MATERNAL AND NEONATAL HEALTH

Factors influencing the practice of exclusive breastfeeding among Hong

Kong Chinese women: a questionnaire survey
Ching-Man Ku and Susan KY Chow

Aims and objectives. The purpose of this article is to explore the relationships between breastfeeding knowledge, self-efficacy
and demographic factors on breastfeeding patterns among Hong Kong Chinese primiparous women.
Background. There is substantial evidence showing that maternal education, social class, ethnic background and religion are
related to the decision to initiate as well as continue breastfeeding. Nevertheless, not much is known about how the controllable
factors are able to influence the practice with the Hong Kong Chinese population.
Design. A cross-sectional and correlational design.
Methods. A convenience sample of 82 subjects who had normal vaginal delivery in the maternity unit of a regional hospital in
Hong Kong was recruited.
Results. Linear regression analysis showed that subjects who lived with their mothers-in-law, had higher household income and
higher gravida would be associated with a higher score in the Breastfeeding Self-Efficacy Scale. On the other hand, decisions to
breastfeed made later in the pregnancy, father-in-law to pei-yue (the Chinese practice whereby the new mother is expected to
stay at home and to avoid all household chores and social activities during the first month after giving birth) and older in age
would be associated with a lower score. Pei-yue is Chinese ritual of which the woman who has delivered should stay at home for
one month and being taken care by others (this Chinese term is used throughout the article to indicate the time period
described). Generalised estimating equations model revealed that women who had searched through the Internet for breastfeeding information, who had husbands to pei yue, lived in private housing, were married, had a domestic helper to pei yue
and who had attained higher education were more likely to practice exclusive breastfeeding.
Conclusion. The social support from the family and breastfeeding self-efficacy have implications for continuing the practice of
breastfeeding for primiparous women.
Relevance to clinical practice. Future efforts aimed at promoting exclusive breastfeeding could include the modifiable factors
into consideration to better tailor interventions for successful, exclusive breastfeeding.
Key words: exclusive breastfeeding, knowledge, self-efficacy
Accepted for publication: 26 February 2010

Introduction
Breastfeeding has been recognised worldwide as being beneficial for both the mother and child, as breast milk is
considered the best source of nutrition for an infant.
Breastfeeding provides economic and social benefits to the
family, the health care system and the employer, as breastfed
Authors: Ching-Man Ku, MSc, RN, Registered Midwife, United
Christian Hospital, Kwun Tong, Kowloon, Hong Kong; Susan KY
Chow, PhD, RN, Assistant Professor, School of Nursing, The Hong
Kong Polytechnic University, Hunghom, Kowloon, Hong Kong,
China

2434

infants typically require fewer sick care visits, prescriptions

and hospitalisation, especially if breastfed exclusively or
almost exclusively (Ball & Wright 1999), reducing maternal
absenteeism, where it has already been observed that maternal absenteeism is significantly lower (Newton 2004).
Another notable social benefit of breastfeeding is on the
environment, where a fall in demand for the accoutrements
Correspondence: Susan KY Chow, Assistant Professor, School of
Nursing, The Hong Kong Polytechnic University, Hunghom,
Kowloon, Hong Kong, China. Telephone: 852 27666775.
E-mail: hssusan@polyu.edu.hk

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

doi: 10.1111/j.1365-2702.2010.03302.x

Maternal and neonatal health

of bottle feeding (artificial teats, plastic bottles and milk

powder tins) will reduce the levels of pollutants released and
the depletion of natural resources used to produce them.
Exclusive breastfeeding is recommended for the first
six months of life and continued breastfeeding with complementary foods is recommended for the first two years
and beyond (Kramer & Kakuma 2002, WHO 2002). The
American Academy of Pediatrics (2005) has also made
similar recommendations for mothers to exclusively breastfeed their babies for the first six months.

Breastfeeding practices
Despite the known benefits of exclusive breastfeeding, a study
conducted in Argentina revealed that the exclusive breastfeeding rate at four months postdelivery was 56% and at
six months it was 19% (Cernadas et al. 2003). While in
Georgia, Russia, the breastfeeding in maternity wards was at
about 97%, the exclusive breastfeeding rate was 18% at
four months (UNICEF 2006). In a study of feeding practices
in 105 counties of rural China, 9822% of the 20,914 babies
in the study were breastfed. While the percentage of exclusive
breastfeeding in the first four months after birth in the urban
areas was 52% and in the rural areas was 2435% (Wang
et al. 2005). The situation among Hong Kong Chinese is not
optimistic. Surveys conducted by the government showed
that breastfeeding is very common, with 70% of the new
mothers practicing breastfeeding in 2006. However, early
weaning persisted and the exclusive breastfeeding rate at four
to six months after delivery was only 135% (Hong Kong
Government, 2007). Another Asian country, Singapore, also
shared a similar trend. The National Breastfeeding Survey
2001 demonstrated an encouraging breastfeeding initiation
rate of 945%, only 211% of mothers continued to breastfeed after six months, with fewer than 5% breastfeeding
exclusively (Foo et al. 2005).
There is substantial evidence showing that maternal
education, social class, mothers comfort in breastfeeding,
fathers occupation and religion are related to the decision to
initiate and continue breastfeeding (Venancio & Monteiro
2006, Kelly & Watt 2005, Duong et al. 2005). Other aspects,
such as the desires or attitudes of mothers regarding
breastfeeding, mother-infant bonding, family support, mode
of delivery and history of smoking, are important in initiation
and sustaining breastfeeding (Beck & Watson 2008, Chandrashekhar et al. 2007, Scott & Binns 1999).
Several studies have focused on evaluating the factors
related to breastfeeding practices, but there are few that
focus on evaluating the practice of exclusive breastfeeding.
Moreover, there is a lack of research investigating the

