Factors predicting six-month exclusive breastfeeding among mothers in Ho Chi Minh City, Vietnam

Factors predicting six-month exclusive breastfeeding among mothers in Ho Chi Minh City, Vietnam

Nhan Thi Nguyen, Tassanee Prasopkittikun, Sudaporn Payakkaraung and Nopporn Vongsirimas

Faculty of Nursing, Mahidol University, Bangkok, Thailand

Abstract

Purpose – Exclusive breastfeeding (EBF) rates continue to be low in Vietnam. This study aimed to determine

the factors predicting 6-month EBF among mothers in Ho Chi Minh City, Vietnam.

Design/methodology/approach – A cross-sectional study was conducted with 259 mothers of infants aged

between six to nine months at well-baby clinics in Ho Chi Minh City. The questionnaires used for data collection

included personal background questionnaire, perceived benefits of breastfeeding scale, breastfeeding selfefficacy scale-short form, perceived barriers to breastfeeding scale and the family support of breastfeeding

scale. Descriptive statistics, bivariate and multiple logistic regression were used for data analysis.

Findings – About 32% of the Vietnamese mothers practiced 6-month EBF. By increasing one unit of perceived

benefits of breastfeeding, perceived self-efficacy in breastfeeding and family support, the mothers’ likelihood to

give 6-month EBF would increase 19% (AOR 5 1.19, 95% CI 5 1.08, 1.31), 12% (AOR 5 1.12, 95% CI 5 1.04,

1.19) and 10% (AOR 5 1.10, 95% CI 5 1.04, 1.16), while previous breastfeeding experience, maternal age and

maternal education could not significantly contribute to the 6-month EBF.

Originality/value – This is the first study in Vietnam using a nursing model, the health promotion model, as a

framework to identify factors predicting 6-month EBF. An effective program for promoting EBF could be

developed by manipulating and tailoring the predicting factors to fit the Vietnamese mothers’ needs through a

mother class, lactation clinic or individual approach.

Keywords Exclusive breastfeeding, Perceived benefits, Perceived self-efficacy, Family support, Vietnam

Paper type Research paper

Introduction

Exclusive breastfeeding (EBF), infant feeding comprising only breast milk in the first six

months without other liquids or solids, is the most efficacious form of feeding for an

infant’s early months of life. Breastfeeding benefits have been proved in terms of health

and economic gains. For infants, breast milk contains comprehensive nutrients, in

particular the antibodies which protect against inflammation and infection [1]. Research

has proved that babies who were exclusively breastfed for the first six months experienced

less and a higher rate of infant survival, compared to non-breastfed infants [2]. Breastfed

babies show a higher intelligence quotient than non-breastfed babies [3]. Evidence also

suggested that EBF provides the mothers with short-term and long-term protection

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© Nhan Thi Nguyen, Tassanee Prasopkittikun, Sudaporn Payakkaraung and Nopporn Vongsirimas.

Published in Journal of Health Research. Published by Emerald Publishing Limited. This article is

published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce,

distribute, translate and create derivative works of this article (for both commercial and non-commercial

purposes), subject to full attribution to the original publication and authors. The full terms of this licence

may be seen at http://creativecommons.org/licences/by/4.0/legalcode

The first author is grateful to the Mahidol-Norway Capacity Building Initiative for ASEAN for their

financial support during her doctoral study and dissertation.

The current issue and full text archive of this journal is available on Emerald Insight at:

https://www.emerald.com/insight/2586-940X.htm

Received 30 March 2020

Revised 24 May 2020

Accepted 28 May 2020

Journal of Health Research

Vol. 36 No. 2, 2022

pp. 219-230

Emerald Publishing Limited

e-ISSN: 2586-940X

p-ISSN: 0857-4421

DOI 10.1108/JHR-03-2020-0080

against postpartum depression, ovarian cancer, breast cancer and type 2 diabetes [4, 5].

