Effects of Breastfeeding Knowledge and Health Beliefs Regarding Gestational Diabetes Mellitus on the Breastfeeding Intention of Pregnant Women

doi:10.21203/rs.3.rs-3343250/v1

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Research Article

Effects of Breastfeeding Knowledge and Health Beliefs Regarding Gestational Diabetes Mellitus on the Breastfeeding Intention of Pregnant Women

https://doi.org/10.21203/rs.3.rs-3343250/v1

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Purpose: Research has shown that breastfeeding knowledge related to gestational diabetes mellitus (GDM) and GDM-related breastfeeding health beliefs affect breastfeeding intention. However, research has been limited on the effects of pregnant women’s GDM-related breastfeeding knowledge and GDM-related breastfeeding health beliefs on breastfeeding intentions. Therefore, this study aimed to examine the effect of GDM-related breastfeeding knowledge and GDM-related breastfeeding health beliefs on breastfeeding intention.

Methods: A total of 229 healthy pregnant women visiting an antenatal clinic in Nepal participated in this study between January and March 2023. They completed a questionnaire that assessed their GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and breastfeeding intention. The data were analyzed using descriptive statistics, independent t-tests, one-way analysis of variance, Scheffé’s post-hoc test, and logistic regression analysis.

Results: Of the participants, 86.9% (n = 199) indicated their breastfeeding intention, even with a relatively low level of GDM-related breastfeeding knowledge. Logistic regression analysis of the factors influencing breastfeeding intention yielded a significant model (χ²= 38.80, p < .001) with significant variables. GDM-related breastfeeding knowledge (OR: 1.0, 95% CI: 1.02-1.40), GDM-related breastfeeding health beliefs (OR: 1.09, 95% CI: 1.04-1.15), and immediate family history of diabetes mellitus (OR: 5.38, 95% CI: 1.98-14.620) were found to affect breastfeeding intentions.

Conclusion: Efficient interventions regarding breastfeeding for pregnant women should be implemented. They should provide sufficient information on the benefits of breastfeeding to prevent the long-term influence of GDM and strategies reinforcing GDM-related breastfeeding health beliefs through positive breastfeeding experiences.

breast feeding

diabetes

gestational

intention

knowledge

health belief model

pregnant women

Nepal

Gestational diabetes mellitus (GDM) refers to a disorder of glucose metabolism first encountered or discovered during pregnancy. According to the 2021 International Diabetes Federation, 16.7% of pregnant women were diagnosed with hyperglycemia during pregnancy. In 80.3% of these women, the hyperglycemia was due to GDM [1]. GDM is a threat to the health of women and their babies and has potential long-term effects. For example, it can lead to obstetric complications, such as gestational hypertension, macrosomia delivery, and high-risk delivery. Additionally, around 50% of diagnosed women are likely to progress to type-2 diabetes mellitus (T2DM) within 5 to 10 years after childbirth. Furthermore, babies exposed to high blood sugar during pregnancy have a higher risk of being overweight and developing obesity and T2DM [1, 2].

Analyzing regional differences in the prevalence of hyperglycemia in pregnancy worldwide shows that GDM is higher primarily in low- and middle-income countries that have limited maternal care [3]. Among them, Southeast Asia, including Nepal, has the highest rate of incidence at 28.0% [4]. In Nepal, the number of patients with diabetes mellitus (DM) was about 490,000 in 2011. However, by 2021, this number increased to about 1.13 million, increasing nearly 2.3 times over 10 years, and the number of people with undiagnosed DM was reportedly 43.5%. Accurate statistics on the prevalence of GDM in Nepal are unknown. However, a recent study showed that it is approximately 2.61% and continuously increasing [5].

Breastfeeding has a positive effect on the health of women with GDM and their babies. Studies have shown that if women with GDM breastfeed for one year, their insulin resistance is lowered, blood sugar control is excellent, and the incidence of T2DM is reduced. In addition, it is recommended that women with GDM should breastfeed their babies for more than one year, as it reduces the possibility of obesity, T2DM, and cardiovascular diseases [6]. However, despite these benefits, not many women practice breastfeeding beyond six months [7].

