Breastfeeding plays a significant role in reducing morbidity and mortality (Cleminson et al., 2016) and promoting long-term health for preterm infants (gestational age < 37 weeks; Størdal et al., 2017). Individuals who were not exclusively breastfed as infants have higher rates of health problems as they age, including respiratory infections, allergies, digestive problems, malnutrition, diabetes, obesity (Victora et al., 2016), and childhood and adolescent cancers (Rafizadeh et al., 2019). Breastfeeding has also been associated with the intelligence and academic performance of children (Belfort et al., 2016). The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for all infants (including preterm infants) because of the significant health benefits to mother–infant dyads (World Health Organization, 2002; Britton et al., 2006). According to WHO, EBF refers to “giving no other food or drink—not even water—except breast milk. It, however, allows the infant to receive oral rehydration salts (ORS), drops, and syrups (vitamins, minerals, and medicines)” (World Health Organization, 2017). However, the rate of EBF in China is currently unsatisfactory, especially in the neonatal intensive care unit (NICU) setting, where fewer than 15% of mothers practice EBF (Shi and Zhang, 2015). Research also found that breastfeeding attrition occurs in 32 to 58% of breastfeeding mothers within the first 6 weeks (Janke, 1992), indicating that EBF in the first 6 weeks postpartum is key to breastfeeding continuation.

Multiple factors contribute to breastfeeding as a social behavior (Guo et al., 2016). Clarifying the factors associated with EBF in mothers of preterm infants is critical to helping educate women on the importance of EBF (World Health Organization, 2002). Factors related to breastfeeding can be generally categorized into demographics (such as age, education, and parity) and psychosocial characteristics of preterm mothers (including previous breastfeeding experience, mother–infant separation, breastfeeding intention, maternal leave time, breastfeeding attitude, breastfeeding self-efficacy, breastfeeding knowledge and skill, family and social support, nipple problems, insufficient milk, EBF before discharge, and depression [per the Edinburgh Postnatal Depression Scale score]; Blyth et al., 2004; Quan and Yang, 2005; Wilhelm et al., 2008; Gilmour et al., 2009; Whalen and Cramton, 2010; Demirci et al., 2013; Manno et al., 2015; Wang et al., 2019). Characteristics of preterm infants also contribute to breastfeeding success and include factors such as gestational age, birth weight, dysphagia, insufficient oral sucking power, and time to start sucking breast milk after delivery (Lou et al., 2014; Sonko and Worku, 2015; Tao et al., 2016; Geddes et al., 2018; Wang et al., 2019). Encouragingly, some of these factors can be improved through intervention (Fishbein and Ajzen, 2010; Insaf et al., 2011; Saffari et al., 2016; Thomas-Jackson et al., 2016; Araban et al., 2018; Suárez-Cotelo et al., 2019), including mothers’ breastfeeding intention, attitude, subjective norms, knowledge, depression, perceived level of control over breastfeeding (i.e., perceived behavioral control), and EBF before discharge (Fishbein and Ajzen, 2010; Insaf et al., 2011; Saffari et al., 2016; Thomas-Jackson et al., 2016; Araban et al., 2018; Suárez-Cotelo et al., 2019).

Breastfeeding intention, attitude, perceived behavioral control, and subjective norm are all considered key factors of breastfeeding initiation and duration (Janke, 1992; Bai et al., 2010; Tengku Ismail et al., 2016). Furthermore, interventional studies suggest that breastfeeding knowledge, depression, and EBF before discharge influence breastfeeding intention (Insaf et al., 2011; Thomas-Jackson et al., 2016; Suárez-Cotelo et al., 2019), although the relationships between each of these factors remain unclear, particularly those surrounding normative beliefs (Göksen, 2002; Kloeblen-Tarver et al., 2002) and perceived behavioral control (Avery et al., 1998; Bai et al., 2010). Therefore, identifying the factors that are significantly associated with breastfeeding intention and behavior and analyzing the interactions between these factors are essential to the development of a tailored breastfeeding promotion intervention for preterm mothers.

