Abstract
Background. Exclusive breastfeeding is one of the most important determinants of infant health and growth. Despite global recommendations, adherence to exclusive breastfeeding remains suboptimal in many countries, and misconceptions continue to be among the main barriers. This study aimed to identify misconceptions related to exclusive breastfeeding among pregnant women and examine their association with demographic factors in the city of Tabriz, Iran.
Methods. This descriptive-analytical cross-sectional study was conducted in 2021 among 225 pregnant women attending outpatient clinics at Al-Zahra and Taleghani hospitals in Tabriz. Data were collected using a 30-item questionnaire rated on a five-point Likert scale (0=strongly disagree to 4=strongly agree). All items represented misconceptions; thus, higher scores indicated greater misconception levels. The total score (0–120) was categorized into four levels (low, moderate, high, very high) based on the 25th, 50th, and 75th percentiles. Content validity was assessed using the Content Validity Ratio (CVR) and Content Validity Index (CVI), with acceptable thresholds of ≥0.62 and ≥0.79, respectively. Reliability was confirmed through a test–retest approach and calculation of the Intraclass Correlation Coefficient (ICC), with values above 0.60 indicating adequate reliability. Data were analyzed using appropriate statistical tests in SPSS version 26, and p<0.05 was considered statistically significant.
Results. The most common misconceptions were the perceived need to give infants water during hot weather, the belief that breastfeeding causes changes in breast shape, and concerns about infants becoming underweight with exclusive breastfeeding. The least frequent misconceptions were the perceived ease of formula feeding and the belief that colostrum is unsuitable. The overall mean misconception score indicated a moderate level. Among demographic variables, only maternal education was significantly associated with misconception scores (p<0.05), with higher-educated mothers reporting more misconceptions. No significant associations were found for age, employment status, or parity.
Conclusion. Misconceptions about exclusive breastfeeding remain prevalent among pregnant women, particularly those related to water supplementation and breast appearance. The higher misconception levels among more educated mothers may reflect exposure to diverse yet unreliable information sources. Strengthening health literacy and providing targeted, evidence-based prenatal education may help correct these misconceptions and improve breastfeeding-related behaviors.
Extended Abstract
Background
Early childhood represents a critical period during which modifiable factors—particularly nutrition—can exert lasting effects on health and developmental outcomes. The World Health Organization recommends exclusive breastfeeding for the first six months of life, followed by continued breastfeeding alongside appropriate complementary foods up to two years of age or beyond. Evidence consistently demonstrates that breastfeeding protects against numerous childhood conditions, including otitis media, diarrheal diseases, lower respiratory infections, sudden infant death syndrome, inflammatory bowel disease, childhood leukemia, diabetes, obesity, asthma, and atopic dermatitis. Long-term cognitive and neurodevelopmental advantages have also been reported.
Despite these well-established benefits, global adherence to exclusive breastfeeding remains suboptimal. Cultural beliefs, traditional practices, and the transmission of inaccurate information across generations contribute significantly to this challenge. In Iran, although several initiatives have aimed to promote breastfeeding, limited attention has been paid to systematically examining maternal misconceptions. Given the influence of cultural beliefs on maternal decision-making, identifying these misconceptions is essential for developing targeted and context-specific educational interventions.
Methods
This descriptive–analytical cross-sectional study was conducted over six months in 2021 among pregnant women attending prenatal care clinics at Al-Zahra and Taleghani teaching hospitals in Tabriz, Iran. Participants were selected through convenience sampling. Inclusion criteria were being pregnant, attending the clinics for routine prenatal care, and willingness to participate. Exclusion criteria included cognitive or psychological disorders, inability to understand the questionnaire, unwillingness to continue participation, or incomplete responses.
The sample size was determined based on the rule of five participants per item for the 30-item instrument. Considering a design effect of 1.2 and a 20% anticipated dropout rate, the final sample size was set at 225. Data were collected using a researcher-developed 30-item questionnaire assessing misconceptions about exclusive breastfeeding. All items were unidirectional; agreement indicated a misconception, and disagreement indicated a correct belief. Items were rated on a five-point Likert scale (0–4), yielding a total score of 0–120. Higher scores reflected greater misconception levels. Total scores were categorized into four levels based on percentile cutoffs: low (0–30), moderate (31–60), high (61–90), and very high (91–120). Mean item scores (0–4) and percentage-of-maximum scores were also calculated.
