Factors Influencing Breastfeeding Motivation in Chinese Postpartum Women Based on Self-Determination Theory: A Cross-Sectional Study

Abstract

Chinese

Background:

Understanding breastfeeding motivation determinants is essential for woman-centred support. Limited evidence exists on factors influencing breastfeeding motivation among Chinese women, particularly through self-determination theory.

Research Aim:

This study investigated breastfeeding motivation levels and associated factors in Chinese postpartum women.

Methods:

A cross-sectional study recruited 222 postpartum women from a tertiary hospital in Shandong, China. Sociodemographic data were collected, and breastfeeding motivation was assessed at 6 weeks postpartum using the Breastfeeding Motivation Scale. Univariate analysis and multiple linear regression identified factors associated with autonomous and controlled motivation for breastfeeding.

Results:

Mean autonomous and controlled motivation scores for breastfeeding were 56.44 ± 8.14 and 25.44 ± 4.42, respectively. Multivariate linear regression revealed that multiparity (β = 2.397, p = 0.011) and higher education (β = 5.554, p = 0.021) were positively associated with autonomous motivation, whereas multiparity (β = −1.446, p = 0.003) and higher education (β = −2.508, p = 0.041) were negatively associated with controlled motivation. Caesarean delivery reduced both autonomous (β = −1.921, p = 0.049) and controlled motivation (β = −2.255, p < 0.001). Conventional antenatal education lowered autonomous motivation (β = −6.777, p < 0.001) but increased controlled motivation (β = 3.506, p < 0.001).

Conclusion:

Multiparity and higher education were associated with greater autonomous and lower controlled breastfeeding motivation, whereas conventional antenatal breastfeeding education showed the opposite pattern. Caesarean delivery was associated with lower levels of both motivation types. Autonomy-supportive prenatal programs may help promote sustained breastfeeding motivation.

Graphical Abstract

This is a visual representation of the abstract.

Keywords

breastfeeding China cross-sectional study motivation postpartum women self-determination theory

Background

Breast milk is the optimal source of nutrition for infants, and breastfeeding is the most effective way to promote infant growth and development and maternal health (Lumbiganon et al., 2016; Sun et al., 2017). The World Health Organization (World Health Organization & United Nations Children’s Fund, 2003) recommends initiation within the first hour after birth, exclusive breastfeeding for 6 months, and continued breastfeeding up to 2 years of age. Globally, exclusive breastfeeding rates during infants' first 6 months have increased by 10 percentage points over the past decade, reaching 48% in 2023, approaching the WHO target of 50% by 2025 (United Nations Children’s Fund, & World Health Organization, 2023). China's Breastfeeding Promotion Action Plan (2021-2025) aims to achieve an exclusive breastfeeding rate exceeding 50% for infants under six months by 2025 (National Health Commission of China [NHC], 2021). However, the current exclusive breastfeeding rate for infants at 6 months in China remains at only 29.2%, indicating a substantial gap (China Development Research Foundation [CDRF], 2019). Breastfeeding duration in China is generally short, with low rates of continuation to two years of age. Only 11.5% of infants are breastfed at 1 year and 6.9% at 2 years, with a median duration of 8.63 months (Yang et al., 2016). These findings underscore the urgent need to strengthen breastfeeding promotion initiatives and optimize maternal and child health policies to align with international standards.

Breastfeeding motivation represents the intrinsic drive influencing a woman’s decision to initiate and sustain breastfeeding (Lau et al., 2022). It underpins breastfeeding intention and shapes maternal feeding practices (Lau et al., 2017; Sardo, 2016). Previous studies have shown that higher motivation is associated with both breastfeeding initiation and longer duration (Maleki Saghooni et al., 2021). Understanding the factors that influence motivation is therefore essential for supporting breastfeeding initiation and continuation. Breastfeeding motivation is influenced by multidimensional determinants, including maternal education, pregnancy-related factors, psychological status, and familial and social support, which collectively inform a woman’s decision-making process, underscoring the need for holistic, individualised support to foster positive breastfeeding experiences (Kestler-Peleg et al., 2015; Li & Zhang, 2020). Women with lower education often face reduced breastfeeding initiation rates, while employment pressures and short maternity leave are associated with earlier cessation, and inadequate familial and community support systems significantly compromise breastfeeding establishment (El-Houfey et al., 2017; Rodríguez Vázquez et al., 2023). Breastfeeding motivation may enhance women’s autonomy and capacity to navigate feeding challenges. Women who feel empowered in decision-making are more likely to choose breastfeeding voluntarily and sustain it for longer (Lau et al., 2017). Despite these insights, there remains a notable gap in research examining the specific motivations behind women’s breastfeeding choices. These decisions are shaped by individual circumstances, cultural values, and structural support and warrant further investigation.

Key Messages

Research on breastfeeding motivation, especially in China’s sociocultural context, remains limited. This gap hinders the development of culturally attuned support strategies for Chinese women.

While self-determination theory (SDT) links autonomous motivation to well-being and controlled motivation to anxiety in Western studies, Asian dynamics are understudied.

Our findings identify four key determinants of breastfeeding motivation: parity, birth mode, educational attainment, and antenatal breastfeeding education, offering clinical implications for health-care providers. This study enhances understanding of culturally specific motivations, aiding health-care providers in improving maternal well-being.