Promoting breastfeeding can be strengthened by incorporating health-based behavior theories including the theory of reasoned action (TRA; Ajzen and Madden, 1986), the theory of planned behavior (TPB), and the knowledge, attitude, and practice (KAP) model (Gebeyehu et al., 2023). Although the TRA does not account for personal control factors in the decisions of pregnant women about breastfeeding, a modified version, the TPB (Fishbein and Ajzen, 2010), includes perceived behavioral control (PBC). This addition significantly improved the explanatory and predictive power of behavior (Wang and Jiang, 2021) compared with the KAP. The TPB also considers the effects of social, attitudinal, and behavioral determinants (Esquerra-Zwiers et al., 2022) and is an ideal theoretical framework to understand human behavior (Ajzen, 1991). Briefly, the TPB framework suggests that the intention to perform a behavior is linked to the actual behavioral performance. This framework has been widely used to better understand parent behaviors, including breastfeeding in full-term infants (Khoury et al., 2005; McMillan et al., 2009; Guo et al., 2016). Indeed, a recent study reported that PBC explains 65% of the EBF intention of mothers and predicts 79% of the variance in EBF (Bajoulvand et al., 2019). A previous study explored the factors related to EBF attrition of preterm mothers at week 6 postpartum through binary logistic regression analysis (Huang et al., 2023) and found that breastfeeding attitude, social and professional support, perceived control, and knowledge were associated with breastfeeding attrition. Thus, the purpose of this study was to explore the role of EBF-related predictors (particularly breastfeeding intention) in breastfeeding behavior among preterm mothers at week 6 postpartum based on the TPB. The Infant Feeding Intention Scale (Nommsen-Rivers and Dewey, 2009) and the Breastfeeding Behavioral Questionnaire (Alami et al., 2014; Bajoulvand et al., 2019) were used to assess breastfeeding intention and behavior. Structural equation modeling (SEM) was used to examine the following hypotheses (Figure 1A) via exploration of the paths between the factors (namely breastfeeding attitude, subjective norms, perceived behavioral control, intention, knowledge, EBF before discharge, and depression) related to breastfeeding behavior at week 6 postpartum among mothers of preterm infants.

The hypotheses of this study were confirmed using model testing with acceptable fitness indices. These findings support a previous study investigating factors that contribute to breastfeeding attrition (Huang et al., 2023) and further identified that perceived breastfeeding control, breastfeeding attitude, social and professional support, knowledge, depression, and EBF before discharge are factors related to both breastfeeding intention and behavior. Prior study by our group determined that breastfeeding intention is a key factor in attrition; here, we further investigated the mechanisms of factors related to breastfeeding behavior and the mediating role of breastfeeding intention. Notably, we confirmed that breastfeeding intention is a key factor in breastfeeding behavior in preterm mothers and further identified that it fully mediates breastfeeding attitude, social and professional support, knowledge, depression, and EBF before discharge on breastfeeding behavior. Therefore, the results of the model testing further confirmed the theory of TPB, which generally suggests that the intention to perform goal-driven behaviors is critical to actually performing that behavior (Ajzen, 2011). Hence, preterm mothers’ breastfeeding attitude, social and professional support, perceived breastfeeding control, and other factors (including their knowledge, depression, and EBF before discharge) significantly influenced their breastfeeding behavior via fully or partially influencing breastfeeding intention.

These findings suggest that perceived breastfeeding control is the strongest predictor of breastfeeding intention, followed by social and professional support and breastfeeding attitude. Recent studies (Dodgson et al., 2003; Bajoulvand et al., 2019) also report that perceived breastfeeding control is the best predictor of breastfeeding intention, and the central role of perceived breastfeeding control is reflective of the realistic understanding of participants of the limitations placed on the likely success of breastfeeding efforts (Dodgson et al., 2003). Indeed, preterm mothers with enhanced perceived breastfeeding control and breastfeeding skills after discharge should be able to cope with various problems that arise in breastfeeding even after 6 weeks postpartum, which might further influence EBF intention and behavior. Early intervention to promote breastfeeding may include strategies to enhance perceived breastfeeding control, practice correct breastfeeding techniques, and solve EBF problems (Gu et al., 2016).

