Abstract
This study investigates the association between dissatisfaction with breast size prior to pregnancy and prenatal breastfeeding self-efficacy in Türkiye. While 65.6% of women reported dissatisfaction with their current breast size, the majority (80.5%) did not believe that breast size affects breastfeeding success, and 86.5% did not associate it with milk production. The mean absolute dissatisfaction score was 2.38 (SD = 2.57), and the mean prenatal breastfeeding self-efficacy score was 78.29 (SD = 14.04). No significant association was found between breast size dissatisfaction and prenatal breastfeeding self-efficacy (r = –0.021, p = 0.634), even after controlling for previous breastfeeding experience (r = –0.034, p = 0.434). These results indicate that size dissatisfaction is not a significant predictor of prenatal self-efficacy in this population. The study uniquely contributes to literature by revealing a cultural decoupling of esthetic body image from functional confidence, suggesting maternal resilience to appearance anxieties. Consequently, interventions should prioritize structural and psychosocial support over body image concerns.
Introduction
The female body has long been a canvas for cultural and societal ideals, with breasts often symbolizing femininity and sexuality (Lombardo et al., 2019; Pazhoohi et al., 2020; Swami and Tovée, 2013). While many cultures associate larger breast sizes with heightened attractiveness and maternal capability (Dixson et al., 2015; Kościński et al., 2020), empirical research on preferences remains inconsistent, with studies across various cultural contexts reporting preferences ranging from mid-sized figures to a diverse spectrum of sizes; this suggests that pervasive misconceptions regarding an “ideal” size persist (Dixson et al., 2015; Kościński et al., 2020; Oon et al., 2022; Swami et al., 2022). Regardless of these varying preferences, the internalization of such societal ideals frequently leads to body dissatisfaction, with significant implications for self-esteem and psychosocial well-being (Abdoli et al., 2024; Swami et al., 2020a; Swami and Furnham, 2018). Accordingly, it is not surprising that recent cross-cultural research involving over 18,000 women across 40 countries found that approximately 70% of participants experienced a mismatch between their ideal and actual breast size; specifically, only 29.3% were satisfied with their breasts, while 47.5% desired larger and 23.2% desired smaller breasts (Swami et al., 2020b). Such dissatisfaction extends beyond cosmetic concerns and may influence biological and psychosocial processes, including pregnancy and breastfeeding (Lin et al., 2025; Swami et al., 2022; Zhou et al., 2025).
Breastfeeding self-efficacy has long been recognized as a process shaped by a mother’s socio-demographic characteristics and obstetric history (Brockway et al., 2017; Rodgers et al., 2018; Zhou et al., 2025). However, contemporary research suggests that these traditional factors are deeply intertwined with psychological evaluations of the body. Specifically, studies conducted in diverse cultural contexts, such as Türkiye and Israel, indicate that a positive body image significantly enhances breastfeeding self-efficacy in both primiparous and multiparous women (Bülbül and Menekşe, 2024; Geller et al., 2024). Beyond simple associations, recent evidence positions positive body image as a critical determinant during pregnancy; for instance, factors such as monthly income, social support, and positive body image have been shown to explain 53.5% of the total variance in third-trimester breastfeeding self-efficacy (Zhou et al., 2025). Notably, positive body image has been found to partially mediate the relationship between social support and self-efficacy (Zhou et al., 2025). Furthermore, systematic reviews have shown that body image plays a significant role in shaping postpartum breastfeeding trajectories (Morley-Hewitt and Owen, 2020); however, this relationship appears to be highly complex, potentially being influenced by diverse sociocultural determinants and individual physiological factors like maternal sizes and weights (Bigman et al., 2021). While several studies have established a link between global body image and breastfeeding self-efficacy, the specific role of pre-pregnancy breast size dissatisfaction remains critically underexplored as a localized and potent form of appearance anxiety. Despite advancements in breastfeeding awareness, pervasive misconceptions about breast size persist across diverse cultures. These include beliefs that smaller breasts cannot produce enough milk or that larger breasts are inherently superior for breastfeeding, which can erode maternal confidence and act as barriers to successful breastfeeding (Sosseh et al., 2023; Zhang et al., 2018). For example, a study conducted in China identified breast size as a factor associated with breastfeeding difficulties (Huang et al., 2017). These findings underscore the necessity for more nuanced and targeted research that accounts for specific dimensions of body image, such as breast size dissatisfaction, alongside sociocultural determinants.