Self-determination theory (SDT), originally developed by Ryan and Deci within the positive psychology paradigm, is an empirically validated framework for understanding human motivation (Ryan & Deci, 2000). It provides particular insight into the psychological processes that influence women's autonomous decision-making regarding health behaviors, including infant feeding choices (Kestler-Peleg et al., 2015). The theory postulates that autonomous versus controlled regulatory processes differentially influence behavioral persistence and psychological well-being across health domains (Jochems et al., 2017). Applied to infant feeding, higher autonomous motivation has been associated with more positive breastfeeding practices and longer duration (Akgün & Taştekin, 2020). A mother's sense of self-determination emerges as a crucial element in understanding breastfeeding motivation, highlighting the importance of personal agency in feeding decisions (Kestler-Peleg et al., 2015). When breastfeeding is driven by autonomous motivation (AM), reflecting alignment with personal values and desires, women tend to report stronger breastfeeding intentions, higher confidence, and greater likelihood of continued breastfeeding (Mizrak Şahin et al., 2019). In contrast, controlled motivation (e.g., external pressure or guilt) has been associated with greater psychological distress and lower self-efficacy, which may hinder the maintenance of breastfeeding over time (Kestler-Peleg et al., 2015). AM arises when women make a personal, values-based choice to breastfeed, reflecting their own genuine desires. In contrast, CM reflects external pressures (e.g., social expectations) or internalised guilt. Kestler-Peleg et al. (2015) applied SDT to breastfeeding motivation and well-being, and found that AM was positively related to greater maternal confidence and life satisfaction, while CM was related to anxiety, depression, and lower self-efficacy. These findings suggest that early identification and management of maternal anxiety and depression, coupled with enhancing women's subjective well-being and self-efficacy, may positively influence breastfeeding motivation.

The Breastfeeding Motivation Scale (BMS) was developed by Kestler-Peleg et al. (2015) based on SDT to assess women's motivations for breastfeeding. SDT focuses on the autonomy of women in infant feeding decisions, an area that remains relatively underexplored and may inform breastfeeding support in China. Health professionals and family members should support women’s positive experiences and autonomous decision-making, ensuring breastfeeding choices remain firmly with the mother. Currently, research on breastfeeding motivation remains limited globally (Çerçer & Nazik, 2023; Karakaya & Kılıç, 2024; Mizrak Şahin et al., 2019; Yıldırım Gökşen & Özkan, 2024). In China, sociocultural factors, particularly intergenerational family pressures rooted in traditional culture, have not been well examined in relation to women's breastfeeding motivation. To address this gap, the present study was guided by SDT and examined key determinants of breastfeeding motivation within China's sociocultural context.

Methods

Research Design

A cross-sectional study was conducted at a tertiary hospital in Shandong, China, from October 2024 to March 2025. This design enabled efficient examination of relationships between motivational constructs and breastfeeding-related variables within a defined postpartum period. However, the causal relationships cannot be inferred, because exposures and outcomes were measured simultaneously. The study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Participants were postpartum women who had received antenatal care and delivery services at the study hospital and returned for their routine 6-week (42-day) postnatal assessment. In alignment with China’s national postnatal health-care policies, this visit included three mandated components: physiological recovery assessment, psychological status evaluation, and breastfeeding support. To accommodate diverse preferences, participants could complete the survey via electronic or paper questionnaires. The BMS was used to assess women's motivations during this visit. Ethical approval for this study was obtained from an institutional Human Research Ethics Committee (Approval No. 2023YX083) and conducted in accordance with the Declaration of Helsinki (2013 Revision).

Setting and Relevant Context

Data was sourced from a university-affiliated tertiary Baby-Friendly Hospital serving women across urban, peri-urban, and rural regions of Shandong Province. This hospital conducts approximately 1,800 deliveries annually and has maintained Baby-Friendly Hospital Initiative (BFHI) certification since 1996. This institution represents a provincial health-care benchmark, providing integrated services spanning perinatal care, maternal health education, and community outreach programs. As the world's most populous nation, China's implementation of the three-child policy (NHC, 2021) places new demands on maternal health-care systems. This study focuses on Shandong Province—a demographic powerhouse with 101.5 million residents and the nation's third-highest birth rate. Within this critical region, we examined postpartum women at tertiary hospitals. The identified determinants of breastfeeding motivation may inform the development of strategies to increase exclusive breastfeeding rates and reduce infant malnutrition.

Breastfeeding motivation serves as the proximal driver of maternal lactation behaviors and the precursor to breastfeeding intention, functioning as a predictive variable for sustained breastfeeding practices. This motivation is influenced by multiple factors, including individual maternal characteristics and socio-familial support systems. Consequently, adopting a preventive perspective through investigating modifiable influencers of breastfeeding motivation and implementing targeted early interventions is imperative for cultivating proactive and autonomous motivation, thereby enhancing breastfeeding rates. Presently, research on breastfeeding motivation within China remains at a nascent stage, with a paucity of empirical studies examining its contextual determinants.

Sample

This cross-sectional study adhered to the STROBE guidelines for reporting observational studies. The sample size was calculated using the autonomous breastfeeding motivation score as the primary outcome. With reference to prior research (Ma et al., 2025) reporting a mean AM score of 49.94 (SD = 7.62), we estimated the required sample size to achieve adequate statistical power. According to the cross-sectional study sample size calculation formula:

n = {(Z_{1 - α / 2})}^{2} \times σ^{2} / E^{2},

Where Z_1-α/2 is the critical value of the standard normal distribution at 95% confidence level (1.96), σ is the overall standard deviation (7.62), and E is the allowable error (1.5 points). The yielded a minimum sample size of 100 participants. To further analyze the influencing factors, this study was planned to use a multiple linear regression model incorporating 11 independent variables including age, litter size, place of residence, education, occupation, family structure, monthly income, duration of maternity leave, duration of planned breastfeeding, mode of delivery, and pregnancy guidance. According to the rule of thumb for sample size estimation for regression analysis (10–20 observations are needed for each independent variable), the required sample size ranges from 110 to 220 cases. Considering the sample size estimation results of the cross-sectional survey, the regression analysis needs, and the expected 20% nonresponse rate, the sample size was finally determined to be 220 cases in this study. A total of 230 questionnaires were distributed during the actual survey, and 222 valid questionnaires were recovered, with an effective recovery rate of 96.5%, which satisfied the sample size requirements of the study design.

The study included postpartum women in China who chose to breastfeed. Inclusion criteria were: aged ≥18 years with term pregnancies (≥37 weeks’ gestation); provided informed consent and participated voluntarily; breastfeeding maintained for at least 6 weeks postpartum to ensure established lactation and meaningful assessment of motivation; adequate literacy and communication skills; singleton pregnancy. Exclusion criteria were: severe psychiatric disorders or acute/chronic infectious diseases; severe comorbidities contraindicating breastfeeding (e.g., uncontrolled HIV/AIDS or active tuberculosis); neonates with congenital anomalies or severe illnesses affecting feeding.