Breastfeeding is not only baby-friendly but also planet-friendly because it keeps the

environment unharmed. Breast milk is not industrially manufactured; thus it does not

produce waste that cannot be absorbed back into nature as found in the production of

formula milk [6]. In terms of economic gains, breastfeeding has also saved expenditures for

both family and nation [7].

Due to the significant advantages of EBF, mothers have long been recommended to

exclusively breastfeed their infants for the first six months to achieve the optimal health,

growth and development of the infants [8]. However, only about 40% of infants worldwide

aged from 0–6 months are exclusively breastfed [9]. Particularly, Vietnam, a developing

country in Southeast Asia, has a slow improvement rate of EBF in recent years; that is, from

11% in 2012 to 24% in 2016 [10, 11]. The government of Vietnam has launched several

strategies to promote breastfeeding by implementing the Baby-Friendly Hospital Initiative

(BFHI) [12], banning the advertisement of infant formula [13] and extending paid maternity

leave from four months to six months [14]. However, 6-month EBF among Vietnamese

mothers remains problematic; this is partly due to their wrong beliefs about the baby’s needs

of water and more food [15] and not realizing the importance of colostrum [16]; the influence of

infant formula advertisements [17]; the non-compliance with BFHI regulation [18]; and the

influence of grandparents or significant others [15, 19].

Because of the low rate of 6-month EBF worldwide, including in Vietnam, factors affecting

EBF need to be studied and manipulated to promote EBF programs. Previous studies report

the affecting factors that may be categorized as socio-cultural and demographic (including

age, education, occupation, religion, marital status, ethnicity, household income and place of

residence) [20, 21], biomedical (including parity, previous breastfeeding experience,

gestational age, delivery method, smoking status and birth weight of infant) [21–23],

health-service related (including initiation of breastfeeding, female pediatrician and bedsharing practice) [22, 24], belief and perception (including colostrum feeding, breastfeeding

attitudes and breastfeeding knowledge) [18, 23] and behavior-specific cognitions and affect

(including perceived benefits of breastfeeding, breastfeeding self-efficacy, perceived potential

barriers of breastfeeding and social support) [25–27].

While there are several published studies on the factors related to EBF, few studies were

found in the context of Vietnam. Previous studies addressing the factors influencing EBF

were mostly conducted in northern Vietnam [10, 18, 28]. The differences between northern

and southern Vietnam in terms of historical, political, social and economic contexts may

affect the way of people’s thoughts, beliefs and practices in various aspects [29], in

particular the work and family roles of women [30]. In addition, the lack of a conceptual or

theoretical framework to guide the study seems to be a limitation of the current studies

based in Vietnam [10, 18, 28]. A theoretical framework helps specify the key factors that

influence a phenomenon of interest; thus, the health promotion model [31] was applied to the

current study because of its wide use in the field of health promotion, particularly in

breastfeeding research [32–34]. Thus, partly based on this model, the current study was

conducted to examine the predictability of the factors of individual characteristics and

experiences and behavior-specific cognitions and effects on 6-month EBF of mothers in Ho

Chi Minh City, Vietnam.

Methods

Study design

A cross-sectional study was used to achieve the research purpose.

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Research settings

In Ho Chi Minh City, three tertiary hospitals offer child health supervision at the hospitals’

well-baby clinics, the other hospitals do not have well-baby clinics. The three well-baby

clinics were the research settings for data collection.

Participants

A convenience sampling was employed with mothers who brought their infants to receive

immunization at the well-baby clinics. Mothers with the following criteria were included in

the study: being 18 years of age or older; being able to communicate, read and write in the

Vietnamese language; living with husband and/or family members. Mothers experiencing

any health problems and/or taking medicine and prohibited from breastfeeding by a doctor

were excluded. Eligible infants included a singleton baby with gestational age at least

37 weeks, while those with birth defects (e.g. cleft lip, cleft palate) and/or any health problems

where the doctor prohibited breastfeeding were excluded.