Content validity was evaluated by a panel of 10 experts using the Content Validity Ratio (CVR) and Content Validity Index (CVI), with acceptable thresholds of ≥0.62 and ≥0.79. Reliability was assessed through a test–retest procedure on 30 participants over one week, and an Intraclass Correlation Coefficient (ICC) above 0.60 indicated acceptable stability.
Data were analyzed using SPSS version 26. Descriptive statistics included means, standard deviations, frequencies, and percentages. The Kolmogorov–Smirnov test assessed normality. Independent t-tests were used for dichotomous variables, and one-way ANOVA with Tukey post hoc tests for multi-category variables. Statistical significance was defined as p<0.05.
Results
A total of 225 pregnant women meeting the inclusion criteria participated in this cross-sectional study, and all questionnaires were completed without missing data.
The mean age of participants was 29.77±7.00 years, ranging from 16 to 51 years. The mean total misconception score was 44.02±6.66, indicating a “moderate” level of misconceptions in the study population. Mean item scores ranged from 0.73 to 2.06. The highest misconception score was observed for the statement: “Healthy infants under six months of age need additional water in hot weather” (mean=2.058; 51.44%). The second most common misconception was “Breastfeeding causes changes in the mother’s breast shape and body” (mean=1.996; 49.89%). The lowest misconception score was related to the item “Formula feeding is easier than breastfeeding” (mean=0.733; 18.33%), followed by “Colostrum should be discarded because it may cause neonatal jaundice” (mean=1.022; 25.56%).
Comparison of misconception scores between women aged <30 years and those aged ≥30 years using an independent t-test showed no statistically significant difference between the age groups (p=0.072).
To examine misconceptions based on parity, participants were categorized into three groups: one pregnancy, two pregnancies, and three or more pregnancies. One-way ANOVA revealed no significant differences in misconception scores among these groups (p=0.311).
Regarding educational level, participants were grouped into three categories: illiterate/ primary, middle/high school, diploma-level education or higher. One-way ANOVA demonstrated a statistically significant difference in misconception scores between educational groups (p<0.001). Post hoc analysis using Tukey’s test indicated that women with diploma-level education or higher had significantly higher misconception scores compared with those in lower educational categories.
Finally, misconception scores were compared between employed and non-employed mothers using an independent t-test. No statistically significant difference was observed between the two groups (p=0.141), indicating that employment status was not associated with the level of breastfeeding-related misconceptions among participants.
Conclusion
This study demonstrated that misconceptions about exclusive breastfeeding remain common among pregnant women, with the most frequent being the perceived need to give infants water during hot weather and concerns about changes in breast shape due to breastfeeding. Among all demographic variables examined, only maternal education was significantly associated with misconception levels, with more highly educated mothers reporting higher scores. This pattern suggests that higher educational attainment does not necessarily guarantee access to accurate breastfeeding information and that exposure to diverse but unreliable sources may contribute to confusion and the persistence of incorrect beliefs. Given the critical role that maternal attitudes play in decisions related to initiating and maintaining exclusive breastfeeding, targeted and evidence-based educational interventions during prenatal care are essential. Enhancing maternal health literacy and directly addressing prevalent misconceptions may improve breastfeeding behaviors and contribute to better health outcomes for both mothers and infants.
Practical Implications of Research
The findings underscore the need for targeted prenatal education that directly addresses common misconceptions such as the perceived need for supplemental water in hot weather, concerns about breast shape changes, and inaccurate beliefs regarding maternal diet and milk production. Integrating evidence-based guidance on these topics into routine prenatal counseling may help correct these misunderstandings.
Concerns related to breastfeeding in the workplace highlight the importance of providing structural support for employed mothers, including dedicated lactation spaces and flexible scheduling.
Given that higher educational attainment was associated with greater misconception levels, strengthening maternal health literacy and information-appraisal skills should be prioritized. Incorporating brief misconception-screening questions into routine prenatal visits may also facilitate early identification and timely correction of inaccurate beliefs.