Measurement

We developed a structured questionnaire to collect sociodemographic characteristics including: maternal age, parity, mode of birth, current residence, educational attainment, occupational status, household composition, monthly household income, maternity leave duration, intended breastfeeding duration, and previous breastfeeding education. The BMS, originally developed by Kestler-Peleg et al. using SDT as its conceptual framework, assesses women's breastfeeding motivations (Kestler-Peleg et al., 2015). The scale consists of 24 items, each rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). The BMS employs a dimensional scoring approach without composite total scoring, wherein higher subscale scores indicate greater motivational strength within each respective construct (Liu & Gu, 2022). According to the behavioral regulation framework of SDT, the scale is divided into five dimensions: enjoyment and bonding (9 items), maternal self-perception (5 items), pressure from significant others (4 items), practical needs (4 items), and infant health (2 items). The first two dimensions represent AM, while the latter three represent CM. The scale does not calculate a total score; instead, higher scores in each dimension indicate stronger motivation in that area. The Cronbach's α coefficients for the dimensions were 0.930, 0.820, 0.820, 0.740, and 0.620, respectively. This study employed the Chinese version of the BMS, translated and validated by Liu et al. through rigorous cross-cultural adaptation (Liu & Gu, 2022). The Chinese version comprises four dimensions and 24 items: enjoyment (8 entries); connection and maternal self-perception (8 entries), significant others' pressure (4 entries), and pragmatic needs (4 entries), the first two dimensions were attributed to AM and the last two dimensions to CM, and the scoring was consistent with the original scale. The content validity index of the Chinese version of the BMS scale level was 0.901, the Cronbach's α coefficients of the dimensions ranged from 0.709 to 0.934, and the split-half reliabilities ranged from 0.717 to 0.930. In the current study, the Cronbach’s α coefficients for the four dimensions of the BMS were 0.937 for enjoyment, 0.912 for connection and maternal self-perception, 0.763 for significant others' pressure, and 0.763 for pragmatic needs, indicating acceptable to excellent internal consistency.

Data Collection

Eligible women were recruited through systematic random sampling on Mondays, Wednesdays, Fridays, and Sundays from women returning for 6-week postnatal check-ups. To maintain methodological rigour, three research assistants completed standardised training before study commencement. Their responsibilities included uniformly explaining the study objectives and procedures, providing standardised questionnaire instructions, and obtaining written informed consent. Participants self-administered the questionnaire in their preferred format (paper-based or electronic), with all completions occurring on-site under research supervision. Research assistants performed immediate quality checks upon submission. Participants were guaranteed both data confidentiality protection and the unconditional right to withdraw without repercussions.

Data Analysis

All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY). Continuous variables were assessed for normality using the Kolmogorov-Smirnov test and visual inspection of Q-Q plots. Normally distributed variables as mean ± standard deviation (SD), while nonnormally distributed variables as median (interquartile range [IQR]). Categorical variables as counts and percentages (n, %).

For univariate analysis, we employed independent samples t-tests for comparisons between two-group and one-way analysis of variance (ANOVA) for comparisons among three or more groups. Variables that were statistically significant in the univariate analyses (p < 0.05) and theoretically relevant according to previous literature and the SDT framework were included in the multivariable regression models. Categorical variables were entered into the regression models using dummy coding. Primipara, vaginal delivery, senior high and below, and no antenatal breastfeeding health education were used as the reference categories for parity, mode of delivery, education level, and antenatal breastfeeding health education, respectively. Prior to regression analysis, key assumptions of linear regression were examined. Multicollinearity was assessed using variance inflation factors (VIF) and tolerance values. VIF values < 5 and tolerance values > 0.1 were used to indicate the absence of multicollinearity between the independent variables in regression analysis. The normality of residuals was evaluated through visual inspection of normal probability plots, and homoscedasticity was assessed by examining scatterplots of standardized residuals versus predicted values. The goodness-of-fit of the final regression model was evaluated using adjusted R-squared (Adj. R²) to account for the number of predictors in the model. All statistical tests were two-tailed, and a P-value < 0.05 was considered statistically significant. For multiple comparisons, we applied Bonferroni correction to control for type I error inflation.

Results

Characteristics of the Sample

The study included 222 women with a mean age of 31.05 years (SD = 4.61). Key characteristics included: 60% (n = 133) were aged >30 years, 50.5% were primiparous, and 70.3% (n = 156) resided in urban areas. Over 70% had attained at least a high school education, and 79% were in formal employment. Nuclear family structures (cohabiting couples only) accounted for 49.1% of participants. Economically, 93% of households reported a monthly income exceeding 5,000 CNY (≈US$685, purchasing power parity-adjusted). Notably, only 4.5% received less than 3 months of statutory maternity leave (reflecting China’s national minimum of 98 days), while 23.9% planned to meet the WHO-recommended 2-year breastfeeding duration. The caesarean birth rate was 35.6% (n = 79) and 51% had received antenatal breastfeeding education. (Table 1).

Table 1.

Baseline characteristics of study participants (N = 222).

Variables	N (%) / Mean ± SD
Maternal age (range: 21~44, yr)	31.05 ± 4.61
< 30	89 (40.1)
≥ 30	133 (59.9)
Parity
Primipara	112 (50.5)
Multipara	110 (49.5)
Residence
Urban area	156 (70.3)
Rural area	66 (29.7)
Education
Senior high and below	65 (29.3)
Junior college	144 (64.9)
Bachelor or above	13 (5.8)
Maternity occupation
Managers	65 (29.3)
General staff	81 (36.5)
Self-employed	28 (12.6)
Unemployed	48 (21.6)
Family structure
Nuclear family^a	109 (49.1)
Stem family^b	113 (50.9)
Monthly household income (CNY)
< 5000 (equal to 687.5 USD)	16 (7.2)
5000~10000 (equal to 687.5~1375USD)	75 (33.8)
>10000 (equal to 1375USD or more)	131 (59.0)
Length of maternity leave
< 3 months	10 (4.5)
3–6 months	96 (43.3)
> 6 months	16 (7.2)
No maternity leave^c	100 (45)
Duration of planned breastfeeding
< 6 months	8 (3.6)
6~12 months	88 (39.6)
13~24 months	73 (32.9)
> 24 months	53 (23.9)
Mode of birth
Vaginal	143 (64.4)
Cesarean	79 (35.6)
Antenatal breastfeeding health education^d
Yes	114 (51.4)
No	108 (48.6)

Note. ^aNuclear family indicates a family structure of two generations, including parents and unmarried children.

