Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study.

BACKGROUND: Breastfeeding self-efficacy is known to positively influence breastfeeding behaviors. While previous research has studied the determinants of breastfeeding self-efficacy in general, these determinants are unstudied among postpartum women in rural China. This study aims to describe the breastfeeding self-efficacy of postpartum women in rural China and identify determinants of breastfeeding self-efficacy using the Dennis breastfeeding self-efficacy framework.
METHODS: Using a multi-stage random cluster sampling design, cross-sectional survey data were collected from 787 women within the 0-6 months postpartum period in 80 rural townships. Surveys collected data on breastfeeding self-efficacy, characteristics related to the Dennis breastfeeding self-efficacy framework, and demographic characteristics. Multiple linear regression analysis was used to identify determinants of breastfeeding self-efficacy.
RESULTS: Participants reported a moderate level of breastfeeding self-efficacy, with an item mean score of 3.50. Self-efficacy was lowest for exclusive breastfeeding. Breastfeeding attitudes (β = 0.088, P< 0.001), breastfeeding family support (β = 0.168, P< 0.001), and social support from significant others (β = 0.219, P< 0.001) were positively associated with breastfeeding self-efficacy. Breastfeeding problems, including trouble with latching (β = -0.170, P< 0.001), not producing enough milk (β = -0.148, P< 0.001), and milk taking too long to secrete (β = -0.173, P< 0.001) were negatively associated with breastfeeding self-efficacy.
CONCLUSION: The findings indicate that positive attitudes, breastfeeding family support and social support contribute to greater breastfeeding self-efficacy in rural China, whereas difficulties with breastfeeding are associated with reduced self-efficacy. Researchers and practitioners should investigate effective strategies to improve social support and family support for breastfeeding, promote positive attitudes towards breastfeeding, and provide women with actionable solutions to breastfeeding problems.

Introduction

Despite the established benefits of breastfeeding, current infant breastfeeding rates remain suboptimal in low- and middle-income countries (LMICs). Breastfeeding not only provides optimal infant nutrition but also has short- and long-term health benefits for infants and mothers [1], prompting the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) to strongly recommend that mothers initiate breastfeeding within one hour of birth, exclusively breastfeed their infants for the first six months of life and maintain breastfeeding for the first two years of life [2]. Despite these recommendations, a recent study has found that only 37% of infants under six months in LMICs were exclusively breastfed [3], well below the WHO 90% benchmark [4]. To effectively address the suboptimal breastfeeding situation, it is necessary to identify the key modifiable factors that influence breastfeeding behavior.

The international literature has shown that breastfeeding self-efficacy (BSE) is one of the most crucial, modifiable factors influencing postpartum women’s breastfeeding behavior [5, 6]. BSE is derived from the self-efficacy concept of Bandura [7]. Dennis developed a framework for BSE in 1999 [8], defining BSE as a mother’s perceived ability to breastfeed her child. In Dennis’s framework, BSE influences a mother’s breastfeeding decisions, including the decision to breastfeed, how much effort should be given to breastfeeding, and how to respond to challenges during breastfeeding [5, 6, 8]. High BSE has also been associated with greater likelihood of exclusive breastfeeding in the first 6 months after birth [9].

Given the established links between BSE and breastfeeding outcomes, it is important to understand what factors may contribute to BSE. In Bandura’s self-efficacy framework and Dennis’s BSE framework, four factors are posited to modify self-efficacy: a.) Performance accomplishments; b.) Vicarious experiences; c.) Verbal persuasion; and d.) Emotional arousal [7, 8] (Fig 1). Performance accomplishments refer to the expectation that one’s future outcomes will be similar to past experiences. Thus, successful breastfeeding (positive performance accomplishments) may increase BSE, whereas repeated failures or problems (negative performance accomplishments) may diminish BSE. Vicarious experiences, which refer to seeing others succeed or fail in a breastfeeding, can create beliefs about one’s own skills and abilities, thus impacting BSE. Verbal persuasion, or encouragement from influential people such as friends and family, can also promote the BSE of mothers. Finally, emotional arousal (such as depression, stress, or anxiety) may influence a mother’s self-efficacy in general and BSE in particular [8]. Empirical studies have found evidence linking factors such as positive breastfeeding experiences, breastfeeding knowledge, breastfeeding attitudes, social support, and postpartum depression, to BSE [10, 11]. However, negative performance accomplishments (i.e., difficulties in successfully breastfeeding) have been less studied internationally, leaving a gap to be filled in the literature.

Fig 1

Diagrammatic representation of the Dennis breastfeeding self-efficacy framework.

In addition, because cultural context may influence self-efficacy and related factors, there is a need for more studies of BSE in various LMIC settings, particularly those with documented low rates of breastfeeding. One understudied setting with low rates of breastfeeding is rural China. China is the most populous country in the world, and more than 60% of the country’s population lives in rural areas. Although the weighted prevalence for breastfeeding in China is 79.6%, only 20.8% of infants are breastfed exclusively for six months [12]. In rural China, exclusive breastfeeding rates among children younger than six months are even lower: a survey in 26 poor, rural counties of China found that the rate of exclusive breastfeeding was only 58.3% among newborn infants, declining further to 29.1% in those aged three to four months and 13.6% in those aged five to six months [13].

Little is known about BSE in rural China; however, previous studies have measured the level of BSE among postpartum women in urban areas of China. These studies have found that the mean scores of items on the Breastfeeding Self-Efficacy Scale in Hong Kong, Shanghai and Guangzhou were 3.92 [14], 3.67 [15] and 3.38, [16] respectively. Interventions targeting BSE have also been shown to be effective in promoting breastfeeding practices among postpartum women in urban areas in China [17, 18]. However, because self-efficacy is a psychological category that is related to many socio-cultural factors, the results of international studies and studies in China’s urban areas are not necessarily representative of rural China, and the lack of studies examining BSE among postpartum women in rural China presents another gap in the existing literature. Given the low rates of breastfeeding in rural China and the important role that BSE plays in breastfeeding behavior in the international literature, research on BSE in rural China is needed to inform public health policies and improve breastfeeding outcomes. Therefore, this study aims to describe the BSE of postpartum women in rural China, and to identify the determinants of BSE among postpartum women in rural China based on the Dennis BSE framework.

Methods

Design

This study was conducted using a multi-stage random cluster sampling design and cross-sectional survey to assess BSE among women 0–6 months postpartum in rural China and to identify determinants of BSE based on the Dennis BSE framework. This research design was based on two main considerations. First, a large-scale survey gives the research team adequate statistical power to identify population-level trends and correlations. Second, the survey research method can help us to obtain first-hand research data directly from postpartum women in rural areas of China.

Setting

This study was conducted in poor rural areas of one prefecture in Sichuan Province, China. Located in the interior of southwest China, Sichuan ranks 18th of the 31 provinces in terms of Gross Domestic Product (GDP) per capita [19]. Almost half (46.21%) of Sichuan’s population is rural, with an average rural disposable income of USD 2,461, lower than the national average rural disposable income of USD 2,647 [19]. The sample prefecture was selected because it is relatively representative of Sichuan’s rural population: 52% of the prefecture’s population are rural residents, close to that of Sichuan overall (46.21%) [20]. Within the prefecture, there is one general hospital and one maternal and child health hospital in each county, a government-funded hospital in each township, and a doctor trained in medicine and public health in each village.

Sample

The research team sampled rural mothers within the 0–6 months postpartum period following a multi-stage cluster sampling protocol. First, four nationally-designated poverty counties were selected within the sample prefecture. Second, sample townships were chosen within each sample county. To select townships representative of typical rural areas, the sampling frame excluded non-rural townships and rural townships with populations of less than 10,000. Of the remaining townships, 20 townships per county were randomly selected by a computer-generated random numbers method, resulting in a total of 80 townships. Finally, a list of all mothers with registered births within the 6 months prior to the survey was obtained from the township health center in each sample township. A total of 842 postpartum women were identified and invited to participate in the study by the research team, with the assistance of local township and village doctors. In total, 55 eligible postpartum women failed to enroll in the study due to out-migration or travel at the time of the survey, intellectual disability or mental illness that prevented ability to give informed consent, or refusal to participate. Of the 842 lactating postpartum women who enrolled in this study, 787 postpartum women completed all aspects of the questionnaire, with a response rate of 93.5%.

Measurements

Outcome measurement

The “BSE” outcome was measured using the Chinese (Mandarin) version of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), which has been validated in mainland China with a Cronbach’s alpha of 0.94 [5]. The BSES-SF is comprised of 14 positively-worded statements regarding mothers’ self-efficacy in their ability to breastfeed [16, 21]. In addition to these 14 items, we also included two items (“I can always exclusively breastfeed without my child receiving even a drop of water;” and “I can always stop someone from trying to feed my child liquids or foods other than breast milk before six months of age”) adapted from a BSE scale by Boateng et al. [22] to better measure maternal self-efficacy in exclusive breastfeeding in rural China. Two experienced independent researchers fluent in English and Chinese translated the two additional items into Chinese (Mandarin) before addition. Combining the 14 items from the BSES-SF with the two items from Boateng et al [22], the BSE questionnaire in this study includes 16 items measured on a 5-point Likert-type scale with answers ranging from not at all confident (1) to always confident (5). Responses were summed to calculate a total score ranging from 16 to 80, with higher scores indicating higher BSE. In the present study, the Cronbach’s alpha for this questionnaire is 0.88.

Covariate measurements

After an extensive literature review, the research team developed a “Breastfeeding Problems Questionnaire” that encompasses the most prevalent problems associated with breastfeeding [23-31]. This questionnaire contains 19 items that measures concerns or difficulties of mothers during the first two weeks of breastfeeding. Each question in the questionnaire was answered with a “yes” or “no” answer. All items of the Breastfeeding Problems Questionnaire are presented in S1 Table.

Breastfeeding attitudes were assessed using the Iowa Infant Feeding Attitude Scale (IIFAS) [32]. This 17-item scale covers various dimensions of infant feeding attitudes, which mothers were asked to rank on a 5-point Likert scale from strongly disagree (1) to strongly agree (5). Higher scores indicate a more positive attitude to breastfeeding. The tool has been found to be reliable and valid, with a Cronbach’s alpha of 0.62 in mainland China [33]. In the present study, the Cronbach’s alpha is 0.56.

The “Breastfeeding Knowledge Questionnaire” was adapted and modified from the Breastfeeding Knowledge Questionnaire-Short Form (BFKQ-SF) [34] by the research team to fit the setting of rural China. This questionnaire has 12 items. Each correct answer is scored as 1, while wrong or unclear answers are scored as 0. The total score ranges from 0–12, with higher scores indicating greater knowledge about breastfeeding. All items of the Breastfeeding Knowledge Questionnaire can be found in S2 Table.

