Breastfeeding self-efficacy in adult women and its relationship with exclusive maternal breastfeeding

Objective: to analyze the relationship between maternal self-efficacy to breastfeed and sociodemographic, obstetric, and neonatal variables; between the duration of exclusive breastfeeding and sociodemographic variables; and between the breastfeeding self-efficacy and the duration of exclusive breastfeeding at the intervals of 30, 60, and 180 days postpartum. Method: a longitudinal and prospective study conducted with 224 women. A sociodemographic questionnaire, the Breastfeeding Self-Efficacy Scale – Short Form, and a questionnaire on breastfeeding and child feeding were used for collecting the data. Fisher’s exact test and Pearson’s correlation coefficient test were used for analysis. Results: there was no association between breastfeeding self-efficacy and the duration of exclusive breastfeeding identified at 30, 60, and 180 days. Self-efficacy was associated with the type of delivery and complications in the postpartum period. There was also an association between religion and exclusive breastfeeding 30 and 60 days postpartum, and assistance with baby care and exclusive breastfeeding at 60 days. Conclusion: It was identified that the type of delivery, complications in the postpartum period, religion, and assistance with baby care corroborate to increase maternal confidence in the ability to breastfeed.


Introduction
The contributions of breastfeeding are already known worldwide, and its benefits are extended not only to the health of women and children, but also to the whole family and society (1) and, due to these contributions, the World Health Organization (WHO) and the Brazilian Ministry of Health (MoH) recommend exclusive breastfeeding (EBF) until the child's sixth month of life (2) . Despite all the benefits described in the scientific literature, only 37% of the children born in Brazil are exclusively breastfed until the sixth month of life, a rate below the one recommended by the WHO, which is at least 50% (2)(3)(4) .
The breastfeeding practice is a complex process that goes beyond biological determinism, and the woman's decision to breastfeed or not also involves social, cultural, economic, and psychological factors (5) . A study carried out in the Federal District (Brazil) found that the causes for early weaning were related to the beliefs of weak milk and to the women's need to return to work (6) .
Another study carried out in Valencia (Spain) observed that there was a relationship with breastfeeding time and maternal age, parity, low milk production, and low weight gain of the baby (7) .
The support received by women during this process is also a factor that strongly influences the practice of breastfeeding, whether such support is received by family members, friends, or health professionals (8) .
In addition, today women also seek support through social networks, websites, and Internet pages that provide information on breastfeeding practices, being a new type of health intervention (9) .
Some research studies indicate that early interruption of breastfeeding can be related to the low confidence of women in their ability to breastfeed their babies, which is an important variable that influences the initiation and maintenance of breastfeeding (10)(11) .
Maternal confidence in the ability to breastfeed is also known as breastfeeding self-efficacy, and can be modified through individual interventions with women (10) .
The construct of breastfeeding self-efficacy construct consists of four sources of information, which directly influence women's decision to start and maintain this practice: by the woman's personal experience; by living with other breastfeeding women (vicarious experience); by the information received both from their social support network and from the health professional who accompanies them; and by their physical and emotional condition (12) .
Those who trust their ability are known to usually breastfeed longer than those who do not have such a perception (10) . For the health professionals, who are essential in encouraging and supporting breastfeeding, the identification of mothers who are at risk for early weaning (based on modifiable variables), such as low breastfeeding self-efficacy, can facilitate the development and evaluation of interventions that favor breastfeeding (13)(14) .
Brazil is a country with great cultural and economic diversity, so understanding the behavior of women in different scenarios can provide subsidies for the improvement of public policies to promote and protect breastfeeding. Thus, the objectives of this study were to analyze the relationship between maternal breastfeeding self-efficacy and sociodemographic, obstetric, and neonatal variables; the duration of exclusive breastfeeding and sociodemographic variables, and the breastfeeding self-efficacy and the duration of exclusive breastfeeding at the intervals of 30, 60, and 180 days postpartum.

Method
A longitudinal and prospective study conducted on 224 randomly selected women, following these inclusion criteria: being 18 years old or older, with at least 24 hours postpartum, in sound physical condition to breastfeed, accompanied by their children in joint accommodation, who had children of full term gestational age, and who had a landline or cell phone. The exclusion criteria were the following: women with hearing and/or visual impairment, disoriented in terms of time, space or person, with newborns who were receiving special care and/or who had an anomaly or malformation.
The study was carried out in Ribeirão Preto, from Breastfeeding Self-Efficacy Scale -Short Form (BSES-SF), a Canadian scale validated in Brazil (15) , used to assess maternal confidence in the ability to breastfeed. BSES-SF is a Likert-type scale containing 14 questions divided into: Technical Domain, and Domain of Intrapersonal Thinking; each question has five possible answers ranging from 1 to 5 points, namely: 1-totally disagree, 2-disagree, 3-sometimes agree, 4-agree, 5-totally agree, and the sum of the scores varies from 14 to 70 points.
The second moment of the study was characterized by telephone searches carried out at 30, 60, and 180 days after the delivery, using a third data collection