Stem Family indicates a family structure of three generations, including grandparents, a couple of married parents and their unmarried children.

The 'no maternity leave' group primarily consisted of self-employed women and those engaged in informal employment.

Antenatal breastfeeding health education is a preventive intervention for pregnant women who have received systematic instruction on breastfeeding knowledge and skills during pregnancy, which helps to prepare them physiologically and psychologically for breastfeeding after delivery.

Breastfeeding Motivation Profiles

AM scores reflected women's positive breastfeeding experiences: Enjoyment (M = 27.58, SD = 4.67), representing intrinsic satisfaction with breastfeeding; Connection and Maternal Self-Perception (M = 28.86, SD = 3.80), representing the emotional bond with their infant and strengthened sense of maternal role. The total AM score (M = 56.44, SD = 8.14). CM scores captured external influences on feeding decisions: Significant others' pressures (M = 12.17, SD = 2.53), reflecting expectations from family or health-care providers; and pragmatic needs (M = 13.28, SD = 2.31), representing lifestyle and logistical factors affecting feeding choices. Total CM score (M = 25.44, SD = 4.42). (Table 2).

Table 2.

Score on dimensions of maternal breastfeeding motivation (N = 222).

Dimensions	Scores (Mean ± SD)
Enjoyment	27.58 ± 4.67
Connection and maternal self-perception	28.86 ± 3.80
Autonomous motivation	56.44 ± 8.14
Significant other pressures	12.17 ± 2.53
Pragmatic needs	13.28 ± 2.31
Controlled motivation	25.44 ± 4.42

Univariate Analysis of Breastfeeding Motivation Determinants

We examined factors influencing women's breastfeeding motivation through univariate analysis, with AM and CM scores as dependent variables. Independent variables included: maternal age, parity, residential location (urban/rural), education level, occupation status, mode of birth, family structure, monthly income, intended breastfeeding duration, maternity leave duration, and antenatal breastfeeding education exposure. Analysis revealed significant variations in motivation levels across maternal characteristics: multiparous women demonstrated higher AM scores (t = –2.486, p = 0.014) and lower CM scores (t = 3.142, p = 0.002) compared to primiparous women. Women with bachelor's degrees or higher exhibited higher levels of AM (M = 62.54, SD = 4.14; F = 3.437, p = 0.034) and lower levels of CM (M =19.92, SD =2.29; F = 6.635, p = 0.002). Compared to those having caesarean sections, women experiencing vaginal births showed higher AM (t = 2.443, p = 0.015) and lower CM (t = 3.694, p < 0.001). Furthermore, women who received breastfeeding education prenatally compared with noneducated counterparts demonstrated higher AM scores (t = 7.50, p < 0.001) and lower CM scores (t = –6.38, p < 0.001). In contrast, maternal age, residential location, occupation, family structure, household income level, maternity leave duration, and duration of breastfeeding revealed no statistically significant associations (p > 0.05) (Table 3).

Table 3.

Univariate analysis of factors influencing maternal breastfeeding motivation (N = 222).

	Autonomous Motivation			Controlled Motivation
Variables	(Mean ± SD)	F/t	P	(Mean ± SD)	F/t	P
Maternal age (year)		–0.468	0.64		–0.411	0.682
< 30	56.12 ± 8.74			25.29 ± 4.36
≥ 30	56.65 ± 7.74			25.54 ± 4.48
Parity		–2.492	0.013		3.142	0.002
Primipara	55.74 ± 8.81			23.96 ± 4.07
Multipara	58.36 ± 6.76			22.25 ± 4.00
Residence		–0.327	0.744		1.268	0.206
City	56.32 ± 8.51			25.69 ± 4.41
Town	56.71 ± 7.23			24.86 ± 4.45
Education level		3.437	0.034		6.635	0.002
Senior high and below	56.98 ± 7.55			22.43 ± 3.39
Junior college	56.57 ± 8.23			23.71 ± 4.37
Bachelor or above	62.54 ± 4.14			19.92 ± 2.29
Maternity occupation		0.916	0.434		1.334	0.264
Managers	57.51 ± 7.41			24.95 ± 4.70
General staff	55.35 ± 8.95			26.22 ± 4.01
Self-employed	57.07 ± 9.33			25.00 ± 4.97
Unemployed	56.46 ± 6.81			25.04 ± 4.33
Family structure		–1.587	0.114		1.473	0.142
Nuclear Family	55.50 ± 7.96			25.94 ± 4.48
Stem family	57.24 ± 8.29			25.06 ± 4.31
Monthly household income (CNY)		1.472	0.232		0.539	0.584
< 5000	54.81 ± 6.95			25.56 ± 5.23
5000~10000	55.44 ± 8.03			25.85 ± 4.25
> 10000	57.21 ± 8.30			25.19 ± 4.44
Length of maternity leave		0.856	0.465		0.631	0.596
< 3 months	54.00 ± 11.53			26.80 ± 3.94
3~6 months	56.08 ± 8.69			25.41 ± 4.33
> 6 months	55.00 ± 10.05			24.38 ± 4.35
No maternity leave involved	57.25 ± 6.81			25.51 ± 4.59
Duration of planned breastfeeding		0.536	0.658		0.065	0.979
< 6 months	54.13 ± 11.63			25.75 ± 5.04
6~12 months	56.32 ± 7.42			25.52 ± 4.47
13~24 months	56.10 ± 8.54			25.47 ± 4.55
> 24 months	57.45 ± 8.26			25.23 ± 4 .19
Mode of delivery		2.443	0.015		3.694	< 0.001
Vaginal	58.03 ± 7.91			23.82 ± 4.55
Cesarean	55.33 ± 7.76			21.74 ± 2.66
Antenatal breastfeeding health education		7.42	< 0.001		–6.33	< 0.001
Yes	60.53 ± 5.45			21.54 ± 3.26
No	53.36 ± 8.52			24.78 ± 4.27

Multivariate Regression Analysis of Breastfeeding Motivation Determinants

Multiple linear regression models were used to identify independent predictors of AM and CM. Parity, mode of delivery, educational attainment, and antenatal breastfeeding education were included in the regression models based on their statistical significance in univariate analyses and their theoretical relevance according to previous literature and the SDT framework.

