International Journal of Nursing and Health Science
2015; 2(3): 28-36
Published online June 10, 2015 (http://www.openscienceonline.com/journal/ijnhs)
A Literature Review of the Factors That Influence
Breastfeeding: An Application of the Health Belief
Department of Nursing science, Faculty of Medical sciences University of Jos, Jos, Plateau State, Nigeria
Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
To cite this article
Andy Emmanuel. A Literature Review of the Factors That Influence Breastfeeding: An Application of the Health Believe Model.
International Journal of Nursing and Health Science. Vol. 2, No. 3, 2015, pp. 28-36.
Breastfeeding is beneficial for both mother and child. Exclusive breastfeeding rate and early initiation of breastfeeding has not
reached desirable level in many countries. Understanding the factors that influence infant feeding will help in promotion,
protecting and supporting breast feeding. This review identified the determinants of infant feeding practices and presented it
using the Health Belief Model as a frame work. Several data bases were searched with specific keywords and findings reveal
that maternal sociodemograhpic characteristic like age, education, parity, economic status, and employment may influence
breastfeeding. Other factors include, antenatal attendance, multiple births, type of delivery, previous breastfeeding experience,
breastfeeding support, Knowledge of individual’s feeding as babies, maternal prenatal feeding intention and infant birth weight.
Women will breastfeed as recommended if they are influenced to develop a positive perception about breastfeeding.
Breastfeeding, Determinants, Health Belief Model, Breastfeeding Intention, Infant Feeding
Suboptimal breastfeeding is responsible for the death of
1.4 million children and the disability of 44 million globally
(Black et al, 2008). Therefore, it has been recommended that
all women should breastfeed their infants exclusively in the
first six months and subsequently with supplementary
feeding for 2 years for optimal growth and development
(UNICEF, 2013). The World Health Organization and
UNICEF had launched several programmes like the baby
friendly hospital initiative and the International Code of
Marketing of Breast Milk Substitutesin order to protect,
promote and support breastfeeding in response to persistent
decline in the rate of breast feeding globally (Fairbank et al,
2000; UNICEF, 2013). The factors that influence infant
feeding are complex and vary from one setting to another.
Understanding these factors is necessary in addressing the
declining rate of breastfeeding.
Exclusive Breastfeeding for six months is beneficial for
women because it ensures better reproductive and
postmenopausal health (NRDC, 2005; Murimi Dodge, Pope,
& Erickson, 2010). Breastfeeding has a beneficial effect on
the health of women. Studies have shown that breastfeeding
helps in losing pregnancy weight faster (Kramer and Kakuma
2012; Baker Gamborg, Heitmann, Lissner, et al 2008; Sanusi
and Falana, 2013). A study revealed that women who
breastfed lost 4.4kg within a year, while those who did not
breastfeed only lost 2.4 kg (P<0.05) (Dewey, Heinig and
Nommsen, 1993).This underlines the effectiveness of
breastfeeding especially if practiced exclusively in the first
six months, in reducing weight gain during pregnancy.
Breastfeeding promotes uterine contraction, thereby reducing
blood loss after delivery and promotes uterine involution
(NRDC, 2005). Breastfeeding reduces the risk of type 2
diabetes and cardiovascular diseases (Davis, Stichler and
Poeltler, 2012). It also lowers the risk of breast, endometrial
and ovarian cancers (Labbok, 2001; NRDC, 2005; Centre for
Community Child Health, 2006; Huo, Adebamowo, et al
2008; Sule, 2011; Davis, Stichler and Poeltler, 2012).
