step 4: Defining attributes |
| Step 5: Identify model case |
| Step 6: Identify other cases |
| Step 7: Confirm antecedents and consequences |
| Step 8: Define empirical reference |
Source: Walker and Avant (2011)
Results
Step 1: Identify concept
The concept of maternal ‘attitude’ in relation to breastfeeding was chosen as it is a frequently used term, based on a number of beliefs and values, and influences behaviour change.
Step 2: Aims and purpose
As maternal attitude is based on a number of assumptions, it can be misinterpreted, misused or overused without a clear definition. It is therefore important to fully understand the concept of maternal attitude to breastfeeding. A positive attitude is predictive of an increased prevalence of initiation and duration of breastfeeding, and breastfeeding results in improved clinical health outcomes. Having a clear understanding of the concept may facilitate the development of interventions to improve breastfeeding intent, initiation and duration.
Step 3: Identify all uses
The term ‘attitude’ is most often defined as a noun. The Mirriam Webster's dictionary define it as:
The first two definitions were the most relevant to this analysis.
Synonyms include opinions, ideas, beliefs, convictions, feelings, thoughts, perception, judgment, turn of mind, point of view, frame of mind, way of thinking, way of looking at things, reaction and position/posture. Using a Google search, 396 million citations of the term ‘attitude’ were identified and used in a variety of different topics, including magazines, quotes, education and music.
Attitude and theories of behaviour
‘Attitude’ is a frequently used term within psychology. One example relates to the theory of planned behaviour (Ajzen, 1991). The model is based on the premise that individuals make logical, reasoned decisions to engage in specific behaviours by evaluating the information available to them. According to the theory of planned behaviour, the behavioural intention depends on:
The theory of planned behaviour refers to ‘attitude toward the behaviour’ as the degree to which a person has positive or negative feelings of the behaviour of interest. It entails consideration of the outcomes following the behaviour change. The individual's attitude towards performing the behaviour (i.e, the person's overall positive or negative feelings with respect to performing the behaviour) is based on the person's beliefs that performing the behaviour will lead to various positive or negative outcomes. This framework is used in multiple studies in health psychology, patient education and self-management, social media and health behaviour change.
In contrast to the dictionary definition, Fazio and Williams (1986) define ‘attitude’ as a summary judgment of an object or event, which helps individuals to structure and understand their complex social environment. In this definition, ‘attitude’ is a subjective yet non-tangible concept acquired through learning over a period of time and influenced by individual's personality and situation.
According to Eagly and Chaiken (1993), attitude is a psychological tendency that is expressed by evaluating a particular entity with some degree of favour or disfavour. They developed the affect, behaviour and cognition (ABC) model, and suggest that the affective component relates to individual's feelings towards an object, behaviour refers to the individual's intention towards an object, and cognition refers to the belief, an individual has about an object.
A further useful perspective is construal level theory. This situates attitude in many social cognitive domains, including judgment of moral behaviour, persuasion, values-behaviour consistency, and ideological consistency (Alison et al, 2010). Construal level theory indicates that individuals' response to social events is determined by their social cognitive perspective, based on their psychological representation of the event (Nussbaum et al, 2003). They describe it as relating to four dimensions: time, space, social distance, and probability.
Literature review
Maternal attitude in the context of breastfeeding is important. Searching the PubMed database using the term ‘attitude’ resulted in 158 973 articles. The term ‘breastfeeding’ and a date limitation of previous 5 years (2013–2018) was added and resulted in 931 papers. Of these, 111 were selected as the title contained ‘maternal attitude’ and ‘breastfeeding’. Cross-referencing articles identified further sources from outside this range.
Determinants of women's decision to breastfeed include knowledge and attitude as well as professional and personal support. Women in higher socioeconomic groups with higher levels of education are more likely to choose breastfeeding (Bai et al, 2009). Additional factors include socio-cultural context; the attitude of the woman's partner, family and friends; and the support and involvement of health professionals (Bai et al, 2009). A study conducted by Radzyminski and Callister (2015) reported findings from 53 health professional interviews and concluded that health professionals lacked knowledge and skills regarding assessment and management of breastfeeding. In addition, inconsistencies were noted between the levels of supportive behaviour that health professionals gave to women.
