Factors Influencing Exclusive Breastfeeding among Urban Employed Mothers: A Case-Control St

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Pornnapa Tangsuksan
Ameporn Ratinthorn
Siriorn Sindhu
Diane L Spatz
Chukiat Viwatwongkasem


             Promoting exclusive breastfeeding among urban employed mothers is a complex phenomenon. Understanding the multiple level factors related to this and how they influence employed mothers’ regarding exclusive breastfeeding could help identify strategies to support mothers continuing exclusive breastfeeding. This study aimed to identify maternal, social, and workplace level factors and the interaction effects among those factors that influence exclusive breastfeeding for six months among urban employed mothers. This case-control study investigated among 57 cases (exclusive breastfeeding for six months) and 228 controls (non-exclusive breastfeeding for six months) in six purposively-selected hospital settings in Bangkok, Thailand between September 2015 and June 2016. Data were collected through six self-administered questionnaires; Demographic Questionnaire, Iowa Infant Feeding Attitude Scale, Perceived Self-efficacy in Breastfeeding Questionnaire, Breastfeeding Knowledge Questionnaire, Perceived Breastfeeding Support Assessment Tool, and Infant Feeding Form, and were analyzed by descriptive statistics, univariate and multivariate logistic regression.

            The results revealed that maternal factors (family income, attitudes, intention, confidence, and knowledge) and workplace factors (maternity leave and working times) co-predicted exclusive breastfeeding six months. In the interaction effect model, the interaction effect between workplace policy on maternity leave and attitudes toward breastfeeding also exerted significant influence. The findings suggest that multiple level interventions to promote exclusive breastfeeding in employed women are needed. In clinical practice, nurses and midwives should implement antepartum interventions including assessment of maternal attitudes and intentions to breastfeed, providing breastfeeding knowledge to increase mothers’ confidence, and advice about planning to combine breastfeeding and employment. Of great concern was a finding that more than 75% of the non-EBF mothers reported not having sufficient breastfeeding facility support in the workplace. Workplace policies should be reviewed in terms of sufficient paid maternity leave, workplace breastfeeding support, and an appropriate number of working hours, and this has implications for governments and multiple workplaces across the country. Nurses have a significant role to play in advocating for and contributing to such policies to increase the numbers of women successfully breastfeeding longer whilst employed.  


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Tangsuksan P, Ratinthorn A, Sindhu S, Spatz DL, Viwatwongkasem C. Factors Influencing Exclusive Breastfeeding among Urban Employed Mothers: A Case-Control St. PRIJNR [Internet]. 2020 Jan. 2 [cited 2022 Aug. 10];24(1):54-72. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/169846
Original paper


1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51.

2. Victora CG, Horta BL, Loret de Mola C, Quevedo L, Pinheiro RT, Gigante DP, et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. The Lancet Global Health. 2015;3(4):e199-205.

3. Global breastfeeding scorecard 2018: enabling breastfeeding through policies and programmes [Internet]. New York: United Nations Children’s Fund; World Health Organization. July 2018. [cited 2019 April 30]. Available from: https://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2018/en.

4. Infant and Young Child Feeding: exclusive breastfeeding, predominant breastfeeding [Internet]. United Nations Children’s Fund, Division of Data Research and Policy 2018. [cited 2019 March 26]. Available from: https://data. unicef.org/topic/nutrition/infant-and-young-child-feeding/.

5. Balogun OO, Dagvadorj A, Anigo KM, Ota E, Sasaki S. Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: a quantitative and qualitative systematic review. Maternal & Child Nutrition. 2015;11(4):433-51.

6. Chekol DA, Biks GA, Gelaw YA, Melsew YA. Exclusive breastfeeding and mothers’ employment status in Gondar town, Northwest Ethiopia: a comparative cross-sectional study. International Breastfeeding Journal. 2017;12:27.

7. Dagher RK, McGovern PM, Schold JD, Randall XJ. Determinants of breastfeeding initiation and cessation among employed mothers: a prospective cohort study. BMC Pregnancy and Childbirth. 2016;16(1):194.

8. Abou-ElWafa HS, El-Gilany AH. Maternal work and exclusive breastfeeding in Mansoura, Egypt. Family Practice. 2018,1-5.

9. Altamimi E, Al Nsour R, Al Dalaen D, Almajali N. Knowledge, attitude, and practice of breastfeeding among working mothers in South Jordan. Workplace Health & Safety. 2017;65(5):210-8.

10. Henry-Moss D, Lee J, Benton K, Spatz DL. An exploration of lactation facilities and planning in U.S. Higher Education Campuses. Breastfeeding Medicine: the Official Journal of the Academy of Breastfeeding Medicine. 2019; 14(2):121-7.

11. Ratnasari D, Paramashanti BA, Hadi H, Yugistyowati A, Astiti D, Nurhayati E. Family support and exclusive breastfeeding among Yogyakarta mothers in employment. Asia Pacific Journal of Clinical Nutrition. 2017;26(Suppl 1):S31-S35.

12. Johnston ML, Esposito N. Barriers and facilitators for breastfeeding among working women in the United States. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN / NAACOG. 2007;36(1):9-20.

13. Sallis JF, Owen N. Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior: theory, research, and practice. 5 ed. San Francisco: Jossey-Bass; 2015. p. 43-64.

14. Hirani SA, Karmaliani R. The experiences of urban, professional women when combining breastfeeding with paid employment in Karachi, Pakistan: A qualitative study. Women and Birth: Journal of the Australian College of Midwives. 2013;26(2):147-51.

15. Sulaiman Z, Liamputtong P, Amir LH. The enablers and barriers to continue breast milk feeding in women returning to work. Journal of Advanced Nursing. 2016;72(4):825-35.