Practice of exclusive breastfeeding

associations between the variables and predictors for

exclusive breastfeeding. Even though the value of breastfeeding is well publicised, efforts should be devoted in
investigating the causes and correlations related to exclusive breastfeeding to maximise the benefits of this healthy
life behaviour.

Aim
The aim of this study is to explore the relationships between
breastfeeding knowledge, self-efficacy and demographic factors on breastfeeding patterns among Hong Kong Chinese
primiparous women.

Objectives
1 To examine the breastfeeding patterns of primiparous
women.
2 To examine the relationships between demographic factors, breastfeeding self-efficacy and breastfeeding knowledge.
3 To delineate factors that are independent predictors of
exclusive breastfeeding.

Research method
Design
This study was a non-experimental, cross-sectional design.
The data were collected during hospitalisation with telephone
follow-up interviews conducted at six weeks postpartum.
The study setting was the maternity unit of a regional general
public hospital, the subjects were recruited from the 40bedded postnatal ward.

Sampling
Subject recruitment took place between AprilJuly 2007. To
meet the inclusion criteria, subjects were primiparas who
intended to breastfeed or exclusively breastfeed; able to read
and communicate in Chinese; maternal age older than 18;
singleton pregnancy; no major obstetrical complications and
baby was healthy with no congenital abnormalities. A
convenience sample of women who met the inclusion
criteria was generated. Participants were excluded if their
babies were born before 37 weeks of gestation (prematurity).
Based on the previous study of Blyth et al. (2002),
Breastfeeding Self-Efficacy is one of the predictors of
breastfeeding practice at four months after delivery. The

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

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C-M Ku and SKY Chow

odds ratio of 224 was used as reference for sample size

calculation. To achieve 5% alpha and 80% power, twotailed test, the required sample would be 79. The calculation
was derived using the computer software package, nQuery
Advisor (Elashoff 2000). A total of 82 subjects were
recruited and 100% of the subjects participated in the
telephone follow-up.

Instruments
The Breastfeeding Knowledge Questionnaire (BKQ) and
Breastfeeding Self-Efficacy Scale (BSES) were chosen to
measure the knowledge and self-report efficacy of the
subjects. The BKQ was developed by Gulick (1982) and
was used to assess participants knowledge on exclusive
breastfeeding. The 26-multiple-choice questionnaire assesses
clients knowledge about the advantages of exclusive
breastfeeding, simple physiology of breastfeeding and
breastfeeding management. The scale was translated into
Chinese and back translated following the techniques
described by Bracken and Barona (1991). To investigate
its validity and reliability, content validity of the translated
instrument was examined by a panel of experts experienced
in breastfeeding. The content validity index (CVI) was 092
and considered satisfactory, as the acceptable index is
above 075 (Portney & Watkins 2009). The reliability of
the instrument was assessed by the testretest method.
Intraclass correlation coefficient (ICC) was 081 which
showed significant agreement and correlation among the
two tests.
The BSES was developed by Dennis and Faux (1999). It is
a 33-item, self-report instrument to measure self-perceived
confidence in breastfeeding. The scores are summed to
produce a range from 33165, with higher scores indicating
higher levels of breastfeeding self-efficacy. The scale has
been translated into Mandarin Chinese (Dai & Dennis
2003) and Spanish (Torres et al. 2003) and is commonly
used in overseas studies (Blyth et al. 2002, Dunn et al.
2006, Hauck et al. 2007). The CVI of the translated
instrument was 094, and ICC was shown very satisfactory
at 094.

Ethical considerations
Ethical approvals were obtained from The Hong Kong
Polytechnic University and the research ethics committee of
the study hospital before commencement of data collection.
An information sheet regarding the details of the study was
provided to the participants, informed consent was obtained
from all participants before data collection.
2436

Data collection
The recruited subjects completed the BKQ and BSES within
one to two days after delivery. The demographic and medical
information were obtained from the subjects and through
retrieval of medical records. Telephone follow-up interviews
were conducted at six weeks postpartum to obtain the
information on exclusive breastfeeding practice in week 1,
2, 4 and 6.

