
==== Front
Turk Arch Pediatr
Turk Arch Pediatr
Turkish Archives of Pediatrics
2757-6256
Turkish Pediatrics Association

10.5152/TurkArchPediatr.2024.24160
tap-59-5-440
Review
Research Trends on Self-Efficacy in Breastfeeding Mothers During 2000-2023: A Bibliometric Analysis
Wayan Dian Ekayanthi Ni 1http://orcid.org/0000-0003-2776-648X

Besral Besral 2http://orcid.org/0000-0001-8140-7467

1 Public Health Study Program, Universitas Indonesia Faculty of Public Health, Depok, Indonesia
2 Department of Biostatistics, Universitas Indonesia Faculty of Public Health, Depok, Indonesia
Corresponding author:Ni Wayan Dian Ekayanthi ક ekayanthijegeg@gmail.com
Cite this article as: Wayan Dian Ekayanthi N, Besral B. Research trends on self-efficacy in breastfeeding mothers during 2000-2023: A bibliometric analysis. Turk Arch Pediatr. 2024;59(5):440-448 .

9 2024
01 9 2024
59 5 440448
23 7 2024
12 8 2024
2024 authors
2024
authors
https://creativecommons.org/licenses/by-nc/4.0/ Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Objective:

Self-efficacy is important in supporting breastfeeding behaviors and enhancing breastfeeding practices. This study aimed to explore research trends, identify knowledge gaps, and provide a comprehensive overview of breastfeeding self-efficacy.

Materials and Methods:

Data were retrieved from the Scopus online database on March 20, 2024, encompassing articles published in English between 2000 and 2023. The search strategy focused on articles containing the keywords “self-efficacy,” “breastfeeding,” and “mother.” VOSviewer version 1.6.19 was then used to map the data and visually identify research clusters.

Results:

The analysis yielded a significant increase in breastfeeding self-efficacy research over the past 2 decades. The United States led in publication numbers (117 documents), while Canada dominated citations (2792 citations). Furthermore, the analysis identified 8 critical themes in 8 different clusters, encompassing various aspects of breastfeeding, including determinants, behaviors, interventions, and mental health considerations during lactation, and employed research methodologies. One crucial gap identified in this study pertains to low breastfeeding social support. This includes a lack of support from peer groups, social networks, and social media platforms. Addressing this gap can be a valuable reference point for developing future interventions to bolster breastfeeding self-efficacy.

Conclusion:

Bibliometric analysis contributes to exploring research trends, identifying knowledge gaps, and providing a comprehensive overview of breastfeeding self-efficacy.

Keywords

Self-efficacy
breastfeeding
mother
bibliometric analysis
This study received no funding.
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pmcWhat is already known on this topic?

Extensive research has demonstrably established the multifaceted benefits of breastfeeding for infants.

Self-efficacy, an individual’s belief in their capability to perform specific tasks successfully, plays a critical role in breastfeeding success.

The extensive body of research on breastfeeding self-efficacy necessitates a deeper understanding of research trends and potential knowledge gaps.

An analysis is needed to identify research trends related to breastfeeding self-efficacy.

What this study adds on this topic?

This study provides information on research trends of breastfeeding self-efficacy.

This study identified 8 critical themes in 8 different clusters, encompassing various aspects of breastfeeding.

By addressing these research gaps and exploring new research methods, we can pave the way for advancing breastfeeding self-efficacy research, ultimately leading to improved breastfeeding practices and positive outcomes for both mothers and infants.

Introduction

The right to access breast milk is a fundamental requirement for all neonates. Extensive research has demonstrably established the multifaceted benefits of breastfeeding for infants.1 Breast milk offers a significant health advantage for newborns, providing essential nutrients and a unique composition of beneficial microbes. These microbes contribute to developing the infant’s gut microbiome, ultimately enhancing their immune system. Breast milk plays an essential role in preventing adverse health outcomes in infants.2 Breast milk offers numerous advantages over formula, including optimal nutrition, enhanced infection protection, improved gut function, stronger immune system development, and better brain development. While formula attempts to replicate breast milk’s nutritional composition, it cannot fully match the comprehensive health benefits provided by human milk. Exclusive breastfeeding for the first 6 months of life is strongly recommended by health organizations worldwide to promote optimal growth and development.3