According to a report from the Nepal Demographic and Health Survey 2016, 99% of women in Nepal responded that they breastfeed [8]. However, Dharel et al. [9] found that the breastfeeding rate for more than six months was less than 30% and that 48.6% of the women partially breastfed after six months.

Breastfeeding intention refers to an individual’s subjective decision to practice breastfeeding and the probability of actually doing so [10]. It appears to be an important predictor of breastfeeding initiation [11] and duration [12]. Hence, identifying and promoting breastfeeding intentions of pregnant women with GDM is crucial.

Women’s breastfeeding intentions and practices are related to obstetric, social, and cognitive factors, including breastfeeding knowledge and breastfeeding health beliefs [13]. Based on the health belief model, which promotes health behaviors [14], cognitive factors are, in particular, crucial determinants of breastfeeding practice [15, 16]. Most importantly, women with GDM face more burdens and barriers regarding breastfeeding than healthy women due to complications from the condition and delayed breastfeeding initiation [13]. This highlights the need to explore GDM-related breastfeeding knowledge and breastfeeding health beliefs.

Knowledge is key to moving people through the stages of behavioral change. Specifically, providing enough knowledge about the benefits of a health behavior increases the probability of a person participating in that health behavior [17]. Evans et al. [11] showed that breastfeeding knowledge is one of the factors influencing breastfeeding intention. Therefore, we contend that it is important to identify the level of GDM-related breastfeeding knowledge that affects breastfeeding intention.

Beliefs are ideas that an individual considers to be right and that modify their behavior through personal experience, culture, social norms, or education [10]. A person decides whether to participate in certain health behaviors based on their beliefs about health problems. That is, they decide whether to adopt a health behavior based on their perceived susceptibility, severity, benefits, and disability and their self-efficacy Essentially, people’s intention to engage in health behaviors is likely to be higher when: people are more aware about the severity of health problems because of not engaging in healthy behaviors; people are more aware about the benefits of engaging in healthy behaviors; and when the barriers to performing these behaviors are lower [10]. Studies have identified GDM-related breastfeeding health beliefs as a significant factor affecting breastfeeding intention [15, 16].

Even though pregnant women’s GDM-related breastfeeding knowledge and breastfeeding health beliefs influence their breastfeeding intention, research remains scant on the effects of pregnant women’s GDM-related breastfeeding knowledge and GDM-related breastfeeding health beliefs on breastfeeding intentions. In Nepal, some studies have examined GDM, but they have focused on the demographic characteristics of women with GDM [18], risk factors of GDM [19], obstetric characteristics related to GDM [20], or the characteristics of babies born to women with GDM [21].

Based on the above and to address the gaps identified, this study aimed to explore the relationship between GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and the breastfeeding intention of pregnant women in Nepal. It sought to determine how GDM-related breastfeeding knowledge and GDM-related breastfeeding health beliefs affect women’s breastfeeding intentions. Ultimately, it intended to improve the health of Nepalese pregnant women and their children to enhance their quality of life through breastfeeding practice.

Study design

We conducted a survey to determine GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and breastfeeding intention and examined the cross-sectional data obtained.

Setting and sample

This study analyzed the responses of 229 pregnant women who were aged 18 or more and had a gestational age of 20 weeks or more at the time of the study. Women who visited the antenatal clinic at the Nepal Korea Friendship Hospital in Kathmandu, Nepal, between January 10 and March 15, 2023, were recruited in this study through convenience sampling. Prior to the survey, the purpose of the study was explained to the participants, who then voluntarily provided written informed consent. Participants were excluded from the study if they presented comorbidities such as hypertension, liver disease, kidney disease, or metabolic disease, as these concurrent diseases could potentially affect the main variables of this study, namely GDM-related health beliefs and breastfeeding intention [16].

Before data collection, the researcher held three meetings to prepare the research assistants—two local outpatient nurses from the antenatal clinic at the hospital—to help participants who may have difficulty in completing the self-administered questionnaire. To recruit participants, a recruitment notice was posted at the entrance of the antenatal clinic four weeks before data collection. The research assistants provided information about the questionnaire to participants who volunteered to participate in the study. Participants who could read and write were administered the questionnaire. Data from those who had difficulty reading and writing were collected in the form of verbal responses by the research assistant, who read out the questions to the participant. The questionnaire took approximately 20 minutes to complete, and a gift was provided for participation.