Family support for breastfeeding perceived by the mother was measured using a scale designed by Zhu et al. [35]. The scale contains nine items, with response ranked on a Likert scale ranging from strongly disagree (1) to strongly agree (4). Mothers with scores of 27 or higher are considered to have positive support. The scale has been evaluated for reliability and validity and has been proven to be effective at measuring family support for the breastfeeding of mothers [35]. In the present study, the Cronbach’s alpha is 0.78.

The Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure perceived social support (unrelated to breastfeeding) from family, friends and significant others [36]. This scale contains 12 items, with responses ranked on a 7-point Likert scale from strongly disagree (1) to strongly agree (7). Scores range from 12 to 84, with higher scores indicating higher levels of perceived social support [37]. In the present study, the Cronbach’s alphas for the MSPSS total scale and family, friends, and significant others subscales are 0.89, 0.82, 0.85, and 0.80, respectively.

The 21-item version of the Depression Anxiety Stress Scales (DASS-21) is a 21-item questionnaire first presented by Lovibond in 1995 that uses seven questions to measure each of the symptoms of stress, anxiety, and depression [38]. This questionnaire is designed as a Likert questionnaire, with item scores ranging from zero to three indicating different levels of severity of a particular symptom experienced over the past week. In the present study, the Cronbach’s alpha for the DASS-21 total scale and depression, anxiety, and stress subscales are 0.91, 0.82, 0.71, and 0.81, respectively.

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item instrument developed to identify mothers who may be experiencing postpartum depression [39]. Each item has four possible answers, with item scores ranging from zero to three. Total possible scores range from 0 to 30, with higher scores indicating a more elevated risk for postpartum depression [39]. The cutoff point for assessing depression varies by country, with an appropriate EPDS cutoff score of >10 for postnatal depression in China [40]. In the present study, the Cronbach’s alpha is 0.79.

Participant characteristics

Participant characteristics were collected through a demographic questionnaire developed by the research team. Characteristics included mother’s age, parity (primipara or multipara), marital status, education level, occupation, household economic level, mode of delivery (vaginal birth or cesarean section), and infant age in months. To assess the economic level of the household, we created a household asset index using polychoric principal component analysis based on whether the household owned the following assets: tap water, water heater, washing machine, computer, broadband, refrigerator, air conditioner, motorcycle, car, heating facility, toilet facility, and cooking fuel.

Data collection

Data were collected through a large-scale cross-sectional survey. To ensure the accuracy and consistency of our data collection, a uniform training session was provided to enumerators; in addition, following Li et al. [15], a pilot study was conducted among twenty participants in two non-sample townships to ensure the survey was appropriate and understandable for rural mothers in the study area. We used Survey Solutions Version 21.01 (The World Bank Group, Washington, DC) to administer the survey.

All data obtained were verified three times before being officially recorded and used for analysis. First, after the initial survey, each enumerator’s data were checked by a separate enumerator before leaving the township to ensure its integrity and accuracy. The data were then verified a second time by a member of the research team to confirm that the questionnaire was filled out completely and without errors. Finally, the data were handed over to another member of the research team that managed the online survey data for a third verification to confirm that there were no errors. If any errors were found, the corresponding questionnaire was rejected, and the enumerator interviewed the mother again to answer the survey questions.

Data analysis

All data analyses were performed using Stata 15.1 (StataCorp, College Station, TX). Descriptive statistics were used to analyze BSE; breastfeeding problems; breastfeeding knowledge; breastfeeding attitude; breastfeeding family support; social support; postpartum depression, anxiety, and stress symptoms; and demographic characteristics. Kolmogorov-Smirnov tests were conducted for all continuous variables to assess the distribution of the data. To identify potentially significant influencing factors, different analyses were applied according to the characteristics of the independent variables: a one-sided independent sample t-test was employed to compare BSE between two groups, and analysis of variance was used to compare BSE among three or more groups. Spearman’s correlation coefficients were conducted to test the correlation between BSE and continuous variables which were not normally distributed. Multiple linear stepwise regression models were used to perform multivariate analysis and identify the determinants of BSE. P values below 0.05 were considered statistically significant.

Ethical considerations

This study received ethical approval from the Stanford University Institutional Review Board (Protocol 44312) on October 28, 2019 and the Sichuan University Ethical Review Board (Protocol K2019029) on July 15, 2019. All participants provided written, informed consent to participate in the study before the survey began. Participants were given guarantees of voluntary participation and confidentiality.

Results

Characteristics of the participants

Demographic characteristics of the 787 postpartum women who participated in the study are shown in Table 1. The results of the Kolmogorov-Smirnov for maternal age suggest that the distribution is not normal (Z = 2.314, P< 0.05). The median age of the postpartum women was 27 years (IQR = 24~31). The majority of the participants were multipara (69.5%). Almost all participants were married (98.7%), and 48.8% of mothers had graduated from junior high school. Only 20.1% of mothers were working or self-employed, and 26.2% of mothers had a very low household economic level. In addition, 55.3% of the mothers had given birth by cesarean section. About half (45.9%) of babies were aged 1–3 months, while 18.2% were under 1 month and 36.0% were 4–6 months.

Table 1

Descriptive characteristics of postpartum women in rural China (N = 787).

Domain	Characteristics	N (%)
Socio-demographic	Age (years)a
	18–30	583 (74.1)
	≥31	204 (25.9)
	Marital status
	Married/Partner	777 (98.7)
	Single	10 (1.3)
	Education
	Lower than junior high school	90 (11.4)
	Junior high school	384 (48.8)
	Senior high school	134 (17.0)
	College/university or higher	179 (22.7)
	Occupation
	Farming	6 (0.8)
	Working/self-employed	153 (20.1)
	Not working	623 (79.2)
	Household economic level b
	Very low	206 (26.2)
	Low	192 (24.4)
	Moderate	197 (25.0)
	High	192 (24.4)
Birth-related	Parity
	Primipara	240 (30.5)
	Multipara	547 (69.5)
	Mode of delivery
	Vaginal delivery	352 (44.7)
	Cesarean section delivery	435 (55.3)
	Infant age (months)
	0–1	143 (18.2)
	1–3	361 (45.9)
	4–6	283 (36.0)

Notes.

a We divided mothers into two age groups using 30 years as a node, following the methods of a previous study of BSE in urban China by Zhu et al. [41].

b Household economic level was operationalized based on participants’ familial possession of twelve different household assets using principal component analysis, including tap water, water heater, washing machine, computer, broadband, refrigerator, air conditioner, motorcycle, car, heating facility, toilet facility, and cooking fuel, which was then divided into four different levels using quartiles.

Description of BSE of the postpartum woman in rural China

The BSE scores of the study participants are presented in Table 2. The results of the Kolmogorov-Smirnov test suggest that the distribution of BSE scores is normal (Z = 1.082, P> 0.05). At the time of the survey, the average BSE score among the participants was 55.95 (SD = 8.92), and the mean score for each item was 3.50 (SD = 0.56). Mothers were most confident with “dealing with the fact that breastfeeding can be time-consuming,” and were least confident with “being able to exclusively breastfeed without their child receiving even a drop of water.” The data show that respondents were relatively less confident in their breastfeeding technique (mean = 3.41) and relatively more confident in dealing with interpersonal concerns in breastfeeding (mean = 3.86). Overall, postpartum women in rural China reported a moderate level of BSE.

Table 2

Participant responses to the Breastfeeding Self-Efficacy scale (N = 787).

Item	Mean (SD)
Interpersonal Concerns
I can always deal with the fact that breastfeeding can be time-consuming.	4.05 (0.63)
I can always keep wanting to breastfeed.	3.96 (0.74)
I can always comfortably breastfeed with my family members present.	3.57 (0.94)
Breastfeeding Technique
I can always ensure that my child is properly latched on for the whole feeding.	3.86 (0.79)
I can always tell when my child is finished breastfeeding.	3.68 (0.87)
I can always successfully cope with breastfeeding like I have with other challenging tasks.	3.62 (0.84)
I can always be satisfied with my breastfeeding experience.	3.56 (0.86)
I can always continue to breastfeed my child for every feeding.	3.46 (0.93)
I can always manage the breastfeeding situation to my satisfaction.	3.44 (0.89)
I can always manage to keep up with my child’s breastfeeding demands.	3.42 (1.02)
I can always determine that my child is getting enough milk.	3.37 (0.98)
I can always manage to breastfeed even if my child is crying.	3.23 (0.97)
I can always breastfeed my child without using formula as a supplement.	3.20 (1.08)
I can always finish feeding my child on one breast before switching to the other breast.	3.10 (1.06)
I can always stop someone from trying to feed my child liquids or foods other than breast milk (e.g. infant formula, milk, porridge, juice, tea [whatever is given]), before 6 months of age.	3.61 (1.04)
I can always exclusively breastfeed without my child receiving even a drop of water.	2.84 (1.04)
Mean score of each item	3.50 (0.56)
Total score	55.95 (8.92)

Note. The Breastfeeding Self-Efficacy Scale includes the Interpersonal Thoughts subscale and the Technique subscale, with each item rated on a 5-point Likert-type scale (1 = not at all confident to 5 = always confident).

The relationships between demographic characteristics and BSE are shown in Table 3. The results find that none of the demographic variables were significantly associated with BSE.

Table 3

Differences in breastfeeding self-efficacy among various demographic sub-groups (N = 787).

Domain	Characteristics	Breastfeeding self-efficacy
		Mean (SD)	F	P-Value
Socio-demographic	Age (years)		0.85	0.356
	18–30	55.77 (8.77)
	≥31	56.44 (9.32)
	Marital status		0.90	0.344
	Married/Partner	55.92 (8.87)
	Single	58.60 (12.27)
	Mother’s education		1.84	0.139
	Lower than junior high school	57.92 (8.56)
	Junior high school	55.52 (8.97)
	Senior high school	55.63 (8.55)
	College/university or higher	56.09 (9.18)
	Mother’s occupation		0.54	0.583
	Farming	54.50 (8.34)
	Working/self-employed	55.35 (8.06)
	Not working	56.11 (9.13)
	Family economic level		2.10	0.098
	Very low	56.48 (8.30)
	Low	56.65 (9.03)
	Moderate	54.62 (8.60)
	High	56.02 (9.64)
Birth-related	Mother’s parity		0.77	0.381
	Primipara	55.53 (8.98)
	Multipara	56.13 (8.89)
	Mode of delivery		1.24	0.267
	Vaginal delivery	56.34 (8.81)
	Cesarean section delivery	55.63 (9.00)
	Infant age (months)		0.41	0.663
	0–1	56.55 (8.79)
	1–3	55.76 (8.92)
	4–6	55.88 (9.00)

Note. F = value of ANOVA.