Absence of menstruation due to breastfeeding serves as
temporary contraception for some women (Kuti, Adeyemi
and Owolabi, 2007).This is effective for some women who
breastfed exclusively for six months (Kuti, Adeyemi and
International Journal of Nursing and Health Science 2015; 2(3): 28-36 29
Owolabi, 2007).Breastfeeding is cost effective as finances do
not have to be set aside for infant formula (NRDC, 2005
Centre for Community Child Health, 2006).Breastfeeding
gives women a sense of bonding with their babies (NRDC,
2005 Centre for Community Child Health, 2006) and
promotes mental health of women (Davis, Stichler and
Breastfeeding is also beneficial for the infant. Adequately
breastfed infants grow more rapidly and are healthier than
those who were not (Ukegbu, Ebenebe and Ukegbu, 2010,
Gale, Logan, et al, 2012). Breast milk confers a child with
significant protection against many infectious diseases
because it containsantibodies (immuno globulins) that
strengthen the Childs immunity (Ukegbu, 2010; Murimi et al,
2012; Lamberti, Zakarija-Grković, et al, 2013). Breastfeeding
reduces the incidence of meningitis, malaria, asthma,
respiratory diseases (such as pneumonia), ear infection,
diarrhoea, and urinary tract infection (Ukegbu, 2010;
Murimiet al, 2012; Ibadin et al, 2012; Lamberti et al 2013).
Kramer and Kakuma (2012) posited that in the first six
months of life, exclusive breastfed infants are six times less
likely to die from diarrhoea and 2.5 times less likely to die
from acute respiratory infection. Breastfeeding lowers the
risk of allergy and food intolerance and improve brain
development (Centre for Community Child Health, 2006: 7).
Infants exclusively breastfed for six months have higher IQ,
lower risk of childhood obesity, diabetes and lower risk of
mental health problems, as they enter their teenage (UNICEF,
2010, Davis, et al 2012). Breastfed children have at least six
times greater chance of survival in the early months than
non-breastfed children (UNICEF, 2013). Early breastfeeding
reduce infant morbidity and mortality as a result of the
preventive benefits of breastfeeding in reducing long term
diseases (WHO, 2007).
The aim of this review is to utilise the Health Believe
Model to highlight the factors that influence breastfeeding
practices globally. Understanding these factors and how they
influence various infant feeding practices is important in
improving breastfeeding practice through appropriately
targeted and designed promotion programs.
2. Literature Search
CINAHL, GOOGLE SCHOLAR, MEDLINE through
PUBMED and EBSCO were searched using the following
key words; exclusive breastfeeding or formula feeding or
mixed feeding and Health Belief Model, benefit of
breastfeeding, breastfeeding and infant feeding practices.
Articles published from 2005 to date were included. Articles
with information about factors that influence infant feeding
with regards to initiation, mixed feeding, formula feeding,
exclusive breastfeeding and duration of feeding were also
Articles without key words related to the search terms
were excluded. Additional literature was sourced from WHO
and UNICEF websites, reference checking, and text books.
Figure 1. The Health Belief Model (Adapted from Kabiru, Beguy, Crichton, and Zulu, 2011)1.
1The Health Belief Model depicted in Figure1 was originally used by Kabiru et al (2011) in a study of HIV/AIDS among youths in Kenya. For this study the topic has
been changed from HIV/AIDS to breastfeeding
30 Andy Emmanuel: A Literature Review of the Factors That Influence Breastfeeding: an Application of the Health Believe Model
The Health Belief Model was developed in the 1950s to
explain why medical screening programs in the US were not
successful (Hayden, 2009). Hayden (2009:1) concluded that
“The underlying concept of the original Health Belief Model
is that, health behaviour is determined by personal beliefs or
perceptions about a disease and the strategies available to
decrease its occurrence”. The main constructs of the model
are: perceived susceptibility (individual’s perception of
exposure to danger and likelihood to contract a disease),
perceived severity or seriousness (individual’s perception of
the gravity of disease), perceived barriers and perceived
benefits (Janz and Becker, 1984; Hayden, 2009). Three more
constructs were added later resulting in the expansion of the
Health Belief Model to include modifying variables, cues to
action and self-efficacy (Hayden, 2009). According to
Hayden (2009), the first four constructs are modified by
variables such as culture, past experience, educational level,
skill and motivation to produce the individual perception.
The individual perception together with cues to action and
self-efficacy determine the health behaviour or action (see
3.1. Personal Perception
Perceived seriousness, Perceived susceptibility, Perceived
benefits, and Perceived barriers /cost of action are important
determinants of health behaviour. The practice of
breastfeeding in a particular community depends on general
perception of the community about breastfeeding.
