Breastfeeding empowerment and its relationship with health literacy and spousal support among breastfeeding mothers in Tabriz, Iran: a cross-sectional study

Abstract

Background

Breast milk is crucial for the health and survival of infants, but exclusive breastfeeding often fails due to various reasons such as lack of breastfeeding empowerment.

Objectives

This study aimed to determine the status of breastfeeding empowerment and its relationship with health literacy and perceived spousal support among breastfeeding mothers while recognising that other related factors also contribute to breastfeeding empowerment.

Design

Cross-sectional study.

Setting

Primary health centres of Tabriz city, Iran.

Participants

Included 342 breastfeeding mothers with infants aged 6 months or younger in Tabriz, Iran.

Results

The mean (SD) scores for breastfeeding empowerment, health literacy and partner support were 141.98 (33.92) out of a possible range of 37 to 185, 126.08 (21.27) out of a possible range of 33 to 165 and 64.95 (12.62) out of a possible range of 20 to 100, respectively. Based on the adjusted general linear model, for every unit increase in perceived spousal support, women’s breastfeeding empowerment score increased significantly (B=0.546; 95% CI 0.29 to 0.79; p<0.001). Additionally, working mothers had a significantly higher breastfeeding empowerment score compared with housewives (B=13.91; 95% CI 0.88 to 27.73; p=0.04), and currently, breastfeeding mothers had a significantly higher score compared with mothers who were not currently breastfeeding (B=72.26; 95% CI 60.42 to 84.10; p<0.001).

Conclusions

The findings of this study underscore the critical role of perceived spousal support in enhancing breastfeeding empowerment among mothers. By encouraging spousal involvement, families can create a supportive environment that values and facilitates breastfeeding. Healthcare providers also can play an essential role in offering guidance and resources to both mothers and their partners. By emphasising the importance of spousal support in breastfeeding, a supportive culture can be fostered that values breastfeeding as a natural aspect of motherhood.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Validated questionnaires were used to measure breastfeeding empowerment, health literacy and perceived spousal support, ensuring data reliability.

• The reliance on self-reported measures may introduce bias, as mothers might overestimate their breastfeeding empowerment and perceived support.

• The study does not account for all potential determinants and confounders of breastfeeding empowerment, such as the influence of female support groups and family dynamics.

• Future research should explore additional factors influencing breastfeeding practices to provide a more comprehensive understanding.

Introductions

Breastfeeding is both biologically and morally the inalienable right of infants, and breast milk is essential for improving the health, quality of life and survival of infants.^{1 2} According to the United Nations International Children’s Emergency Fund (UNICEF) reports, exclusive breastfeeding in the first 6 months of life could prevent the deaths of approximately 1.3 million children under the age of five.³ In addition, the WHO estimates that infants who are not breastfed have a 40% higher risk of death between the ages of 9–12 months and a 48% higher risk of death for infants under 2 months old.^{4 5} Therefore, the WHO emphasises the importance of exclusive breastfeeding during the first 6 months of an infant’s life.⁶

According to global statistics in 2020, approximately 44% of infants aged 0 to 6 months were exclusively breastfed.⁶ According to the 2022 UNICEF report, only 48% of mothers in low- and middle-income countries (LMICs) exclusively breastfeed their infants during the first 6 months of life.³ In addition, reports from the WHO reveal exclusive breastfeeding rates of 44% in Asia and 53.1% in Iran.⁵ In 2014, only 58% of infants in East Azerbaijan Province were exclusively breastfed for the first 6 months of life.⁷ The WHO plans to increase the exclusive breastfeeding rate for infants younger than 6 months to 50% globally by the year 2025.⁸

Many factors may stop exclusive breastfeeding, such as an infant’s low birth weight, a mother’s perceived insufficient milk supply, smoking and poor maternal knowledge about breastfeeding and motherhood.⁹ The inability to breastfeed, doubts about one’s ability to breastfeed and perceived insufficient milk supply are commonly cited as the main reasons for early cessation or decreased exclusive breastfeeding among mothers.¹⁰ Breastfeeding empowerment influences breastfeeding initiation and continuation.¹¹ Empowerment in breastfeeding includes domains of knowledge, attitude, skills of proper breastfeeding technique, skills of preventing and solving breastfeeding problems, breastfeeding sufficiency, negotiation and receiving family support and breastfeeding self-efficacy.¹² It increases mothers’ control over their environment, encourages demand-based active participation and helps them resolve their breastfeeding problems, thereby improving their breastfeeding self-efficacy and increasing the duration of exclusive breastfeeding.¹¹ The breastfeeding abilities of mothers are influenced by several factors, such as their attitudes toward breastfeeding, their knowledge of breastfeeding techniques, their ability to solve breastfeeding problems, and their perceived family support.¹²