16. Mirkovic KR, Perrine CG, Scanlon KS. Paid maternity leave and breastfeeding outcomes. Birth (Berkeley, Calif). 2016;43(3):233-9.

17. Xiang N, Zadoroznyj M, Tomaszewski W, Martin B. Timing of return to work and breastfeeding in Australia. Pediatrics. 2016;137(6):e20153883.

18. Sun K, Chen M, Yin Y, Wu L, Gao L. Why Chinese mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first six months. Journal of Child Health Care. 2017;21(3):353-63.

19. International Labour Organization. Labor force participation rate, female (% of female population ages 15+) [Internet]. Geneva:, ILOSTAT database 2018. [cited 6 May 2019]. Available from: https://data.worldbank.org/indicator/SL.TLF.CACT.FE.ZS.

20. World Social Protection Report 2017–19: Universal social protection to achieve the Sustainable Development Goals [Internet]. Geneva: International Labour Office. 2017. [cited 2019 May 8]. Available from: https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/wcms_604882.pdf

21. Dasgupta S, Bhula-or R, Fakthong T. Earnings differentials between formal and informal employment in Thailand [Internet]. Bangkok: ILO Regional Office for Asia and the Pacific. 2015. [cited 2019 May 8]. Available from: https://www.ilo.org/public/libdoc//ilo/2015/489640.pdf

22. Dinour LM, Szaro JM. Employer-based programs to support breastfeeding among working mothers: a systematic review. Breastfeeding Medicine: the Official Journal of the Academy of Breastfeeding Medicine. 2017;12:131-41.

23. Bronfenbrenner U, Ceci SJ. Nature-nurture reconceptualized in developmental perspective: a
bioecological model. Psychological Review. 1994;101(4):568-86.

24. Johnson AM, Kirk R, Muzik M. Overcoming workplace barriers: a focus group study exploring African American mothers’ needs for workplace breastfeeding support. Journal of Human Lactation: Official Journal of International Lactation Consultant Association. 2015;31(3):425-33.

25. Thomas C, O’Riordan MA, Furman L. Effect of the knowledge and attitudes of a support person on maternal feeding choice. Journal of Human Lactation: Official Journal of International Lactation Consultant Association. 2017;33(1):195-204.

26. Dunn RL, Kalich KA, Fedrizzi R, Phillips S. Barriers and contributors to breastfeeding in WIC mothers: a social ecological perspective. Breastfeeding Medicine: the Official Journal of the Academy of Breastfeeding Medicine. 2015;10(10):493-501.

27. Ciftci EK, Arikan D. The effect of training administered to working mothers on maternal anxiety levels and breastfeeding habits. Journal of Clinical Nursing. 2012;21(15-16):2170-8.

28. Valdes V, Pugin E, Schooley J, Catalan S, Aravena R. Clinical support can make the difference in exclusive breastfeeding success among working women. Journal of Tropical Pediatrics. 2000;46(3):149-54.

29. Apichatvorapong C. The relationship between stress and its related factors influence exclusive breastfeeding among working mothers [master’s thesis]. Bangkok (Thailand): Mahidol University, Faculty of Graduate Studies; 2004. Chapter 4, Infant feeding practices; p. 58.

30. Kelsey JL, Whittemore AS, Evans AS, Thompson WD. Methods in observational epidemiology. 2 ed. New York: Oxford University Press; 1996.

31. Tsai SY. Impact of a breastfeeding-friendly workplace on an employed mother’s intention to continue breastfeeding after returning to work. Breastfeeding Medicine: the Official Journal of the Academy of Breastfeeding Medicine. 2013;8:210-6.

32. Maneesriwongul W, Dixon JK. Instrument translation process: a methods review. Journal of Advanced Nursing. 2004;48(2):175-86.

33. De la Mora A, Russell DW, Dungy CI, Losch M, Dusdieker L. The Iowa Infant Feeding Attitude Scale: analysis of reliability and validity. Journal of Applied Social Psychology. 1999;29(11):2362-80.

34. Poungkaew N. Effects of self-efficacy promoting program on breastfeeding behavior and duration among first-time working mothers [master’s thesis]. Bangkok (Thailand): Mahidol University, Faculty of Graduate Studies; 2005.

35. Hirani SA, Karmaliani R, Christie T, Parpio Y, Rafique G. Perceived Breastfeeding Support Assessment Tool (PBSAT): development and testing of psychometric properties with Pakistani urban working mothers. Midwifery. 2012;29:599-607.

36. Sharma B, Jain R. Right choice of a method for determination of cut-off values: a statistical tool for a diagnostic test. Asian Journal of Medical Sciences. 2014;5(3):30-4.

37. Shepherd L, Walbey C, Lovell B. The role of socialcognitive and emotional factors on exclusive breastfeeding duration. Journal of Human Lactation: Official Journal of International Lactation Consultant Association. 2017;33(3):606-13.

38. Februhartanty J, Wibowo Y, Fahmida U, Roshita A. Profiles of eight working mothers who practiced exclusive breastfeeding in Depok, Indonesia. Breastfeeding Medicine: the Official Journal of the Academy of Breastfeeding Medicine. 2012;7(1):54-9.

39. Reeves EA, Woods-Giscombe CL. Infant-feeding practices among African American women: socialecological analysis and implications for practice. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society. 2015;26(3):219-26.

40. Ministry of Public Health and network organizations target at least 50% of Thai children exclusively breastfed for 6 months by the year of 2025 [press release]. Bangkok: Department of Health, Ministry of Public Health. 2018. [cited 2019 May 8]. Available from: https://www.anamai.moph.go.th/ewt_news.php?nid=12470

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