3.2. Perceived Seriousness / Perceived
The perception of seriousness is a function of medical
information or knowledge an individual has about a disease
(Hayden, 2009). It may also come from beliefs a person has
about the difficulties a disease would create or the effect it
would have on his or her life in general(Hayden, 2009).The
tendency of engaging in behaviour to reduce risk of a disease
increases with increased perceived risk of the diseases.
An adequate breastfeeding education will enable women to
understand and appreciate the seriousness of health
challenges associated with suboptimal breastfeeding. If
women understood the degree of health challenges that may
arise due to inadequate infant feeding, it is likely that they
will change for the benefit of their health and that of their
baby. Inadequate knowledge regarding breastfeeding
negatively influence infant feeding.
3.3. Perceived Benefits
This is a person’s view of usefulness of new behaviour in
reducing the risk of developing a disease; people tend to
adopt healthier behaviour when they believe a new behaviour
will decrease their chances of developing a disease (Hayden,
2009). If women are aware of the benefits of adequate
breastfeeding for them and their infants, they may likely
practice it. Most women do not practice breastfeeding as
recommended probably because they are ignorant of the
benefit of associated with such practice. Adequate
enlightenment especially during antennal care is vital in
3.4. Perceived Barrier
This is an individual’s own evaluation of the obstacles in
the way of him or her adopting a new behaviour. Women
have various experiences with breastfeeding (Schmied and
Barlay, 1999). Mothers commonly complain of painful / sore
nipple or breast (Lamontagne, Hamelin et al, 2008; Raffle,
Ware et al, 2011; Jager (2012), low milk
production(Lamontagne, Hamelin et al, 2008;Raffle, Ware et
al, 2011; Jager, 2012; Mutekanga and Atekyereza, 2007;
Muluye, 2012), Infants refusal to suck (Lamontagne,
Hamelin et al, 2008; Jager (2012), breast infection, maternal
illness (Doherty, Sanders et al, 2012), and Stress(Ugbaoja,
Berthrand, et al, 2013). Others include exclusive
breastfeeding not culturally acceptable (Ugbaoja, Berthrand,
et al 2013; Ajibade, Okunlade et al, 2013), husband refusal
(Ugbaoja, Berthrand et al, 2013) and delayed milk production
after delivery (Mutekanga and Atekyereza, 2007). Most
women can breastfeed as recommended if given the support
they need to overcome barriers associated with breastfeeding
3.5. Modifying Variables
The four major constructs of perception are modified by
other variables such as culture, educational level, past
experiences, skill, socio-demographic variables and
3.6. Maternal Age
The relationship between maternal age and infant feeding
practices differs from place to place. Ogunlesi (2010) posited
that maternal age is not a significant determinant of
breastfeeding. On the other hand, other studies have
demonstrated that maternal age at the time of birth influenced
breastfeeding initiation and duration (Li, Zhang, et al 2004;
Centre for Community Child Health 2006). Studies have
shown that older maternal age is associated with exclusive
breastfeeding and longer duration of breastfeeding (Bolton,
Chow,et al 2009; Ukegbu, et al 2010), while others,
associated low rates of exclusive breastfeeding with younger
maternal age (Qureshi, Oche, et al, 2011; Lawoyin et al, 2001;
Brown, Raynor, et al, 2011). These findings suggest that the
relationship between maternal age and breastfeeding varies
from place to place, therefore, health workers should
understand how maternal age influence breastfeeding
practices in their locality in order to plan better promotion
International Journal of Nursing and Health Science 2015; 2(3): 28-36 31
The influence of education on infant feeding practices
varies from one setting to another (Centre for Community
Child Health, 2006; Ahmed, 2008; Sapna, Ameya 2009;
Okeh, 2010; Ajibade et al 2013).Maternal education below
secondary level contributed to prelacteal feeding and failure
to practice exclusive breastfeeding (Ogunlesi, 2010).Women
with low level of education are less likely to practice
exclusive breastfeeding (Li,Zhang et al, 2004; Uchendu,
Ikefuna, and Imodi, 2009; Qureshi,Oche et al,2011). On the
other hand, another study reported that lower maternal
education attainment is related to increase in breastfeeding
practices (Lawoyin, et al 2001).Highly educated women may
be able to breastfeed exclusively as recommended because
they are more likely to understand the benefits of
breastfeeding when compared with less educated women
who may not see any need for that but may breastfeed longer
as a tradition. An enlightenment campaign in various
languages centered on the benefits of exclusive breastfeeding
could help improve practice.