Addressing these multifaceted factors is particularly essential within the sociocultural context of Türkiye, where breastfeeding is highly valued yet increasingly influenced by both traditional and modern body ideals. To date, limited research in Türkiye has addressed this intersection, often focusing on objective physical markers or broad psychological constructs rather than specific maternal perceptions. Notably, Taflan et al. (2015) investigated the relationship between physical breast size and breastfeeding duration, yet their findings suggested that objective physiology alone does not dictate breastfeeding outcomes (Taflan et al., 2015). While their study provided valuable clinical data, its retrospective and purely physical focus did not account for the psychological impact of breast size perception—specifically how a mother’s subjective dissatisfaction with her body, regardless of its actual size, might act as a prenatal cognitive barrier. On the psychological side, Bülbül and Menekşe (2024) demonstrated that a positive global body image enhances breastfeeding self-efficacy (Bülbül and Menekşe, 2024). However, their research focused on a general appreciation of the body, which may not fully capture the unique and localized anxieties associated with the “feeding organ” itself. This highlights a critical need to move beyond global body image and examine more localized appearance concerns, such as pre-pregnancy breast size dissatisfaction. In the sociocultural fabric of Türkiye, where maternal identity is intrinsically linked to the perceived adequacy of the nourishing body, understanding these specific perceptions is essential. Such a focused approach addresses a missing link in the literature by examining how localized appearance-related anxiety translates into functional self-efficacy, providing a more nuanced understanding of maternal health behaviors than general body positivity alone. Since perceptions of breastfeeding self-efficacy during the antenatal period play a critical role in postnatal breastfeeding initiation and maintenance, addressing these perceptions is essential. Therefore, strengthening breastfeeding self-efficacy during the prenatal period, a modifiable factor, may significantly enhance postpartum breastfeeding success (Brockway et al., 2017). This study aims to investigate the relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy, addressing a critical gap in the literature. The findings are expected to provide healthcare professionals, particularly midwives and lactation consultants, with valuable insights for developing more effective, culturally sensitive interventions to support mothers. The research question guiding this study is as follows: (1) Is there a relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy?
Method
Research design
A descriptive, cross-sectional study design was utilized to investigate the relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy. The reporting of this study was guided by STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (von Elm et al., 2007).
Setting, target population and the sample
The study was conducted between April and November 2024 in the antenatal clinics of a university hospital in Türkiye. These clinics provide antenatal care services, including routine pregnancy monitoring, detailed ultrasonography, prenatal screening, and care for high-risk pregnancies, such as those involving gestational diabetes, hypertension, or fetal growth restrictions.
Since the total population size was not pre-determined, the sample size was calculated using Epi Info (version 7.3) based on an expected prevalence of 50%, a 5% margin of error, and a 97% confidence level. The minimum required sample size was determined to be 471 participants. To account for potential data loss and to increase statistical power, a total of 518 pregnant women were included in the study. Participants were recruited using a consecutive sampling method from those who presented to the antenatal clinics of a university hospital in Türkiye between April and November 2024, and who met the predetermined inclusion criteria. The inclusion criteria were as follows: (a) aged 18 years or older, (b) literate and fluent in Turkish, (c) between 28 and 42 weeks of gestation, (d) singleton pregnancy without complications, (e) no history of psychiatric disorders or breastfeeding-related breast issues, and (f) willingness to participate in the study. Exclusion criteria included: (a) under 18 years old, (b) illiteracy or inability to speak Turkish, (c) gestational age below 28 weeks, (d) history of chronic or psychiatric illness, (e) prior breastfeeding-related breast issues (e.g. flat or inverted nipples, breast masses, breast cancer, or previous breast surgery), (f) multifetal pregnancies (e.g. twins) or high-risk conditions (e.g. pre-eclampsia), and (g) lack of willingness to participate.