The sample size was calculated using the G* Power Software [35] based on the effect size

of 2.15 from a previous study [36] with the power of 0.8, a significance level of 0.05. According

to the calculation, the sample size was equal to 247. A 5% of attrition rate was estimated;

therefore 259 participants were finally recruited into the study.

Ethical considerations

The study was approved by the Institutional Review Board (IRB) Committee from the Faculty

of Nursing, Mahidol University, Thailand (COA No.IRB-NS2019/487.06.03). Ethical approval

was also obtained from two tertiary hospitals in Ho Chi Minh City (No.548/QÐ-BVTD and

No.322/QD-BVHV).

Research instruments

Five self-administered questionnaires used for collecting data in the current study were

described as follows:

(1) The personal background questionnaire was developed by the researchers consisting

of the items relating to the age of the mother, education level, parity, breastfeeding

experience, delivery method, age of the infant and EBF practice.

(2) The perceived benefits of breastfeeding scale were developed by Wangsawat et al.

[37] to measure the perception of mothers about the benefits of breastfeeding. The

scale consisted of 19 items with a 4-point rating scale ranging from 1 (strongly

disagree) to 4 (strongly disagree). The higher scores indicated greater perceived

benefits of breastfeeding.

(3) The perceived barriers to breastfeeding scale was developed by the researchers,

which is used for measuring a mother’s perceptions of barriers to her breastfeeding.

This 20-item scale consisted of three sources of barriers including barriers from

mother, infant and the socio-environment. The response scale varied from 1 (strongly

disagree) to 4 (strongly agree). The higher scores indicated the higher perceptions of

the barriers faced. Content validity was checked by three breastfeeding experts and

the item-level content validity index of this scale was 0.91.

(4) The breastfeeding self-efficacy scale-short form was developed by Dennis [38]

consisting of 14 items and used for assessing a mother’s confidence in her ability to

breastfeed her baby. Responses to each item were scored on a 5-point rating scale

ranging from 1 (not at all confident) to 5 (always confident). The higher scores

indicated higher confidence in breastfeeding.

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221

(5) The family support of breastfeeding scale was developed by Srisawat et al. [39] to

measure the family support on breastfeeding practice of mothers. This 20-item scale

consisted of four subscales including emotional, appraisal, informational and

instrumental support with 5 items each. Respondents were asked to rate their

agreement ranging from 1 (strongly disagree) to 4 (strongly agree). The higher scores

indicated higher levels of family support.

Each questionnaire, except for the personal background questionnaire, was back translated

from its original language into the Vietnamese language by the researchers and nursing

scholars. A pilot study with 25 mothers who met the same criteria as the study sample was

implemented to check for the reliability of the study questionnaires. Cronbach’s alpha

coefficient was valued at 0.88, 0.92, 0.92 and 0.92 for the perceived benefits of breastfeeding,

perceived barriers to breastfeeding, breastfeeding self-efficacy and family support scales,

respectively.

Data collection

Eligible mothers were identified from the medical chart by staff nurses at the well-baby

clinics. If eligible mothers were willing to participate in the study, then staff nurses introduced

the researcher (NTN) to them. The researcher explained the purpose of the study and their

rights. The mothers who agreed to participate were asked to sign a consent form. After their

babies received the vaccination, an entire package of the questionnaires was hand-delivered

to the mothers and an explanation of how to answer the questionnaires was also given. The

questionnaires were self-administered by the mothers in a specially prepared room and took

about 30–40 min to complete.

Data analysis

Data were analyzed using the statistical package of social sciences version 18.0. The

significance level of the statistical test was set at 0.05. Descriptive statistics were used to

describe the variables of interest and determine the rate and the duration of EBF practice

among Vietnamese mothers. The univariate analyses using Pearson product-moment

correlation and point-biserial were employed to examine the relationship between the study

factors and 6-month EBF practice. Both binary and multiple logistic regressions were used to

determine the strength of association between the significant factors and 6-month EBF

practice.