Data analysis
Data were coded and analysed using the Statistical Package
for the Social Sciences (SPSS ) version 15.0 (SPSS Inc., Chicago,
IL, USA). Descriptive statistics were used to describe the
sample characteristics and breastfeeding duration. Linear
regression was used to examine the predictors of breastfeeding self-efficacy. The generalised estimating equation (GEE)
methods logistic regression was used to estimate the multiple
predictors of practicing exclusive breastfeeding. This is
considered an appropriate method to identify predictors in
the repeated measures studies or longitudinal designs
(Ballinger 2004, Hanley et al. 2003). The statistical significance was set at p < 005.

Results
Sample characteristics
There were subjects (n = 82) recruited for the study. The mean
age of the mothers was 284 (SD 51, range 1840). The
majority (n = 71, 866%) were born in Hong Kong and were
married (n = 77, 97%). Of all recruits, 659% (n = 54) had
completed secondary school and 171% (n = 14) had completed tertiary education. Fifty-six subjects (683%) stated
that the pregnancies were planned. Fifty-four per cent
(n = 45) of the subjects were pregnant for the first time. The
subjects having higher gravida were because of either previous
spontaneous abortions or terminations of pregnancies.
Table 1 shows the demographic characteristics of the subjects.
There was less than half of the mothers who had decided to
breastfeed their babies before conception (n = 36, 439%),
while a further 329% (n = 27) made the same decision during
the first trimester. Decisions made in second (n = 8, 98%) and
third (n = 9, 11%) trimester share similar proportions and
only two mothers (24%) decided to breastfeed their babies
after delivery. The mean of planned duration of breastfeeding
their babies was 6806 days (SD 6287, range 0365).
Only a minority (85%) of the mothers expressed that they
received no information regarding breastfeeding. Over half of

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Maternal and neonatal health

Practice of exclusive breastfeeding

Table 1 Demographic characteristics of subjects

Characteristics

Total
(n = 82)

Born in Hong Kong

Yes
71
No
11
Ex-smoker
Yes
15
No
67
Marital status
Married
77
Single
5
Highest education attained
Primary
2
Secondary
54
Postsecondary
12
Bachelor or higher degree holder
14
Occupation
Semi-professional, or general management 16
Clerk, sales person or in tertiary industry
39
Sole proprietor
3
Technical worker
3
Semi-technical worker
3
Housewife
17
Student
1
No. of weeks of maternity leave after delivery
6
13
8
28
10
24
14
17
Occupation of the husband
Professional, or high management level
5
Semi-professional, general management
22
Clerk, sales person or tertiary industry
19
Small business owner (with employee(s))
3
Sole proprietor
5
In-charge
2
Technical worker
21
Semi-technical worker
5
Household income per month (HKD)
400110 000
9
10 00115 000
12
15 00120 000
20
20 00125 000
13
25 00130 000
8
>30 001
20
Living conditions
Public housing estate
29
House Ownership Scheme
19
Private properties
34

Per cent (%)

866
134
183
817
939
61
24
659
146
171
195
476
37
37
37
207
12
159
341
293
207
61
268
232
37
61
24
256
61
11
146
244
159
98
244
354
232
415

the subjects (561%) had attended antenatal talks, 293%

conducted Internet search on breastfeeding information,
183% obtained the information from their own mothers
while 146% from other relatives and more than a quarter of

the subjects (293%) obtained breastfeeding information

from their friends.
From the information obtained from the phone follow-up
at six weeks postpartum, about half of the subjects (n = 42,
512%) were still breastfeeding, with a few (n = 16, 195%)
practicing exclusive breastfeeding. The mean number of days
practicing exclusive breastfeeding among the subjects was
1525 days (SD 1596, range 042).

Breastfeeding knowledge and self-efficacy

The mean score of the BKQ was 1222 (SD 264, range 519),
with a total score of 24. Although the majority of the
mothers had chosen to breastfeed their babies, only half of
them (n = 45, 549%) could identify the advantages of breast
milk over artificial formula. From the practical aspect, only
2683% (n = 22) of the subjects knew the best way to help
the baby begin sucking and a few of them (n = 15, 1829%)
knew the characteristics of proper latch on. Only 11 subjects
(1341%) could identify the best ways to help to establish
ample milk supply, with fewer (n = 9, 1098%) able to
identify the important factors in promoting milk let down.
Table 2 shows the details of BKQ scores.
The mean score of BSE was 11668 (SD 1436, range 81
145), with a total score of 165. When the subscales were
examined, the sum scores of internal thoughts (items 118)
and technique were 6394 (SD 824, range 4181) and 5274
(SD 700, range 3568), respectively. The results further
indicated that mothers were least satisfied with their breastfeeding experiences, felt uncomfortable to breastfeed in
public and in front of the family members. They were happy
to focus on getting through one feed at a time and depended
on family to support their decision to breastfeed. Table 3
gives the details of BSE scores