Measures
Demographic characteristics data form
This form included eight items capturing socio-demographic data, such as age, education, employment, income, and BMI, as well as five items addressing obstetric characteristics, including parity, age at first pregnancy, number of pregnancies, and number of living children. Additionally, the form included three items related to breastfeeding history and a separate, specific item to assess anatomical nipple characteristics (e.g. flat or inverted nipples). This item served as a screening tool to identify and exclude participants with potential physical barriers to breastfeeding. Participants were also asked to subjectively report their pre-pregnancy bra size in terms of cup size (categorized as A, B, C, or D in this study) and band size (measured in centimeters (cm); categorized as 70, 75, 80, 85, 90, 95, and 100 in this study).
Breast size rating scale (BSRS)
Breast size dissatisfaction was operationalized as the discrepancy between actual and ideal breast size and was assessed using the BSRS (Swami et al., 2015). The BSRS is a figural rating scale consisting of 14 computer-generated grayscale images of women with progressively increasing breast sizes (for the original figures, see Swami et al., 2015). All images are presented without facial features to reduce potential bias. Participants were asked to indicate which image most closely represented their current breast size and which image they ideally desired, using a 14-point scale (1 = figure with the smallest breast size, 14 = figure with the largest breast size). Breast size dissatisfaction was calculated as the absolute difference between the current and ideal ratings, with higher scores indicating greater dissatisfaction. Permission to use the BSRS was obtained from the original author via email.
Prenatal breastfeeding self-efficacy scale (PBSES)
Originally developed by Wells et al. (2006) and adapted into Turkish by Aydin and Pasinlioglu (2018), this 20-item Likert scale measures self-efficacy (1 = Not confident at all, 5 = Completely confident). The scale ranges from a minimum of 20 to a maximum of 100, with an increase in score denoting an increase in perceived breastfeeding self-efficacy. Higher scores indicate greater self-efficacy. The Turkish version’s Cronbach’s alpha was 0.86, and in this study, it was recalculated as 0.918.
Data collection procedure
Data were collected face-to-face by Researchers 2 and 3 in a private clinic room after the purpose of the study was explained and informed consent was obtained. Each interview lasted approximately 15 minutes. Researcher 2 holds a doctorate in women’s health and diseases nursing, while Researcher 3 has a bachelor’s degree in nursing.
Data analysis
Data analysis was performed using IBM SPSS Statistics version 25. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize participants’ sociodemographic, obstetric, and breastfeeding-related characteristics. The normality of continuous variables was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Since all key variables were found to deviate significantly from normal distribution (p < 0.05), non-parametric methods were applied.
The relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy was assessed using Spearman’s rank correlation coefficient. In addition, partial correlation analysis was conducted to control for the potential confounding effect of previous breastfeeding experience. The level of statistical significance was set at p < 0.05 for all analyses.
Results
The study investigating the relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy yielded the following findings. A total of 518 pregnant women participated in the study.
Sociodemographic and obstetric characteristics
Table 1 presents the socio-demographic and obstetric characteristics of the participants. The mean age of the women was 30.84 years (SD = 5.02, range: 19–45), and the mean BMI was 26.25 (SD = 5.20, range: 17.30–50.64). Regarding education levels, 33.8% (n = 175) of participants had a university degree, while 19.3% (n = 100) had completed only primary education. In terms of employment status, 54.8% (n = 284) were not working. Income level data indicate that 63.9% (n = 331) reported income levels above the minimum wage, and 91.3% (n = 473) had social security. Among the participants, 45.8% (n = 237) were primigravida, and 54.2% (n = 281) were multigravida. Regarding breastfeeding history, 49.2% (n = 255) had previously breastfed, while 45.8% (n = 237) were experiencing their first pregnancy.
Socio-demographic and obstetric characteristics of women (n = 518).