Subjective norm, primarily regarded as social and professional support, was also a significant factor of breastfeeding intention in the current study. Research (Bar-Yam and Darby, 1997; Arora et al., 2000; Sullivan et al., 2004) suggests that breastfeeding decisions are largely influenced by intimate partners, particularly the father of the baby. Indeed, the beliefs of partners seem to matter more than the mother’s own beliefs in predicting breastfeeding intention and behavior (Rempel and Remple, 2004). Regardless of the partner’s beliefs, general support during breastfeeding initiation is critical for continued success, as mothers receiving support during breastfeeding initiation and beyond promote a calm and relaxed environment, which helps them produce prolactin and oxytocin for continued production and excretion of breast milk (Lawrence and Lawrence, 2005). As preterm mothers face increased challenges with breastfeeding, they usually receive specific support from family members and hospital staff (i.e., family integrated care, FICare). In the FICare programs, preterm mothers and their partners participate in educational sessions that increase their knowledge of EBF and help them understand the importance and benefits of breastfeeding, especially for preterm infants (Ding et al., 2023). While this support is beneficial to the breastfeeding decisions and intentions of the parents (Ding et al., 2023), more parents may attempt breastfeeding if supported through bedside teaching and deep involvement by hospital staff in daily feeding (breastfeeding or bottle feeding) in the NICU (Zielińska et al., 2017). Therefore, the influence of subjective norms on breastfeeding intention needs further clarification via qualitative, observational, and interventional studies.

This study also confirmed that breastfeeding attitude is influential to breastfeeding intention. Preterm infants often face a variety of breastfeeding dilemmas, such as maternal–infant separation (Victora et al., 2016), uncoordinated sucking swallowing–respiratory function (Hair et al., 2016), and failure to create appropriate negative pressure during sucking (Mangili and Garzoli, 2017). If mothers recognize these difficulties and realize that breast milk is the optimal nutrition for their preterm infants, they may establish a positive attitude toward breastfeeding and be more inclined to opt for EBF. Notably, this study found that breastfeeding knowledge positively impacts breastfeeding intention, while a previous study suggests that the level of breastfeeding knowledge influences both intention and type of feeding of the newborn (Suárez-Cotelo et al., 2019). Indeed, the positive attitude of mothers toward breastfeeding may be associated with their perceived knowledge about the benefits of breastfeeding to the growth and development of preterm infants. Mothers who receive education regarding the health and emotional benefits of EBF often improve their attitude toward breastfeeding (Bai et al., 2010). Moreover, knowledge of breastfeeding skills may promote perceived control of mothers on pumping, storage, and transportation of breast milk. Thus, when encountering difficulties in breastfeeding preterm infants, mothers should then seek a solution using their adequate breastfeeding knowledge.

This study found that EBF before discharge positively impacts breastfeeding intention. EBF before discharge depends on lactation amount, and insufficient lactation is the primary factor leading to low breastfeeding rates of preterm infants after discharge (Fewtrell et al., 2016). Lactogenesis stage II usually occurs between the 3rd and 8th day postpartum. A stratified study on the lactation volume of preterm mothers on the 4th day postpartum found that mothers whose lactation volume was at level I (<140 mL) had a 9.5-fold probability of insufficient lactation at week 6 postpartum, compared with those at level II (140–394 mL) and level III (≥395 mL; Hill, 2005). A cross-sectional study conducted in China further reported that the rate of EBF during hospitalization positively correlated with the rate of EBF at week 6 postpartum (Quan and Yang, 2005). These findings may partially explain the results of the current study, although the rate (only 14%) of EBF before discharge was low among preterm mothers in this study. However, the low rate of EBF before discharge does suggest that nurses should strengthen breastfeeding education during hospitalization to avoid delayed initiation of lactogenesis stage II, which is the key to the success of EBF.