Relationships between demographic factors and

breastfeeding self-efficacy
Pearson product moment correlation was performed between
the scores of Breastfeeding Knowledge and the results of
Breastfeeding Self-Efficacy with the correlation coefficient
equal to 029 (p = 0008). Linear regression was used to
examine the predictors of breastfeeding self-efficacy. The BSE
result was the dependent variable in the regression analysis.
A series of multiple regression procedures was performed
to examine the contribution of selected correlating variables,
including the demographic factors, biomedical factors,
outcome measures such as whether the mother was still breastfeeding (either partially or exclusively) at six weeks postpartum, the total number of days of exclusive breastfeeding,

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

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C-M Ku and SKY Chow

Table 2 Results of Breastfeeding Knowledge Questionnaire (n = 82)

Area covered in the Breastfeeding Questionnaire

Number of subjects correctly

answered, n (%)

Advantages of breast milk over formula for the infant

Benefits of breastfeeding over bottle feeding for the mother
Whether breast size for a mother matters in nursing her baby
Management of inverted nipples for the expectant mother who wants to breastfeed her baby
Breast changes occurring during pregnancy
Best way to get the baby to begin sucking
Characteristics of correct sucking
Length of time the baby permitted to nurse at each breast during each feeding on the first day
Best way to remove the baby from the nipple and breast
Best time to burp the baby
Management of a sleeping baby
Most important factor in producing breast milk
Let down reflex establishment
Ways best help the mother to establish an ample milk supply
Management of breast engorgement
Most important factor in promoting milk let down
Sequence of which side of the breasts for next breastfeed
Most important factor which determines milk production
Bowel movements of a breastfed baby
Supplementing breastfeeding with artificial formula
Nursing interval in the first few weeks
Signs that baby got enough milk
Food choice to meet the additional 500 calorie intake needed by nursing mother
Relationship between sexual feelings and breastfeeding

45
37
76
39
24
22
15
67
56
45
45
65
53
11
63
9
28
29
69
36
56
34
74
4

and the BKQ scores were assigned as independent variables

for prediction. The stepwise regression model was significant
with adjusted R-square = 045. The results showed that
women who lived with their mothers-in-law, had higher
household income and higher gravida would be associated
with a higher score in the BSES. On the other hand,
decisions made to breastfeed later in pregnancy, the presence
of fathers-in-law to pei-yue and being older would be
associated with a lower score. Please refer to Table 4 for the
analysis results.
The dependent variables in the study were exclusive
breastfeeding at 0, 1, 2, 4 and 6 weeks postdelivery. The
GEE results showed that primiparous women who had
received breastfeeding information from the Internet
(OR = 9303, 95% CI: 268532239), whose husbands were
able to pei yue (OR = 5793, 95% CI: 180818565), who
lived in flats under the Home Ownership Scheme Accommodation (relative to living in public housing estate)
(OR = 8733, 95% CI: 227933466), who are married
mothers (relative to single mothers) (OR = 643658, 95% CI:
35111803376), with a domestic helper to pei yue
(OR = 6984, 95% CI: 134236351), higher educational
attainment (OR = 2369, 95% CI: 115104) and higher
Breastfeeding Self-Efficacy Scale (OR = 1104, 95% CI:
2438

(5488)
(4512)
(9268)
(4756)
(2927)
(2683)
(1829)
(8171)
(6829)
(5488)
(5488)
(7927)
(6463)
(1341)
(7683)
(1098)
(3415)
(3537)
(8415)
(4390)
(6829)
(4146)
(9024)
(488)

10611149) were positively associated with exclusive

breastfeeding. Time1 (week 1, relative to baseline) (OR =
0506, 95% CI: 03150812), Time2 (week 2, relative to
baseline) (OR = 0178, 95% CI: 00910349), Time3 (week
4, relative to baseline) (OR = 0044, 95% CI: 00210094),
Time4 (week 6, relative to baseline) (OR = 002, 95% CI:
00090045), higher household incomes (OR = 0492, 95%
CI: 03210755) and receiving breastfeeding information
from friends (OR = 0182, 95% CI: 00450736) are negatively associated with exclusive breastfeeding. Table 5 shows
the results of the GEE model.

Discussion
Some of these findings are similar to those reported
internationally, while a few results reflect the unique social
and cultural environment in Hong Kong and the special
characteristics of Chinese women in Hong Kong society. The
rate of exclusive breastfeeding in our study sample was
persistently low, and breastfeeding knowledge was neither
significantly correlated to breastfeeding self-efficacy nor the
duration of exclusive breastfeeding. However, breastfeeding
self-efficacy provided a statistically significant explanation
for exclusive breastfeeding prevalence. The duration after

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

Maternal and neonatal health

Table 3 Results of Breastfeeding
Efficacy Scale (BSES)