Despite these well-documented advantages, concerning data reveal that less than half of all infants globally receive exclusive breastfeeding.4,5 Notably, a significant disparity exists across regions. South Asia boasts the highest prevalence of exclusive breastfeeding at 60%, while North America falls short with only 26%.5

Suboptimal breastfeeding rates are attributed to a confluence of factors, including maternal choice to forgo breastfeeding, insufficient support networks from partners, family members, and healthcare providers, a knowledge deficit regarding the benefits of breastfeeding, and both maternal and infant health concerns.6 Additionally, inadequate promotion and support for breastfeeding within healthcare systems, along with a lack of public funding allocated to pregnancy and breastfeeding support services, are recognized as significant barriers to achieving exclusive breastfeeding goals.7 Furthermore, challenges specific to mothers and infants8 can also hinder breastfeeding success. These challenges encompass difficulties with latching and nipple pain, the complexities of navigating breastfeeding as a working mother,9 and a lack of maternal self-efficacy,10 which refers to a mother’s confidence in her ability to breastfeed effectively.

Self-efficacy, an individual’s belief in their capability to perform specific tasks successfully,11 plays a critical role in breastfeeding success. In breastfeeding, self-efficacy refers to a mother’s confidence in her ability to provide breast milk for her infant, and breastfeeding also offers the advantage of overcoming challenges that may arise during the feeding process. A mother’s self-efficacy significantly impacts her breastfeeding journey and success. Often, difficulties with breastfeeding stem from a lack of confidence in a mother’s ability to provide adequate milk for her baby.

Worldwide, extensive research has explored the multifaceted relationship between breastfeeding self-efficacy and various maternal outcomes. Studies have identified self-efficacy as a dominant factor influencing a mother’s satisfaction with breastfeeding.12 Conversely, low self-efficacy has been linked to concerns about insufficient milk supply, potentially leading to early breastfeeding termination.13

Understanding the level of mothers’ breastfeeding self-efficacy can help healthcare workers predict breastfeeding duration and the success of exclusive breastfeeding and identify mothers at risk of early weaning. Research has demonstrated a consistent positive correlation between breastfeeding self-efficacy and breastfeeding outcomes. Mothers who exclusively breastfeed exhibit significantly higher self-efficacy levels than mothers who discontinue breastfeeding early.14 These findings highlight the importance of supporting and promoting positive breastfeeding behaviors and practices.

The extensive body of research on breastfeeding self-efficacy necessitates a deeper understanding of research trends and potential knowledge gaps. Bibliometric analysis offers a valuable tool to achieve this objective. By analyzing publication patterns, citations, and author collaborations, this approach can illuminate key research themes, emerging areas of inquiry, and potentially neglected aspects of breastfeeding self-efficacy. Furthermore, a bibliometric analysis can be instrumental in identifying future research directions and facilitating the development of novel research questions related to mothers’ breastfeeding self-efficacy. Therefore, this study aims to describe, identify gaps, and analyze research trends related to self-efficacy among breastfeeding mothers.

The novelty of this research lies in applying bibliometric analysis to provide a detailed analysis of research trends and identify knowledge gaps in breastfeeding self-efficacy.

Materials and Methods

This study employs a combined approach of bibliometric and content analysis. Bibliometric analysis aims to (1) provide a comprehensive overview of research on breastfeeding self-efficacy, (2) identify potential knowledge gaps, and (3) suggest new avenues for future research.15

A comprehensive dataset was retrieved from the Scopus-indexed journal database on March 20, 2024. To ensure focused and relevant results, a search strategy was implemented utilizing the keywords “self-efficacy and breastfeeding and mother.” This search yielded a total of 555 articles published between the years 2000 and 2023. For consistency, the document type was restricted to articles written in English. The retrieved search results were then exported in comma-separated values format to facilitate further analysis using VOSviewer software. VOSviewer, a bibliometric analysis software, generated visual data maps. These maps will be instrumental in identifying and analyzing research trends related to self-efficacy in breastfeeding mothers.