Results

Demographic characteristics

Overall, 259 eligible mothers with an average age of 30.63 (SD 5 5.77) years participated in

the study. About 65% of the mothers were educated to high school level or lower. While 48%

of participants were multiparous mothers, only 35.9% had previous experience of

breastfeeding. Nearly 55% of the mothers had normal delivery while the remainder

received the cesarean section delivery method (Table 1).

Exclusive breastfeeding features

Table 2, among 259 mothers in Ho Chi Minh City, Vietnam, about 32% of mothers could

breastfeed exclusively during the first six months while the remainder could not. An average

EBF duration was 112.44 days (SD 5 64.18).

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Behavior-specific cognitions and affect variables

The average total scores of the behavior-specific cognitions and affect variables in the current

study are displayed inTable 3. The percentages of average total scores were also computed to

ease the comparison. Note that perceived barriers to breastfeeding arose from each source

fairly evenly. For family support, the instrumental support was the most noticeable high,

followed by emotional, appraisal and informational support respectively.

Analysis of factors predicting 6-month EBF

The preliminary analysis was done by examining the relationships between previous

breastfeeding experience, maternal age, maternal education, perceived benefits, perceived

Characteristics N %

Age (years)

20–35 209 80.7

>35 50 19.3

Mean 5 30.63, SD 5 5.77, Median 5 30, Min–Max 5 20–45

Education

High school or lower 168 64.9

Higher than high school 91 35.1

Mean 5 12.66, SD 5 2.60, Median 5 12, Min–Max 5 7–18

Number of children

1 135 52.1

2 97 37.5

3 23 8.9

4 4 1.5

Mean 5 1.60, SD 5 0.72, Median 5 1, Min–Max 5 1–4

Parity

Primiparous 135 52.1

Multiparous 124 47.9

Method of delivery

Natural birth 142 54.8

Cesarean section 117 45.2

Previous breastfeeding experience

No 166 64.1

Yes 93 35.9

Exclusive breastfeeding practice n %

No 31 12.0

Yes 228 88.0

<One month (30 days) 11 4.2

<Two months (60 days) 17 6.6

<Three months (90 days) 11 4.2

<Four months (120 days) 42 16.2

<Five months (150 days) 43 16.6

<Six months (180 days) 22 8.5

Six months (180 days) 82 31.7

Note(s): Mean (SD) 5 112.44 (64.18), Range 5 0–180 (days)

Table 1.

Frequency and

percentage of the

mothers’

characteristics

(N 5 259)

Table 2.

Frequency and

percentage of the

mothers who were

exclusively

breastfeeding

(N 5 259)

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223

barriers, perceived self-efficacy, family support and 6-month EBF using a chi-square test and

independent t-test. The results (Table 4), indicated that both groups of mothers showed

significant differences in all study variables, except their education.

According to the assumptions for statistical use, the multicollinearity between the

study variables was found. That is, the perceived barriers to breastfeeding showed high

correlations with perceived benefits of breastfeeding (r 5
0.81, p < 0.001), perceived

self-efficacy in breastfeeding (r 5
0.84, p < 0.001) and family support (r 5
0.80, p < 0.001).

The tolerance value of perceived barriers to breastfeeding was less than 0.2, and the variance

inflation factor (VIF) value was greater than 5. Such finding forced the deletion of perceived

barriers to breastfeeding from the main analysis.

The findings from the bivariate logistic regression revealed that previous breastfeeding

experience, maternal age, perceived benefits, perceived self-efficacy and family support had a

significant association with 6-month EBF. The multivariate logistic regression indicated that

perceived benefits of breastfeeding, perceived self-efficacy in breastfeeding and family

support made significant contributions to the EBF practice while previous breastfeeding

experience, maternal age, maternal education did not. That is, the mothers who did practice

6-month EBF had significantly higher odds of perceived benefits of breastfeeding

(AOR 5 1.19, 95% CI 5 1.08, 1.31), perceived self-efficacy in breastfeeding (AOR 5 1.12,

95% CI 5 1.04, 1.19) and family support (AOR 5 1.10, 95% CI 5 1.04, 1.16) compared to those

who did not practice 6-month EBF, Table 5.