The sample size of this study was calculated using the G*Power 3.1.9.7 program. With reference to previous studies on the breastfeeding intentions of pregnant women with GDM [15, 16], a significance level of .05, a power of .95, a two-tailed test, and an odds ratio (OR) of 1.89 were applied. The appropriate sample size was calculated as 211. Considering a dropout rate of 20%, 250 participants were initially surveyed. After 21 questionnaires were excluded for being insincere, 229 were included in the final analysis.

Instruments

General characteristics

The general characteristics of participants included in this study were age, education level, occupation, socioeconomic status (based on house ownership), current gestational age, past delivery experience, and immediate family history of DM [15, 16].

GDM-related breastfeeding knowledge

The researchers developed the instrument for assessing GDM-related breastfeeding knowledge based on the literature [15, 16]. The content validity thereof was confirmed by two obstetrical gynecology physicians and five women’s health nursing professors. The scale content validity index (S-CVI) value was .89. The instrument comprised 14 items: four items about physical characteristics after delivery, two items about factors interfering with breastfeeding, and eight items about the advantages of breastfeeding. Each question was answered by selecting one of the options among “correct,” “wrong,” or “I don’t know.” One point was assigned when the response was “correct,” and 0 otherwise (for “wrong” or “I don’t know”). The total score could range from 0 to 14, with a higher total score indicating more GDM-related breastfeeding knowledge. The reliability in this study was KR (Kuder-Richardson) -20 = .71.

GDM-related breastfeeding health beliefs

The researchers developed the instrument for assessing GDM-related breastfeeding health beliefs based on literature [15, 16]. The content validity thereof was confirmed by two obstetrical gynecology physicians and five women’s health nursing professors. The S-CVI value was .94. The instrument comprised 15 items measuring five factors: perceived sensitivity, perceived severity, perceived benefits, perceived barriers, and self-efficacy. It was scored on a five-point Likert scale ranging from 1 (“not at all”) to 5 (“very much so”). A combined score for each of the five sub-factors was calculated. Higher scores indicated more GDM-related breastfeeding health beliefs. In this study, the Cronbach’s α value was .85 for the overall instrument.

Breastfeeding intention

To measure breastfeeding intention, participants were asked: “Are you planning to breastfeed after this birth?” The response options “I will do it for sure” and “I will do it as much as possible” were classified as “I have the intention to breastfeed.” Responses indicating “I don’t know,” “I probably won’t,” and “I will definitely not” were classified as “I have no intention to breastfeed” [16].

Ethical considerations

This study was approved by the Institutional Review Board of Chungbuk National University (Approval no. 2022029606). Prior to the start of the face-to-face survey, the study purpose and survey method were explained to the participants. They were also informed that the collected data would not be used for any purpose other than research and that their confidentiality and anonymity were guaranteed. They were also informed that participation was voluntary, that they could withdraw at any time, and that there would be no disadvantages if they refused to participate. Only those who understood the survey instructions and provided voluntary consent were administered the questionnaire. Each questionnaire was assigned an ID number, and the collected data was encrypted and managed on a computer. Research-related data will be stored for three years in a locked document box and then discarded.

Data analysis

All statistical analyses were performed using IBM SPSS Statistics 26 for Windows (IBM Corp., Armonk, USA). Statistical significance was set as p < .05. Participants’ general characteristics, GDM-related breastfeeding knowledge, and GDM-related breastfeeding health beliefs were presented using percentages, means, and standard deviations. Differences in participants’ GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and breastfeeding intentions based on their general characteristics were analyzed using chi-square (χ²) tests, independent t-tests, one-way analysis of variance, and Scheffé post-hoc test. Logistic regression analysis was performed to delineate the factors affecting breastfeeding intention.

