Breastfeeding self-efficacy and maternity care practices: implications for the National Strategy
Abstract
Background: Breastfeeding self-efficacy (BFSE) is a key determinant of breastfeeding initiation, continuation and exclusivity, and may be shaped by maternity clinic practices, as operationalized by the Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps, also a key component of the Cyprus National Strategy, despite no BFHI certification in the country. However, the relationship between these practices and women’s BFSE remains underexplored.
Methods: Implementation of the “Ten Steps” was assessed based on self-reports of 568 mothers from all 5 public and 29/35 private maternity clinics nationwide. Data were collected within 24–48 hours postpartum using the BFHI Questionnaire and the BFSE Scale–Short Form. BFSE was also assessed at one month postpartum. Associations between the Ten Steps and BFSE were examined in stepwise linear regression models adjusted for socio-demographic variables, considering individual steps and levels of implementation (none, partial, full).
Results: Rooming-in (step 7), although suboptimal, was most consistently associated with higher BFSE at both 48 hours (β = 0.38; 95% CI: 0.22–0.54) and one month postpartum (β = 0.30; 95% CI: 0.12–0.48). Mothers who reported guidance for feeding on demand (step 8) and avoidance of pacifiers (step 9) were more likely to report higher BFSE at one month postpartum, while early breastfeeding initiation (step 4) was associated with 48-hours BFSE only. Prior breastfeeding experience and intention to exclusively breastfeed for six months were also significant predictors of BFSE at both time points.
Conclusions: Given the importance of BFSE for breastfeeding continuation and exclusivity, strengthening the implementation of currently sub-optimal practices may improve the persistently low breastfeeding outcomes in Cyprus. The potential bidirectional nature of this association suggests that, alongside system-level efforts, empowering women to advocate for key practices may further support their implementation.
Key messages: • Focusing on strengthening specific currently sub-implemented Ten Steps may improve breastfeeding continuation and exclusivity through enhanced maternal breastfeeding self-efficacy.
• Maternity practices and BFSE may influence each other, highlighting opportunities to combine system-level improvements with empowering women to advocate for optimal breastfeeding support.
Related
- Two approaches, one goal: rethinking breastfeeding promotion in maternity hospitals.
- The Influence of Type of Maternity Care Provider on Early Breastfeeding Rates. A Retrospective Cohort Study of All Women Who Gave Birth in Victoria, Australia 2010 to 2020.
- [Knowledge, attitudes and misinformation about institutional breastfeeding support in a university community: Implications for primary and community care].
- Advancing Respectful Maternity Care: co-developing the RESPECT National Strategy in Cyprus
- "Just a number" - larger-bodied women's experiences of weight-centric and weight-inclusive maternity care: a national online photovoice study.
BibTeX
@article{economou2026breastfeeding,
title = {{Breastfeeding self-efficacy and maternity care practices: implications for the National Strategy}},
author = {E Economou and O Kolokotroni and I Paphiti-Demetriou and C Kouta and E Lambrinou and E Hadjigeorgiou and V Hadjiona and N Middleton},
journal = {The European Journal of Public Health},
year = {2026},
month = oct,
doi = {10.1093/eurpub/ckag169.1682},
url = {https://doi.org/10.1093/eurpub/ckag169.1682},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Breastfeeding self-efficacy and maternity care practices: implications for the National Strategy
AU - E Economou
AU - O Kolokotroni
AU - I Paphiti-Demetriou
AU - C Kouta
AU - E Lambrinou
AU - E Hadjigeorgiou
AU - V Hadjiona
AU - N Middleton
PY - 2026
DA - 2026/10/01
JO - The European Journal of Public Health
DO - 10.1093/eurpub/ckag169.1682
UR - https://doi.org/10.1093/eurpub/ckag169.1682
AB - Background: Breastfeeding self-efficacy (BFSE) is a key determinant of breastfeeding initiation, continuation and exclusivity, and may be shaped by maternity clinic practices, as operationalized by the Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps, also a key component of the Cyprus National Strategy, despite no BFHI certification in the country. However, the relationship between these practices and women’s BFSE remains underexplored. Methods: Implementation of the “Ten Steps” was assessed based on self-reports of 568 mothers from all 5 public and 29/35 private maternity clinics nationwide. Data were collected within 24–48 hours postpartum using the BFHI Questionnaire and the BFSE Scale–Short Form. BFSE was also assessed at one month postpartum. Associations between the Ten Steps and BFSE were examined in stepwise linear regression models adjusted for socio-demographic variables, considering individual steps and levels of implementation (none, partial, full). Results: Rooming-in (step 7), although suboptimal, was most consistently associated with higher BFSE at both 48 hours (β = 0.38; 95% CI: 0.22–0.54) and one month postpartum (β = 0.30; 95% CI: 0.12–0.48). Mothers who reported guidance for feeding on demand (step 8) and avoidance of pacifiers (step 9) were more likely to report higher BFSE at one month postpartum, while early breastfeeding initiation (step 4) was associated with 48-hours BFSE only. Prior breastfeeding experience and intention to exclusively breastfeed for six months were also significant predictors of BFSE at both time points. Conclusions: Given the importance of BFSE for breastfeeding continuation and exclusivity, strengthening the implementation of currently sub-optimal practices may improve the persistently low breastfeeding outcomes in Cyprus. The potential bidirectional nature of this association suggests that, alongside system-level efforts, empowering women to advocate for key practices may further support their implementation. Key messages: • Focusing on strengthening specific currently sub-implemented Ten Steps may improve breastfeeding continuation and exclusivity through enhanced maternal breastfeeding self-efficacy. • Maternity practices and BFSE may influence each other, highlighting opportunities to combine system-level improvements with empowering women to advocate for optimal breastfeeding support.
SN - 1101-1262
SN - 1464-360X
ER -