Explanatory variables related to Dennis’s BSE framework

Breastfeeding problems

Table 4 presents the descriptive statistics for breastfeeding problems and their univariate correlations with BSE. We find that in the first two weeks of breastfeeding, 44.1% of the postpartum women felt back pain; 28.5% reported problems with their child sucking or latching on properly; and 47.1% perceived insufficient milk supply. Among 17.2% of mothers, the side effects of cesarean sections affected breastfeeding; 16.1% reported that their child was distracted or disinterested in breastfeeding; and 37.2% had problems with slow milk secretion. Only 15.0% of mothers reported that their child was not growing fast enough or losing too much weight, and 17.0% had problems with clogged milk ducts.

Table 4

Descriptive statistics of breastfeeding problems and univariate analysis with breastfeeding self-efficacy (N = 787).

Breastfeeding problems variables	N (%)	Breastfeeding self-efficacy
		Mean (SD)	t	P-Value
Breast pains			1.69	0.091
Yes	469 (59.59)	55.50 (8.79)
No	318 (40.41)	56.60 (9.07)
Back pains			2.51	0.012*
Yes	347 (44.09)	55.05 (9.05)
No	440 (55.91)	56.65 (8.75)
Baby had trouble sucking or latching on onto the breast			6.28	< 0.001***
Yes	224 (28.46)	52.86 (8.34)
No	563 (71.54)	57.17 (8.85)
Sore, cracked, or bleeding nipples			1.62	0.106
Yes	335 (42.57)	55.35 (8.80)
No	452 (57.43)	56.39 (8.98)
Not producing enough milk			7.84	< 0.001***
Yes	371 (47.14)	53.40 (8.26)
No	416 (52.86)	58.21 (8.87)
C-Section affected breastfeeding			3.15	< 0.001***
Yes	135 (17.15)	53.76 (8.86)
No	652 (82.85)	56.40 (8.87)
Episiotomy (cut vagina)			2.18	0.030
Yes	43 (5.46)	53.07 (7.91)
No	744 (94.54)	56.11 (8.95)
Doctor suggested not to breastfeed			1.14	0.256
Yes	16 (2.03)	53.44 (8.66)
No	771 (97.97)	56.00 (8.92)
Baby choked when breastfeeding			0.42	0.678
Yes	484 (61.50)	55.84 (8.93)
No	303 (38.50)	56.11 (8.90)
Baby wouldn’t wake up to nurse regularly enough			1.38	0.167
Yes	256 (32.53)	55.31 (8.74)
No	531 (67.47)	56.25 (8.99)
Baby was not interested in nursing or got distracted			3.20	< 0.001***
Yes	127 (16.14)	53.64 (8.63)
No	660 (83.86)	56.39 (8.91)
Baby nursed too often			1.40	0.163
Yes	346 (43.96)	55.45 (9.00)
No	441 (56.04)	56.34 (8.84)
Milk taking too long to secrete			8.17	< 0.001***
Yes	293 (37.23)	52.71 (8.20)
No	494 (62.77)	57.87 (8.77)
Baby didn’t gain enough weight or lost too much weight			2.24	0.025*
Yes	118 (14.99)	54.25 (7.92)
No	669 (85.01)	56.24 (9.05)
Not enough time to feed child			0.29	0.770
Yes	95 (12.07)	55.69 (9.11)
No	692 (87.93)	55.98 (8.89)
Infection of the breasts (e.g., abscess, yeast)			0.03	0.977
Yes	17 (2.16)	55.88 (7.03)
No	770 (97.84)	55.95 (8.96)
Clogged milk duct			2.72	0.007**
Yes	134 (17.03)	54.04 (9.32)
No	653 (82.97)	56.34 (8.79)
Breast engorgement			-0.43	0.665
Yes	529 (67.22)	56.04 (8.81)
No	258 (32.78)	55.75 (9.15)
Milk leaked too much			-1.65	0.099
Yes	493 (62.64)	56.35 (8.98)
No	294 (37.36)	55.27 (8.78)

Notes.

* P< 0.05

**P< 0.01

***P<0.001.

t = value of t- test.

The univariate analysis shows that eight of these breastfeeding problems had a significant association with BSE (Table 4). Specifically, these problems included back pain (P = 0.012), child latching poorly (P< 0.001), insufficient breast milk (P< 0.001), cesarean delivery affecting breastfeeding (P< 0.001), baby not interested or distracted by breastfeeding (P< 0.001), secreting breast milk too slowly (P< 0.001), baby not growing fast enough or losing too much weight (P = 0.025), and clogged milk duct (P = 0.007).

Other covariates

Table 5 presents the descriptive statistics of the Dennis BSE Framework variables excluding breastfeeding problems. The results of the Kolmogorov-Smirnov test suggest that the distribution of all these variables is not normal (P< 0.05); we therefore use the median and interquartile range for our subsequent analysis. At the time of the survey, the median score for breastfeeding knowledge was 7, indicating a “good” level of knowledge. For the IIFAS, the median score was 62, indicating that breastfeeding attitudes in rural areas of China were at a medium to high level, with a high proportion of women holding positive breastfeeding attitudes. Breastfeeding family support had a median score of 34, implying that most women had positive family support for breastfeeding. The social support score averaged 66 indicating that participants generally perceived themselves as having high levels of social support. The median score on the EPDS was 4, which was lower than the cutoff point for postpartum depression. The median total score on the DASS-21 was 4; median score on the DASS-Depression, DASS-Anxiety, and DASS-Stress were 1,1, and 2, respectively; implying that the mental health status of mothers was normal in general.

Table 5

Descriptive statistics of the Dennis breastfeeding self-efficacy framework variables excluding breastfeeding problems and univariate correlations with breastfeeding self-efficacy (N = 787).

Variables	Median (IQR)	Score range	The relationship with breastfeeding self-efficacy
			Spearman’s correlation coefficient	P-Value
Breastfeeding Knowledge Score	7 (5–8)	2–11	0.051	0.151
IIEAS Score	62 (59–65)	46–81	0.139	< 0.001***
EDPS Score	4 (2–7)	0–25	-0.128	< 0.001***
DASS Score	4 (1–9)	0–46	-0.161	< 0.001***
DASS of Depression	1 (0–2)	0–16	-0.145	< 0.001***
DASS of Anxiety	1 (0–2)	0–16	-0.098	0.006**
DASS of Stress	2 (0–5)	0–16	-0.158	< 0.001***
Family Support Score for breastfeeding	34 (30–36)	15–45	0.310	< 0.001***
MSPSS Score	66 (58–72)	15–84	0.224	< 0.001***
Significant others	23 (19–24)	4–28	0.251	< 0.001***
Family	23 (20–24)	4–28	0.197	< 0.001***
Friends	21 (18–24)	4–28	0.136	< 0.001***

Notes. Abbreviations: IIFAS, Lowa Infant Feeding Attitude; EDPS, Edinburgh Postnatal Depression; DASS, Scale of Depression Anxiety Stress; MSPSS, Multidimensional Scale of Perceived Social Support;

* P< 0.05

**P< 0.01

***P<0.001.

The analysis finds that several the BSE Framework variables were significantly associated with the BSE of rural mothers (Table 5). In particular, breastfeeding attitudes of the mothers (r = 0.166, P< 0.001), family support for breastfeeding (r = 0.297, P< 0.001) and social support (r = 0.214, P< 0.001) have significantly positive correlations with BSE. At the same time, the results show that depression (EPDS score: r = -0.099, P = 0.006; DASS of Depression: r = -0.120, P< 0.001) and stress (r = -0.137, P< 0.001) had significantly negative relationships with BSE.

Identification of the determinants of BSE among postpartum women in rural China based on the Dennis BSE framework

The stepwise multiple linear regression finds that six variables explain 24% of the variance of BSE among postpartum women in rural China (Table 6). Breastfeeding attitudes (β = 0.088, P< 0.001), breastfeeding family support (β = 0.168, P< 0.001), and social support from significant others (β = 0.219, P< 0.001) were positively associated with BSE. In contrast, three breastfeeding problems, including the child having trouble sucking or latching onto the breast (β = -0.170, P< 0.001), not producing enough milk (β = -0.148, P< 0.001), and milk taking too long to secrete (β = -0.173, P< 0.001) were negatively associated with BSE (Table 6).

Table 6

Determinants of breastfeeding self-efficacy among postpartum women in rural China, linear regression model (N = 787).

Variables	B	95%CI	SE	β	t	P-Value
Breastfeeding attitudes a	0.158	(0.043, 0.272)	0.058	0.088	2.71	0.007**
Social support from significant others b	0.357	(0.224,0.490)	0.068	0.168	5.28	< 0.001***
Family support for breastfeeding	0.433	(0.307,0.560)	0.065	0.219	6.71	< 0.001***
Baby had trouble sucking or latching on onto the breast	-3.361	(-4.493, -2.143)	0.620	-0.170	-5.42	< 0.001***
Not producing enough milk	-2.644	(-3.903, -1.385)	0.641	-0.148	-4.12	< 0.001***
Milk taking too long to secrete	-3.190	(-4.493, -1.886)	0.664	-0.173	-4.80	< 0.001***

Notes. Adjusted R2 = 0.24;

* P<0.05

**P<0.01

***P<0.001.

a Breastfeeding attitudes were assessed using the Iowa Infant Feeding Attitude Scale (IIFAS).

b Social support from significant others was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS).

Discussion

This study aimed to examine BSE and its determinants among postpartum women in rural China. To our knowledge, although previous research has studied the determinants of BSE in general, and among women living in urban China, this is the first study to explore the determinants of BSE in China’s rural areas. This exploration may assist health care professionals in identifying mothers experiencing low BSE, who may be at risk of prematurely discontinuing breastfeeding, and identify possible target areas for researchers and practitioners seeking to improve BSE among women in rural China.

In our study, the overall average BSE score among the participants was 55.95, with a mean item score of 3.50. When we compare the mean item score of our study to samples obtained from cities in other regions of China, we find that the BSE scores of mothers in rural China are lower than those reported in Tianjin, Hongkong, and Shanghai, China. Previous studies in these three cities reported mean BSE item scores of 3.92, 3.54, and 3.67 [15, 16, 42], respectively. The difference in mean item scores can partially be explained by the fact that these three studies were all conducted in urban areas of China; the majority of the participants were educated women and the population was likely to have (on average) a higher income, more family assets, and better support resources than individuals/families in rural China. Additionally, there is evidence that health care professionals in rural China often provide inadequate information/support on issues of child nutrition/breastfeeding, potentially causing further differences in BSE scores [43, 44].