General characteristics and breastfeeding intention

The average age of the 229 participants was 29.01 (± 5.19) years, most of whom (87, 38.0%) were aged 25–30 years. Most participants had university or a higher level of education (173, 75.5%) and were housewives (182, 79.5%). Furthermore, 154 (67.2%) participants paid monthly rent based on their socioeconomic status. The current gestational age of 89 (38.9%) participants was less than 28 weeks. An immediate family member of 103 participants (45%) had been diagnosed with DM. Finally, most participants had breastfeeding intention (199, 86.9%) (Table 1).

Table 1

General Characteristics and Breastfeeding Intention (N = 229)
Variable	Categories	N (%) or M ± SD	Min–Max
Age (years)		29.01 ± 5.19	18–40
	< 25	42 (18.3)
	25–29	87 (38.0)
	30–34	54 (23.6)
	≥ 35	44 (19.2)
Education level	No education to high school	56 (24.5)
	University or higher	173 (75.5)
Occupation	Housewife	182 (79.5)
	Other	47 (20.5)
SES^a	Owned house	75 (32.8)
	Rented house	154 (67.2)
Current gestational age (weeks)	< 28	89 (38.9)
	28–31	70 (30.6)
	32–35	43 (18.8)
	≥ 36	27 (11.8)
Past delivery experience	Yes	86 (37.6)
	No	143 (62.4)
Immediate family history of DM^b	Yes	103 (45.0)
	No	126 (55.0)
Breastfeeding intention	Yes	199 (86.9)
	No	30 (13.1)
^aSES = Socioeconomic status; ^bDM = diabetes mellitus

GDM-related breastfeeding knowledge

For GDM-related breastfeeding knowledge, the overall correct response rate of participants was 30.2%. Items with high percentages of correct answers were as follows: “When a woman with high blood sugar breastfeeds, it raises the baby’s blood sugar level” (F) (47.2%); “Women with GDM are less likely to develop postpartum obesity if they breastfeed for more than six months” (T) (37.1%); and “When a woman with GDM breastfeeds, her blood sugar level decreases when she is hungry” (T) (33.2%). Conversely, the following items had the lowest correct answer rate: “The breastfeeding of women with GDM reduces the likelihood of obesity in their children’s infancy (1–3 years old)” (T) (20.5%); “If a woman with GDM is breastfeeding for more than six months, the likelihood of a recurrence of GDM is reduced” (T) (22.3%); and “The mammary glands of women with GDM may start producing breast milk later than normal women” (T) (24.9%) (Table 2).

Table 2

Correct Answer Rate of GDM-Related Breastfeeding Knowledge (N = 229)
No.	Item (T^a/F^b)	% (n)
1	When a woman with GDM^c breastfeeds, her blood sugar level decreases when she is hungry. (T)	33.2 (76)
2	When a woman with GDM gives birth, the amount of insulin she needs in her body decreases compared to her pregnancy period. (T)	28.4 (65)
3	If a woman with GDM is overweight, the breastfeeding process and start of breastfeeding may be delayed compared to a normal woman. (T)	29.3 (67)
4	When a woman with high blood sugar breastfeeds, it raises the baby’s blood sugar level. (F)	47.2 (108)
5	The breastfeeding of women with GDM reduces the likelihood of obesity in their children’s infancy (1–3 years). (T)	31.4 (72)
6	Breastfeeding by a woman with GDM prevents hypoglycemia in the early stages of the birth of a newborn baby. (T)	30.6 (70)
7	If a woman with GDM continues breastfeeding for more than six months, her body needs less insulin. (T)	27.9 (64)
8	Women with GDM do not delay the development of mammary glands if their blood sugar levels are well controlled. (T)	32.3 (74)
9	The mammary glands of women with GDM may start producing breast milk later than normal women. (T)	24.9 (57)
10	If a woman with GDM is breastfeeding for more than six months, it reduces her chances of developing adult diseases/geriatric diseases (diabetes, high blood pressure, myocardial infarction/ angina) later. (T)	31.0 (71)
11	Women with GDM are less likely to develop postpartum obesity if they breastfeed for more than six months. (T)	37.1 (85)
12	The breast milk of a woman with GDM immediately after delivery may be sticky compared to that of a normal woman. (T)	27.1 (62)
13	If a woman with GDM is breastfeeding for more than six months, the likelihood of a recurrence of GDM is reduced. (T)	22.3 (51)
14	The breastfeeding of women with GDM reduces the likelihood of obesity in their children’s infancy (1–3 years) (T)	20.5 (47)
Overall average correct answer rate		30.2
^aT = true; ^bF = false; ^cGDM = gestational diabetes mellitus