Note: The net minimum wage for the year 2024 is 20,002.50 TRY.
Most participants, 80.5% (n = 417), reported that they did not believe breast size affects breastfeeding success, while 19.5% (n = 101) indicated a belief that it does. Similarly, 86.5% (n = 448) did not associate breast size with milk production, whereas 13.5% (n = 70) believed that it played a role (Table 1).
Descriptive findings on breast size preferences, dissatisfaction, and prenatal breastfeeding self-efficacy scores
When examining the distribution of participants’ breast size preferences, the most frequently reported preference was for a smaller breast size (n = 253, 48.8%). While 34.4% of participants (n = 178) reported satisfaction with their current breast size, 16.8% (n = 87) expressed a desire for larger breasts. These results suggest that dissatisfaction with breast size is most commonly driven by the perception that one’s current breast size is too large. Notably, the proportion of participants satisfied with their breast size (34.4%, n = 178) was lower than the proportion who were dissatisfied (65.6%, n = 340). The preference for a smaller breast size (n = 253, 48.8%) was approximately three times greater than the preference for a larger size (n = 87, 16.8%).
In the total dataset, mean current breast size was 8.31 (SD = 3.33), mean ideal breast size was 6.82 (SD = 2.70), and mean absolute dissatisfaction was 2.38 (SD = 2.57; min-max: 0–13). The participants’ mean total score on the Prenatal Breastfeeding Self-Efficacy Scale was 78.285 ± 14.035 (26–100).
Association between Pre-Pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy
The relationship between breast size dissatisfaction and prenatal breastfeeding self-efficacy was examined using Spearman’s rank correlation coefficient (Table 2). The analysis revealed no statistically significant correlation between the two variables (r = –0.021, p = 0.634). Furthermore, when controlling for previous breastfeeding experience, the partial correlation also remained non-significant (r = –0.034, p = 0.434).
Correlation between breast size dissatisfaction and prenatal breastfeeding self-efficacy.
r: correlation coefficient; p: significance (two-tailed).
Spearman’s rho. **Partial correlation.
Discussion
Breast size dissatisfaction is a critical psychosocial variable that influences body image and breastfeeding behaviors, shaped largely by societal norms and cultural expectations (Swami et al., 2020b). However, its impact on prenatal breastfeeding self-efficacy has remained underexplored. This study contributes to the literature by investigating the relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy.
There was no significant relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy; this finding remained unchanged even after controlling for previous breastfeeding experience as a confounding factor. Our results align with recent findings from a study in Israel, which similarly reported that breast size dissatisfaction was not significantly associated with breastfeeding self-efficacy (Geller et al., 2024). The consistency between our findings and those observed in the Israeli population (Geller et al., 2024) provides critical insight into the cultural boundary conditions of body image effects. While Western-centric literature typically predicts that appearance dissatisfaction undermines health-related self-efficacy, our results suggest that in specific sociocultural contexts—particularly where motherhood is a highly salient and revered identity—the “functional” aspect of the breast may be cognitively prioritized over its “esthetic” form. This finding is particularly informative as it challenges the standard assumption in health psychology that appearance-related dissatisfaction universally erodes health-related self-efficacy. In Türkiye, breastfeeding is widely seen as a fundamental maternal responsibility. Therefore, concerns about breast appearance may be less important to mothers than their role as a provider for their infants. Consequently, the null finding in both Turkish and Israeli contexts may reflect a shared cultural resilience; specifically, a process where mothers decouple their subjective feelings about breast appearance from their objective belief in their biological capacity to nourish. This meaningful null finding contributes to the literature by demonstrating that external appearance-based influences do not always translate into a lack of maternal health confidence. Moreover, this cognitive shift suggests that during the prenatal period, appearance-related anxieties are often overshadowed by the profound transition into the maternal role, which emphasizes utility over form. Such a perspective explains why our result contrasts with previous research that identified body image concerns as primary drivers of maternal self-perception and breastfeeding behaviors (Morley-Hewitt and Owen, 2020; Swami et al., 2015). One possible explanation for this discrepancy is that breastfeeding self-efficacy may be more strongly