Results

Research Characteristics

The search in the Scopus-indexed journal database retrieved 555 articles published between 2000 and 2023. Figure 1 shows the number of article publications from 2000-2023. The annual publication rate exhibited fluctuations, with a notable increase observed since 2013. This upward trend culminated in a peak of 68 articles published in 2020, followed by a slight decrease to 57 articles in 2021. However, preliminary data suggest a potential resurgence in publications during 2022 and 2023, with 79 and 83 articles retrieved, respectively.

Content Analysis

Global Research Landscape

The analysis of publication origins revealed a geographically diverse range of research on breastfeeding self-efficacy. Articles were identified from a total of 66 countries across the globe. Table 1 presents the 10 countries with the highest publication output in this field.

Table 1 presents the top 10 countries with the highest publication output and citation counts related to breastfeeding self-efficacy research between 2000 and 2023. While the United States holds the top position with 117 publications, Canada has the highest total number of citations (2792) despite having fewer publications (54) with a total link strength of 40.

In Figure 2, the visualization of the co-authorship network with key analysis countries shows that the United States has the most extensive circle with a network connected to various countries.

Affiliation Analysis

The analysis of publication affiliations revealed patterns of collaboration among research institutions. A visual representation of these institutional collaborations is provided in Figure 3.

The University of Toronto, Canada, emerged as the most productive institution, contributing 35 publications within the selected timeframe (2000-2023). Universidade Federal do Ceará, Brazil (14 publications), and the University of Aarhus, Denmark (12 publications), followed closely behind.

Table 2 presents the 10 affiliates with the highest publication output in breastfeeding self-efficacy research.

While Table 2 highlights the top 10 affiliates based on publication volume, it also offers valuable insights into citation counts. Interestingly, the University of Toronto maintains its leading position, with the highest number of articles (35) and the most citations (2582 citations) within the analyzed period. This translates to an impressive average of 73.77 citations per article for the university’s publications on breastfeeding self-efficacy.

Most Frequently Cited Studies

Table 3 presents the most highly cited articles within the retrieved dataset of breastfeeding self-efficacy research publications indexed by Scopus. This table will provide insights into the most influential research on this topic.

Table 3 indicates that Blyth’s 2002 article, published in the journal Birth, is the most cited with 302 citations.

Cluster Analysis

To elucidate current research trends in breastfeeding self-efficacy, a bibliometric analysis was conducted using VOSviewer software version 1.6.19. This software facilitates the creation of visual maps to depict the co-occurrence of keywords within the retrieved publications. Two primary visualizations were generated: a network visualization (Figure 4) and an overlay visualization (Figure 5). In both visualizations, the size of each circle corresponds to the frequency of a particular keyword. Keywords appearing more frequently are represented by larger circles.

Figure 4 presents a network visualization depicting the co-occurrence of keywords within the retrieved publications on breastfeeding self-efficacy research. The various colors represent 8 distinct clusters, each potentially reflecting a thematic area of research.

Theme 1: Breastfeeding Determinants

An analysis of keywords within Cluster 1 reveals a central theme focused on the determinants of breastfeeding. This theme encompasses many factors influencing breastfeeding success, including baby factors (ankyloglossia, birth weight, lingual frenulum) and maternal factors (attitudes, knowledge, gestational age, maternal obesity, parity, nutrition). Additionally, the type of delivery (cesarean section, vaginal delivery, obstetric intervention) emerges as a potential determinant. The theme also highlights the diverse research methodologies employed within this area, such as studies investigating lactation interventions, those using qualitative analysis to understand experiences, and systematic reviews that synthesize existing research.

Further enriching the understanding of determinants, your previous research identified social support, attitude, knowledge, and even a husband’s age as significant predictors of a mother’s breastfeeding self-efficacy.16 This finding aligns with other studies17 that highlight the influence of various factors on a mother’s intention to breastfeed. These factors include having fewer children, past breastfeeding experience, knowledge about breastfeeding, self-efficacy regarding breastfeeding abilities, and the level of perceived social support available.