Accordingly, while adequate support from others can improve new mothers’ breastfeeding experiences,¹³ poor social support decreases their self-efficacy in infant care.¹⁴ The results of a review study showed that all types of emotional and informational support from relatives, family members and friends increase the likelihood of breastfeeding initiation and continuation.¹⁵ Spousal/partner support is the most important support women receive in the postpartum period.¹⁶ This type of support can tremendously help mothers go through the postpartum period and easily adapt to the psychological and physiological changes that result from hormonal changes.¹⁷ The two types of spousal support include physical support (eg, meeting women’s needs, helping them overcome their physical problems and assisting them with daily housework) and psychological support (eg, motivation, attention and companionship).¹⁸ Women with supportive spouses are more likely to initiate breastfeeding immediately after hospital discharge and to continue breastfeeding over a long period of time. High levels of spousal support and encouragement are associated with great confidence in breastfeeding and excellent breastfeeding decisions and coping skills.¹⁹ A recent systematic review found that partner support, particularly in the form of emotional and practical assistance, significantly improves breastfeeding initiation and duration.²⁰ In a recent study in the United States, an increase in emotional, social and physical spousal support in the early postpartum period led to higher breastfeeding self-efficacy among mothers.¹⁷ The results of another study in Turkey showed that positive spousal support in the early postpartum period improves exclusive breastfeeding rates. In fact, social support, especially support from a partner/spouse, positively affects mothers’ breastfeeding experiences, whereas a lack of social and spousal support negatively influences these experiences.¹³

Health literacy is another important factor that can influence women’s ability to engage in health-promoting behaviours and protect themselves and their infants.²¹ Health literacy is defined as ‘a person’s ability to acquire and implement knowledge and information to maintain and improve his/her health in an appropriate individual and social context’.²² Poor educational qualifications are generally associated with low health literacy.²³ In a study carried out on the general population in five Iranian provinces, only 28.1% of participants had an adequate level of health literacy, which indicates that they possess sufficient understanding and application of health information highlighting a significant gap in knowledge and skills among mothers.²⁴ Improving maternal health literacy is crucial, as it has been shown to increase the likelihood of mothers choosing to breastfeed their infants.²¹ Furthermore, low maternal health literacy has been associated with early cessation of breastfeeding, underscoring the need for targeted interventions to enhance knowledge and support for new mothers.²⁵ Therefore, health literacy levels can be used by healthcare providers during the prenatal and puerperium periods to identify women at risk of early cessation of breastfeeding.^{6 24}

Due to the positive effects of breastfeeding on maternal and neonatal health, the influence of breastfeeding empowerment on breastfeeding continuation and the fact that a few studies have examined breastfeeding empowerment and related factors,^{11 12 26} the primary aims of this study were (a) to determine the status of breastfeeding empowerment among breastfeeding mothers, (b) to determine the relationships between breastfeeding empowerment and spousal support and (c) health literacy, using cross-sectional data.

Methods

Study design and participants

This cross-sectional study used cluster sampling to enrol 342 breastfeeding mothers with 6-month-old or younger infants who were referred to the health centres of Tabriz city in Iran for primary healthcare from April to September 2022. These centres were public health centres that provided free services to the local community. All participants received care at no cost to themselves. The inclusion criteria consisted of mothers who had infants aged 6 months or younger, had breastfed their infants regardless of duration or frequency of breastfeeding and possessed reading and writing skills. Mothers whose infants were born with congenital anomalies and did not breastfeed their infants at all regardless of the reason were excluded from the study.

The initial sample size was determined to be 171 based on the ‘Overcoming Breastfeeding Problems’ domain of women’s empowerment, as reported in the study by Dehgani (2023).²⁷ This calculation considered, SD=5.3, α=0.05, d=0.03 and mean=25.84. Due to the use of cluster sampling, a design effect of 2 was applied to account for the increased variability inherent in this sampling method,²⁸ resulting in a final sample size of 342.

Sampling

Using cluster sampling, the researcher first randomly selected 8 health centres from the total of 65 in Tabriz, ensuring that one centre was chosen from each of the eight districts of Tabriz city to capture both geographic and socioeconomic diversities. These centres served as clusters for the study. Eligible mothers with infants under 6 months who regularly visited these health centres for growth monitoring and infant vaccination from April to September 2022 were identified through Iran’s Integrated Health System (IHS), known as the ‘SIB System’. To ensure a representative sample, the number of selected women from each health centre was determined proportionally based on the number of eligible mothers at each centre. Participants were then randomly selected from these clusters using the www.random.org website. In the next step, the researcher contacted the selected women by telephone to screen them for the inclusion and exclusion criteria, and then, the eligible women were briefly informed about the study goals and invited to participate in the study by visiting the respective health centres at a specific time. In an in-person session, the researcher thoroughly explained the research objectives to all participants and obtained written informed consent from those who were willing to participate in the study. Finally, the researcher completed the questionnaires through a face-to-face interview with participants before their infants were vaccinated.