Practice of exclusive breastfeeding

Self-

BSES items
Internal thought
Continue to breastfeed my baby for every feeding
Determine that my baby is getting enough milk
Manage the breastfeeding situation to my satisfaction
Focus on getting through one feed at a time
Breastfeed my baby without using formula as a supplement
Successfully cope with breastfeeding like I have with
other challenging tasks
Feed my baby with breast milk only
Refrain from bottle feeding for the first 4 weeks
Keep feeling that I really want to breastfeed my baby
for at least 6 weeks
Manage to keep up with my babys breastfeeding demands
Keep wanting to breastfeed
Stay motivated to breastfeed my baby
Be satisfied with my breastfeeding experience
Motivate myself to breastfeed successfully
Maintain my milk supply by using the supply and demand rule
Monitor breast milk by keeping track of my babys
urine and bowel movement
Accept the fact that breastfeeding may temporarily limit
my freedom
Deal with the fact that breastfeeding can be
time-consuming
Technique
Tell when my baby is finished breastfeeding
Position my baby correctly at my breast
Feel if my baby is sucking properly at my breast
Recognise the signs of a good latch
Count on my friends to support my decision
to breastfeed
Ensure that my baby is properly latched on for
the whole feeding
Manage to breastfeed even if my baby is crying
Keep my baby awake at my breast during a feeding
Feed my baby every 23 hours
Finish feeding my baby on one breast before
switching to the other breast
Take my baby off the breast without pain to myself
Comfortably breastfeed in public places
Comfortably breastfeed with my family members present
Hold my baby comfortably during breastfeeding
Depend on my family to support my decision to breastfeed

Table 4 Stepwise regression results

Risk factors
Time decided for BF
Live with mother-in-law
Father-in-law to pei yue
Family income
Gravida
Age
*Significant at p < 005.

b (95% CI)

p-value

5329
1678
12223
4159
6376
0713

*<0001
*<0001
*0009
*<0001
*<0001
*0017

( 7553 to 3105)
(1023523325)
( 21328 to 3118)
(23225997)
(31289624)
( 1297 to 0129)

Mean (SD)

Range

371
309
390
405
315
355

(068)
(071)
(066)
(066)
(074)
(067)

25
25
25
25
25
25

312 (076)
370 (081)
360 (091)

15
25
15

390
380
367
293
354
356
361

(064)
(078)
(072)
(068)
(076)
(063)
(073)

35
25
25
14
25
25
25

363 (064)

25

344 (079)

15

345
365
384
367
378

(065)
(078)
(071)
(074)
(067)

25
25
25
25
25

367 (075)

25

333
329
380
390

(080)
(075)
(076)
(073)

25
15
25
25

352
231
266
384
401

(072)
(078)
(088)
(074)
(062)

25
15
15
25
35

delivery, living conditions, maternal education level, searching through Internet for breastfeeding information, marital
status, husband to pei yue, having a domestic helper to pei
yue, household income and information from friends all
influenced the mothers wishes and decisions to exclusively
breastfeed. In traditional Chinese culture, pei yue refers to
the practice whereby the new mother is expected to stay at
home and to avoid all household chores and social activities
during the first month after delivery. Hong Kong is a

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C-M Ku and SKY Chow

Factors

Odds ratio (95% CI)

p-value

Time1 (week 1 vs. baseline)

Time2 (week 2 vs. baseline)
Time3 (week 4 vs. baseline)
Time4 (week 6 vs. baseline)
Received information from Internet
Husband to pei yue
Live in Home Ownership Scheme Accommodation
(relative to living in public housing estate)
Married (relative to single)
Domestic helper to pei yue
Highest education attained
Breastfeeding Self-Efficacy Scale
Household income
Friends as source of breastfeeding information
Mother-in-law to pei yue
Own father to pei yue
Live with mother-in-law
Number of weeks of maternity leave
after delivery
Live with mother
Antenatal talk as a source of
breastfeeding information
Ex-smoker
Husbands occupation: technical worker
Infants gender (relative to female)
Born in Hong Kong
Number of times the women has been
pregnant regardless of outcome
Mother as source of breastfeeding information

0506 (03150812)
0178 (00910349)
0044 (00210094)
002 (00090045)
9303 (268532239)
5793 (180818565)
8733 (227933466)

*0005
*<0001
*<0001
*<0001
*<0001
*0003
*0002

643658 (35111803376)
6984 (134236351)
2369 (115104)
1104 (10611149)
0492 (03210755)
0182 (00450736)
0388 (00911661)
0232 (00421273)
31 (062215446)
075 (0426132)

*<0001
*0021
*0028
*<0001
*0001
*0017
0202
0093
0167
0319

3639 (056823315)
0322 (01011034)

0173
0057

0203
0246
1737
0272
1481

(00251637)
(0057107)
(06224852)
(00362033)
(07412961)

0134
0062
0292
0205
0267

0501 (01212079)

0341

Table 5 Multiple prediction model of

six-week exclusive breastfeeding

*Significant at p < 005.

metropolitan city but it has retained many aspects of

traditional Chinese culture.