Theme 2: Breastfeeding Behaviors, Influencing Factors, Promotion Strategies, and Research Methodologies

Thematic analysis of keywords within Cluster 2 reveals Theme 2, which centers on breastfeeding practices and associated factors. This theme explores various dimensions of breastfeeding behavior, including direct and bottle-feeding. It delves into the decision-making processes of mothers, considering the influence of their attitudes, intentions, interpersonal communication, personal experiences, and return-to-work considerations. Additionally, Theme 2 encompasses research on breastfeeding promotion strategies, including counseling interventions, pilot projects, and social network approaches. Furthermore, the studies within this cluster employ a range of methodologies, such as pilot studies, ethnological investigations, and factor analysis. Of particular note, research suggests a robust positive correlation between a mother’s confidence in breastfeeding and both the duration and exclusivity of breastfeeding practices.18

Theme 3: Risk Factors for Breastfeeding Self-efficacy, Mental Health

Cluster 3, through keyword analysis, reveals Theme 3, which delves into the interplay between risk factors for breastfeeding self-efficacy and maternal mental health. This theme encompasses a diverse range of potential impediments to a mother’s confidence in breastfeeding, including attention difficulties in child-parent interactions, depressive symptoms, educational attainment, employment status, maternal age and behaviors, stress levels, and social standing. Additionally, Theme 3 explores the realm of maternal mental health, specifically focusing on anxiety, postpartum depression, and stress. Research within this cluster highlights a significant association between maternal anxiety and both a decrease in the exclusivity of breastfeeding and a shortened duration of breastfeeding practices. This finding underscores the critical role of actively monitoring and effectively managing maternal anxiety during the postpartum period to support optimal breastfeeding outcomes.19

Theme 4: The Role of Health Workers in Breastfeeding Education, Breastfeeding Education on Self-efficacy and Social Support, Racial and Ethnic Factors in Breastfeeding

Theme 4, derived from keyword analysis of Cluster 4, explores the multifaceted interplay between healthcare worker involvement in breastfeeding education, the impact of such education on self-efficacy and social support, and the influence of racial and ethnic factors on breastfeeding practices. The research highlights significant racial and ethnic disparities in breastfeeding rates, underscoring the critical need for culturally tailored breastfeeding programs to enhance breastfeeding initiation and continuation.20 A study on Chinese Australian mothers emphasizes the importance of immediate perinatal support interventions to strengthen their knowledge base, breastfeeding intention, and confidence in delaying formula introduction and promoting exclusive breastfeeding in the early postpartum period.21

Furthermore, research suggests that healthcare professionals should equip mothers with factual breastfeeding information and actively support the development of maternal confidence in breastfeeding practices before discharge.18 It highlights the crucial role of healthcare workers in fostering breastfeeding self-efficacy. Additionally, the research underscores the significant positive association between social support networks and breastfeeding self-efficacy, with mothers receiving more social support exhibiting higher confidence levels in their breastfeeding abilities.22

Theme 5: Factor Analysis, Development of Breastfeeding Self-efficacy Research for Mothers with Premature Babies

Analysis of keywords within Cluster 5 reveals Theme 5, which focuses on developing research methodologies to investigate breastfeeding self-efficacy in mothers with premature infants. This theme highlights the need for research specifically tailored to this population.23 Notably, existing research suggests significantly lower breastfeeding self-efficacy and satisfaction among mothers of premature babies compared to mothers of full-term infants.24

Theme 6: Psycho, Social Demographic Factors to Breastfeeding and Breastfeeding on Working Mother

An analysis of keywords within Cluster 6 reveals a theme centered on the interplay between psychosocial and sociodemographic factors influencing breastfeeding practices, particularly among working mothers. This theme highlights the importance of maternal education, intention, self-efficacy, and prior breastfeeding experience as potential early indicators of breastfeeding cessation. Research suggests that interventions to bolster self-efficacy and resource availability for these mothers may prove beneficial.25 Additionally, the theme emphasizes the significance of educational interventions during the transition back to work to enhance self-efficacy and support mothers in achieving their breastfeeding goals.26 Notably, self-efficacy emerges as a critical predictor of breastfeeding duration. Workplaces can be crucial in promoting breastfeeding practices by fostering an environment that supports working mothers.27

Theme 7: Multicenter Study to Maternal and Child Health and Breastfeeding Self-efficacy

Analysis of keywords within Cluster 7 reveals Theme 7, which underscores the value of employing a multicenter study design to investigate the complex relationship between maternal and child health and breastfeeding self-efficacy. This research design offers valuable insights that can inform the development of effective interventions aimed at improving breastfeeding practices.28

Theme 8: Cross-sectional Study on Breastfeeding

An analysis of keywords within Cluster 8 reveals Theme 8, which centers on the prevalence of cross-sectional study designs employed in research investigating breastfeeding self-efficacy.16,17,21

Figure 5 presents a visual representation of keyword co-occurrence, similar to the approach used in Figure 4. Circle size within this figure reflects keyword frequency; larger circles indicate keywords that appear more frequently within the analyzed text corpus. Additionally, the color gradient (blue to yellow) signifies the year of publication, as indicated in the figure legend.