The models explained 22.8% of the variance in AM (adjusted R² = 0.228, F = 22.762, p < 0.001) and 25.2% in CM (adjusted R² = 0.252, F = 25.864, p < 0.001). The results indicated that multiparous women compared to primiparous women showed higher AM for breastfeeding (β = 2.397, 95%CI [0.54, 4.25], p = 0.011) and lower CM (β =−1.446, 95%CI [−2.38, −0.51], p = 0.003). Caesarean birth versus vaginal birth was associated with reduced AM (β = −1.921, 95%CI [−3.83, 0], p = 0.049) and lower CM (β = −2.255, 95%CI [−3.22, −1.29], p < 0.001). Women with bachelor’s degrees or higher demonstrated higher levels of AM (β = 5.554, 95%CI [0.85, 10.26], p = 0.021) and lower CM (β = −2.508, 95%CI [−4.90, −0.12], p = 0.041). Breastfeeding education during pregnancy demonstrated contrasting motivational effects: significantly lower AM scores (β = −6.777, 95%CI [−8.65, −4.90], p < 0.001) and higher CM scores (β = 3.506, 95%CI [2.56, 4.45], p < 0.001). No multicollinearity was detected. Complete results are detailed in Tables 4 and 5.

Table 4.

Multiple linear regression analysis of breastfeeding autonomy motivation scores (N = 222).

Variables	β	SE	Standardized β	t	P	95% CI
Parity	2.397	0.940	0.151	2.551	0.011	(0.54, 4.25)
Mode of delivery	−1.921	0.970	−0.119	−1.980	0.049	(−3.83, 0.00)
Education level	5.554	2.389	0.164	2.324	0.021	(0.85, 10.26)
Antenatal breastfeeding health education	−6.777	0.950	-0.427	−7.134	< 0.001	(−8.65, −4.90)

Note. Autonomous motivation: R² = 0.239; Adjust R² = 0.228; F = 22.762, P <0.001.

Table 5.

Multiple linear regression analysis of breastfeeding controlled motivation scores (N = 222).

Variables	β	SE	Standardized β	t	P	95% CI
Parity	−1.446	0.478	−0.176	−3.022	0.003	(−2.38, −0.51)
Mode of delivery	−2.255	0.494	−0.269	−4.567	< 0.001	(−3.22, −1.29)
Education level	−2.508	1.219	−0.143	−2.057	0.041	(−4.90, −0.12)
Antenatal breastfeeding health education	3.506	0.484	0.427	7.250	< 0.001	(2.56, 4.45)

Note. Controlled motivation: R² = 0.262; Adjust R² = 0.252; F = 25.864, P <0.001.

Discussion

This study applied the Chinese BMS to examine women's feeding motivations and postpartum support needs in China. The current study revealed a significant association between BMS and parity, education level, mode of delivery, and antenatal breastfeeding education. Grounded in SDT, two motivational profiles were identified. Women with strong AM breastfeed from personal conviction, demonstrating greater adaptability to feeding challenges and sustained persistence despite difficulties (Lau et al., 2017). These findings underscore the importance of reinforcing women's intrinsic motivation through woman-centred care. In contrast, CM was often driven by external pressures, such as familial or societal expectations, and may be associated with emotional distress and earlier discontinuation (Carrasco-López et al., 2025). Previous research has indicated that partners play a significant role in influencing maternal breastfeeding practices (Rempel et al., 2017). Fathers’ attitudes, encouragement, and practical support can significantly influence maternal breastfeeding confidence, motivation, and duration (Zeng et al., 2024). Fathers may support breastfeeding initiation in the early postpartum period and help sustain breastfeeding through emotional support, companionship, and shared household responsibilities (Leng et al., 2019). Future studies may consider using validated paternal support scales to further examine dyadic motivational processes. In contemporary Chinese society, breastfeeding is frequently framed as both a biological imperative and moral obligation (To et al., 2022), creating complex psychosocial tensions for women. This cultural paradigm creates significant psychosocial tensions where women may suppress their physical and emotional needs to conform to idealised standards of motherhood. These external pressures fundamentally compromise autonomous decision-making, frequently resulting in both exacerbated maternal guilt (when women are unable to meet unrealistic standards) and reduced long-term breastfeeding adherence.

Our findings reveal parity-based differences in breastfeeding motivation, consistent with previous studies (Y. Huang et al., 2019; Wu et al., 2023). Compared with primiparous women, multiparous women had higher AM and lower CM, suggesting more self-determined feeding practices. Higher AM appears particularly important for sustaining breastfeeding (Erdoğan & Özerdoğan, 2025; Lau et al., 2018). Primiparous women face compounded challenges due to limited experience with childbirth and breastfeeding. In contrast, multiparous women often have prior breastfeeding experience, possess more technical skills and have accumulated childcare experience, which may strengthen confidence and intrinsic motivation (Albanese et al., 2024). Based on these findings, we recommend health-care systems implement targeted interventions to support primiparous women, including practical training on common breastfeeding difficulties and timely postpartum lactation support. Peer support may also help women adapt to breastfeeding and early motherhood. Such programs would particularly benefit primiparous women who face the dual challenge of mastering breastfeeding techniques while adapting to new maternal roles.