Low exclusive breastfeeding rate at six weeks postpartum

The World Health Organization has emphasised the importance of examining exclusive breastfeeding rates when
conducting longitudinal research on breastfeeding (WHO
2001). Our results demonstrated that 512% of mothers
practiced breastfeeding at six weeks postpartum and the
corresponding exclusive breastfeeding rate was only 195%.
The above result was comparable to a previous local study by
Chan et al. (2000) which indicated that one-half of the 39
study participants had weaned their babies off breastfeeding
by six weeks.
Although we were not able to accurately compare the
results from our study against Chan et al.s study, both
studies suggested that Hong Kong was not meeting the
recommendations set by the WHO in the past seven years.
The data from the Australian Bureau of Statistics (2003)
indicated that their rate for exclusive breastfeeding rate at
2440

three months was 54% and at six months was 32%. While
in Brazil, the exclusive breastfeeding rate at six months was
29% (La Leche League International, 2006). The breastfeeding rate in Hong Kong is even less than some of the
developing countries, such as India, having an exclusive
breastfeeding rate of 43% at six months and Indonesia, with
a rate of 42% at six months (La Leche League International,
2006).
Our result shows consistency with a local study by
Dodgson et al. (2003) who revealed short exclusive breastfeeding duration among the samples. The necessity of
returning to work for postpartum women was one of the
factors affecting the rate of exclusive breastfeeding. Paid
maternity leave in Hong Kong is six weeks postdelivery; this
externally enforced condition explains the cessation of
exclusive breastfeeding in mothers who return to work. The
phenomenon could further be explained by Chinese culture as
parents or grandparents have traditionally fed infants with
congee at an early stage of life, considering congee to be
nutritious, as Asian people consume rice daily as the major
source for carbohydrate. This could explain the marked

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

Maternal and neonatal health

decline in exclusive breastfeeding that occurs in early weeks

postpartum.

Breastfeeding knowledge
Although the correlation coefficients between breastfeeding
knowledge and breastfeeding self-efficacy were statistically
significant in this study, the correlation was small. The
result corroborated the evidence in a previous study by
Chezem et al. (2003). Despite a positive and significant
correlation on breastfeeding self-efficacy and knowledge, a
small value of correlation coefficient has little relation to
exclusive breastfeeding duration or breastfeeding self-efficacy. Although information on the benefits of breastfeeding
has been widely promoted in antennal classes and should
impact the initiation of the health behaviours, nonetheless, it
does not significantly affect the duration of exclusive
breastfeeding. As resources for promoting breastfeeding
are limited, we could consider re-directing these resources
and efforts to other factors such as breastfeeding selfefficacy, which contributes significantly to the duration of
exclusive breastfeeding.

Breastfeeding self-efficacy
From the GEE model, breastfeeding self-efficacy is a statistically significant factor associated with exclusive breastfeeding. The more confidence the mothers had in their
breastfeeding performance, the more likely (OR 1104,
p < 0001) they were to breastfeed their babies exclusively
at different time points. Previous studies have revealed that
skills are needed to realise the desired behaviour self-efficacy
on breastfeeding duration (Etrem et al. 2001, OBrien et al.
2008).
For most mothers, breastfeeding is not a simple, nutritional decision as related knowledge has been imparted
during pregnancy (Greene et al. 2003). Although all subjects
in the study were committed to breastfeeding, most reported
that they nonetheless found it embarrassing and felt uncomfortable to breastfeed in front of others. This was not a
unique phenomenon among the mothers, but also for local
university students. Tarrant and Dodgson (2007) studied 400
university students on their views on breastfeeding in public.
Students found it an acceptable practice but embarrassing
and restrictive of the mothers freedom. Moreover, breastfeeding is also strongly influenced by social beliefs. In the
United States, the overall population appears to approve of
breastfeeding in public, but less educated or older persons are
less likely to do so (Li et al. 2004). On the contrary, it was a
criminal offence to prevent a mother to breastfeeding her

Practice of exclusive breastfeeding

child in public in Scotland (Macleod 2004). The above

highlights the psychosocial factors that mothers often face
that may influence their breastfeeding behaviour. Although
they want to practice breastfeeding, few public places in
Hong Kong provide clean and private nursing rooms for
breastfeeding women. Embarrassment adds to the level of
difficulty they are expected to encounter. Ultimately, breastfeeding is perceived as inconvenient, embarrassing, inappropriate and restrictive of the mothers freedom. Our results
also indicated that mothers having friends to provide
information on breastfeeding were less likely to breastfeed
their babies. Only a minority of mothers with very high level
of commitment and having high faith in breast milk will
persist and continue breastfeeding.
Based on our findings, we believe that the concept of
confidence building should be addressed in all programmes
promoting exclusive breastfeeding and mothers should be
encouraged with an open discussion on the issue. Using the
non-threatening approach could help women to identify
reasons behind the problems and allow room for the health
care workers to work with the clients to overcome precipitate
barriers, in turn, may help to increase their confidence. For
populations where breastfeeding is not a normative behaviour, questions related to why it is not and why people have
doubt should be addressed in the early stages of life, such as
in school programs or through mass media, or in early
pregnancy (Etrem et al. 2001). Approaches to managing
obstacles to healthy behaviour should be an integral part of
the health education plan. Using both group and individual
approaches may help to identify problems and at the same
time use group dynamics to empower the clients. Whilst it is
important to address the obstacles, it is worthwhile to look
into why mothers are most satisfied with the breastfeeding
experience. Be satisfied with my breastfeeding experience
was one of the three items that achieved the lowest score in
the BSES. Peer support group with experienced mothers who
are successful in exclusive breastfeeding is considered an
effective way to appreciate the satisfaction that one may gain
from breastfeeding. Large-scale campaigns on breastfeeding
should be encouraged to change peoples attitudes and
perceptions to make this the normative healthy behaviour
in the city.
The success of educational efforts is highly dependent on
reducing the feeling of embarrassment and the provision of a
supportive environment. Legislation could be enacted to
facilitate shopping malls and public areas such as parks to
provide clean, pleasurable nursing rooms to mothers for
breastfeed. The psychological factors negatively influencing
breastfeeding could be reduced as mothers will perceive more
freedom and will be less homebound while breastfeeding.