Differences in participants’ breastfeeding intentions based on their GDM-related breastfeeding knowledge and health beliefs

There was a statistically significant difference in participants’ breastfeeding intention according to their GDM-related breastfeeding knowledge (t = 2.59, p = .010) and health beliefs (t = 3.82, p < .001). Regarding the sub-factors of GDM-related breastfeeding health beliefs, participants’ breastfeeding intention differed significantly based on their perceived severity (t = 3.08, p = .002), perceived benefit (t = 3.52, p = .001), perceived disability (t = 3.04, p = .003), and self-efficacy (t = 2.52, p = .013) (Table 3).

Table 3

Differences in Breastfeeding Intention according to GDM-Related Breastfeeding Knowledge and Health Beliefs (N = 229)
Variable	M ± SD	Breastfeeding intention		t (p)
Variable	M ± SD	Yes (n = 199)	No (n = 30)	t (p)
GDM^a-related breastfeeding knowledge	4.23 ± 2.91	4.42 ± 2.88	2.97 ± 2.86	2.59 (.010*^b)
GDM-related breastfeeding health beliefs	3.16 ± 0.55	3.21 ± 0.53	2.81 ± 0.52	3.82 (.000***)
Perceived susceptibility	3.10 ± 0.65	3.14 ± 0.62	2.86 ± 0.78	1.88 (.069)
Perceived severity	3.13 ± 0.73	3.19 ± 0.71	2.76 ± 0.74	3.08 (.002**)
Perceived benefits	3.03 ± 0.76	3.10 ± 0.74	2.59 ± 0.75	3.52 (.001**)
Perceived barriers	3.16 ± 0.74	3.22 ± 0.71	2.79 ± 0.79	3.04 (.003**)
Self-efficacy	3.35 ± 0.70	3.40 ± 0.69	3.06 ± 0.74	2.52 (.013*)
^aGDM = gestational diabetes mellitus ^bp < .05, p < .01, **p < .001: p < .05 was considered statistically significant

Differences in participants’ GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and breastfeeding intention based on their general characteristics

Participants’ GDM-related breastfeeding knowledge differed significantly based on only past delivery experience (t = 1.99, p = .049). Participants’ GDM-related breastfeeding health beliefs differed significantly based on their education level (t = -2.70, p = .007) and current gestational age (t = 3.20, p = .024). Participants’ breastfeeding intention differed significantly based on their education level (χ² = 6.66, p = .010) and immediate family history of DM (χ² = 17.11, p < .001) (Table 4).