Our findings demonstrate that higher maternal education is associated with stronger AM for breastfeeding, which corroborates previous findings by Lange et al. (Lange et al., 2016). This finding is consistent with previous studies showing that higher maternal education is associated with more positive breastfeeding attitudes, higher breastfeeding initiation rates, and more favorable perceptions of breastfeeding benefits (Wako et al., 2022). This may be explained by the fact that women with higher educational attainment likely possess greater health literacy, enabling more effective acquisition of breastfeeding information (Mohammed et al., 2024). Their educational background may foster participation in breastfeeding education programs and enhanced problem-solving capacity when facing lactation challenges (Victora et al., 2015). Higher maternal education is associated with stronger breastfeeding self-efficacy, a key determinant of sustained breastfeeding (Shafaei et al., 2020). Conversely, women with lower education exhibit higher CM and greater vulnerability to external feeding influences. These findings highlight the need for tailored interventions targeting this population. Low-literacy-appropriate strategies, such as visually oriented materials and culturally sensitive counseling, may help address specific knowledge gaps and misconceptions while enhancing breastfeeding motivation. Distribution of these interventions should aim not only to improve breastfeeding knowledge but also to enhance women’s confidence, a potentially modifiable factor that could help reduce education-related disparities in breastfeeding outcomes. By adopting these woman-centred approaches, health-care systems may reduce education-related inequities in breastfeeding outcomes while respecting diverse learning needs and cultural contexts.

Contrary to previous findings (Lange et al., 2016), caesarean birth was associated with reduced AM and CM in our study. This discrepancy may reflect two mechanisms. First, postoperative pain and delayed lactogenesis may reduce breastfeeding self-efficacy (S. Li et al., 2024). Second, higher rates of preterm birth in caesarean deliveries compound early feeding difficulties (Lange et al., 2016). Caesarean section is a risk factor for suboptimal breastfeeding outcomes, with postoperative pain and delayed lactation as key barriers (Azzeh et al., 2018; İsik et al., 2016; Khanal et al., 2015). Women undergoing caesarean sections may perceive less societal pressure to breastfeed due to medicalized birth contexts, or they may face practical barriers (e.g., pain, delayed lactation) that reduce externally motivated efforts. Further research should examine how birth experiences influence motivational pathways, particularly in different cultural contexts.

Our study identified an unexpected negative association between conventional antenatal breastfeeding education and AM, a result that contradicts previous reports of extended breastfeeding duration following prenatal education (Cangöl & Şahin, 2017; Shi et al., 2019). It is also inconsistent with the expectations of SDT, which suggests that supportive education should facilitate the internalization of health behaviors and strengthen autonomous motivation (Rodríguez Vázquez et al., 2023). One possible explanation relates to the style of educational delivery. If breastfeeding education is presented in a directive or prescriptive manner, emphasizing maternal obligation rather than personal choice and competence, it may reinforce controlled motivation rather than foster autonomous motivation. Another possible explanation involves cultural context. In many countries and regions, including China, breastfeeding is strongly promoted within health-care systems and public discourse (C. Huang et al., 2022). Women receiving antenatal education may therefore perceive stronger external expectations from health-care providers, family members, or society, increasing feelings of obligation or pressure to breastfeed. Such external pressures may function as controlled motivation rather than an internally endorsed choice. In addition, differences in the content, format, and timing of antenatal breastfeeding education may influence motivational outcomes. We recommend updating antenatal curricula to align with SDT, adopting autonomy-supportive communication (e.g., "Choose the option that suits you best") to empower women's informed breastfeeding decisions.

This research has several limitations that should be considered. First, the study was conducted in a single tertiary hospital, which may limit the generalizability of the findings. Maternal characteristics, health-care practices, and breastfeeding support systems may vary across regions and health-care settings. Therefore, caution should be exercised when generalizing these findings to other populations. Second, the cross-cultural applicability of our findings requires careful interpretation, given that breastfeeding motivation is influenced by complex interactions between traditional cultural values and national policy frameworks that vary significantly across different countries and regions. Third, this cross-sectional design limits the ability to infer causal relationships between variables. Fourth, only women who were still breastfeeding at 6 weeks postpartum were included, because breastfeeding is typically established by this stage, allowing meaningful assessment of motivation. Women who discontinued earlier may present greater heterogeneity and early lactation difficulties, which could confound this assessment of motivation. This may limit generalizability and introduce selection bias, potentially overestimating breastfeeding motivation. Additionally, as the data were collected using self-reported questionnaires, the findings may be subject to social desirability bias. Future multicenter studies including more diverse health-care settings would strengthen the external validity of these findings.

Conclusion

Our findings identify four key determinants of breastfeeding motivation: parity, mode of birth, educational attainment, and antenatal breastfeeding education. These findings carry important clinical implications for health-care providers. Before delivering breastfeeding support, clinicians should first evaluate women’s motivation levels and identify modifiable factors that may enhance AM. Future research should prioritise the development of culturally adapted motivational interventions and the development of standardised assessment tools for clinical practice.

Footnotes

Acknowledgements

We thank all the women who participated in this study and the health-care professionals who contributed to this study.

Abbreviations

SDT Self-determination theory

AM Autonomous motivation

CM Controlled motivation

BMS Breastfeeding Motivation Scale

ORCID iD

Wei Xia

Ethical Considerations

This study was approved by the Ethics Committee of Shandong Second Medical University (Approval No. 2023YX083).

Consent to Participate

Written informed consent was obtained from all participants prior to data collection.

Author Contributions

Shuliang Zhao: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Software; Writing—original draft.

Aihua Wang: Methodology; Resources; Supervision; Validation; Writing—review & editing.

Wei Xia: Project administration; Resources; Software; Supervision; Visualization; Writing—review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Research data are not shared.