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

2441

C-M Ku and SKY Chow

Factors affecting breastfeeding self-efficacy and exclusive

breastfeeding
As indicated by overseas studies, sociodemographic factors
were consistently related to the initiation and discontinuation
of exclusive breastfeeding. Although many women initiated
breastfeeding, their exclusive breastfeeding rate remains low.
Babys grandmother is often one of the most commonly
reported obstacles in breastfeeding (Cox 2004). This study
showed that the presence of mother-in-law in the subjects
home is a factor described as being associated with higher
breastfeeding self-efficacy. Although we have no information about mothers-in-laws breastfeeding history, the personal breastfeeding experience of grandmothers might
influence the mothers decisions on how to feed their
babies. Despite the influence on breastfeeding self-efficacy,
the presence of mothers-in-law did not significantly influence the duration of exclusive breastfeeding as indicated in
the GEE model.
Maternal age has been widely reported as a variable
affecting infant feeding choices (Dennis 2002, Avery et al.
1998). We found that age is negatively correlated with breast
self-efficacy in regression analysis; older age is associated
with lower breastfeeding self-efficacy. Most participants in
our study had their first babies in their late 20s to early 30s
(range 2832, 488%). Maternal age is a significant factor
affecting breastfeeding self-efficacy but not the practice of
exclusive breastfeeding as indicated in the GEE model.
Further research is warranted to include mothers of wider
age range to determine the relationship between age and
breastfeeding self-efficacy.
In contrast to previous overseas studies, where a higher
household income has been associated with higher rate of
exclusive breastfeeding (Giashuddin et al. 2003, Senarath
et al. 2007), in our study, higher household income is
associated with a lower rate of practising exclusive breastfeeding at different time points. Researchers have shown
that women with higher household income in the developing
countries may perceive breastfeeding as old-fashioned and a
sign of lesser social status, perceiving bottle feeding to be
modern and westernized (Rogers et al. 1997). Hong Kong
is a metropolitan city and the primiparous mothers in this
study who have higher household income are associated
with higher breastfeeding self-efficacy. There may be an
assumption that the subjects were actually practicing partial
breastfeeding at different time points, but not exclusively
breastfeeding. That is, although the subjects possessed
higher breastfeeding self-efficacy, they were unable to
sustain exclusive breastfeeding practices at different time
points.
2442

Living conditions were often associated with household

income. The overcrowded living environment makes it
more difficult for the mother to find a convenient, private
feeding location if living with families. Having a fatherin-law to pei-yue was associated with the low self-efficacy to
breastfeed as woman find it embarrassing to breastfeed in
front of her father-in-law and will soon decide to terminate
the practice. Nevertheless, this is a non-modifiable factor that
health care workers find difficult to overcome.
This study found a positive association between the level of
maternal education and exclusive breastfeeding duration,
which is consistent with most studies on breastfeeding (Scott
et al. 2001, Li et al. 2002, Gudnadottir et al. 2006, Senarath
et al. 2007). Education provides the most effective motivation for behavioural change and is identified as a social goal
as well as individual goal. Our study results revealed that the
majority of the mothers received health education on
breastfeeding from health care professionals during their
pregnancies. Mothers who actively searched for breastfeeding
information via the Internet during the antenatal period were
more likely to exclusively breastfeed for a longer duration.
Using the Internet as a source for breastfeeding information is
one of the significant factors associated with higher rate of
practicing exclusive breastfeeding at different time points.
Learning from the Internet is usually learner-centred, emphasising independence and self-paced. This is particularly
suitable for women considering breastfeeding and seeking
information prior to delivery to prepare themselves for the
experience and during the postnatal period. A study by
Huang et al. (2007) in Taiwan suggested that web-based
breastfeeding education programme can achieve success in
promoting breastfeeding and provide health professionals
with an evidence-based intervention. The Internet is considered a useful tool for the health promotion practitioner,
whether working with individuals, groups or in a whole
population setting.
Intended breastfeeding duration has been widely used as a
predictor for length of breastfeeding (Avery et al. 1998,
Dodgson et al. 2003, Duckett et al. 1998). However, the
results from these studies showed that the variable did not
significantly affect either breastfeeding self-efficacy or duration of exclusive breastfeeding. Our study tried to use another
variable to measure intention the time period during which
the decision to breastfeed was made. Results showed that a
late decision to breastfeed is associated with a lower
breastfeeding self-efficacy. Bourgoin et al. (1997) and Scott
et al. (1997) have indicated that breastfeeding behaviours
were strongly associated with the time decided for the
behaviour. Health promotion is to develop self-esteem and
self-confidence of the clients for behavioural change.