Table 4

Differences in GDM-Related Breastfeeding Knowledge and Health Beliefs and Breastfeeding Intension according to General Characteristics
Variable	Categories	GDM^a-related breastfeeding knowledge		GDM-related breastfeeding health beliefs		Breastfeeding intention
		M ± SD	t/F (p) (Sheffe)	M ± SD	t/F (p) (Sheffe)	Yes (n = 199)	No (n = 30)	χ² (p)
		M ± SD	t/F (p) (Sheffe)	M ± SD	t/F (p) (Sheffe)	n(%)	n(%)	χ² (p)
Age	< 25	3.79 ± 3.11	1.20 (.311)	3.15 ± 0.56	0.90 (.443)	37 (16.3)	5 ( 2.2)	2.25 (.523)
	25–29	4.44 ± 3.05		3.10 ± 0.61		75 (33.0)	12 (5.3)
	30–34	3.85 ± 2.62		3.24 ± 0.53		45 (19.8)	9 (4.0)
	≥ 35	4.73 ± 2.82		3.21 ± 0.55		41 (18.1)	3 (1.3)
Education level	No education to high school	3.75 ± 2.91	-1.43 (.155)	2.99 ± 0.58	-2.70 (.007**)	43 (18.8)	13 (5.7)	6.66 (.010*^d)
	University or higher	4.39 ± 2.90		3.21 ± 0.53		156 (68.1)	17 (7.4)
Occupation	Housewife	4.14 ± 2.82	-0.91 (.366)	3.19 ± 0.56	1.73 (.085)	160 (69.9)	22 (9.6)	0.80 (.372)
	Other	4.57 ± 3.26		3.03 ± 0.49		39 (17.0)	8 (3.5)
SES^b	Owned house	4.27 ± 2.80	0.13 (.899)	3.22 ± 0.37	1.28 (.141)	65 (28.4)	10 (4.4)	0.00 (.942)
	Rented house	4.21 ± 2.97		3.12 ± 0.61		134 (58.5)	20 (8.7)
Current gestational age (Weeks)	< 28	4.25 ± 2.98	0.08 (.972)	3.02 ± 0.60	3.20 (.024*)	74 (32.3)	15 (6.6)	5.20 (.158)
	28–31	4.29 ± 2.73		3.23 ± 0.47		65 (28.4)	5 (2.2)
	32–35	4.05 ± 2.97		3.21 ± 0.58		35 (15.3)	8 (3.5)
	≥ 36	4.33 ± 3.19		3.31 ± 0.41		25 (10.9)	2 (0.9)
Past delivery experience	Yes	4.76 ± 3.39	1.99 (.049*)	2.98 ± 0.67	-3.58 (.000) ***)	72 (31.4)	14 (6.1)	1.22 (.269)
	No	3.92 ± 2.54		3.26 ± 0.43		127 (55.5)	16 (7.0)
Immediate family history of DM^c	Yes	4.31 ± 3.10	0.37 (.710)	3.21 ± 0.63	1.80 (.073)	79 (34.5)	24 (10.5	17.11 (.000 ***)
	No	4.17 ± 2.75		3.08 ± 0.52		120 (52.4)	6 (2.6)
^aGDM = gestational diabetes mellitus; ^bSES = socioeconomic status; ^cDM = diabetes mellitus ^dp < .05, p < .01, **p < .001: p < .05 was considered statistically significant

Factors affecting breastfeeding intention

As noted, a logistic regression analysis was performed to identify the factors affecting participants’ breastfeeding intention. In the univariate analysis, participants’ breastfeeding intentions differed significantly based on their education level, immediate family history of DM, GDM-related breastfeeding knowledge, and GDM-related breastfeeding health beliefs. Of these, categorical variables, such as education level and immediate family history of DM, were treated as dummy variables and analyzed.

Furthermore, the logistic regression model for breastfeeding intention was significant (χ² = 38.80, p < .001). Factors significantly influencing participants’ breastfeeding intention were GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and education level. That is, the possibility of breastfeeding intention increased 1.09 times (95% CI = 1.04–1.15) for each 1-point increase in the GDM-related breastfeeding health belief score. The possibility of breastfeeding intention increased 1.20 times (95% CI = 1.02–1.40) for each 1-point increase in GDM-related breastfeeding knowledge score. Finally, the possibility of breastfeeding intention increased 5.38 times (95% CI = 1.98–14.62) when an immediate family member was diagnosed with DM (Table 5).

Table 5

Factors Affecting Breastfeeding Intention (N = 229)
	B	SE	Wald	OR	95% CI		P
	B	SE	Wald	OR	Lower	Upper	P
Constant	-3.32	1.29	6.61	0.04			0.010*^c
GDM^a-related breastfeeding health beliefs	0.09	0.03	11.53	1.09	1.04	1.15	0.001**
GDM-related breastfeeding knowledge	0.18	0.08	5.38	1.20	1.03	1.40	0.020*
Education level (Ref. university or higher)	-0.63	0.45	1.98	0.53	0.22	1.28	0.159
Immediate family history of DM^b (Ref. No)	1.68	0.51	10.86	5.38	1.98	14.62	0.001**
χ² = 38.80, p = .000***
^aGDM = gestational diabetes mellitus; ^bDM = diabetes mellitus ^cp < .05, p < .01, **p < .001: p < .05 was considered statistically significant

This study aimed to determine the breastfeeding intention and the factors influencing it among pregnant women in Nepal. To this end, the study analyzed the GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and breastfeeding intention of 229 pregnant women who were aged 18 years or more with a gestational age of 20 weeks or more.