Further examination of the BSE items in the present study suggests that mothers were least confident in their ability to exclusively breastfeed without their child receiving even some water. This lack of confidence in exclusive breastfeeding is largely consistent with the low rates of exclusive breastfeeding observed in other studies in rural China [13]. Moreover, compared to interpersonal concerns in breastfeeding, participants scored lower on items related to breastfeeding technique. These findings are similar to the study conducted in Xiamen, China, which also found that mothers were less confident in their breastfeeding technique [41]. Therefore, these results suggest that it may be necessary to develop interventions to educate women in breastfeeding techniques and promote women’s confidence in exclusive breastfeeding in rural China.

The empirical results of this study also find that women who had negative breastfeeding experiences had significantly lower BSE than those without such experiences. Three variables related to breastfeeding problems, including the child having trouble sucking or latching onto the breast, not producing enough milk, and milk taking too long to secrete, were all significantly associated with lower BSE. Such breastfeeding problems may also explain the diminished confidence in breastfeeding techniques reported among postpartum women in our study. Although few studies have examined the role of negative breastfeeding experiences in BSE, the findings align with the Dennis BSE framework, which theorizes that successful performance accomplishments increase BSE, whereas repeated failures or difficulties diminish it [8].

Early challenges with breastfeeding may be particularly salient for BSE among postpartum mothers in rural China. Previous research has shown that more than half of postpartum women in rural China experienced problems in the early stages of breastfeeding [45]. In our study, 28.5% of postpartum women experienced difficulty with latching during the first two weeks of breastfeeding, 47.1% experienced insufficient milk supply, and 37.2% experienced slow milk secretion. Postpartum women who encounter these problems in the early stages of breastfeeding may feel inadequate in their breastfeeding techniques and overwhelmed by challenges, thus reducing BSE. Moreover, although these problems can be alleviated by educating women on effective breastfeeding techniques, it is often difficult for postpartum women in rural areas to obtain relevant counseling and guidance [46]. When breastfeeding problems arise but cannot be solved in a timely and effective manner, postpartum women’s BSE decreases, and mothers may eventually give up breastfeeding [47]. Therefore, public health services in rural China should focus on helping new mothers resolve early problems they encounter during the breastfeeding process, especially insufficient milk, poor sucking or latching, and slow milk secretion.

In contrast to breastfeeding problems, the results find that social support from significant others and family support for breastfeeding were both significantly associated with higher BSE among postpartum women in rural China. This finding is consistent with BSE studies internationally [48, 49], as well as studies of self-efficacy in general, both of which find that social support can increase one’s coping abilities and competence [50]. This also aligns with the Dennis BSE framework, which suggests that verbal persuasion from family members, especially significant others, encourages mothers to continue breastfeeding their infants despite challenges [8]. As the closest and most important social network, family members are particularly important sources of emotional support for postpartum women in general [51] and in breastfeeding promotion specifically [52]. In addition to emotional support, postpartum women with higher levels of breastfeeding support receive relatively more practical assistance from family, which may help them to persist in breastfeeding [35]. In rural China, however, family members and significant others rarely receive education on breastfeeding or how to support breastfeeding mothers [41]. Educating family members about the importance of breastfeeding support for postpartum women may therefore increase BSE, motivation to breastfeed, and success in breastfeeding.

Consistent with previous research [49], positive breastfeeding attitudes among mothers were also found to be significantly associated with higher BSE in our study. Attitudes towards breastfeeding have also been identified as an indicator of breastfeeding behavior among women in urban China [33]. Encouraging postpartum women to develop positive attitudes towards breastfeeding may improve BSE and promote breastfeeding among women in rural China.

Finally, our study found that physiological or emotional responses, including stress, anxiety, and depression, were not determinants of BSE among women in rural China. This contradicts to the Dennis BSE framework, which posits that physiological or emotional responses can affect BSE [8]. These findings also contradict a previous study in Vietnam, which found that mothers with a higher level of postpartum depression tend to have lower BSE in the early postpartum period [10]. This discrepancy may be due to cultural differences between rural China and Vietnam, and further research is needed to better understand the links between mental health and BSE.

Limitations

Some important factors such as prior breastfeeding experiences (a component of performance accomplishments in the Dennis BSE framework) and effects of role modeling (a component of vicarious experience in the Dennis BSE framework) were not collected in this study and should be examined in further research. Furthermore, as our assessment of BSE was collected at a single point in time, we were unable to examine how BSE may change over the duration of breastfeeding, and we may have missed determinants of BSE that evolve with maternal breastfeeding experience. Further research is needed to examine the full range of determinants of BSE and their temporal and causal associations to BSE, to help health care professionals identify mothers at different stages of the postpartum period who are at high risk of low BSE and develop effective interventions to improve BSE in rural China.

Implications

This study highlights the importance of improving BSE, and particularly self-efficacy in exclusive breastfeeding, among postpartum women in rural China by identifying some of the primary determinants of BSE. Health care professionals should develop multi-dimensional strategies to foster BSE, such as intervening to enhance the breastfeeding attitudes of mothers, adopting a family-centered approach in the provision of breastfeeding education, and rallying comprehensive social support for postpartum women. The findings of our study also indicate that health care providers should increase education on breastfeeding techniques and assist women in resolving common breastfeeding problems, such as poor latching, insufficient breast milk and slow secretion of breast milk, in order to improve BSE.

Conclusions

The findings indicate that BSE among postpartum women in rural China is relatively low compared to urban China, pointing to a need for strategies to promote BSE. Positive attitudes towards breastfeeding, as well as social support and family support for breastfeeding, contribute to greater BSE in rural China. In contrast, difficulties with breastfeeding are associated with reduced BSE. Researchers and practitioners should investigate effective strategies to improve social support for breastfeeding, promote positive attitudes towards breastfeeding, and provide women with education on breastfeeding techniques and actionable solutions to breastfeeding problems. With greater effort placed on these now-identified critical points, BSE and breastfeeding practices could be meaningfully improved in rural China.

19 items of the Breastfeeding Problems Questionnaire.

(DOCX)

Click here for additional data file.

12 items of the Breastfeeding Knowledge Questionnaire.

(DOCX)

Click here for additional data file.

Stata data files.

(DTA)

Click here for additional data file.

28 Jan 2022

Submitted filename: Predictors of breastfeeding self Comment.docx

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13 Mar 2022

Dear Editor,

My coauthors and I thank you for your comments and suggestions concerning our manuscript “Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study” (No: PONE-D-21-31115). We also deeply appreciate the thoughtful comments from the reviewers, which have improved the paper.

We have studied the comments carefully and have revised our paper accordingly. This letter provides point-by-point responses to each comment and summarizes relevant changes in the manuscript. These changes are highlighted yellow in the revised manuscript. Primary changes to the paper include the following:

• We have revised the title of the manuscript to “Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study” and replaced “predictors” with “determinants” throughout the revised manuscript.

• We have reworked the Introduction section to ensure a brief literature gap and bring the landscapes of Chinese postpartum women’s breastfeeding self-efficacy.

• We have updated a detailed description of the process of selecting the actual participants of the study in the Methods section.

• We have reworked the Conclusion section to make it clearly according to our findings.

• We have also obtained the assistance of an editor to correct language usage flaws including punctuations, wordings, spelling and grammar errors throughout the manuscript.

The material in the manuscript has not and will not be offered elsewhere for possible publication as long as it is under consideration by PLOS ONE.

Once again, we are very grateful for your consideration of our work. We look forward to receiving your feedback on the updated manuscript.

With best regards,

Huan Zhou

Professor, Chair, Department of Health Behavior and Social Medicine

West China School of Public Health, Sichuan University

Email: zhouhuan@scu.edu.cn

Editor’s comments to author:

Editor Comment: Dear authors on your scholarly work; you have brought an important study. However, the manuscript has some language usage flaws including punctuations, wordings, spelling and grammar errors. These problems are found throughout the manuscript. Moreover, there are several methodological limitations as the reviewer raised. Therefore, kindly address all the reviewers’ concerns and also please make repeated proof-reading before resubmitting the manuscript. This would help increase the readership of the manuscript if published.

Response to Editor Comment:

Thank you for your time and consideration. We have addressed each reviewer comment and have revised the manuscript according to the reviewers’ comments. Specifically, we have:

• Revised the title of the manuscript to “Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study” and replaced “predictors” with “determinants” throughout the revised manuscript;

• Reworked the Introduction section to include a brief literature review on the current research landscape of women’s breastfeeding self-efficacy in China and more clearly identify gaps in the literature;

• Added a detailed description of our process for selecting study participants in the Methods section;

• Reworked the Conclusion section to speak more closely to the specific findings of our study.;

• Obtained the assistance of an editor to correct language usage flaws including punctuations, wordings, spelling and grammar errors throughout the manuscript.

In the following pages, we provide a point-by-point response to the reviewers’ comments, including specific changes made to the revised manuscript. All changes are highlighted yellow in the revised manuscript.

Response to Reviewer 1

General Comment1: First I want to thank you for the chance to review this interesting manuscript entitled “Predictors of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study”. The study presented in this manuscript is on an important and timely topic. It presents pertinent information for the audience of this journal and would be of interest to its readership. I will first make some general comments and then add specific areas under each section suggested for revision.

Response to General Comment:

Thank you for your comments and recognizing the value of our research. We have carefully considered your comments and revised our paper accordingly.

General Comment2: Before publication, the manuscript will need clearness in the methods and results sections. The authors could use the assistance of an editor for basic grammar and sentence structure corrections as well.

Response to General Comment:

Thank you for pointing this out. We have reworked the Methods and Results sections to ensure clearness (for specific changes, please see our responses to comment 2 in “Response to Reviewer 1” and comments 5-12 in “Response to Reviewer 2”). We have also obtained the assistance of an editor to correct errors in grammar and sentence structure throughout the manuscript. Every change in the manuscript has been highlighted in yellow.

Comment 1: Introduction: Several sections of the introduction need an attention. Readers will expect to see in brief, the literature gap that authors wanted to fill. Additionally, please rewrite and modify your introduction part by removing the frequently misused words.

Response: Thank you for pointing this out. We have modified the Introduction part to remove misused words. All changes are highlighted yellow in the revised manuscript.

We have also clarified the gaps in the existing literature that our study seeks to fill in Introduction section of the revised manuscript on page 6-8, lines 111-166 (revised text in italics):

“Empirical studies have found evidence linking factors such as positive breastfeeding experiences, breastfeeding knowledge, breastfeeding attitude, social support, and postpartum depression, to BSE [10,11]. However, negative performance accomplishments (i.e., difficulties in successfully breastfeeding) have been less studied internationally, leaving a gap to be filled in the literature.

