Breastfeeding plays a self-evident role in the personal entire process of growth and development. It promotes maternal physical and psychological recovery, contributes to early initiation of infants’ growth and development, decreases the risk of long-term disease[1, 2].Promoting and supporting breastfeeding can bring ten times the economic return and a billion-dollar demographic dividend[3, 4]. For this, large-scale breastfeeding promotion measures have been implemented worldwide. Estimatedly, 78 million babies are not early breastfed within the first hour of life and get the few benefits they deserve. Therefore, effective intervention studies of breastfeeding are still necessary. Psychology studies showed that competency influences behaviors. Breastfeeding behaviors were studied through psychological competency iceberg model to develop and validate the new assessment scale of breastfeeding competency.
Breastfeeding is the best nutrition for the infants and the cornerstone for personal healthy growth and development.The World Health Organization has recommended that infants should be exclusively breastfed for the first 6 months of life, receives only breast milk, without any additional breast milk substitutes or liquid[7, 8]. Families and society have been brought great benefits by breastfeeding. For families, breastfeeding is the best way to improve infants survival through protecting infants from the threat of infection such as necrotizing enterocolitis, diarrhea, respiratory tract infections, etc. and saves the lives of about 820 thousand children under five. Children who had breastfeeding have higher IQ levels in the long run and less risk of acute and chronic illnesses such as dental caries, leukemia, obesity, type 2 diabetes mellitus later in life[2, 6, 10–13]. Mothers who breastfeed have a reduced incidence of breast and ovarian cancers, depressive disorder, also could keep the balance of weight after giving birth[14–16]. For society, breastfeeding is the best way to bring ten times the economic return and a billion-dollar demographic dividend through better academic performance and more labor force[3, 4]. However, some recent studies indicated that the rate of exclusive breastfeeding is 38% and the rate of exclusive breastfeeding among 30.71% countries around the world within six months of birth is lower than 20%[17–19]. The status and rate of breastfeeding is different between high-income, low-income countries and middle-income countries[2, 19].Therefore, increasing breastfeeding rate is the one of urgent problems that should be solved.
Competency is an organic combination of cognition, motivation, morality, and social skills. People could successfully master a certain skill or operation by understanding and operating on a series of tasks, problems, and goals based on their competency. Different frameworks have slightly different understandings of abilities, for example in competency iceberg model, abilities are defined as individual, underlying, and deep-seated features which could distinguish between high performers and average performers in any jobs. It could be personal motivations, features, self-images, attitudes or values and knowledge, cognition or skills in any field which could be reliably measured or counted. Competency is closely related to activities, and form, develop, and express in activities which is a prerequisite for engaging activities. In other words, breastfeeding competency affects the occurrence of breastfeeding and mothers who have high competency of breastfeeding have high tendency to breastfeed. The National Nutrition Plan (2017–2030) promulgated by The State Council of the People's Republic of China proposed to increase the rate of breastfeeding, cultivate scientific feeding behaviors, and formulate scientific feeding strategies. The "Thirteenth Five-Year Plan" of Health and Wellness Plan also proposed to vigorously promote breastfeeding and carry out guidance of infant nutrition, feeding, growth and development, and psychological behaviors.
The occurrence and duration of breastfeeding behaviors are affected by multiple factors such as individual factors, socioeconomic, health care systems. Individual factors including maternal attitudes, self-efficacy and knowledge were the reasons for breastfeeding which could predict the beginning and duration of breastfeeding[26, 27]. At the socioeconomical and cultural level, duration and experience of breastfeeding were affected by the factors including workplace, mass media and market context. In health systems, legislation and policy of breastfeeding influence beginning and duration of breastfeeding by providing support[14, 29]. These factors must be understood and controlled at the same time to promote breastfeeding behaviors and increase breastfeeding rate. Only could the effective intervention of breastfeeding be maximized by grasping different factors together. Breastfeeding competency is defined as maternal grasp of different breastfeeding factors. These factors are the prerequisites for establishing and implementing interventions of breastfeeding, and understanding grasp of breastfeeding factors could effectively assess the breastfeeding competency.
In 1973, the competency iceberg model was first established by Harvard psychologist McClelland. It is a common model to assess competency which can distinguish the high performers from the average performers. The four parts of the competency iceberg model include knowledge, skills, self-concept, traits, and motivation. Knowledge and skills are the visible part of the iceberg on the water, motivation and traits are hidden parts of the iceberg underwater, and self-concept lies between the two factors which could be changed by education, psychology and accumulated experience in long term. The competency iceberg model has been used in related research on capacity building in different disciplines, for example, based on this model, Gardner developed training programs for nurses in Australia and New Zealand; Supamane formulated the qualitative interviews outline of the leadership for clinical nurses and established the Thailand clinical nurse leadership model; Wang Xiaoyun applied this model to the safety and quality management of pediatric nursing in order to reduce the occurrence of adverse events; Ma Chifen formulated senior caregivers competency model to promote the development of elderly care.
In order to form a scientific and comprehensive assessment scale for breastfeeding competency, breastfeeding related contents were included in the competence iceberg model. Combining breastfeeding knowledge with "knowledge", breastfeeding skills with model "skills", breastfeeding self-efficacy and maternal self-concept with "self-concept", attitudes and social breastfeeding-related support is combined with " traits and motivation". Breastfeeding competency could be broken down into different parts that could be easier to assess, and divided parts are closely related and independent of each other which can more reliably represent and evaluate breastfeeding competency.