influenced by direct experiences, social support, and educational interventions rather than pre-pregnancy body image perceptions. Furthermore, the variability observed across different populations (O’Reilly et al., 2023) underscores the role of cultural norms in mediating how body satisfaction influences maternal confidence. Although body dissatisfaction, which is exacerbated by societal beauty standards and media exposure, can indeed influence perceptions of femininity and identity (Grabe et al., 2008; Lombardo et al., 2019), its direct impact on functional self-efficacy appears limited in the current study. For instance, large-scale systematic reviews have indicated that pregnant women with higher body image satisfaction were more likely to exclusively breastfeed, whereas those with body image concerns were less likely to initiate breastfeeding or maintain shorter breastfeeding durations (Morley-Hewitt and Owen, 2020). However, it is important to note that breastfeeding self-efficacy is primarily shaped by psychosocial and structural factors, such as social support, maternal education, and economic stability, rather than physical characteristics alone (Brockway et al., 2017; Gillen et al., 2021; Morley-Hewitt and Owen, 2020). This insight is crucial for healthcare providers, as it suggests that breastfeeding support should focus on functional and educational aspects rather than assuming that body image concerns will inherently lower a mother’s perceived capability.
In our study, several contextual factors may account for the lack of a significant association. First, participants demonstrated generally high levels of breastfeeding self-efficacy (mean = 78.29 ± 14.04), suggesting a strong baseline confidence that may buffer the influence of individual body image concerns. Among individuals with elevated self-efficacy, the impact of perceptual variables such as breast size dissatisfaction may be diminished. Second, the findings highlight the potential moderating role of cultural norms. In Turkish society, breastfeeding is not only widely practiced but also deeply integrated into cultural perceptions of motherhood. Supporting this, the majority of participants believed that breast size does not directly affect breastfeeding success (80.5%) or milk production (86.5%). These results align with existing research suggesting that breastfeeding outcomes are determined by glandular tissue functionality, hormonal regulation, and psychosocial factors rather than anatomical characteristics like breast size (Babiszewska-Aksamit et al., 2024; Chanprapaph et al., 2007; Geddes et al., 2021; Renner et al., 2008). The widespread belief that breast size is not a determinant of breastfeeding success underscores the importance of addressing psychological and social factors in breastfeeding education. However, a subset of participants (19.5%) believed breast size affects breastfeeding success, and 13.5% associated it with milk production. These findings reflect persistent misconceptions within society. Sosseh et al.’s (2023) qualitative study revealed that breast size affects breastfeeding confidence in the community and that there is a belief that women with larger breasts will breastfeed more successfully (Sosseh et al., 2023). Similarly, Zhang et al. (2018) highlighted that myths about small breast size can pressure mothers and undermine breastfeeding self-efficacy (Zhang et al., 2018). The study also found that women with smaller breasts often bought infant formula during pregnancy, reflecting their concerns about breastfeeding (Zhang et al., 2018). Ultimately, while the dominant cultural narrative in our sample appears protective, the existence of these lingering myths suggests that targeted educational interventions are still necessary to support the self-efficacy of the more vulnerable minority.
Strengths and limitations of the study
This study is one of the few that investigates the relationship between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy, offering valuable and original insights into the existing literature. The use of validated and reliable measurement scales enhances the methodological rigor and reliability of the findings, contributing to the robustness of the results. Furthermore, the study provides valuable data on how body image is shaped by psychosocial and cultural contexts, which can inform interventions aimed at improving breastfeeding self-efficacy.
However, the study’s generalizability is limited due to its focus on a specific geographic region. The cross-sectional design also limits the ability to establish causal relationships between the variables under investigation. The reliance on self-reported data introduces potential biases and inaccuracies, as participants may not always provide accurate or consistent responses. Additionally, breast size perceptions were evaluated subjectively, which makes it challenging to determine whether dissatisfaction stems from perceptual factors, such as societal norms, or physical attributes.
