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Closely linked to the behavioural theories to predict initiation and duration is the use of motivational concepts in breastfeeding research. These have included cognitive evaluation theories (Wells et al., 2002) and Self – efficacy (Kingston et al., 2007).

The feasibility of using the cognitive evaluation theory to examine pregnant women’s intent to breastfeed was examined by Wells et al. (2002). They concluded that women who intend to breastfeed have a higher level of intrinsic motivation than those who plan to formula feed. Additionally, women who reported having breastfed a previous child for any length of time also had significantly higher motivation towards breastfeeding than those who had not breastfed before.

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Similarly, Racine et al. (2009b) undertook a qualitative study exploring intrinsic and extrinsic motivation for breastfeeding. The participants were part of a larger longitudinal study to predict duration among low-income women, based on an economically driven conceptual model known as the theory of individual net-benefit maximisation (INBM) (Racine et al., 2009a). It suggested that breastfeeding women can be categorised into three discrete groups: intrinsically motivated, extrinsically motivated and successfully experienced (Racine et al., 2009b). Results from longitudinal part of this study (Racine et al., 2009a) suggest that women were likely to stop breastfeeding when they perceived that they were lacking social and professional support, when they returned to work and if they think breastfeeding will have a negative effect on their own or their infant’s health. Intrinsic motivation was defined as ‘doing something because of interest or enjoyment in the activity’ (Racine et al., 2009b) (p.175). This definition runs counter to Wells et al. (2002) who suggest that intrinsic motivation is internal to the person i.e., concerns about the mother and child’s health.

Wells et al. (2002) asserted that extrinsic motivation is associated with a decrease in sustained performance of a behaviour, which is contrary to doing something for a reward as is utilised by Racine et al. (2009a). Motivation was labelled as intrinsic or extrinsic based reasons given by women for choosing to breastfeed. It could be suggested that this method of categorisation is crude and does not factor in many of the other components of women’s motivation that have been shown to be important by other studies (Stockdale et al., 2008b).

Based on the premise that de-motivation leads to breastfeeding attrition, Stockdale et al. (2008b) carried out an action research project to test the ARCS model of Motivational Instructional Design. The research aim was to develop

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and test a motivational intervention using the ARCS Model (Stockdale et al., 2008a). Phase four of this study experimentally tested a “Designer Breastfeeding” intervention, which included a motivational version of antenatal instruction, book and postnatal midwife support with Baby Friendly Initiative instruction. First-time mothers (n=182) were recruited to a randomised controlled trial. Women’s motivation was measured using a diagnostic measurement tool which had been assessed for validity in phase 2 of the study. Results demonstrated that “Designer Breastfeeding” significantly increased maternal confidence, perceived midwife support and persistence to breastfeed on discharge from hospital and at three weeks. While this design has shown promise in increasing duration to three weeks, the impact on longer duration of breastfeeding has yet to be determined.

The potential impact of motivational instruction on breastfeeding initiation was also explored by Coombs et al. (1998). This study evaluated a self-help manual designed to motivate low-income mothers to initiate breastfeeding. A randomised controlled trial found that the manual positively influenced breastfeeding initiation, with 60% of treatment women initiating breastfeeding compared to 44% of the control group. However, this method of motivational instruction showed no significant difference in breastfeeding duration.

Evidence highlights two motivational factors important to breastfeeding, women lack confidence and professional support (Avery et al., 1998; Chezem et al., 2003; Dodgson et al., 2003). The concept of maternal confidence has been explored by researchers keen to prolong the duration of breastfeeding (Blyth et al., 2002; Nichols et al., 2009). Breastfeeding self-efficacy was first described by Dennis (Dennis, 1999) who utilised Bandura’s (1977) Social Learning Theory as a theoretical framework. Self-efficacy can be defined as ‘confidence in one’s perceived ability to regulate their motivation, thought processes, emotional states, and social environment in performing a specific behaviour’ (Dennis,

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1999) (p.196). Bandura (1997) asserted that this dynamic cognitive process is mediated by four factors that determine the level of an individual’s self- efficacy; a) performance accomplishment (past experiences) b) vicarious experience (seeing others breastfeed) c) verbal persuasion (encouragement from others) and d) emotional arousal (psychological responses such as stress and fatigue).

The concept of self-efficacy, while not specifically related to initiation of breastfeeding has been shown to be an important determinant of duration (O'Campo et al., 1992; Papinczak & Turner, 2000; Blyth et al., 2002; Dennis et al., 2002; Dunn et al., 2006). Furthermore, performance accomplishment is particularly relevant to a women’s future breastfeeding experiences, as successful mastery of breastfeeding leads to the expectation of a similarly successful occurrence in future breastfeeding experiences (Nichols et al., 2009).2 Bandura (1997) has described the mastery experience as the most powerful determinant of self-efficacy. Kingston et al. (2007) have also demonstrated that vicarious experiences positively enhance women’s breastfeeding self-efficacy. This descriptive study of women in Ontario concluded that those women who indicated that they had breastfeeding role models had higher levels of breastfeeding self-efficacy. The study utilised a modified version of the Breastfeeding-Self-Efficacy Scale (BSES), which had been developed and validated by Dennis & Faux (1999) to identify mothers with low breastfeeding confidence.

Wilhelm et al. (2008) looked at the influence of self-efficacy on breastfeeding intention and duration. Comparing motivational interviewing with a control group from birth to the first 6 months they concluded that women with higher levels of intention were likely to breastfeed for longer.

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The higher the incidence of early discontinuation in a country the more limited are the opportunities, for both effective mastery and vicarious experience.

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Many authors have thus speculated that increasing the mother’s self-efficacy would increase the duration of breastfeeding (Blyth et al., 2002; Dennis et al., 2002); however, in common with other psychological theories such as the TpB, the application of interventions based on self-efficacy have been extremely limited. In a small convenience sample of 90 Australians, Nichols et al. (2009) demonstrated that the application of a workbook to increase women’s self efficacy resulted in a trend towards higher self-efficacy and consequently higher levels of breastfeeding. Women in this study were randomly assigned to an intervention or control group. Results, while promising, are limited due to the short duration of follow-up at 4 weeks. Given that the potential impact of such interventions is aimed at increasing duration of breastfeeding, studies that evaluate the impact on duration for the recommended period of six months are required. In a randomised controlled trial of an intervention to increase self- efficacy among 110 nulliparous women, Noel-Weiss et al.(2006) concluded that a workshop to improve self-efficacy had a positive impact on women’s scores. Although they suggest there was a detectable increase in breastfeeding duration at 8 weeks this was not found to reach statistical significance. Thus while the concept of self-efficacy has shown some promise its effect on initiation and duration has yet to be fully determined.