A large study conducted by Dodgson et al (2003), involving 2400 pregnant women, examined factors associated with exclusive breastfeeding intention during pregnancy in rural districts of Bangladesh. Results revealed that exclusive breastfeeding was associated with positive attitude and feelings of self-efficacy. In a further study by Thomas et al (2014), exclusive breastfeeding knowledge and intention were associated with breastfeeding counselling. The authors concluded that increasing maternal knowledge, positive attitude, and self-efficacy were associated with prenatal exclusive breastfeeding intention which predicts breastfeeding's practice, which has been supported by subsequent studies (Fischer and Olson 2014; Thomas et al, 2014; Vijayalakshmi et al, 2015).
Reconsidering construal level theory and social-moral obligation, Ludlow et al (2012) suggested that some mothers see themselves as having a moral and social responsibility to protect their infant from risk. Additional influential factors include personal demographics, culture, family and maternal confidence in the ability to breastfeed (Avery et al, 2009).
There has been a significant decline in the duration of breastfeeding during the 20th century. In the early 1900s, 89% of mothers in the US were still breastfeeding their infant at 4 months (Sedgwick, 1921); however, by 1995, only 22% of mothers in the US were breastfeeding when the infant was 6 months old (Ryan, 1997).
De la Mora et al (1999) developed and validated the 17-item Iowa Infant Feeding Attitude Scale (IIFAS) to assess maternal attitude to breastfeeding. Scores range from 17 to 85, with higher scores reflecting more positive attitudes. The scale includes sections relating to knowledge, opinion, feelings, social norms, experience, support, resources and demographic characteristics. Studies using the scale (Chen et al, 2013) have explored the relationship between maternal attitude and initiation and/or duration of breastfeeding, as well as maternal demographic characteristics and attitude to breastfeeding.
Summary of findings
A number of alternative and contrasting definitions were identified, confirming a lack of clarity around the concept of ‘attitude’. The majority of sources suggested that attitude was a dichotomous concept relating to a positive or negative emotional state. One difficulty of analysing an affective or emotional concept is the potential for subjectivity, which adds further complexity. The majority of definitions related attitude to an emotional reaction to a situation and/or position. This reaction was noted by others and could be described as resulting in positive or negative observed behaviours.
Evidence from psychology provides a useful and comprehensive understanding of the term, particularly in relation to the ABC model (Eagly and Chaiken, 1993). It could be suggested that ‘attitude’ is formed through evaluating learning and life experiences, which results in particular thoughts or feelings towards an object and/or behaviour. These feelings are then expressed verbally or through actions. Attitude therefore specifically leads to behaviour intent or action. Beliefs, knowledge, social norms and cumulative direct or indirect experience regarding the defined object and/or behaviour contribute to thoughts, emotions and behaviour.
Step 4: Defining attributes
Walker and Avant (2011) considered the fourth step as the ‘heart of the concept analysis’, i.e. determining the defining attributes and characteristics of the concept. These are always present and associated with the concept. Taking into account the dictionary definition, consideration of use and findings from the literature review, four attributes were identified. Attitude therefore:
‘Maternal attitude is based on a number of assumptions, it can be misinterpreted, misused or overused without a clear definition. It is therefore important to fully understand the concept of maternal attitude to breastfeeding’
Step 5: Identify model case
In the fifth step of a concept analysis, Walker and Avant advise developing one or more model cases that represent a ‘real life’ example of the concept, using all of the critical attributes identified.
Model case 1
Shaun is a 25-year-old primiparous woman. She is an undergraduate, employed and has a household income of 6000 ¥/month. She has attended many antenatal classes related to breastfeeding and is well supported by friends and relatives. She has a named midwife and access to a lactation consultant. She has read many books about the importance of breastfeeding, has social insurance, and is 37 weeks' pregnant. She plans to breastfeed her baby for more than 6 months because she believes that the breast milk meets the needs for ideal infant growth and development, and will strengthen the baby's resistance and immunity. Shaun also considers breastfeeding to be cheap and therefore affordable, clean and safe as well as convenient. She feels excited about breastfeeding, as she believes that it will enhance the emotional bond between herself and baby. She knows that she will benefit from breastfeeding, as it will reduce her risk of developing cancer.