The lack of a significant relationship in our study may also be attributed to methodological factors, including sample composition and measurement limitations. Breastfeeding self-efficacy is also a complex construct influenced by multifaceted factors, and self-reported measures of body satisfaction may not fully capture the psychological and social dimensions that shape maternal confidence in breastfeeding.
These limitations highlight the need for caution when interpreting the findings and emphasize the importance of conducting larger, culturally diverse studies with longitudinal designs to strengthen the evidence base and provide a more comprehensive understanding of the relationship between body image and breastfeeding self-efficacy.
Future studies
Future research should specifically expand on the educational and clinical potential identified in this study. There is a critical need to evaluate whether body functionality-focused training—which shifts maternal attention from esthetic appearance to the biological utility of the breast—can effectively deconstruct persistent myths and improve breastfeeding outcomes. Specifically, randomized controlled trials (RCTs) in antenatal settings are warranted to test whether such interventions can reduce appearance-related anxiety and enhance prenatal breastfeeding self-efficacy. Future studies should also employ mixed-method evaluations to identify the specific cultural contexts in which these interventions are most effective and for whom they provide the greatest benefit. Furthermore, longitudinal designs should track the trajectories of body satisfaction from early pregnancy through the late postpartum period to determine the most effective intervention windows for healthcare providers. By clarifying these mechanisms, future research can move beyond descriptive analysis to develop targeted, culturally sensitive education programs that strengthen maternal confidence against pervasive appearance-related anxieties.
Conclusion
This study found no significant association between pre-pregnancy breast size dissatisfaction and prenatal breastfeeding self-efficacy within the Turkish sociocultural context. While these findings suggest that appearance-related anxieties may not directly undermine prenatal confidence in this population, they highlight the complex interplay between cultural resilience and maternal identity. Based on these results, several specific recommendations are proposed for healthcare practice and policy.
For healthcare practitioners, particularly midwives and lactation consultants, there is a need to transition from purely physiological counseling to a more holistic approach that addresses body functionality. Rather than assuming that appearance dissatisfaction leads to low self-efficacy, practitioners should focus on deconstructing localized myths during routine prenatal care, such as the perceived link between breast size and milk supply. For policy makers, maternal health policies should prioritize the integration of body positive breastfeeding modules into national health initiatives. Promoting the female body’s biological resilience over its esthetic form could serve as a key strategy to maintain the high baseline of self-efficacy observed in this study.
Ultimately, strengthening breastfeeding self-efficacy requires addressing the psychosocial and structural determinants, including social support and persistent cultural misconceptions, that shape a mother’s belief in her capacity to nourish regardless of her subjective body image perceptions. Future research must now focus on longitudinal assessments to determine whether these anxieties emerge as active barriers during the actual postpartum experience.
Footnotes
Ethical considerations
Ethical approval was granted by the Ethics Committee (Approval Number: E-13562490-050.01.04-456496) and institutional permission was obtained (Approval Number: 48814514). After the purpose of the study was fully explained, both written and verbal consent were obtained, and data were subsequently collected. All study procedures were conducted in accordance with the principles outlined in the Helsinki Declaration.
Consent to participate
All participants were informed about the study aims and their right to withdraw at any stage without repercussions. Written and verbal consent was obtained to ensure voluntary participation.
Consent for publication
Consent for publication is not applicable to this article as it does not contain any identifiable data.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by TÜBİTAK-BİDEB 2209/A Research Support Program for Undergraduate Students (Approval Number: 1919B012324398).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. During the revision of this work the author(s) used ChatGPT-4.0/artificial intelligence tool in order to only language editing. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.
Data availability statement
The datasets generated during the present study are not publicly available. The raw data are securely archived by the author at the university and stored in SPSS files. Researchers may request access to the data by contacting the corresponding author in writing. Data sharing will only be permitted in compliance with the Law on the Protection of Personal Data of the Republic of Türkiye (in the context of the processing of personal data for purposes such as research, planning and statistics by anonymization with official statistics, which is not covered by the law in Article 28, paragraph 1 of the Law) and the ethical standards outlined in the Helsinki Declaration.