References

Akgün

Taştekin

(2020). The effect of information-motivation-behavioral skills on breastfeeding success: A hypothetical model. Journal of Transcultural Nursing, 31(4), 378–386. https://doi.org/10.1177/1043659619872245

Albanese

A. M.

Geller

P. A.

Steinkamp

J. M.

Elwy

A. R.

Frank

H. E.

Barkin

J. L.

(2024). The education of experience: Mixed methods evidence demonstrates the benefit of multiparity. Midwifery, 134, 104015. https://doi.org/10.1016/j.midw.2024.104015

Azzeh

F. S.

Alazzeh

A. Y.

Hijazi

H. H.

Wazzan

H. Y.

Jawharji

M. T.

Jazar

A. S.

Filimban

A. M.

Alshamrani

A. S.

Labani

M. S.

Hasanain

T. A.

Obeidat

A. A.

(2018). Factors associated with not breastfeeding and delaying the early initiation of breastfeeding in Mecca region, Saudi Arabia. Children, 5(1), 8. https://doi.org/10.3390/children5010008

Cangöl

Şahin

N. H.

(2017). Effect of a breastfeeding motivation program maintained during pregnancy on supporting breastfeeding: A randomized controlled trial. Breastfeeding Medicine, 12(4), 218–226. https://doi.org/10.1089/bfm.2016.0190

Carrasco-López

M. J.

Antón-Solanas

Benito-Ruiz

Barrio-Forné

Navas-Ferrer

Ramón-Arbúes

Subirón-Valera

A. B.

(2025). Underpinnings of breastfeeding motivation: A systematic review. Midwifery, 148, 104475. https://doi.org/10.1016/j.midw.2025.104475

Çerçer

Nazik

(2023). The effects of the breastfeeding problems management model on breastfeeding problems, breastfeeding motivation and breastfeeding success: A randomized controlled trial. Journal of Pediatric Nursing, 73, e116–e124. https://doi.org/10.1016/j.pedn.2023.07.021

China Development Research Foundation (2019). Survey on factors influencing breastfeeding in China.

El-Houfey

Saad

Abbas

Rashad

Wadani

(2017). Factors that influence exclusive breastfeeding: A literature review. International Journal of Nursing Didactics, 7(11), 24–31. https://doi.org/10.15520/ijnd.2017.vol7.iss11.264.24-31

Erdoğan

Özerdoğan

(2025). Evaluation of the effect of the father's support on the mother's breastfeeding motivation. Journal of Evaluation in Clinical Practice, 31, e14156. https://doi.org/10.1111/jep.14156

10.

Huang

Zhang

Luo

(2022). Breastfeeding education in Chinese hospitals: A cross-sectional study. International Journal of Nursing Studies, 133, 104310. https://doi.org/10.1016/j.ijnurstu.2022.104310

11.

Huang

Ouyang

Y. Q.

Redding

S. R.

(2019). Previous breastfeeding experience and its influence on breastfeeding outcomes in subsequent births: A systematic review. Women and Birth, 32(4), 303–309. https://doi.org/10.1016/j.wombi.2018.09.003

12.

İsik

Dag

Z. O.

Tulmac

O. B.

Pek

(2016). Early postpartum lactation effects of cesarean and vaginal birth. Ginekologia Polska, 87(6), 426–430. https://doi.org/10.5603/GP.2016.0020

13.

Jochems

E. C.

Duivenvoorden

H. J.

van Dam

van der Feltz-Cornelis

C. M.

Mulder

C. L.

(2017). Motivation, treatment engagement and psychosocial outcomes in outpatients with severe mental illness: A test of self-determination theory. International Journal of Methods in Psychiatric Research, 26(3), e1537. https://doi.org/10.1002/mpr.1537

14.

Karakaya

Kılıç

(2024). The relationship between breastfeeding motivation, workplace breastfeeding support, and job satisfaction among working mothers. African Journal of Reproductive Health, 28(11), 141–151. https://doi.org/10.29063/ajrhhttps://doi.org/10.29063/ajrh20242024/v28i11.14

15.

Kestler-Peleg

Shamir-Dardikman

Hermoni

Ginzburg

(2015). Breastfeeding motivation and self-determination theory. Social Science & Medicine, 144, 19–27. https://doi.org/10.1016/j.socscimed.2015.09.006

16.

Khanal

Scott

J. A.

Lee

A. H.

Karkee

Binns

C. W.

(2015). Factors associated with early initiation of breastfeeding in Western Nepal. International Journal of Environmental Research and Public Health, 12(8), 9562–9574. https://doi.org/10.3390/ijerph120809562

17.

Lange

Nautsch

Weitmann

Ittermann

Heckmann

(2016). Breastfeeding motivation in Pomerania: Survey of neonates in Pomerania study. International Breastfeeding Journal, 12, 3. https://doi.org/10.1186/s13006-016-0093-6

18.

Lau

C. Y. K.

Fong

D. Y. T.

Chan

V. H. S.

Lok

K. Y. W.

J. W. Y.

Sing

Tarrant

(2022). The effect of maternal self-regulated motivation on breastfeeding continuation. Maternal and Child Health Journal, 26(2), 441–448. https://doi.org/10.1007/s10995-021-03274-5

19.

Lau

C. Y. K.

Fong

D. Y. T.

Choi

A. Y.

J. W.

Sing

Tarrant

(2017). Development and measurement properties of the Chinese breastfeeding self-regulation questionnaire. Midwifery, 44, 24–34. https://doi.org/10.1016/j.midw.2016.10.012

20.

Lau

C. Y. K.

Lok

K. Y. W.

Tarrant

(2018). Breastfeeding duration and the theory of planned behavior and breastfeeding self-efficacy framework: A systematic review of observational studies. Maternal and Child Health Journal, 22(3), 327–342. https://doi.org/10.1007/s10995-018-2453-x

21.

Leng

R. N. W.

Shorey

Yin

S. L. K.

Chan

C. P. P.

H.-G.

(2019). Fathers’ involvement in their wives’/partners’ breastfeeding: A descriptive correlational study. Journal of Human Lactation, 35(4), 801–812. https://doi.org/10.1177/0890334419830988

22.

Wupuer

Hou

(2024). Factors influencing delayed onset of lactogenesis: A scoping review. International Journal of General Medicine, 17, 2311–2326. https://doi.org/10.2147/IJGM.S452108

23.

X. Y.

Zhang

X. H.

(2020). Status and influencing factors of self-regulation motivation for breastfeeding among pregnant and postpartum women. Journal of Nursing Science, 35(18), 32–35. https://doi.org/10.3870/j.issn.1001-4152.2020.18.032

24.

Liu

(2022). Sinicization and reliability test of the breastfeeding motivation scale. Chinese Journal of Nursing, 57(12), 1531–1536. https://doi.org/10.3761/j.issn.0254-1769.2022.12.019

25.

Lumbiganon

Martis

Laopaiboon

Festin

M. R.

J. J.

Hakimi

(2016). Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database of Systematic Reviews, 12, CD006425. https://doi.org/10.1002/14651858.CD006425.pub4

26.