The birth was normal and Shaun started to breastfeed within 1 hour with assistance from health professionals. When the baby was 6 weeks old, she reported feeling excited about being a mother and was enjoying breastfeeding. She reported that the assistance from her mother-in-law in caring for the baby was helpful. She plans to return to work, but is already preparing for this by expressing breast milk and freezing it.
This is a model case as it includes all the defined attributes, including a conscious and informed decision to breastfeed. Shaun's decision is informed by knowledge and beliefs that breastfeeding is the best for her and her baby. She has made a decision to breastfeed and activates her decision by breastfeeding her baby at the earliest opportunity after the birth and by putting systems in place (such as help from mother-in-law) to maximise success. A further case illustrates the critical attributes with a different infant feeding outcome.
Model case 2
Xin is a 35-year-old woman pregnant with her second child. She is educated to high school level and is unemployed. She is 37 weeks' pregnant and does not plan to breastfeed this baby. She tried to breastfeed her first baby but recalls this as a bad experience. She remembers feeling tired and fatigued. She reports not getting enough sleep due to frequent feeds and having a lot of breast pain. This made her feel depressed and not enjoy being a mother. Once she gave up breastfeeding and transferred to formula milk, she got more rest, had more energy and felt emotionally better. Based on this experience, she has made a decision not to breastfeed and feels relieved about her decision.
This is a model case because although it results in a different outcome, it still contains all the critical attributes. These include conscious thought about what Xin would like to do once her baby was born, which included recalling her feelings about her last breastfeeding experience. Based on this experience, Xin made a judgment that she did not want to breastfeed this baby and was relieved once that decision was made.
Step 6: Identify other cases
Development of other cases include, a borderline, related, contrary, invented, and illegitimate case and contain some or none of the required critical attributes.
Borderline case
A borderline case contains some, but not all, of the critical attributes.
A midwife working on a maternity ward provides information about why and how to breastfeed to pregnant mothers in an antenatal education programme. She explains and shows the women how to position the baby and the importance of drinking enough fluids and having adequate rest.
This case contains knowledge to inform conscious thoughts and feelings but does not contain the attributes related to decision-making and consequential behaviour and/or action.
Related case
A related case is similar to the model case but does not contain critical attributes.
Qing is a 27-year-old primiparous woman. She had a normal birth and her baby is now 2 days old. After the birth, she started to breastfeed because health professionals asked her to do so, as they felt that was the best for the baby. Her mother-in-law did not want her to breastfeed, and asked her stop once she was discharged from the hospital, so that Qing could get plenty of rest to recover from the birth.
This case is a related case because at no point do the health professionals and/or Qing's mother-in-law attempt to explore what Qing wants, believes or feels about breastfeeding. It does not reflect conscious thoughts that result in an action and/or behaviour. Although the baby needs and receives milk, the choice of which type of milk is not as a consequence of conscience thoughts, belief and independent decision-making.
Contrary case
A contrary case describes a situation that is clearly not the concept of interest.
Mary is a female baby smiling and saying some non-understandable sounds. When she sees her mother's breasts she gets excited as she knows she will get some milk and a cuddle.
This case demonstrates an example of what the concept is not: it does not meet any characteristics or critical attributes related to attitude. Mary is a baby without any developed cognitive ability to think about the issue, knowledge or experience, belief or judgment.
Illegitimate case
An illegitimate case describes a situation that is not in the same context as the one that is intended.
Liu is a 25-year-old woman who has just given birth to her first baby 1 hour ago by caesarian section. While still under anaesthesia, the midwife places the baby on her chest to stimulate breast milk and encourage emotional bonding.
This is an illegitimate case because the woman is unconscious and therefore cannot have conscious thought or feelings to make decisions and take action.
Invented case
An invented case describes a ‘make believe’ or ‘imaginary’ situation not related to the context but does contain some and/or all of the attributes.