Among the study participants, 86.9% had the intention to breastfeed, which reflects the reality of 99% of women who reportedly breastfed, according to the Nepal Demographic and Health Survey 2016 report [8]. However, as the exclusive breastfeeding rate was less than 30% in another study [9], it is important to note that breastfeeding intention during pregnancy does not lead to exclusive breastfeeding more than six months after delivery. Since breastfeeding intention is a crucial determinant of breastfeeding duration [12], various intervention plans must be prepared and implemented, considering the factors influencing breastfeeding intention.This may ensure that pregnant women will continue to breastfeed exclusively beyond six months after giving birth.

In this study, the factors influencing participants’ breastfeeding intention were GDM-related breastfeeding knowledge, health beliefs, and immediate family history of DM. Specifically, the higher the participants’ GDM-related breastfeeding knowledge and health beliefs, and when an immediate family member had been diagnosed with DM, the higher was their breastfeeding intention. Similar results were found in studies on GDM-related breastfeeding health beliefs [11, 15, 16] and breastfeeding knowledge [11] and having an immediate family member with DM [15].

In this study, first, GDM-related breastfeeding knowledge was a factor that significantly affected breastfeeding intention. A previous study emphasized breastfeeding knowledge and a comfortable social environment as factors directly related to the intention to breastfeed exclusively [22]. The overall average correct response rate for GDM-related breastfeeding knowledge of the participants in this study was 30.2%, as noted. Since the correct answer rate did not exceed 50% for all items, there is a necessity to provide GDM-related breastfeeding education targeting pregnant women through hospitals or local maternal health centers. It is also urgent to improve the contents of existing breastfeeding education.

Furthermore, most items on GDM-related breastfeeding knowledge with a low percentage of correct answers pertained to the benefits of breastfeeding. Therefore, the long-term impacts of GDM on women and their babies and the protective effects of breastfeeding should be included in the design of breastfeeding education curricula [13]. Specifically, the provision of GDM-related breastfeeding knowledge should be emphasized more in the early postpartum period than in the gestational period because breastfeeding intention decreases in the postpartum period [23]. Therefore, it is important to continue GDM-related breastfeeding education not only during pregnancy but also after childbirth.

Second, the sub-factors of GDM-related breastfeeding health beliefs that induced significant differences in breastfeeding intention were perceived severity, perceived benefits, perceived barriers, and self-efficacy. Of these, self-efficacy and perceived barriers obtained high scores, while perceived benefits showed a low score. This result may be related to the relatively low breastfeeding benefit score among the abovementioned GDM-related breastfeeding knowledge scores. Breastfeeding intention is higher when pregnant women are more aware of the benefits of breastfeeding and have lower barriers to breastfeeding performance [10]. Therefore, to enhance breastfeeding confidence, the effects of breastfeeding on the long-term influences of GDM should be highlighted [13]. In addition, since perceived barriers interfere with exclusive breastfeeding [13], the difficulties women with GDM may experience when breastfeeding, including delayed breastfeeding initiation and difficultly in breastfeeding if the mother is obese or has given birth by caesarean section, should be explained [6].

Self-efficacy was also noted as an important factor that directly affects breastfeeding intention in several studies [11, 15, 16]. It is also a mediating factor for overcoming the intention-practice gap [24] and increases the possibility of exclusive breastfeeding [13]. To increase self-efficacy, strategies to enhance confidence in breastfeeding through positive experiences are needed [25]. Specifically, reading books on breastfeeding, attending lectures, talking with friends and family who have already experienced breastfeeding, and obtaining information from parenting experts is recommended [25]. In addition, support from medical personnel, family, and friends should be encouraged, along with breastfeeding coping skills according to the infant’s feeding ability.