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 24342445

Maternal and neonatal health

Adequate time is required for both the health care workers

and clients to learn how to handle difficult feelings and
dilemmas towards breastfeeding. In a similar vein, clients
required time to decide on their behavioural change, basing
their decisions on existing policies, facilities and available
services. Furthermore, choosing a healthy behaviour does not
automatically lead to its practice. Time should be allowed to
help people to look at their own motivations, beliefs, values
and attitudes before they carry out decisions.
Being unmarried was a consistent, significant factor in not
practising breastfeeding (Yeoh et al. 2007). The results in our
study also revealed that married mothers were more likely to
practice exclusive breastfeeding at different time points.
Single mothers are often considered deviant in Hong Kong
society and have to deal with multiple life stressors that make
them less committed to breastfeeding. Tarkka (2003) stated
that being married, having a supportive relationship with a
mate and quality of the relationship have been related to
higher material self-efficacy.
In a study by Kong and Lee (2004), the husbands opinion
was ranked as the second most important factor in
influencing the mothers decision to breastfeed. Once the
decision to breastfeed has been taken and the practice
initiated, spousal support during the course of behavioural
change increases self-efficacy, confidence and competence
particular in the early stages of parenting. Having a
domestic helper to pei yue was associated with a higher
rate of practising exclusive breastfeeding at different time
points in this study. The domestic helper is able to share the
housework and allows the mother to concentrate on baby
care and nursing. Being married, having husband and
domestic helper to pei yue are psychological and environmental factors that influence womens decisions to breastfeed and increase their self-esteem, confidence and their
healthy behaviours. Moreover, having a domestic helper is
generally associated with higher socioeconomic status and
family income. Having a higher socioeconomic status has
been positively associated with breastfeeding initiation and
duration, as indicated in the studies from developed countries, such as Canada (Barber et al. 1997) and the United
States (Ryan 1997).
The proportion of caesarean section (11%) and vacuum
extractions (134%) in this study was much lower when
compared with previous studies on primiparous mothers in
Hong Kong (Dodgson et al. 2003). Both variables did not have
a statistical effect in the duration of practising exclusive
breastfeeding in this study. A large-scale local study
(n = 7825), Leung et al. (2002), found there was an increased
adverse risk to the initiation of breastfeeding in women who
had undergone either of these interventions. It is highly

Practice of exclusive breastfeeding

probable that the mode of delivery exerts the greatest effect

on exclusive breastfeeding during the early postpartum period.

Limitations
The sample size, non-random sampling and use of only one
study site for data collection limited the generalisability of
this study. Subjects with a more diverse socio-economic
background could provide a comprehensive picture on the
phenomenon of exclusive breastfeeding. Another limitation
included some factors not measured in this study, such as the
mothers breastfeeding attitude, individuals breast conditions (flat nipples or inverted nipples) and the presence of
postpartum depression. These confounders could affect the
breastfeeding practices and behaviour of the mothers. As this
study collected breastfeeding patterns at six weeks postpartum, recall bias was another limitation of the study.

Conclusion and relevance to clinical practice

Factors influencing the initiation and duration of breastfeeding have been broadly studied, whilst previous studies have
rarely examined the factors associated with exclusive breastfeeding. From a public health perspective, it is important that
newborns are breastfed at birth and exclusively breastfed
during their first six months of life. The analysis indicates
that the decision to breastfeed is made, different social factors
influence the duration of exclusive breastfeeding. Despite the
evidence in favour of the benefits of exclusive breastfeeding,
women switched from breastfeeding, either exclusive breastfeeding or partial breastfeeding, to artificial feeds after
discharge, as a result of lack of societal acceptance of
breastfeeding and lack of self-efficacy. These are the barriers
that need to address to further promote breastfeeding to
achieve the recommendations from WHO. Strenuous public
health efforts are needed to improve breastfeeding behaviours, particularly among socioeconomically disadvantaged
groups. Nurses should also consider assessing women at risk
for suboptimal parenting to provide greater support to
achieve more promising outcomes on breastfeeding.

Acknowledgements
The authors thank Mr Edward Choi for his advices on
statistical analysis.

Contributions
Study design: SC, C-MK; data collection and analysis: C-MK
and manuscript preparation: SC, C-MK.

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C-M Ku and SKY Chow

Conflict of interest
None.

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