Breastfeeding Self-Efficacy Theory-Based Education and Counseling in Pregnant Adolescents

Overview

Adolescence is the period between the ages of 10 and 19, during which individuals undergo physiological, biological, psychological, and social development, transitioning from childhood to adulthood. Pregnancies occurring during this period are defined as adolescent pregnancies. In developing countries, approximately 21 million adolescent pregnancies occur annually among individuals aged 15-19, resulting in around 12 million births. According to national demographic data, a certain percentage of adolescent women have already started childbearing. Pregnancies occurring during this stage, when physical and psychosocial development is still incomplete, bring various medical and social challenges. Adolescent pregnancies are associated with increased maternal and fetal mortality and morbidity risks and are classified as high-risk pregnancies. Therefore, adolescent mothers require close follow-up during both the antenatal and postpartum periods. However, studies indicate that adolescent mothers often fail to attend regular antenatal check-ups, receive inadequate education on breastfeeding, and consequently feel unprepared for motherhood. They tend to have low breastfeeding self-efficacy and develop negative attitudes toward breastfeeding. In the postpartum period, they also experience difficulties in initiating and maintaining breastfeeding. Research highlights the need for education and counseling for adolescent mothers during the antenatal and postpartum periods. Providing education on breastfeeding is particularly important for improving maternal and infant health outcomes. Current approaches to breastfeeding counseling involve face-to-face training provided by healthcare professionals in medical institutions, as well as various alternative methods such as home visits, online/web-based education portals, theory-based training, text messages, emails, and phone consultations. In breastfeeding counseling, it is essential to not only provide education but also ensure continuous follow-up. Monitoring the process is expected to increase adolescent mothers' breastfeeding self-efficacy, foster positive attitudes toward breastfeeding, and extend the duration of breastfeeding. This study aims to assess the effects of antenatal education based on the Breastfeeding Self-Efficacy Theory and postpartum follow-up counseling on adolescent mothers' breastfeeding attitudes and self-efficacy. By enhancing their breastfeeding self-efficacy and attitudes, this study is expected to contribute to resolving challenges related to early initiation and continuation of breastfeeding in the postpartum period.

Study Population and Sample The study population consisted of adolescent pregnant women registered at family health centers in Şanlıurfa, Türkiye. The sample size was calculated using G\*Power version 3.1.9.7. The calculation was based on a two-group, two-time-point repeated-measures analysis of variance for the group-by-time interaction, with a medium effect size of f = 0.25, a statistical power of 95%, and a two-sided significance level of 0.05. The required sample size was estimated as 54 participants, with 27 participants in each group. To account for possible attrition, the sample size was increased by approximately 10%. A total of 60 participants were enrolled and randomly assigned to the intervention group or the control group in a 1:1 ratio. Fifty-five participants completed the study. Study Design and Randomization This was a two-arm, parallel-group randomized controlled trial. Participants who met the eligibility criteria and provided written informed consent were assigned to the intervention or control group using a computer-generated 1:1 randomization list created through Randomizer.org. Intervention Group Participants assigned to the intervention group received two individual, face-to-face antenatal breastfeeding education sessions based on Breastfeeding Self-Efficacy Theory. Each session lasted approximately 55 minutes, with a 10-minute break between sessions. The education addressed the importance of breastfeeding, breast anatomy and lactation physiology, maternal nutrition during breastfeeding, appropriate breastfeeding techniques, infant hunger and satiety cues, breast care, common breastfeeding problems, expression and storage of breast milk, and the emotional aspects of breastfeeding. Verbal instruction, question-and-answer, demonstration, and hands-on practice were used with a flipchart, an infant model, and a breast model. The intervention was structured according to the four sources of breastfeeding self-efficacy: mastery experiences, vicarious experiences, verbal persuasion, and physiological and emotional states. Following the antenatal education, supportive text messages were sent weekly until childbirth. During the first postpartum week, participants received a 45-60-minute home visit to assess breastfeeding practices, identify breastfeeding problems, correct inappropriate practices, and provide individualized counseling and positive feedback. During postpartum weeks 2-6, five weekly telephone counseling sessions, each lasting approximately 15 minutes, were conducted. The counseling sessions addressed participants' breastfeeding experiences, difficulties, and individual support needs. Posttest data were collected at postpartum week 6. Control Group Participants assigned to the control group received routine antenatal and postpartum care provided by healthcare professionals at the family health centers. No additional breastfeeding education, supportive text messages, home visits, or telephone counseling were provided by the research team during the study. Telephone contact was limited to confirming childbirth information and collecting posttest data at postpartum week 6. After posttest data collection was completed, breastfeeding education was offered to control-group participants who requested it. Outcome Measures and Data Collection Tools Breastfeeding self-efficacy was the primary outcome and was assessed using the 14-item Breastfeeding Self-Efficacy Scale-Short Form. The antenatal version was administered at baseline, and the postnatal version was administered at postpartum week 6. Secondary outcomes included breastfeeding knowledge, breastfeeding attitudes, and satisfaction with the intervention. Breastfeeding knowledge was assessed using a 40-item researcher-developed Breast Milk and Breastfeeding Knowledge Assessment Form. Breastfeeding attitudes were assessed using the 46-item Breastfeeding Attitude Assessment Scale. Satisfaction with the intervention was assessed only among intervention-group participants at postpartum week 6 using a 5-item researcher-developed questionnaire. Sociodemographic, obstetric, childbirth, and breastfeeding-related characteristics were collected using a researcher-developed Personal Information Form. Intervention Standardization All antenatal education sessions, text-message support, home visits, and telephone counseling sessions were delivered by the same researcher using standardized educational content and follow-up forms. The researcher had eight years of professional experience in obstetric and gynecologic nursing. Antenatal education sessions were conducted in private education rooms at the participating family health centers. Ethical Considerations Ethical approval was obtained from the Harran University Clinical Research Ethics Committee, and institutional permission was obtained from the Şanlıurfa Provincial Health Directorate. All participants received information about the purpose, procedures, potential benefits, voluntary nature of participation, and right to withdraw from the study without affecting the healthcare services they received. Written informed consent was obtained from all participants before enrollment.