Many scholars posited that maternal employment is in a
continuous competition with breastfeeding (Okeh, 2010;
Raffle, Ware, et al, 2011;Muluye,) and may even be a barrier
to breastfeeding (Velpuri, 2004; Ajibade, Okunlade et al 2013)
especially if there is no adequate planning for breastfeeding
mothers in the workplace. Women’s work may have a
negative impact on breastfeeding because of inadequate time
to breastfeed (Ukwuani and Suchindran, 2003). Working
outside the home after birth was reported to have
significantly reduce the likelihood of exclusive breastfeeding
at six months (Xu, Binns, et al, 2007; Qureshi, Oche, et al
2011; Chuang, Chang, et al, 2010;Matias, Nommsen-Rivers,
et al 2013).Jager, Hartley, et al (2012) identified return to
work as an important factor that influence breastfeeding
because of the challenges women face in trying to sustain
adequate infant feeding practices while working. Women
who are unemployed are less likely to quit breastfeeding
early when compared with women working as administrators
and in manual jobs (Kimbro, 2006) and are more likely to
exclusively breastfeed (Tan, 2011). This implies that women
who work many hours are likely to mix feeding. Occupation
of both parents affects breastfeeding (Lawoyin, Oche et al
A study by Scott, Landers, et al (2001) reported that
mothers who intended to return to full or part time work or
study within 6 months of the birth were less likely to be
breastfeeding at discharge (from hospital) than mothers who
intended to remain at home. Because of the challenges
associated with breastfeeding by working mothers (poor
support for breastfeeding in the work place), WHO ( 2013)
recommended that all women working should be supported
to sustain breastfeeding when they return to work by giving
them a minimum of one break per day to breastfeed or
express breast milk.
3.9. Economic Status
Studies have shown that high socio-economic status was
significantly related to low exclusive breastfeeding rate, and
short duration of overall breastfeeding (Lawoyin, Olawuyi, et
al, 2001; Okeh, 2010; Ekanem, Ekanem, et al 2012; Ajibade,
Okunlade et al, 2013). This is not unconnected to the
employment status of women with high economic status
which has a negative impact on breast feeding. A contrary
opinion was reported by Velpuri, (2004) in which women
with high income status were associated with a high
breastfeeding rate. Adelekan (2003) identified low economic
status as one of the most important determinants of
suboptimal breastfeeding (non-exclusive and short duration)
and concluded that significant improvement in the socio-
economic status of women could help reduce childhood
3.10. Marital Status
Marital status of a woman is an important determinant of
infant feeding practices in some setting (Sika-Bright, 2010;
Ajibade, Okunlade et al 2013). Suboptimal infant feeding is
common with single mothers (Kimani-murage, Madise, et al,
2011; Tampah-Naah and Kumi-Kyereme, 2013).Studes
concluded that single mothers are less likely to breastfeed
adequately and longer due to absence of partners’ support and
confidence compared with married mothers (Lamontagne,
Hamelin, et al, 2008; Ajibade, Okunlade et al 2013). This
conclusion was reached following a chi-square analysis that
indicated a significant relationship (P=0.01) between marital
status and exclusive breastfeeding and duration of
The effect of parity on infant feeding and breastfeeding in
particular is inconclusive because in some settings multi
parity has a positive impact on breastfeeding (Ukegbu,
Ukegbu et al, 2010;Qureshi, Oche et al, 2011) while in other
settings, the impact is negative(Uchendu, Ikefuna et al,
2009).Some studies have shown that parity did not confer
any advantage to breastfeeding practice (Ogunlesi, 2010;
Sapna, Ameya ,2009) meaning that breastfeeding behaviour
of primiparous and multiparous women is the same
(Amatayakul, Wongsawasdi et al, 1999).