Chen

P. Y.

X. F.

Wang

X. Y.

Dai

M. L.

(2025). Current status and influencing factors of breastfeeding motivation in early postpartum women. Journal of Clinical Medicine in Practice, 29(2), 123–128. https://doi.org/10.7619/jcmp.20242006

27.

A Maleki Saghooni

Karshki

Esmaily

Zaidi Feroz

Mirzaii Najmabadi

. (2021). Mothers’ breastfeeding experiences of emotional support needs: A qualitative study in Iran. Journal of Caring Sciences, 10(3), 169–176. https://doi.org/10.34172/jcs.2021.023

28.

Mizrak Şahin

Ozerdogan

Ozdamar

Gursoy

. (2019). Factors affecting breastfeeding motivation in primiparous mothers: An application of breastfeeding motivation scale based on self-determination theory. Health Care for Women International, 40(6), 637–652. https://doi.org/10.1080/07399332.2018.1526289

29.

Mohammed

Calvert

Mugisha

J. O.

Ronald

Asiki

Glynn

J. R.

Oakley

L. L.

Marston

(2024). Association between breastfeeding duration and educational attainment in rural Southwest Uganda: A population-based cohort study. Global Health Action, 17, 2338023. https://doi.org/10.1080/16549716.2024.2338023

30.

National Health Commission of the People’s Republic of China (2021). Breastfeeding promotion action plan (2021–2025). National Health Commission of the People’s Republic of China. https://www.nhc.gov.cn/fys/c100078/202111/574b286677784efaba4059d584a0f8a2.shtml

31.

Rempel

L. A.

Rempel

J. K.

Moore

K. C.

(2017). Relationships between types of father breastfeeding support and breastfeeding outcomes. Maternal & Child Nutrition, 13(3), e12337. https://doi.org/10.1111/mcn.12337

32.

Rodríguez Vázquez

García Díaz

Jiménez Fernández

Corral Liria

. (2023). Exploring tandem breastfeeding motivations via self-determination theory: An interpretative phenomenological study. Journal of Human Lactation, 39(3), 468–477. https://doi.org/10.1177/08903344231166910

33.

Ryan

R. M.

Deci

E. L.

(2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68

34.

Sardo

(2016). Intrinsic and extrinsic motivation to breastfeed scale: Adaptation and validation for Portuguese population. Procedia—Social and Behavioral Sciences, 217, 1133–1141. https://doi.org/10.1016/j.sbspro.2016.02.128

35.

Shafaei

F. S.

Mirghafourvand

Havizari

(2020). The effect of prenatal counseling on breastfeeding self-efficacy and frequency of breastfeeding problems in mothers with previous unsuccessful breastfeeding: A randomized controlled clinical trial. BMC Women’s Health, 20, 94. https://doi.org/10.1186/s12905-020-00947-1

36.

Shi

J. X.

Shi

X. H.

Sun

J. X.

(2019). Survey on breastfeeding knowledge and self-confidence among hospitalized multiparous women and analysis of influencing factors. Chinese Journal of Modern Nursing, 25(9), 1152–1155. https://doi.org/10.3760/cma.j.issn.1674-2907.2019.09.021

37.

Sun

Chen

Yin

Gao

(2017). Why Chinese mothers stop breastfeeding: Mothers’ self-reported reasons for stopping during the first six months. Journal of Child Health Care, 21(3), 353–363. https://doi.org/10.1177/1367493517719160

38.

S. M.

Yang

Dong

Yan

M. W.

Y. Y.

Chung

M. Y.

(2022). Development and validation of a quantitative measure for parent empowerment via transformative learning. Frontiers in Psychology, 13, 934142. https://doi.org/10.3389/fpsyg.2022.934142

39.

United Nations Children’s Fund & World Health Organization (2023). Global breastfeeding scorecard 2023: Rates of breastfeeding increase around the world through improved protection and support. United Nations Children’s Fund. https://www.unicef.org/documents/global-breastfeeding-scorecard-2023

40.

Victora

C. G.

Horta

B. L.

Loret

Mola

Quevedo

Pinheiro

R. T.

Gigante

D. P.

Gonçalves

Barros

F. C.

(2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: A prospective birth cohort study from Brazil. The Lancet Global Health, 3(4), e199–e205. https://doi.org/10.1016/S2214-109X(15)70002-1

41.

Wako

W. G.

Wayessa

Fikrie

(2022). Effects of maternal education on early initiation and exclusive breastfeeding practices in sub-Saharan Africa: A secondary analysis of demographic and health surveys from 2015 to 2019. BMJ Open, 12(3), e054302. https://doi.org/10.1136/bmjopen-2021-054302

42.

World Health Organization & United Nations Children’s Fund (2003). Global strategy for infant and young child feeding. World Health Organization. https://www.who.int/publications/i/item/9241562218

43.

Liu

Wang

Chu

Zhao

Wang

(2023). Breastfeeding competency and its influencing factors among pregnant women in third trimester pregnancy: A cross-sectional study. Scientific Reports, 13, 1240. https://doi.org/10.1038/s41598-023-28477-4

44.

Yang

Lai

Duan

Pang

Jiang

Wang

Zhao

Yin

(2016). Breastfeeding rates in China: A cross-sectional survey and estimate of benefits of improvement. The Lancet, 388, S47. https://doi.org/10.1016/S0140-6736(16)31974-2

45.

Yıldırım Gökşen

D. F.

Özkan

. (2024). The effect of online breastfeeding education on breastfeeding motivation: A randomized controlled study. Journal of Pediatric Nursing, 75, e42–e48. https://doi.org/10.1016/j.pedn.2023.12.026

46.

Zeng

Zheng

Q. X.

Wang

Q. S.

Liu

G.-H.

Liu

X.-W.

Lin

H.-M.

Guo

S.-B.

(2024). Father support breastfeeding self-efficacy positively affects exclusive breastfeeding at 6 weeks postpartum and its influencing factors in Southeast China: A multicentre cross-sectional study. BMC Public Health, 24, 2698. https://doi.org/10.1186/s12889-024-20136-1