Results
Among the 224 (100%) investigated women, age ranged between 18 and 44 years old, with a mean of 24.65 (Standard Deviation -SD=5.79) and a median of 24 years old. With regard to the perception of their own skin color, 44.2% of the women said they were brown-skinned, 47.32% declared they had completed high school, 47.3% declared they were in love, and 79.9% reported having some religion. The majority (59.4%) reported not doing any paid work outside the home and 46.0% reported having their own home. The mean monthly family income declared was R$ 1,943.44 (one thousand, nine hundred and fortythree reais and forty-four cents), 86.6% stated that they would have help from someone to take care of the baby and, from those (n=194), 46.4% reported that help would be obtained from their own mother, 30.9% reported getting help from a partner, 11.3% referred to getting help from their mother-in-law, and 11.3% would get help from other family members and friends.
Regarding the obstetric characteristics, 47.3% of the participants were primigravidas, 50.4% were primiparous, 55.8% of the women did not plan pregnancy, 81.8% The analysis of the association between selfefficacy and the sociodemographic variables (age, selfreported skin color, schooling, religion, marital status, income, and assistance with baby care) did not show a statistically significant result ( Table 1).
As for the obstetric characteristics, the "type of delivery" and "complications in the postpartum" variables showed a statistically significant association with selfefficacy. Women who had a vaginal delivery had a higher level of self-efficacy than those who underwent cesarean section (p=0.0376). The women who had no complications in the postpartum period showed greater self-efficacy than those who had complications (p=0.0410). These results are described in Table 2. Table 3 shows the results of the association between maternal self-efficacy and the variables related to the characteristics of the participants' children and breastfeeding. No statistically significant associations were found for these analyses.
www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3364.    The total EBF time, in days, is shown in Figure 1.  Figure 2 illustrates this result, drawing attention to a positive, but weak, relationship between the two variables.

Discussion
The value of self-efficacy among the study participants pointed out that most of them (83.9%) had a high level of this variable, with the mean of the BSES-SF total score being 58.62 points, corroborating with some studies carried out in the national and international scopes (16)(17)(18) . The present study showed a significant association between breastfeeding self-efficacy and the type of delivery, confirming studies carried out in the Philippines (18) and in the Northeastern region of Brazil (19) .
It also showed a significant association between selfefficacy and the postpartum complications variable.
No scientific studies were found that analyzed the relationship between self-efficacy and complications during pregnancy, labor and delivery, and postpartum.
However, this analysis leads us to the fourth source of information on the self-efficacy construct (emotional and physiological state), since they are relevant data for the health professionals, when they also use verbal persuasion (third source of information on the selfefficacy construct). In this way, the professionals can have a more accurate performance in supporting women during breastfeeding, according to the demand of each one of them (8) .
The final mean EBF duration among the participants was 80.54 days and the median was 59 days and, at the three moments investigated, there was a decrease in the percentage of women who maintained EBF: 64.4% at 30 days, 55.6% at 60 days, and 6.0% at 180 days, being below the indexes in children under six months presented in the world, which is 35.7%, according to a study published in 2016 (1) . The fact that the study site is accredited by the Baby-Friendly In the analysis of associations between the sociodemographic variables and EBF duration at 30, 60, and 180 days after delivery, the "religion" variable had an influence on maintaining this practice at 30 and 60 days after delivery. Considering that individual and population health determinants bring together customs, beliefs, and values, and that this includes religious culture, the choice of women to breastfeed may or may not be influenced by religion or by adhering to traditional or modern values of a given population (21) . Similarly to the present study, an American study involving 4,898 mother-child binomials belonging to the disadvantaged economic class showed that religious affiliation was strongly associated with the beginning of breastfeeding, but weakly associated with its maintenance (22) . Thus, the formation of support and incentive networks that include churches and religious spaces is an essential strategy to strengthen healthy attitudes and behaviors among the population, including breastfeeding (22) .
This study also found a significant association between exclusive breastfeeding at 60 days and assistance to care for the baby, corroborating a study that demonstrates the valuable role of people who support and help women in the postpartum period, even though they are laypeople, which favors breastfeeding (8) . in the short, medium, and long term (23) . Thus, the answers of the participants may have been influenced by the pro-breastfeeding practices of motherhood, a relationship that needs further investigation.

Conclusion
Self-efficacy is a variable that is easily accessible and subject to change, through guidelines and stimuli that strengthen the internal (personal motivation) and external (technical) aspects of breastfeeding. This study analyzed that there is a relationship between breastfeeding self-efficacy and the type of delivery, the absence of complications in the postpartum period, having a religion, and having help with baby care.
The associations of self-efficacy with vaginal delivery and with the absence of complications in the postpartum period reinforce the results that qualified delivery care is beneficial for both women and breastfeeding. In addition, the specificities verified among the participants, related to the religion and assistance with baby care variables as factors that influenced the duration of exclusive breastfeeding, demonstrate that these variables are important to support breastfeeding and deserve greater attention from the professionals who work to promote breastfeeding.
The possibility is also highlighted of further studies that investigate self-efficacy over the months, in order www.eerp.usp.br/rlae 8 Rev. Latino-Am. Enfermagem 2020;28:e3364.
to study more deeply how this construct changes after hospital discharge, in the contextual reality of the woman and of her child.