3.12. Primiparity/Low Parity
Primiparous women are more likely to desire or plan to
breastfeed than multiparous women (Lee, Rubio, et al 2005;
Leuung, Hung, et al, 2003). In some settings longer duration
of breastfeeding has been associated with low parity
suggesting that fewer children in the home incur less cost to
women’s time (Uchendu, Ikefuna et al, 2009). It has been
demonstrated that primiparous women were twice as likely to
be breastfeeding at discharge when compared with
multiparous women; however, there was no association
between parity and overall duration of breastfeeding (Scott,
32 Andy Emmanuel: A Literature Review of the Factors That Influence Breastfeeding: an Application of the Health Believe Model
Landers et al, 2001).
3.13. Multiparity/High Parity
Studies have shown that high breastfeeding rate is
associated with multiparity (Ukegbu, Ukegbu et al, 2010;
Qureshi, Oche et al, 2011). A study revealed that women with
fewer than five children are likely to record low exclusive
breastfeeding duration. (Qureshi, Oche et al, 2011). Tan,
(2011) opined that multiparity is associated with the practice
of exclusive breastfeeding. This means that, primiparous
mothers are less likely to breastfeed exclusively (Lawoyin,
Olawuyi et al, 2001).
3.14. Antenatal Care
Adequate counseling about breastfeeding during antenatal
care could significantly improve breastfeeding(Sapna, Ameya
2009). Antenatal attendance is a potential determinant of
infant feeding practice (Agho, et al 2009; Ghwass and
Ahmed, 2011). Antenatal care increases the likelihood of
early breastfeeding initiation (Ogunlesi, 2010). Mothers who
did not attend antenatal clinic during pregnancy may have a
poor initiation and exclusivity of breastfeeding (Ogunlesi,
3.15. Multiple Births
Mothers of twins face more challenges than mothers of
singletons when it come exclusive breastfeeding. A study
revealed that insufficient milk for the twins and time for
breastfeeding are common causes of early cessation of
breastfeeding among mothers of twins (Damato, Dowling, et
al, 2005). Another study revealed that 89.4% of women with
twins initiated breastfeeding and that support for mothers of
twins to overcome breastfeeding problem over the first 6
weeks may result in a longer duration of breastfeeding
(Damato, Dowling, et al, 2005). Mothers of twins can
breastfeed for the recommended duration if supported
(Damato, Dowling et al2005).
3.16. Type of Delivery
Mothers who had a normal delivery tend to have a positive
attitude towards breastfeeding and had less stressful
experiences with breastfeeding than mothers who gave birth
through caesarean section (Imhonde, Shaibu, et al, 2012;
Carlander, Edman, et al 2009). Caesarean delivery is
associated with formula feeding and low milk production (Li,
Zhang et al, 2004). In a study of the effects of maternal care
practice on breastfeeding, DiGirolamo, Grummer-Strawn et
al, (2008) concluded that type of delivery (vaginal versus
caesarean) had no influence on breastfeeding practices. Patel,
Liebling et al (2003) also reported that type of delivery had
no impact on breastfeeding.
3.17. Birth Weight/Infant Size
Low birth weight infants are less likely to exclusively
breastfeed (Matias, Nommsen-Rivers et al 2012; Butte,
Lopez-alatcon et al, 2002) and may be associated with the
belief that breast milk substitute is required to make up the
low weight (Matias, Nommsen-Rivers,2012).
4. Cue to Action/ Self Efficacy
Cues to action are events, people or things that move
people or things that move people to change their behaviour
e.g. illness of a family members, media report, mass media
campaign while self-efficacy is belief in one’s ability to do
something. Self-efficacy is influenced by personal
accomplishment (personal experience), vicarious experience
(individual performances whether live, recorded or printed),
verbal persuasion from health care professionals, peer
counsellors, family members or personal friends,
physiological and affective state (excitement or satisfaction,
enhances self-efficacy while pain, fatigue, anxiety or stress
reduces ones sense of self efficacy) (Danis, 1999).
4.1. Previous Experiences with
Breastfeeding experience helps in building confidence and
confidence is a potential determinant of breastfeeding
(Brodribb, Fallon, et al 2008; Meedya, Fahy et al,
2010).Women with little or no previous breastfeeding
experience require additional support to be able to breastfeed
adequately (Kronborg, Væth,et al 2007) women with
breastfeeding experience are more likely to intend
tobreastfeed than those who never had any experience
(Mclnnes, Love,et al, 2001). Health beliefs, experience of
friends and family could encourage or discourage
breastfeeding (Raffle, Ware et al, 2011).A study reported that
less confident women are four to five times more likely to
experience breastfeeding failure (Dennis, 1999).Furthermore,
a longitudinal study of pregnant women in Australia to
determine the influence of antenatal services on
breastfeeding revealed that mothers with high breastfeeding
confidence were more likely to breastfeed compared with
women with low breastfeeding confidence (79.3% versus
50.5%) (Blyth, Creedy et al, 2004).