Keywords positioned closer to the yellow spectrum represent more recent research terms related to breastfeeding self-efficacy (published closer to 2020 or later), while keywords positioned toward the blue spectrum represent research conducted near or before 2014. Notably, the phrase “The key to breastfeeding” is depicted in a darker shade of green compared to “self-efficacy” and “breastfeeding self-efficacy” (represented by lighter green). This suggests that research focused solely on breastfeeding, without the specific emphasis on self-efficacy, emerged earlier in the research timeline. Conversely, investigating breastfeeding self-efficacy gained momentum closer to 2018 and beyond.

Discussion

Implications

The past 20 years have witnessed a significant surge in research focused on breastfeeding self-efficacy. The bibliometric analysis reveals several key trends in this area of inquiry. These trends include investigations into breastfeeding initiation and continuation determinants, breastfeeding behaviors, interventions and promotional strategies to support breastfeeding, mental health considerations during the breastfeeding period, and methodological approaches employed in breastfeeding self-efficacy research.

The analysis also highlights potential areas for further exploration, particularly those directly impacting breastfeeding self-efficacy. These underexplored areas include the experiences of working mothers (such as workplace environment and employment status); factors related to the infant’s health at birth (such as prematurity and birth weight); the mother’s psychological well-being (such as self-esteem, motivation, satisfaction, and coping mechanisms); and the role of social support networks (such as peer groups, social support systems, and social media) in breastfeeding success.

Additionally, the potential of employing systematic review methodologies deserves further investigation. By delving deeper into these underexplored areas and exploring new research methods, we can advance breastfeeding self-efficacy research, ultimately leading to improved breastfeeding practices and contributing positive outcomes for both mothers and infants.

Strengths and Limitations

This research leverages bibliometric analysis as a robust tool to map and provide a comprehensive overview of existing research on breastfeeding self-efficacy. The analysis encompasses various aspects, including country distribution of research, affiliation analysis, identification of the most-cited studies, journal analysis, and cluster analysis of keywords. However, there are a few limitations to consider.

Firstly, the analysis relies solely on publications retrieved from the Scopus database. While Scopus offers a vast and well-regarded collection of peer-reviewed articles, incorporating additional databases such as Web of Science and PubMed could provide a more comprehensive picture of the research landscape.

Secondly, the analysis focuses exclusively on journal articles. Other publication types, such as books, editorials, and gray literature (such as reports and dissertations), might offer valuable insights and potentially different perspectives.

Finally, the effectiveness of the analysis hinges on the chosen keywords. Future studies could explore the use of alternative and potentially broader keyword sets to obtain an even more complete and nuanced understanding of the research landscape.

Conclusion

This bibliometric analysis has yielded valuable insights into research trends related to breastfeeding self-efficacy. Notably, the past 20 years have witnessed a significant increase in research activity within this domain. The analysis identified several key areas of research focus, including the determinants of breastfeeding initiation and continuation, breastfeeding behaviors, interventions and promotional strategies to support breastfeeding, and mental health considerations during breastfeeding. However, the analysis also revealed potential gaps in the current research landscape, particularly in areas directly impacting breastfeeding self-efficacy. These underexplored areas encompass the experiences of working mothers (such as workplace environment and employment status), factors related to the infant’s health at birth (such as prematurity and birth weight), the mother’s psychological well-being (such as self-esteem, motivation, satisfaction, and coping mechanisms), and the role of social support networks (such as peer groups, social support systems, and social media) in breastfeeding success. Additionally, the analysis highlights the potential of employing systematic review methodologies for further research endeavors. By addressing these research gaps and exploring new research methods, we can pave the way for advancing breastfeeding self-efficacy research, ultimately leading to improved breastfeeding practices and positive outcomes for both mothers and infants.