In this study, 93.8% of preterm mothers had an EPDS incidence score ≥ 13 during hospitalization, and their level of depressive symptoms negatively impacted their intention to breastfeed. Preterm birth is a traumatic event for preterm mothers (Gulamani et al., 2013), and these women often have higher levels of depressive symptoms than mothers of full-term infants up to 12 weeks postpartum (Vigod et al., 2010). These results are in concordance with prior studies that reported heightened levels of stress, anxiety, and depressive symptoms both during and beyond the NICU stay of premature infants (Zhang et al., 2014). Indeed, studies have confirmed that depression affects the endocrine and metabolic functions of the body, inducing a variety of hormone-level disorders. Lactation regulation depends on prolactin, oxytocin, and other neurohormones and is vulnerable to adverse emotions. At the same time, depressed mothers are prone to fatigue, and have poor initiative to actively empty the breast, resulting in a further decline in lactation, which affects breastfeeding confidence, reduces breastfeeding intention, and leads to early breastfeeding cessation (Cohen, 1988; Dennis and McQueen, 2007; Insaf et al., 2011). Therefore, the negative experiences preterm mothers endure may be associated with high levels of depressive symptoms, which continuously weaken breastfeeding intention until and through week 6 postpartum. This study also indicates that effective intervention strategies to improve breastfeeding intention and behavior for the target population (such as parent support, psychological and emotional counseling, parent training, and infant developmental support) are essential to reducing negative emotions and further promoting prolactin secretion (Cohen, 1988; Dennis and McQueen, 2007; Zhang et al., 2014). The role of breastfeeding intention also indicates that multifaceted intervention strategies to improve breastfeeding behavior should be considered for the preterm mother, including adopting individual instruction and support on breastfeeding techniques and problem-solving to improve breastfeeding knowledge and perceived breastfeeding control of mothers; implementing group education to emphasize the benefit of EBF; rectifying cognitive misconceptions of preterm mothers regarding nutrition needs for infants to enhance maternal attitude toward breastfeeding; and sharing successful breastfeeding experiences or stories from other mothers or nursing staff to enhance subjective norms (Gu et al., 2016). In addition, the breastfeeding intention–behavioral gap should not be neglected. Previous studies have shown that implementation intention is a key strategy that helps to transform behavioral intention into behavior (Latimer et al., 2006). In other words, once an intention is formed, it is necessary to adopt an action plan, which includes the specific steps of “when, where, and how” for initiating the behavior, as well as the identification of anticipated barriers and setbacks with corresponding coping plans (Martinez-Brockman et al., 2017). Therefore, it is necessary to evaluate the role of implementation intention to promote the transformation of breastfeeding intention into breastfeeding behavior in future intervention studies.

This study preliminarily confirmed that TPB predicts breastfeeding behavior among mothers with preterm infants at week 6 postpartum. The crucial mediating role of breastfeeding intention was also identified between breastfeeding attitude, subjective norms, perceived control, knowledge, depression, and EBF before discharge with breastfeeding behavior. The findings of this study indicate that standardized questionnaires should be included in the health information system to identify preterm mothers with a high risk of EBF attrition. The tailored intervention led by nurses should focus on the breastfeeding intention and behavior of high-risk mothers with preterm infants.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

RH contributed to conceptualization, methodology, and original drafts. HH, XY, and LD contributed to the acquisition of data and data analysis with the assistance of YZ, YH, CC, and JS. XL and HH participated in making SEM. SZ and HJ participated in project administration, supervision and review. All authors contributed to the article and approved the submitted version.

This study was supported by the National Natural Science Foundation of China (grant number: 72004163), China Health Human Resources Training Programme (no. RCLX2320052), and “Reservoir” Talent Development Program of Shanghai First Maternity and Infant Hospital.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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