Variables (items)

Total scores

Possible Range Actual Range Mean SD %

Perceived benefits of BF (19) 19–76 27–76 58.80 10.10 77.4

Perceived barriers to BF (20) 20–80 22–76 49.68 14.50 62.1

Maternal (10) 10–40 10–38 24.47 7.66 61.2

Infant (4) 4–16 4–16 10.13 3.40 63.3

Socio-environment (6) 6–24 6–24 15.07 4.23 62.8

Perceived self-efficacy in BF (14) 14–70 18–70 48.61 14.66 69.4

Family support (20) 20–80 31–78 56.19 13.73 70.2

Emotional support (5) 5–20 6–20 14.32 3.53 71.6

Appraisal support (5) 5–20 6–20 13.82 4.10 69.1

Informational support (5) 5–20 5–20 13.05 4.46 65.3

Instrumental support (5) 5–20 6–20 15.01 3.28 75.1

Note(s): BF, Breastfeeding

Variables

6-month EBF

X2

/t p-value

No Yes

N Mean (SD) n Mean (SD)

Previous BF experience

No 122 44 5.68a 0.02

Yes 55 38

Maternal age 177 29.9 (5.26) 82 32.21 (6.51)
3.04b <0.01

Maternal education 177 12.59 (2.56) 82 12.83 (2.68)
0.70b 0.49

Perceived benefits of BF 177 54.50 (8.65) 82 68.09 (5.85)
12.91b <0.001

Perceived barriers to BF 177 56.36 (12.18) 82 35.26 (6.28) 14.79b <0.001

Perceived self-efficacy in BF 177 42.25 (13.00) 82 62.34 (6.19)
13.31b <0.001

Family support 177 50.47 (12.30) 82 68.52 (6.83)
12.43b <0.001

Note(s): EBF, Exclusive Breastfeeding; a

Chi-square Test; b

Independent t-test

Table 3.

Descriptive statistics of

the behavior-specific

cognitions and affect

variables (N 5 259)

Table 4.

The study variables in

relation to 6-month

exclusive

breastfeeding

(N 5 259)

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Discussion

Among 259 Vietnamese mothers in Ho Chi Minh City, the rate of 6-month EBF was about

32% which was higher than the national rate of 24% reported by UNICEF in 2016 [11]. The

increase of 6-month EBF in Viet Nam could be a result of the government’s policy of

breastfeeding promotion and people’s awareness of the tremendous advantages of EBF.

Recently, the government introduced a law banning the advertisement of breast milk

substitutes and prolonged paid maternity leave from four to six months [14] which might

result in high awareness of EBF.

The result revealed that by increasing one unit of perceived benefits of breastfeeding,

perceived self-efficacy in breastfeeding and family support, the mothers’ likelihood of

practicing 6-month EBF would increase by 19, 12 and 10%. The influence of perceived

benefits of breastfeeding on 6-month EBF was found in the current study. According to their

response to the measurement of this perception, the Vietnamese mothers were well aware of

the benefits of breastfeeding in terms of being a source of antibodies; helping increase

affective bonding between father, mother and baby; being the best food for babies due to its

comprehensive nutrients; helping the babies have good emotional development; and saving

money. Through cognitive processes, or the procedures used to incorporate new knowledge

and make decisions based on said knowledge [40], a behavioral response specific to such

cognition would be performed. It is logical to explain that once the mother learns about the

benefits of breastfeeding for her infant and herself, such information is stored in her memory

and would be retrieved to help her choose to practice 6-month EBF. Moreover, both intrinsic

(such as feeling positive about being a mother and close bonding with the baby) and extrinsic

(such as saving money and the health status of the baby) rewards that were obtained would

motivate the sustainability of EBF for six months.