In addition, because cultural context may influence self-efficacy and related factors, there is a need for more studies of BSE in various LMIC settings, particularly those with documented low rates of breastfeeding. One understudied setting with low rates of breastfeeding is rural China. China is the most populous country in the world, and more than 60% of the country’s population lives in rural areas. Although the weighted prevalence for breastfeeding in China is 79.6%, only 20.8% of infants are breastfed exclusively for six months [12]. In rural China, exclusive breastfeeding rates among children younger than six months are even lower: a survey in 26 poor, rural counties of China found that the rate of exclusive breastfeeding was only 58.3% among newborn infants, declining further to 29.1% in those aged three to four months and 13.6% in those aged five to six months [13].

Little is known about BSE in rural China; however, previous studies have measured the level of BSE among postpartum women in urban areas of China. These studies have found that the mean scores of items on the Breastfeeding Self-Efficacy Scale in Hong Kong, Shanghai and Guangzhou were 3.92 [14], 3.67 [15] and 3.38 [16], respectively. Interventions targeting BSE have also been shown to be effective in promoting breastfeeding practices among postpartum women in urban areas in China [17,18]. Because self-efficacy is a psychological category that is related to many socio-cultural factors, however, the results of international studies and studies in China’s urban areas are not necessarily representative of rural China, and the lack of studies examining BSE among postpartum women in rural China presents another gap in the existing literature. Given the low rates of breastfeeding in rural China and the important role that BSE plays in breastfeeding behavior in the international literature, research on BSE in rural China is needed to inform public health policies and improve breastfeeding outcomes. Therefore, this study aims to describe the BSE of postpartum women in rural China, and to identify the determinants of BSE among postpartum women in rural China based on the Dennis BSE framework.”

REFERENCES:

14. Ip WY, Gao LL, Choi KC, Chau JPC, Xiao Y. The Short Form of the Breastfeeding Self-Efficacy Scale as a Prognostic Factor of Exclusive Breastfeeding among Mandarin-Speaking Chinese Mothers. J Hum Lact. 2016;32(4):711–20. PMID: 27474407

15. Li T, Guo N, Jiang H, Eldadah M. Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study. J Hum Lact. 2019 Aug 5;35(3):583–91. http://journals.sagepub.com/doi/10.1177/0890334418812044 PMID: 30517822

16. Dai X, Dennis CL. Translation and validation of the breastfeeding Self-Efficacy Scale into Chinese. J Midwifery Women’s Heal. 2003;48(5):350–6. https://doi.org/10.1016/s1526-9523(03)00283-6 PMID: 14526349

17. Wu DS, Hu J, Mccoy TP, Efird JT. The effects of a breastfeeding self-efficacy intervention on short-term breastfeeding outcomes among primiparous mothers in Wuhan, China. J Adv Nurs. 2014;70(8):1867–79. https://doi.org/10.1111/jan.12349 PMID: 24400967

18. Liu Y, Li N, Mei Z, Li Z, Ye R, Zhang L, et al. Effects of prenatal micronutrients supplementation timing on pregnancy-induced hypertension: Secondary analysis of a double-blind randomized controlled trial. Matern Child Nutr. 2021;(January):e13157. https://doi.org/10.1111/mcn.13157 PMID: 33594802

Comment 2: Methods: The method part needs more amendment. Particularly, the measurement part should be revised and shortened for more simplicity. Regarding the data collection, you have mention whether questionnaire is adapted or adopted, and say something about the validity and reliability of your tool.

Response: Thank you for bringing this to our attention. We have shortened the measurement part of the methods and added details on the validity and reliability of each tool in the Methods section of the revised manuscript on page 11-15, lines 226-328 (revised text in italics). If the reviewer still feels that this section is too long, we are happy to move details on the measurements to a supplemental appendix.

“The “BSE” outcome was measured using the Chinese (Mandarin) version of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), which has been validated in mainland China with a Cronbach’s alpha of 0.94 [5]. The BSES-SF is comprised of 14 positively-worded statements regarding mothers’ self-efficacy in their ability to breastfeed [16, 21]. In addition to these 14 items, we also included two items (“I can always exclusively breastfeed without my child receiving even a drop of water;” and “I can always stop someone from trying to feed my child liquids or foods other than breast milk before six months of age”) adapted from a BSE scale by Boateng et al. [22] to better measure maternal self-efficacy in exclusive breastfeeding in rural China. Two experienced independent researchers fluent in English and Chinese translated the two additional items into Chinese (Mandarin) before addition. Combining the 14 items from the BSES-SF with the two items from Boateng et al [22], the BSE questionnaire in this study includes 16 items measured on a 5-point Likert-type scale with answers ranging from not at all confident (1) to always confident (5). Responses were summed to calculate a total score ranging from 16 to 80, with higher scores indicating higher BSE. In the current study, the Cronbach’s alpha for this questionnaire is 0.88.”

After an extensive literature review, the research team developed a “Breastfeeding Problems Questionnaire” that encompasses the most prevalent problems associated with breastfeeding [23-31]. This questionnaire contains 19 items that measures concerns or difficulties of mothers during the first two weeks of breastfeeding. Each question in the questionnaire was answered with a “yes” or “no” answer. All items of the Breastfeeding Problems Questionnaire are presented in S1 Table.

Breastfeeding attitudes were assessed using the Iowa Infant Feeding Attitude Scale (IIFAS) [32]. This 17-item scale covers various dimensions of infant feeding attitudes, which mothers were asked to rank on a 5-point Likert scale from strongly disagree (1) to strongly agree (5). Higher scores indicate a more positive attitude to breastfeeding. The tool has been found to be reliable and valid, with a Cronbach’s alpha of 0.62 in mainland China [27]. In the present study, the Cronbach’s alpha is 0.56.

The “Breastfeeding Knowledge Questionnaire” was adapted and modified from the Breastfeeding Knowledge Questionnaire-Short Form (BFKQ-SF) [33] by the research team to fit the setting of rural China. This questionnaire has 12 items. Each correct answer is scored as 1, while wrong or unclear answers are scored as 0. The total score ranges from 0-12, with higher scores indicating greater knowledge about breastfeeding. All items of the Breastfeeding Knowledge Questionnaire can be found in S2 Table.

Family support for breastfeeding perceived by the mother was measured using a scale designed by Zhu et al. [34]. The scale contains nine items, with response ranked on a Likert scale ranging from strongly disagree (1) to strongly agree (4). Mothers with scores of 27 or higher are considered to have positive support. The scale has been evaluated for reliability and validity and has been proven to be effective at measuring family support for the breastfeeding of mothers [29]. In the current study, the Cronbach’s alpha is 0.78.

The Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure perceived social support (unrelated to breastfeeding) from family, friends and significant others [35]. This scale contains 12 items, with responses ranked on a 7-point Likert scale from strongly disagree (1) to strongly agree (7). Scores range from 12 to 84, with higher scores indicating higher levels of perceived social support [35]. In the present study, the Cronbach’s alphas for the MSPSS total scale and family, friends, and significant other subscales are 0.89, 0.82, 0.85, and 0.80, respectively.

The 21-item version of the Depression Anxiety Stress Scales (DASS-21) is a 21-item questionnaire first presented by Lovibond in 1995 that uses seven questions to measure each of the symptoms of stress, anxiety, and depression [36]. This questionnaire is designed as a Likert questionnaire, with item scores ranging from zero to three indicating different levels of severity of a particular symptom experienced over the past week. In the present study, the Cronbach’s alpha for the DASS-21 total scale and depression, anxiety, and stress subscales are 0.91, 0.82, 0.71, and 0.81, respectively.

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item instrument developed to identify mothers who may be experiencing postpartum depression [37]. Each item has four possible answers, with item scores ranging from zero to three. Total possible scores range from 0 to 30, with higher scores indicating a more elevated risk for postpartum depression [38]. The cutoff point for assessing depression varies by country, with an appropriate EPDS cutoff score of >10 for postnatal depression in China. In the current study, the Cronbach’s alpha is 0.79.”

Comment 3: Conclusion: Your conclusion is somewhat vague. Better if you write it clearly according to your finding.

Response: Thank you for pointing this out. We have updated the sentences in the Conclusion section on page 39, line 659-674 of the revised manuscript (revised text in italics):

“The findings indicate that BSE among postpartum women in rural China is relatively low compared to urban China, pointing to a need for strategies to promote BSE. Positive attitudes towards breastfeeding, as well as social support and family support for breastfeeding, contribute to greater BSE in rural China. In contrast, difficulties with breastfeeding are associated with reduced BSE. Researchers and practitioners should investigate effective strategies to improve social support for breastfeeding, promote positive attitudes towards breastfeeding, and provide women with education on breastfeeding techniques and actionable solutions to breastfeeding problems. With greater effort placed on these now-identified critical points, BSE and breastfeeding practices could be meaningfully improved in rural China.”

Comment 4: References

Please, review your references and adjust according to the PLOS specifications.

Response: We have reviewed and adjusted our references to ensure that they are in compliance with PLOS specifications. All changes are highlighted yellow in the revised manuscript.

Comment 5: Since PLOS ONE does not copyedit accepted manuscripts, the authors should employ an editor to assist with ambiguous and grammatical errors that appear throughout the text. There are multiple grammar and sentence structure corrections that are required prior to publication.

Response: Thank you again for bringing this to our attention. We have also obtained the assistance of an editor to correct errors in grammar and sentence structure throughout the manuscript. Every change in the manuscript has been highlighted in yellow.

Response to Reviewer 2

Comment 1：In the title should be used an appropriate word/term in line with epidemiological study deign, which is predictors leads to case-control rather than cross-sectional study. Please modify it?

Response: Thank you for pointing this out. This study is a cross-sectional study, and the appropriate term is “determinants” rather than “predictors”. We have revised the title of the manuscript to read as follows (revised text in italics)：

“Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study”

Comment 2：In the abstract section line 37-39, all of the factors inversely associated with the predictors of BSE, but we are interpreting with a wrong way. Please see and correct accordingly.

Response: In our study, stepwise multiple linear regression analysis was used to explore the factors influencing BSE. The results of the regression found that six variables explained 24% of the variance in BSE. The six variables include positive breastfeeding attitudes, social support from significant others, family support for breastfeeding, the child having trouble sucking or latching onto the breast, the mother not producing enough milk and the mother’s milk taking too long to secrete.