Third, when a participant had an immediate family member with DM, her breastfeeding intention was higher than the intention of those without a family member with DM. This is likely the result of directly experiencing a family member’s struggle with the effects of DM and knowledge thereof [13], which may affect breastfeeding intention [11]. A previous study showed that pregnant women with a family member with DM demonstrated a significant difference in breastfeeding intention [15] and had higher GDM-related breastfeeding knowledge than those without DM in the family [26]. This is likely because other family members perceive DM as being more serious than the patient [27]. The anxiety or fear of the pregnant woman that her baby may develop DM in the future increases her breastfeeding intention.

Having a family history of DM is a risk factor for women with GDM in developing T2DM [6]. A pregnant woman is 2.3 times more likely to develop GDM if the family member with T2DM is a parent, 8.4 times greater if it is a sibling, and 8 times greater if the mother of the pregnant woman was diagnosed with GDM during her own pregnancy [28]. Therefore, it is essential to advertise that GDM screening should be performed between 24 and 28 weeks of pregnancy if there is an incidence of DM in the immediate family. It is also important to promote interventions, such as a proper diet, exercise, and lifestyle modification to prevent GDM [29].

Finally, though education was not a significant factor affecting breastfeeding intention, it was one of the general characteristics that induced significant differences in breastfeeding intention. In previous studies, the higher the education level, the higher was GDM-related breastfeeding knowledge [15, 30] and the higher the breastfeeding practice rate [31]. Therefore, during breastfeeding education, considering pregnant women with low education or illiteracy, complicated medical contents and terminologies should be thoroughly explained and simplified, and audiovisual materials, such as pictures and videos, should be used to aid understanding. Furthermore, it is necessary to promote the effectiveness of breastfeeding education through community, national campaigns, and publicity (e.g., TV and radio) [30] and by medical personnel.

This study had some limitations. The data for this study were collected from participants in one hospital in Nepal, selected via convenience sampling method. Thus, the results cannot be generalized to all pregnant women in Nepal. Additionally, since breastfeeding intention is limited to pregnant women, more work is needed to identify an effective intervention point by tracking the timing of changes in breastfeeding intention after childbirth and to explore what other factors affect it, apart from GDM-related breastfeeding knowledge and GDM-related breastfeeding health beliefs. Further research should verify the effectiveness of an integrated breastfeeding intervention program to improve the breastfeeding intention of pregnant women and increase the rate of breastfeeding practice.

The results of this study show that the breastfeeding intention of Nepalese pregnant women is significantly influenced by GDM-related breastfeeding knowledge, GDM-related breastfeeding health beliefs, and immediate family history of DM. GDM potentially affects the health and quality of life of women and their babies in the long term. Therefore, a breastfeeding intervention strategy that enhances GDM-related breastfeeding knowledge and strengthens GDM-related health beliefs through education emphasizing the positive role of breastfeeding should be encouraged.

GDM

gestational diabetes mellitus

diabetes mellitus

T2DM

type-2 diabetes mellitus

odds ratio

S-CVI

scale content validity

confidence interval

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Chungbuk National University (Approval no. 2022029606).

Consent for publication

Not applicable

Availability of data and materials

Data is available on request from the corresponding author PHO

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable

Authors’ contributions

SP and HOP were involved in conceptualization. All authors contributed to methodology and data curation. SP and HOP participated in formal analysis, visualization, and writing original draft. All authors performed writing review, editing, and validation. Supervision was done by SP.

Acknowledgments

This research was supported by the Research Support Scholarship of the Health Fellowship Foundation in August, 2022

Authors’ information

Not applicable

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No competing interests reported.

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Effects of Breastfeeding Knowledge and Health Beliefs Regarding Gestational Diabetes Mellitus on the Breastfeeding Intention of Pregnant Women

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Abstract

Background

Methods

Study design

Setting and sample

Instruments

General characteristics

GDM-related breastfeeding knowledge

GDM-related breastfeeding health beliefs

Breastfeeding intention

Ethical considerations

Data analysis

Results

General characteristics and breastfeeding intention

GDM-related breastfeeding knowledge

Differences in participants’ breastfeeding intentions based on their GDM-related breastfeeding knowledge and health beliefs

Factors affecting breastfeeding intention

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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