The finding that perceived self-efficacy was also a significant predictor of 6-month

EBF did confirm the important role of self-efficacy in EBF as found in Australia [41] and

China [42], for example. A six-month duration is quite long and a mother whose

breastfeeding self-efficacy is not established may feel discouraged and doubt her ability

to maintain 6-month EBF as intended. In contrast, a mother who develops high

breastfeeding self-efficacy, despite any challenges, would exert every effort to overcome

the constraints and obstacles and attain the desired outcomes by providing EBF [43].

Furthermore, according to the HPM, perceived self-efficacy is influenced by activityrelated effects; thus, positive effects happening to the mother during breastfeeding would

make her feel greater efficacy.

Family support in the current study is considered as an interpersonal influence. Beliefs,

attitudes and supportive behaviors that family members provide to one another is very

Variables

Bivariate Multivariate

Unadjusted OR [95% CI] p-value Adjusted OR [95% CI] p-value

Previous breastfeeding experience

No ref

Yes 1.92 [1.12, 3.28] 0.02 0.64 [0.23, 1.80] 0.40

Maternal age (years) 1.07 [1.02, 1.12] <0.01 1.06 [0.96, 1.16] 0.26

Maternal education (years) 1.04 [0.94, 1.15] 0.49 0.87 [0.73, 1.04] 0.13

Perceived benefits of BF 1.34 [1.25, 1.44] <0.001 1.19 [1.08, 1.31] <0.01

Perceived self-efficacy in BF 1.25 [1.18, 1.33] <0.001 1.12 [1.04, 1.19] <0.01

Family support 1.18 [1.13, 1.23] <0.001 1.10 [1.04, 1.16] <0.001

Note(s): BF 5 Breastfeeding; For bivariate analysis - X2 5 149.775, df 5 1, p < 0.001; Nagelkerke R2 5 61.6%;

For multivariate analysis - X2 5 192.118, df 5 6, p < 0.001; Nagelkerke R2 5 73.4%

Table 5.

Bivariate and

multivariate logistic

regression of factors

predicting 6-month

EBF among

Vietnamese

mothers (N 5 259)

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225

influential to Vietnamese mothers regarding their EBF practice. Previous studies conducted

in both northern and southern Vietnam reported similar results indicating that Vietnamese

mothers’ decision on EBF practice depended on the instruction and preferences of their

grandmothers, mothers, mothers-in-law [15, 44] and husbands [28]. Despite regional and

historical differences, people from both northern and southern Vietnam highly valued family

connections and viewed elders as the leaders in families who were very influential in decision

making [45]. Thus, in the context of breastfeeding, when significant family members agreed

with EBF practice, they would act as helpful breastfeeding resources and promote good

breastfeeding practice resulting in an increase in duration and exclusivity of breastfeeding

[46]. That is why mothers in the current study with high family support of breastfeeding were

more likely to give 6-month EBF compared to those with less support.

Maternal education did not affect the 6-month EBF practice in the current study for both

bivariate and multivariate analyses. This finding was inconsistent with the previous studies

conducted in northern Vietnam reporting maternal education as a significant factor of EBF

[18, 28]. This is probably because the current study was conducted in the south where people

are more dynamic and look forward to applying new things in their life, while people in the

north are more conservative and afraid of change [47]. It is easy for the southerners in Ho Chi

Minh City, in particular, to apply modern technology and smart devices to access information

and other resources about breastfeeding. Whatever the educational level the mothers in this

study had obtained, they could retrieve breastfeeding information easily and equally. Even

though previous breastfeeding experience and maternal age were correlated with the 6-

month EBF in the current study, they did not show significant effects when they were entered

together with the other study factors in multivariate analysis. Note that previous

breastfeeding experience and maternal age were correlated with perceived self-efficacy

(r 5 0.28, p < 0.001) and perceived benefits (r 5 0.23, p < 0.001), respectively; and these two

factors could predict the EBF. The possible reason may be because what accounted for the

variance explained in the outcome (EBF) was already shared with these two behavior-specific

cognition factors.