Among these variables, the regression coefficients for breastfeeding attitudes (β= 0.088, P< 0.001), breastfeeding family support (β= 0.168, P< 0.001), and social support from significant others (β= 0.219, P< 0.001), were positive, indicating that higher scores on these variables were associated with higher BSE. In contrast the regression coefficients of the three variables related to breastfeeding problems, including the child having trouble sucking or latching onto the breast (β= -0.170, P< 0.001), not producing enough milk (β= -0.148, P< 0.001) and milk taking too long to secrete (β= -0.173, P< 0.001), were negative, indicating that difficulties with breastfeeding were associated with reduced BSE. We have updated the sentence in the Abstract section of the revised manuscript page 2-3, lines 36-43 (revised text in italics):

“Participants reported a moderate level of breastfeeding self-efficacy, with an item mean score of 3.50. Self-efficacy was lowest for exclusive breastfeeding. Breastfeeding attitudes (β= 0.088, P< 0.001), breastfeeding family support (β= 0.168, P< 0.001), and social support from significant others (β= 0.219, P< 0.001) were positively associated with breastfeeding self-efficacy. Breastfeeding problems, including trouble with latching (β= -0.170, P< 0.001), not producing enough milk (β= -0.148, P< 0.001), and milk taking too long to secrete (β= -0.173, P< 0.001) were negatively associated with breastfeeding self-efficacy.”

Comment 3: Your conclusion should be consider drawing out the “so whats” of your findings to drive the points, but we are stated your conclusion that are the roles of health professionals.

Response: Thank you for bringing this to our attention. We have updated the sentences in the Conclusion section on page 39, line 659-674 of the revised manuscript (revised text in italics):

“The findings indicate that BSE among postpartum women in rural China is relatively low compared to urban China, pointing to a need for strategies to promote BSE. Positive attitudes towards breastfeeding, as well as social support and family support for breastfeeding, contribute to greater BSE in rural China. In contrast, difficulties with breastfeeding are associated with reduced BSE. Researchers and practitioners should investigate effective strategies to improve social support for breastfeeding, promote positive attitudes towards breastfeeding, and provide women with education on breastfeeding techniques and actionable solutions to breastfeeding problems. With greater effort placed on these now-identified critical points, BSE and breastfeeding practices could be meaningfully improved in rural China.”

Comment 4: Introduction; Your manuscript missing a section which generally describes the breastfeeding self-efficacy among postpartum women landscapes in China. What is breastfeeding self-efficacy? Why suggests breastfeeding self-efficacy among postpartum women? Has breastfeeding self-efficacy helped elsewhere? What is the general breastfeeding self-efficacy rate? All these you can touch on briefly?

Response: Thank you for pointing this out. The concept of breastfeeding self-efficacy was developed by Dennis and refers to the level of confidence mothers have in their ability to breastfeed their babies. Breastfeeding self-efficacy plays an important role in postpartum women’s breastfeeding behavior. Interventions targeting breastfeeding self-efficacy have proven to be effective in promoting breastfeeding practices among postpartum women in urban areas in China. Studies have measured the level of breastfeeding self-efficacy among postpartum women in urban areas of China, and the results showed that the mean scores of items on the Breastfeeding Self-Efficacy Scale in Hong Kong, Shanghai and Guangzhou were: 3.92, 3.67 and 3.38 respectively.

We have added literature on breastfeeding self-efficacy internationally to the Introduction section of the revised manuscript page 4-5, lines 77-88 (revised text in italics):

“The international literature has shown that breastfeeding self-efficacy (BSE) is one of the most crucial, modifiable factors influencing postpartum women’s breastfeeding behavior [5,6]. BSE is derived from the self-efficacy concept of Bandura [7]. Dennis developed a framework for BSE 1999 [8], defining BSE as a mother’s perceived ability to breastfeed her child. In Dennis’ BSE framework, BSE influences a mother’s breastfeeding decisions, including the decision to breastfeed, how much effort should be given to breastfeeding, and how to respond to challenges during breastfeeding [5,6,8]. High BSE has also been associated with outcomes such as exclusive breastfeeding among postpartum women in the first 6 months after birth [9].”

We have described the landscape of Chinese postpartum women’s breastfeeding self-efficacy to the Introduction section of the revised manuscript page 7-8, lines 142-155 (revised text in italics):

Little is known about BSE in rural China; however, previous studies have measured the level of BSE among postpartum women in urban areas of China. These studies have found that the mean scores of items on the Breastfeeding Self-Efficacy Scale in Hong Kong, Shanghai and Guangzhou were 3.92 [14], 3.67 [15] and 3.38, [16] respectively. Interventions targeting BSE have also been shown to be effective in promoting breastfeeding practices among postpartum women in urban areas in China [17,18]. Self-efficacy is a psychological category that is related to many socio-cultural factors, and the results of foreign and other domestic studies cannot be directly used to guide the practice in rural China. The lack of studies examining BSE among postpartum women in rural China presents another gap in the existing literature. Given the low rates of breastfeeding in rural China and the important role that BSE plays in breastfeeding behavior in the international literature, research on BSE in rural China is needed to inform public health policies and improve breastfeeding outcomes.”

REFERENCES:

5. Glassman ME, McKearney K, Saslaw M, Sirota DR. Impact of breastfeeding self-efficacy and sociocultural factors on early breastfeeding in an urban, predominantly dominican community. Breastfeed Med. 2014;9(6):301–7. https://doi.org/10.1089/bfm.2014.0015 PMID: 24902047

6. Lau CYK, Lok KYW, Tarrant M. Breastfeeding Duration and the Theory of Planned Behavior and Breastfeeding Self-Efficacy Framework: A Systematic Review of Observational Studies. Matern Child Health J. 2018;22(3):327–42. http://dx.doi.org/10.1007/s10995-018-2453-x PMID: 29427014

7. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215. http://doi.apa.org/getdoi.cfm?doi=10.1037/0033-295X.84.2.191 PMID: 847061

8. Dennis C-L. Theoretical Underpinnings of Breastfeeding Confidence: A Self-Efficacy Framework. J Hum Lact. 1999 Sep;15(3):195–201. http://journals.sagepub.com/doi/10.1177/089033449901500303 PMID: 10578797

9. Jama NA, Wilford A, Masango Z, Haskins L, Coutsoudis A, Spies L, et al. Enablers and barriers to success among mothers planning to exclusively breastfeed for six months: A qualitative prospective cohort study in KwaZulu-Natal, South Africa. Int Breastfeed J. 2017;12(1):1–13. https://doi.org/10.1186/s13006-017-0135-8 PMID: 29026431

14. Ip WY, Gao LL, Choi KC, Chau JPC, Xiao Y. The Short Form of the Breastfeeding Self-Efficacy Scale as a Prognostic Factor of Exclusive Breastfeeding among Mandarin-Speaking Chinese Mothers. J Hum Lact. 2016;32(4):711–20. PMID: 27474407

15. Li T, Guo N, Jiang H, Eldadah M. Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study. J Hum Lact. 2019 Aug 5;35(3):583–91. http://journals.sagepub.com/doi/10.1177/0890334418812044 PMID: 30517822

16. Dai X, Dennis CL. Translation and validation of the breastfeeding Self-Efficacy Scale into Chinese. J Midwifery Women’s Heal. 2003;48(5):350–6. https://doi.org/10.1016/s1526-9523(03)00283-6 PMID: 14526349

17. Wu DS, Hu J, Mccoy TP, Efird JT. The effects of a breastfeeding self-efficacy intervention on short-term breastfeeding outcomes among primiparous mothers in Wuhan, China. J Adv Nurs. 2014;70(8):1867–79. https://doi.org/10.1111/jan.12349 PMID: 24400967

18. Liu Y, Li N, Mei Z, Li Z, Ye R, Zhang L, et al. Effects of prenatal micronutrients supplementation timing on pregnancy-induced hypertension: Secondary analysis of a double-blind randomized controlled trial. Matern Child Nutr. 2021;(January):e13157. https://doi.org/10.1111/mcn.13157 PMID: 33594802

Comment 5: Method; line 123-124: As stated above when use the term ‘predictors’ the design should be case-control.

Response: Thank you again for raising this point. As mentioned above, our study is a cross-sectional descriptive study. We incorrectly used the term “predictors”. We have replaced “predictors” with “determinants” throughout the revised manuscript and highlighted all revisions.

Comment 6: Sample; line 139: why we use survey for this particular study, and also how to select the actual participant of the study. Please elaborate it?

Response: In this comment, the reviewer makes two points. The first point asks why we use a survey for this particular study. The second point asks about how we select the study participants of the study. For clarity, we will respond to each point separately.

In response to the first point:

This study used a large-scale cross-sectional survey to collect data. This research design was based on two main considerations. First, this study focuses on understanding the status of breastfeeding self-efficacy among postpartum women in rural China. A large-scale survey gives the research team adequate statistical power to identify population-level trends and correlations. Second, as the target population of this study is postpartum women in rural areas, the survey research method can help us to obtain first-hand research data directly from postpartum women in rural areas of China.

We have added this information to the Research Design subsection of the Methods section on page 9, lines 169-177 in the revised manuscript (revised text in italics):

“This study was conducted using a using a multi-stage random cluster sampling design and cross-sectional survey to assess BSE among women 0-6 months postpartum in rural China and to identify determinants of BSE based on the Dennis BSE framework. This research design was based on two main considerations. First, a large-scale survey gives the research team adequate statistical power to identify population-level trends and correlations. Second, the survey research method can help us to obtain first-hand research data directly from postpartum women in rural areas of China.”

In response to the second point:

The research team implemented a three-step sampling protocol to select the participants for the study. First, four nationally-designated poverty counties were selected within the sample prefecture. Second, sample townships were chosen within each sample county. To select townships representative of typical rural areas, the sampling frame excluded non-rural townships and rural townships with populations of less than 10,000. Of the remaining townships, 20 townships per county were randomly selected by a computer-generated random numbers method, resulting in a total of 80 townships. Finally, a list of all mothers with registered births within the past 6 months of the survey was obtained from the township health center in each sample township. A total of 842 postpartum women were identified and contacted by the research team, with the assistance of local township health center doctors or village doctors to invite.

In total, 55 eligible postpartum women failed to enroll in the study due to out-migration or travel at the time of the survey, intellectual disability or mental illness that prevented ability to give informed consent, or refusal to participate. Of the 842 lactating postpartum women who enrolled in this study, 787 postpartum women completed all aspects of the questionnaire, a response rate of 93.5%.

We have updated a detailed description of the process of selecting the actual participants of the study in the Methods section of the paper, page 10-11, lines 192-208 in the revised manuscript (revised text in italics):

“The research team sampled rural mothers within the 0-6 months postpartum period living in one prefecture of Sichuan province, China, following a multi-stage cluster sampling protocol. First, four nationally-designated poverty counties were selected within the sample prefecture. Second, sample townships were chosen within each sample county. To select townships representative of typical rural areas, the sampling frame excluded non-rural townships and rural townships with populations of less than 10,000. Of the remaining townships, 20 townships per county were randomly selected by a computer-generated random numbers method, resulting in a total of 80 townships. Finally, a list of all mothers with registered births within the past 6 months of the survey was obtained from the township health center in each sample township. A total of 842 postpartum women were identified and contacted by the research team, with the assistance of local township health center doctors or village doctors to invite. In total, 55 eligible postpartum women failed to enroll in the study due to out-migration or travel at the time of the survey, intellectual disability or mental illness that prevented ability to give informed consent, or refusal to participate. Of the 842 lactating postpartum women who enrolled in this study, 787 postpartum women completed all aspects of the questionnaire, with a response rate of 93.5%.”