4.2. Breastfeeding Support
4.2.1. Support from Family and Friends
Women who enjoyed support from family and friends are
likely to breastfeed longer (Wambach and Cohen, 2009).
Presence of mother in-law in the home increased
breastfeeding self efficacy and has implication for continuing
breastfeeding (Ku and Show, 2010). Social support by
women’s partners (husbands encouraging wives to breastfeed)
may promote, and prolonged breastfeeding (Lamontagne,
Hamelin, 2008;Meedya, Fahy et al, 2010; Scott, Landers et al,
2001; Tan, 2011; Brown, Raynor et al, 2011). Grandmothers
are influential in infant feeding choices and can positively
influence breastfeeding, especially if they are aware of
recommended practices (Kerr, Dakishoni, et al, 2008;
Grassley and Eschit, 2008).
International Journal of Nursing and Health Science 2015; 2(3): 28-36 33
4.2.2. Support from Health Workers
Clinicians and health workers may have an influential role
in breastfeeding initiation and continuation (Li, Laung et al,
2004). Professionals can sometimes have a negative
influence when they provide women with breastfeeding
information and recommendations that are confusing
(Lamontagne, 2008).Post natal support from experts increase
breastfeeding duration (Brown, Raynor et al,2011).
Kronborg, Væth et al, (2007) reported that home visits in
the first 5 weeks following birth may prolong the duration of
exclusive breastfeeding. This assertion was made after
observing a significant increase in the duration of
breastfeeding of breastfeeding with an intervention which
focused on assisting women to overcome obstacle to
breastfeeding. Ahmed (2008) identified support for mothers
immediately after delivery as a way of overcoming
breastfeeding problems and enhancing confidence.
4.3. Knowledge of Individuals’ Feeding as
Women who knew how long they were breastfed as a child
showed a longer duration of exclusive breastfeeding and total
breastfeeding than those who did not (Ekstrom, Widström, et
al 2003; Forster, Mclachlan et al, 2006). Therefore, women
who do not know how they were breastfed as babies or who
knew they were formula or mixed fed require counselling
during antenatal care.
4.4. Maternal Prenatal Intention
Maternal prenatal intention to breastfeed has an impact on
infant feeding practices (Donath, Amir and ALSPAC study
Team, 2003). High intention and self efficacy increase the
likelihood to breastfeed for 6 months (Wilhelm, Rodeherst, et
al, 2008). All women should be guided to plan for
breastfeeding of their children in the antenatal period.
Knowledge of individuals’ feeding as babies
Individual perception about breastfeeding is governed by
modifying variables, cues to action and self efficacy. A
successful breastfeeding promotion program depends on the
understanding of the factors that influence perception.
Maternal sociodemograhpic characteristic like age, education,
parity, economic status, and employment may influence
breastfeeding. Other factors include, antenatal attendance,
multiple births, type of delivery, previous breastfeeding
experience, breastfeeding support, Knowledge of individual’s
feeding as babies, maternal prenatal feeding intention and
infant birth weight.A positive perception about breastfeeding
will result in self-efficacy and intention to breastfeed as
1. Enlightenment campaign about benefits of exclusive
breastfeeding for mother and child should be done
using various languages in order to accommodate
women who do not understand English and those with
low educational level.
2. Breastfeeding counseling during antenatal care should
be centered on solving problems associated with
3. Government should liaise with all employers of labour
to ensure and improve breastfeeding support in the
4. Extending maternity leave to six months for all working
mothers could promote exclusive breastfeeding for six
months. The six months leave could be limited to
maximum of three children.
5. Economic empowerment may improve breastfeeding in
6. Special support should be given to young mothers;
women who were formula or mixed fed as babies and
mothers of twins during the postnatal period.
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