The multicollinearity occurred and forced the deletion of one variable; that is, perceived

barriers to breastfeeding, from the study. According to Dormann et al. [48], when collinearity

occurs, it is not necessary because redundancy of the collinear variables are found;

collinearity is most commonly intrinsic, and it may also happen by chance. Such strong

correlations found in the current study were congruent with the theoretical basis explained

for this occurrence. In the context of breastfeeding, the barriers to breastfeeding practice

would cause discomfort, discouragement and dissatisfaction for the mothers during

breastfeeding. However, a mother’s belief in her ability to succeed at breastfeeding plays a

vital role not only in the initiation of breastfeeding her baby but also in the maintenance of

this practice in the face of challenge and difficulty [33,49]. In addition, breastfeeding practice

is driven by a mother’s cognition in terms of acceptability, motives and attitudes toward the

positive consequences that are caused by breastfeeding the baby [50]. Thus, when the mother

perceives the advantages to outweigh the perceived disadvantages, her motives would drive

the breastfeeding to continue despite difficulties encountered. Furthermore, a mother who is

experiencing stress and challenges from her breastfeeding practice would most benefit from

direct and buffering effects of support from her significant others. That is, the received

support would directly reduce the mother’s stress or problems and moderate the negative

impact of such stress or problems on her health [51] which, in turn, help her to continue her

breastfeeding practice [25].

Limitation of the study

The current study used convenience sampling; thus, the representativeness of this study is

limited. This undermines the ability to generalize from the study sample to the population. In

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addition, the accuracy of EBF duration depended on the mothers’ recall; thus, recall bias

possibly existed even though recall data was less than one year [52]. This study was a crosssectional study in which the study factors and 6-month EBF were assessed simultaneously.

It did not depict events experienced by the mothers before the study regarding EBF success

or problems that might affect their 6-month EBF. Therefore, it did not reveal the causes and

effects of practicing or not practicing 6-month EBF [53].

Conclusion and recommendations

The rate of 6-month EBF in this study is slightly higher than the national rate, yet it requires

more effort to increase the rate according to the recommendation of the WHO. The findings

suggest the need of manipulating the modifiable factors (like perceived benefits and selfefficacy in breastfeeding) by designing a breastfeeding promoting program developed for the

mothers to strengthen their awareness toward the advantages of EBF and the beliefs in their

ability to continue EBF for a six-month period. Mothering classes at an antenatal care unit is a

very common service in many countries. Surprisingly though, the hospitals in Ho Chi Minh

City do not pay much attention to the importance of mothering classes and arranged this

class once a month. The findings of this study should hopefully encourage the hospital

administrative board to establish a mother class at antenatal care as a requirement for all

maternity hospitals. Through the mother class, a psycho-educational nursing intervention

would be helpful to promote EBF among pregnant women. Nurses can identify younger

Vietnamese mothers who lack previous breastfeeding experience and, then, provide

breastfeeding support for them promptly. It seems that decision-making on breastfeeding is

more of a cooperative effort. Thus, the involvement of significant family members in the

intervention of EBF promotion is essential. Both clinical and community nurses should also

equip these family members with up-to-date knowledge and positive attitudes toward EBF so

that they will become good supporters of the mothers. For further research, a well-designed

sampling strategy that represents geographical and environmental areas should be

considered to prevent incidental collinearity [48]. In addition, the causal relationships

among the factors influencing the EBF duration should be examined so that a more

comprehensive picture of EBF and its influencing factors could be illustrated. Further study

should also involve infant factors (e.g. illness, birth weight, twin babies) so that the study

phenomena would be fully understood.

Conflict of Interest: None

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Corresponding author

Tassanee Prasopkittikun can be contacted at: tassanee.pra@mahidol.ac.th

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