Comment 7: Line 141-150: These sentences are unclear. Kindly revisit.

Response: Thank you for pointing this out. We have updated the sentence in the Methods section of the revised manuscript page 10-11, lines 192-208 (revised text in italics):

“The research team sampled rural mothers within the 0-6 months postpartum period living in one prefecture of Sichuan province, China, following a multi-stage cluster sampling protocol. First, four nationally-designated poverty counties were selected within the sample prefecture. Second, sample townships were chosen within each sample county. To select townships representative of typical rural areas, the sampling frame excluded non-rural townships and rural townships with populations of less than 10,000. Of the remaining townships, 20 townships per county were randomly selected by a computer-generated random numbers method, resulting in a total of 80 townships. Finally, a list of all mothers with registered births within the past 6 months of the survey was obtained from the township health center in each sample township. A total of 842 postpartum women were identified and contacted by the research team, with the assistance of local township health center doctors or village doctors to invite. In total, 55 eligible postpartum women failed to enroll in the study due to out-migration or travel at the time of the survey, intellectual disability or mental illness that prevented ability to give informed consent, or refusal to participate. Of the 842 lactating postpartum women who enrolled in this study, 787 postpartum women completed all aspects of the questionnaire, with a response rate of 93.5%.”

Comment 8: Line 181: I am not sure you can use the word “extensive” as your manuscript has not really demonstrated the “extensiveness” of your approach.

Response: Thank you for pointing this out. We apologize for the inadequate references provided leading to errors in wording, and we have added references to this section of the revised manuscript page 13, lines 258-260 (revised text in italics):

“After an extensive literature review, the research team developed a Breastfeeding Problems Questionnaire that encompasses the most prevalent problems associated with breastfeeding [23-31].”

REFERENCES:

23. Demirci JR, Bogen DL. An Ecological Momentary Assessment of Primiparous Women’s Breastfeeding Behavior and Problems from Birth to 8 Weeks. J Hum Lact. 2017; 33(2): 285-295. https://doi.org/10.1177/0890334417695206 PMID: 28418803

24. Kronborg H, Væth M. How Are Effective Breastfeeding Technique and Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration? Birth. 2009; 36(1):34-42. https://doi.org/10.1111/j.1523-536X.2008.00293.x PMID: 19278381

25. Karaçam Z, Sağlık M. Breastfeeding problems and interventions performed on problems: Systematic review based on studies made in Turkey. Turk Pediatri Arsivi. 2018; 53(3). https://doi.org/10.5152/TurkPediatriArs.2018.6350 PMID: 30459512

26. Talbert AW, Ngari M, Tsofa B, Mramba L, Mumbo E, Berkley JA, et al. “When you give birth you will not be without your mother” A mixed methods study of advice on breastfeeding for first-time mothers in rural coastal Kenya. Int Breastfeed J. 2016; 11(1):1-9. https://doi.org/10.1186/s13006-016-0069-6 PMID: 27118984

27. Wagner EA, Chantry CJ, Dewey KG, Nommsen-Rivers LA. Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics. 2013; 132(4):e865-e875. https://doi.org/10.1542/peds.2013-0724 PMID: 24062375

28. Odom EC, Li R, Scanlon KS, Perrine CG, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013; 131(3):e726. https://doi.org/10.1542/peds.2012-1295 PMID: 23420922

29. Berridge K, McFadden K, Abayomi J, Topping J. Views of breastfeeding difficulties among drop-in-clinic attendees. Matern Child Nutr. 2005; 1(4):250-262. https://doi.org/10.1111/j.1740-8709.2005.00014.x PMID: 16881907

30. 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. J Child Heal Care. 2017;21:53–363. https://doi.org/10.1177/1367493517719160 PMID: 29119825

31. Liu P, Qiao L, Xu F, Zhang M, Wang Y, Binns CW. Factors associated with breastfeeding duration: A 30-month cohort study in Northwest China. J Hum Lact. 2013;35:583–591. https://doi.org/10.1177/0890334418812044 PMID: 23504474

Comment 9: Line 268; ‘November to December, 2019’ are you sure this was an enough time to conducted enumeration based on your study area coverage? Please see again and modify accordingly.

Response: Thank you for raising this point. From November to December 2019, our research team split into four teams to lead field surveys with enumerators in four sample counties (Langzhong, Nanbu, Yilong and Jialing) at the same time. As a result, we were able to complete the enumeration based on our study area coverage within a two-month period.

Comment 10: Line 273; why we used only 20 participants as pilot study and what was your reference’s we used only 20 participants?

Response: Thank you for this comment. The pilot study for our survey was conducted in two non-sample townships within the sample counties. The purpose of the pilot study was to test the feasibility of the questionnaire and ensure that all questions were appropriate and understandable for rural mothers in our study area. Since this pilot study did not involve any data analysis, this study did not make any special requirements for the sample size. The sample size for this pilot study was based on a study by Li et al. (2019) which piloted their survey among 20 breastfeeding women. To clarify this point, we have added this reference and updated the language in the Methods section of the revised manuscript on page 17-18, lines 355-360 (revised text in italics):

“To ensure the accuracy and consistency of our data collection, a uniform training session was provided to enumerators; in addition, following Li et al. [15], a pilot study was conducted among twenty participants in two non-sample townships to ensure the survey was appropriate and understandable for rural mothers in the study area.”

REFERENCES:

15. Li T, Guo N, Jiang H, Eldadah M. Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study. J Hum Lact. 2019 Aug 5;35(3):583–91. http://journals.sagepub.com/doi/10.1177/0890334418812044 PMID: 30517822

Comment 11: Age category; which age classification are used in the study, which was ’18-30 Vs >31’?

Response: Thank you for this question. The age categories in our study were based on those used in a 2014 study by Jemin Zhu et al., who explored factors influencing breastfeeding self-efficacy in urban China. Zhu’s study similarly divided Chinese mothers into two age groups using 30 years as a node. We have added this reference and a corresponding note in the Results section of the revised manuscript on page 21 in the notes to Table 1 (revised text in italics):

“We divided mothers into two age groups using 30 years as a node, following the methods of a previous study of BSE in urban China by Zhu et al. [41].”

REFERENCES:

41. Zhu J, Chan WCS, Zhou X, Ye B, He HG. Predictors of breast feeding self-efficacy among Chinese mothers: A cross-sectional questionnaire survey. Midwifery. 2014;30(6):705-11. https://doi.org/10.1016/j.midw.2013.12.008 PMID: 24439394

Comment 12: Line 305-306 and line 315-316; we used mean score ± standard deviation, sure that the data distribution is normal?

Response: Thank you for bringing this to our attention. The results of the Kolmogorov-Smirnov test for breastfeeding self-efficacy suggest that the data distribution is normal (Z= 1.082, P> 0.05). We have updated the sentence in the Results section of the revised manuscript on page 22, lines 413-417 (revised text in italics):

“The results of the Kolmogorov-Smirnov test suggest that the distribution of BSE scores is normal (Z=1.082, P> 0.05). The average BSE score among the participants is 55.95 (SD= 8.92), and the mean score for each item is 3.50 (SD= 0.56).”

The results of the Kolmogorov-Smirnov test for maternal age suggest that the data is not normally distributed (Z=2.314, P< 0.05) and that, instead, the median and interquartile range should be used to statistically describe maternal age. We have updated the relevant sentence in the Results section of the revised manuscript on page 20, lines 401-403 (revised text in italics):

“The results of the Kolmogorov-Smirnov for maternal age suggest that the distribution is not normal (Z=2.314, P< 0.05). The median age of the postpartum women was 27 years (IQR= 24~31).”

In addition, we have added the results of the Kolmogorov-Smirnov test for other continuous variables including the Dennis BSE Framework variables in the Results section of the revised manuscript on page 28, lines 458-461 (revised text in italics):

“Table 5 presents the descriptive statistics of the Dennis BSE Framework variables excluding breastfeeding problems. The results of the Kolmogorov-Smirnov test suggest that the distribution of all these variables is not normal (P< 0.05); we therefore use the median and interquartile range for our subsequent analysis.”

Comment 13: Discussion: your discussion could be further developed so it doesn’t appear like a repetition of your objectives.

Response: Thank you for your suggestion. We have enriched and developed the content of the Discussion section on page 33-36, lines 543-602 (revised text in italics):

“The empirical results of this study also found that women who had negative breastfeeding experiences had significantly lower BSE than those without such experiences. Three variables related to breastfeeding problems, including the child having trouble sucking or latching onto the breast, not producing enough milk, and milk taking too long to secrete, were all significantly associated with lower BSE. Such breastfeeding problems may also explain the diminished confidence in breastfeeding techniques reported among postpartum women in our study. Although few studies have examined the role of negative breastfeeding experiences in BSE, the findings align with the Dennis BSE framework, which theorizes that successful performance accomplishments increase BSE, whereas repeated failures or difficulties diminish it [8].

Early challenges with breastfeeding may be particularly salient for BSE among postpartum mothers in rural China. Previous research has shown that more than half of postpartum women in rural China experienced problems in the early stages of breastfeeding [45]. In our study, 28.5% of postpartum women experienced difficulty with latching during the first two weeks of breastfeeding, 47.1% experienced insufficient milk supply, and 37.2% experienced slow milk secretion. Postpartum women who encounter these problems in the early stages of breastfeeding may feel inadequate in their breastfeeding techniques and overwhelmed by challenges, thus reducing BSE. Moreover, although these problems can be alleviated by educating women on effective breastfeeding techniques, it is often difficult for postpartum women in rural areas to obtain relevant counseling and guidance [46]. When breastfeeding problems arise but cannot be solved in a timely and effective manner, postpartum women’s BSE decreases, and mothers may eventually give up breastfeeding [47]. Therefore, public health services in rural China should focus on helping new mothers resolve early problems they encounter during the breastfeeding process, especially insufficient milk, poor sucking or latching, and slow milk secretion.

In contrast to breastfeeding problems, the results find that social support from significant others and family support for breastfeeding were both significantly associated with higher BSE among postpartum women in rural China. This finding is consistent with BSE studies internationally [48,49], as well as studies of self-efficacy in general, both of which find that social support can increase one’s coping abilities and competence [50]. This also aligns with the Dennis BSE framework, which suggests that verbal persuasion from family members, especially significant others, encourages mothers to continue breastfeeding their infants despite challenges [8]. As the closest and most important social network, family members are particularly important sources of emotional support for postpartum women in general [51] and in breastfeeding promotion specifically [52]. In addition to emotional support, postpartum women with higher levels of breastfeeding support receive relatively more practical assistance from family, which may help them to persist in breastfeeding [35]. In rural China, however, family members and significant others rarely receive education on breastfeeding or how to support breastfeeding mothers [41]. Educating family members about the importance of breastfeeding support for postpartum women may therefore increase BSE, motivation to breastfeed, and success in breastfeeding.”