Figure 1. Number of article publications from 2000-2023. Source: Scopus (2024).

Figure 2. Co-authorship countries network visualization.

Figure 3. Top 10 publications based on affiliation and number of documents. Source: Scopus (2024).

Figure 4. Network map visualization of keywords based on co-occurrence.

Figure 5. Overlay visualization of keywords based on co-occurrence.

Table 1. Top 10 Countries in Breastfeeding Self-efficacy Research, Number of Documents, Citations, and Total Link Strength

Rank	Country	Documents	Citations	Total Link Strength	
1.	United States	117	2520	52	
2.	Canada	54	2792	40	
3.	Iran	42	502	4	
4.	United Kingdom	36	867	18	
5.	Australia	33	1386	22	
6.	Turkey	27	310	0	
7.	Brazil	26	318	6	
8.	China	22	511	15	
9.	Indonesia	20	129	8	
10.	Denmark	13	506	4	

Table 2. Top 10 Publications by Affiliation, Number of Documents, Average Citations, and Country

Affiliation	Documents	Citations	Average Citations	Country	
University of Toronto	35	2582	73.77	Canada	
Universidade Federal do Ceará	14	186	13.29	Brazil	
University of Aarhus	12	730	60.83	Denmark	
Tabriz University of Medical Sciences	9	196	21.78	Iran	
Universidade de São Paulo	8	37	4.63	Brazil	
Queensland University	8	531	66.38	Australia	
Curtin University	8	185	23.13	Australia	
Universitas Airlangga	8	26	3.25	Indonesia	
Deakin University	8	29	3.63	Australia	
Social Determinants of Health Research Center	8	77	9.63	Iran	

Table 3. Top 10 List of Most Cited Publications on Scopus Based on Title, Writer, Year, and Journal

Article Title	Writer	Year	Journal	Citations	
Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory	Blyth R.; Creedy D.K.; Dennis C.-L.; Moyle W.; Pratt J.; De Vries S.M.	2002	Birth	302	
A systematic review of professional support interventions for breastfeeding	Hannula L.; Kaunonen M.; Tarkka M.-T.	2008	Journal of Clinical Nursing	187	
Interventions to Improve Breastfeeding Self-Efficacy and Resultant Breastfeeding Rates: A Systematic Review and Meta-Analysis	Brockway M.; Benzies K.; Hayden K.A.	2017	Journal of Human Lactation	186	
Does maternal postpartum depressive symptomatology influence infant feeding outcomes?	Dennis C.L.; McQueen K.	2007	Acta Paediatrica, International Journal of Paediatrics	171	
The influence of psychosocial factors on the duration of breastfeeding	Kronborg H.; Væth M.	2004	Scandinavian Journal of Public Health	153	
Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period	Dennis C.L.	2006	Research in Nursing and Health	153	
Predictors of breastfeeding intention among low-income women.	Mitra A.K.; Khoury A.J.; Hinton A.W.; Carothers C.	2004	Maternal and Child Health Journal	138	
Breastfeeding duration in an Australian population: The influence of modifiable antenatal factors	Blyth R.J.; Creedy D.K.; Dennis C.-L.; Moyle W.; Pratt J.; De Vries S.M.; Healy G.N.	2004	Journal of Human Lactation	127	
Predictors of the duration of exclusive breastfeeding among first-time mothers	Semenic S.; Loiselle C.; Gottlieb L.	2008	Research in Nursing and Health	121	
Effect of immediate and continuous mother-infant skin-to-skin contact on breastfeeding self-efficacy of primiparous women: A randomized control trial	Aghdas K.; Talat K.; Sepideh B.	2014	Women and Birth	120	

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – N.W.D.E.; Design – N.W.D.E.; Supervision – N.W.D.E., B.S.; Materials – N.W.D.E., B.S.; Data Collection and/or Processing – N.W.D.E., B.S.; Analysis and/or Interpretation – N.W.D.E., B.S.; Literature Search – N.W.D.E., B.S.; Writing – N.W.D.E., B.S.; Critical Review – N.W.D.E., B.S.

Acknowledgments: The authors would like to greatly appreciate Ebizmark Trainer Teams for their assistance with bibliometric analysis using VOSviewer software.

Declaration of Interests: The authors have no conflicts of interest to declare.
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