A policeman named Tom is standing in the street, crying and looking distressed. His shoulders are down and his head is drooping. He points to a small snail crawling across the road and shouted that all traffic must stop until the snail was safely across the road.
In this case, Tom demonstrates feelings and emotions, as well as a conscious decision. This may have been based on previous experience and/or knowledge; however the described behaviour is inappropriate and out of context for the situation.
Step 7: Confirm antecedents and consequences
The seventh step in Walker and Avant's model is to identify antecedents and consequence that occur before and as a result of, the ‘occurrence of the concept’ (Nuopponen, 2010). Table 2 presents the antecedents, attributes and consequences.
| Antecedents | Attributes | Consequence |
|---|---|---|
| Knowledge | Judgment | Behaviour/action (or not) |
| Beliefs/personal values | Conscious feelings and/or thoughts | Positive or negative outcome |
| Social norms and culture | Conscious decision-making | Need to intervene (or not) |
| Importance/personal relevance | Behaviour and/or action intent | |
| Demographic characteristics | ||
| Available support |
As an antecedent, knowledge regarding mother and infant benefits of breastfeeding is important and informs attitude. The mother's beliefs, social norms and culture, as well as support from others, affect the decision to initiate and/or continue breastfeeding (Lundberg and Ngoc Thu, 2012; Wang et al, 2014). The direct or indirect previous experience of breastfeeding, educational level, household income and other sociodemographic characteristics such as higher educational attainment is significantly associated with mothers' positive attitude toward breastfeeding (Chen et al, 2013; Leahy-Warren et al, 2014; Tavoulari et al, 2015). Women aged between 30-33 years old, and/or with a higher economic status were found to have a higher IIFAS score indicating a positive attitude towards breastfeeding, while women who lacked support at home and/or workplace, information, education and/or a good household income were found to have a lower IIFAS score (Darwent and Kempenaa, 2014).
Once a conscious decision is made, it will result in behaviour change and/or action, including a decision to take no action, all of which may result in a positive or negative outcomes. The strength of feelings or thoughts about an issue will influence action (or no action) and the ability for the attitude to be challenged and/or changed.
Step 8: Define empirical reference
The last step in Walker and Avant's (2011) model explores the empirical references in the real world to enable one to consider and apply its application. In midwifery, the empirical reference is useful to health professionals because it provides objective and clear consideration of the concept (Walker and Avant, 2011). The attitude characteristics identified lead to behavioural intent and this is then followed by an action (or decision not to act).
There is an interesting debate concerning whether attitude is subjective and cannot be measured. Altmann (2008) proposes that the concept cannot be directly measured; however, in terms of breastfeeding, de la Mora et al (1999) suggest that it can be measured and developed a validated tool to do so. According to Chen et al (2013), women who had higher levels of education and knowledge about breastfeeding; had a high household income, and who were older were more likely to have a stronger attitude to commit to breastfeeding. Providing support and encouragement for breastfeeding during the postnatal period is likely to enhance the woman's experience and increase positive attitudes towards breastfeeding (Tarrant et al, 2014). According to Chen et al (2013), mothers with a high IIFAS score were more likely to initiate breastfeeding.
Health professional training programmes should include information related to breastfeeding knowledge and skills, and methods to support mothers. Strategies should be implemented that support initiation and prolong breastfeeding duration. These should include elements related to education, information and support (Wang et al, 2014).
Conclusion
Attitude is a response to a stimulus and involves a judgment being made based on belief, cumulative experience, values, knowledge, principles, and conscious thought. It results in conscious decision-making, leading to behaviour and/or action intent. The consequence is behaviour and/or action change or a conscious decision not to act.
This article provides new insights regarding maternal attitude to breastfeeding. It has clarified the definition by identifying critical attributes, antecedents and consequences and has illuminated these using case studies. The process has identified a validated tool to measure maternal attitude to breastfeeding and explored different perspective of ‘attitude’ as a concept. Understanding the concept in detail will assist in clinical decision-making, and the development and implementation of interventions to improve clinical outcome.