REFERENCES:

8. Dennis C-L. Theoretical Underpinnings of Breastfeeding Confidence: A Self-Efficacy Framework. J Hum Lact. 1999 Sep;15(3):195–201. http://journals.sagepub.com/doi/10.1177/089033449901500303 PMID: 10578797

35. Zhu X, Liu L, Wang Y. Utilizing a Newly Designed Scale for Evaluating Family Support and Its Association with Exclusive Breastfeeding. Breastfeed Med. 2016 Dec;11(10):526–31. https://doi.org/10.1089/bfm.2016.0090 PMID: 27870578

41. Zhu J, Chan WCS, Zhou X, Ye B, He HG. Predictors of breast feeding self-efficacy among Chinese mothers: A cross-sectional questionnaire survey. Midwifery. 2014;30(6):705-11. https://doi.org/10.1016/j.midw.2013.12.008 PMID: 24439394

45. Zhang LF, Mu M, Nie W, Song SY, Gao QF, Nie JC. [Impact of infant formula sales promotion – recommendation and trial use on breastfeeding practice among mothers of 0 – 6 months infants in poverty-stricken rural areas of China]. Chin J Public Health. 2021; 37(02):280-5. Chinese.

46. Tang L, Binns CW, Luo C, Zhong Z, Lee AH. Determinants of breastfeeding at discharge in rural China. Asia Pac J Clin Nutr. 2013;22(3):443–8. https://doi.org/10.6133/apjcn.2013.22.3.20 PMID: 23945415

47. Nilsson IMS, Kronborg H, Rahbek K, Strandberg-Larsen K. The significance of early breastfeeding experiences on breastfeeding self-efficacy one week postpartum. Matern Child Nutr. 2020;16(3):1–12. https://doi.org/10.1111/mcn.12986 PMID: 32543045

48. Hinic K. Predictors of Breastfeeding Confidence in the Early Postpartum Period. JOGNN - J Obstet Gynecol Neonatal Nurs. 2016;45(5):649–60. http://dx.doi.org/10.1016/j.jogn.2016.04.010 PMID: 27472996

49. Mirghafourvand M, Malakouti J, Mohammad-Alizadeh-Charandabi S, Faridvand F. Predictors of Breastfeeding Self-efficacy in Iranian Women: A Cross-Sectional Study. Int J Womens Heal Reprod Sci. 2018;6(3):380–5. https://doi.org/10.15296/ijwhr.2018.62

50. Clapton-Caputo E, Sweet L, Muller A. A qualitative study of expectations and experiences of women using a social media support group when exclusively expressing breastmilk to feed their infant. Women and Birth. 2021;34(4),370–380. https://doi.org/10.1016/j.wombi.2020.06.010 PMID: 32674991

51. Bai DL, Fong DYT, Lok KYW, Tarrant M. Relationship between the Infant Feeding Preferences of Chinese Mothers’ Immediate Social Network and Early Breastfeeding Cessation. J Hum Lact. 2016;32:301–308. https://doi.org/10.1177/0890334416630537 PMID: 26887843

52. Kim JH, Fiese BH, Donovan SM. Breastfeeding is Natural but Not the Cultural Norm: A Mixed-Methods Study of First-Time Breastfeeding, African American Mothers Participating in WIC. J Nutr Educ Behav. 2017;49:S151. https://doi.org/10.1016/j.jneb.2017.04.003 PMID: 28689552

Comment 14: Line 464-466; this is the limitation of the study design itself not yours, please modify it. Why we are incorporating your strength?

Response: Thank you for pointing this out. We agree that this is the limitation of the study design itself not ours. We have removed this from the revised manuscript.

Comment 15: General comment; There are several grammatical issues in manuscript which make it difficult for the readers to grasp the important points to convey in sections where they occur. I suggest you critically review the manuscript or possibly the service of copyeditor.

Response: Thank you for bringing this to our attention. We have accepted the service of an editor to critically review the manuscript for spelling, grammar and comprehension. All changes are highlighted yellow in the revised manuscript.

Response to the Journal Requirements:

Comment 1: *Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We have critically reviewed the manuscript to ensure that the manuscript meets PLOS ONE’s style requirements, including those for file naming.

Comment 2: *We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Response: Thank you for your note. We do not intend to change the data availability statement.

Comment 3: *Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have reviewed our reference list to ensure that it is complete and correct and that no retracted papers have been cited. All changes are highlighted yellow in the revised manuscript.

We have removed the following references:

1. Semenic S, Loiselle C, Gottlieb L. Predictors of the duration of exclusive breastfeeding among first-time mothers. Res Nurs Heal. 2008; 31:428–441.https://doi.org/10.1002/nur.20275

2. Asgarian A, Hashemi M, Pournikoo M, Mirazimi TS, Zamanian H, Amini-Tehrani M. Translation, Validation, and Psychometric Properties of Breastfeeding Self-Efficacy Scale—Short Form Among Iranian Women. J Hum Lact. 2020;36(2):227–35.

3. Petrozzi A, Gagliardi L. Breastfeeding self-efficacy scale: Validation of the Italian version and correlation with breast-feeding at 3 months. J Pediatr Gastroenterol Nutr. 2016;62(1):137–9.

4. Li S, Li L, Zheng H, Wang Y, Zhu X, Yang Y, et al. Relationship between multifaceted body image and negative affect among women undergoing mastectomy for breast cancer: a longitudinal study. Arch Womens Ment Health. 2018;21(6):681–8. doi:10.1007/s00737-018-0860-z

5. Jiang LC, Yan YJ, Jin ZS, Hu ML, Wang L, Song Y, et al. The Depression Anxiety Stress Scale-21 in Chinese Hospital Workers: Reliability, Latent Structure, and Measurement Invariance Across Genders. Front Psychol. 2020;11(March):1–9.

6. McCarter-Spaulding D, Gore R. Social Support Improves Breastfeeding Self-Efficacy in a Sample of Black Women. Clin Lact. 2012; https://doi.org/10.1891/215805312807022923

We have added the following references:

1. Glassman ME, McKearney K, Saslaw M, Sirota DR. Impact of breastfeeding self-efficacy and sociocultural factors on early breastfeeding in an urban, predominantly dominican community. Breastfeed Med. 2014;9(6):301–7. https://doi.org/10.1089/bfm.2014.0015 PMID: 24902047

2. Wu DS, Hu J, Mccoy TP, Efird JT. The effects of a breastfeeding self-efficacy intervention on short-term breastfeeding outcomes among primiparous mothers in Wuhan, China. J Adv Nurs. 2014;70(8):1867–79. https://doi.org/10.1111/jan.12349 PMID: 24400967

3. Liu Y, Li N, Mei Z, Li Z, Ye R, Zhang L, et al. Effects of prenatal micronutrients supplementation timing on pregnancy-induced hypertension: Secondary analysis of a double-blind randomized controlled trial. Matern Child Nutr. 2021;(January):e13157. https://doi.org/10.1111/mcn.13157 PMID: 33594802

4. Demirci JR, Bogen DL. An Ecological Momentary Assessment of Primiparous Women’s Breastfeeding Behavior and Problems from Birth to 8 Weeks. J Hum Lact. 2017; 33(2): 285-295. https://doi.org/10.1177/0890334417695206 PMID: 28418803

5. Kronborg H, Væth M. How Are Effective Breastfeeding Technique and Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration? Birth. 2009; 36(1):34-42. https://doi.org/10.1111/j.1523-536X.2008.00293.x PMID: 19278381

6. Karaçam Z, Sağlık M. Breastfeeding problems and interventions performed on problems: Systematic review based on studies made in Turkey. Turk Pediatri Arsivi. 2018; 53(3). https://doi.org/10.5152/TurkPediatriArs.2018.6350 PMID: 30459512

7. Talbert AW, Ngari M, Tsofa B, Mramba L, Mumbo E, Berkley JA, et al. “When you give birth you will not be without your mother” A mixed methods study of advice on breastfeeding for first-time mothers in rural coastal Kenya. Int Breastfeed J. 2016; 11(1):1-9. https://doi.org/10.1186/s13006-016-0069-6 PMID: 27118984

8. Wagner EA, Chantry CJ, Dewey KG, Nommsen-Rivers LA. Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics. 2013; 132(4):e865-e875. https://doi.org/10.1542/peds.2013-0724 PMID: 24062375

9. Odom EC, Li R, Scanlon KS, Perrine CG, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatrics. 2013; 131(3):e726. https://doi.org/10.1542/peds.2012-1295 PMID: 23420922

10. Berridge K, McFadden K, Abayomi J, Topping J. Views of breastfeeding difficulties among drop-in-clinic attendees. Matern Child Nutr. 2005; 1(4):250-262. https://doi.org/10.1111/j.1740-8709.2005.00014.x PMID: 1688190710.

11. Zhang LF, Mu M, Nie W, Song SY, Gao QF, Nie JC. [Impact of infant formula sales promotion – recommendation and trial use on breastfeeding practice among mothers of 0 – 6 months infants in poverty-stricken rural areas of China]. Chin J Public Health. 2021; 37(02):280-5. Chinese.

12. Tang L, Binns CW, Luo C, Zhong Z, Lee AH. Determinants of breastfeeding at discharge in rural China. Asia Pac J Clin Nutr. 2013;22(3):443–8. https://doi.org/10.6133/apjcn.2013.22.3.20 PMID: 23945415

13. Clapton-Caputo E, Sweet L, Muller A. A qualitative study of expectations and experiences of women using a social media support group when exclusively expressing breastmilk to feed their infant. Women and Birth. 2021;34(4),370–380. https://doi.org/10.1016/j.wombi.2020.06.010 PMID: 32674991

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18 Mar 2022

Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study

PONE-D-21-31115R1

Dear Dr. Zhou,

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Reviewer #1: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors have made a substantial improvement in their revised document. It now looks modified and clear to the reader.

Reviewer #2: 1.General comment; There are several grammatical issues in manuscript which make it difficult for the readers to grasp the important points to convey in sections where they occur. I suggest you critically review the manuscript or possibly the service of copyeditor.

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Reviewer #1: Yes: Hassen Mosa Halil(MSc)

Reviewer #2: Yes: Bekalu Getnet Kassa

Submitted filename: comment fior the author.docx

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29 Mar 2022

PONE-D-21-31115R1

Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study

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