Data collection tools

The data were collected using the Sociodemographic Characteristics Checklist, Mothers’ Breastfeeding Empowerment Scale (MBES), Postpartum Partner Support Scale (PPSS) and Health Literacy for Iranian Adults (HELIA) Scale.

Sociodemographic Characteristics Checklist: It included 16 questions about the age, job and educational qualifications of the woman and her spouse, family income status, number of pregnancies and births, the interpregnancy interval, the infant’s age, the duration of previous and current breastfeeding, the type of pregnancy (intended or unintended) and living conditions (independently or with extended family).

Mothers’ Breastfeeding Empowerment Scale

This 37-item questionnaire was developed by Mohammadi et al to measure breastfeeding empowerment. The six domains of MBES include adequate breastfeeding knowledge and skills (11 items), perceived breastfeeding adequacy (four items), conscious belief about the value of breastfeeding (7 items), overcoming breastfeeding problems (7 items), negotiation for family support (five items) and breastfeeding self-efficacy (3 items). The items are scored on a five-point Likert scale ranging from completely disagree (score 1) to completely agree (score 5), with higher scores representing higher breastfeeding empowerment (total score range: 37–185).²⁶ Mohammadi et al assessed the psychometric properties of this tool. An assessment of the construct validity of the MBES showed that the six domains of the tool explain 86.49% of the total variance. In addition, the content validity of the scale was confirmed with a content validity index (CVI) and a content validity ratio (CVR) of 0.70 and 0.56, respectively. Finally, the reliability of the MBES was confirmed with a Cronbach’s alpha value of 0.87.²⁶

Postpartum Partner Support Scale

Dennis et al designed this 20-item scale in Canada in 2017.²⁹ In 2021, Eslahi et al translated the PPSS into Persian and assessed its psychometric properties.³⁰ The items are scored on a five-point Likert scale ranging from completely disagree (score 1) to completely agree (score 5), with higher scores indicating greater perceived spousal support (total score range: 20–100). Eslahi et al confirmed the reliability of the PPSS with a Cronbach’s alpha value of 0.96.³⁰

Health Literacy for Iranian Adults (HELIA) scale

Montazeri et al.³¹ designed this 33-item tool to measure the level of health literacy among Iranian adults.³¹ The five subscales of HELIA include reading (4 items), access (6 items), understanding (7 items), appraisal (4 items) and decision (12 items). The items are scored on a five-point Likert scale from never (score 1) to always (score 5). The sum of scores given to all subscales determines the total HELIA score for each person (total score range: 33–165). Montazeri et al confirmed the reliability of all subscales of the HELIA with Cronbach’s alpha values ranging from 0.72 to 0.89.³¹

Before data collection, face validity was assessed by gathering judgments from a panel of 10 nursing and midwifery professors. Content validity was evaluated by calculating the CVI and CVR. Accordingly, CVI values of 0.82, 0.79 and 0.81 were obtained for the MBES, HELIA scale and PPSS, and CVR values of 0.88, 0.85 and 0.86 were obtained for the MBES, HELIA scale and PPSS, respectively. In addition, the reliability of the MBES, HELIA scale and PPSS was confirmed with Cronbach’s alpha values of 0.86, 0.88, and 0.83, respectively.

Data analysis

Data were analysed using SPSS software V.16. The normal distribution of numeric data was assessed and confirmed based on skewness (within ± 1.5) and kurtosis (within ± 2.0). (online supplemental file). Then, the descriptive statistics of mean, SD and frequency (percentage) were used to describe the demographic characteristics, breastfeeding empowerment, health literacy and perceived spousal support of participants. The relationships of breastfeeding empowerment with health literacy and perceived support were examined using the Pearson correlation test (in bivariate analysis) and General Linear Model (GLM) (in multivariate analysis with adjusted sociodemographic characteristics scores). For this purpose, independent t-tests and one-way Analysis of Variance (ANOVA) were first performed to investigate the relationships of sociodemographic characteristics with breastfeeding empowerment. In the next step, variables significantly related to breastfeeding empowerment (p<0.2) (potential confounding variables), along with health literacy and perceived spousal support (independent variables), and breastfeeding empowerment (dependent variable) were entered into the GLM. The GLM is a versatile statistical technique that allows for the analysis of continuous and categorical variables, making it suitable for our research objectives.

Patient and public involvement

Patients and the public did not participate in the design, recruitment and implementation of research or the dissemination of research results.

Results

The researcher asked 374 eligible mothers to participate in the study, of whom 342 individuals were eventually enrolled. Among the 32 mothers who declined participation, several cited time constraints as a significant factor. Nearly half of the mothers (43.2%) and their spouses (44.4%) had academic degrees. The majority of mothers (76.6%) reported that their family income was sufficient. More than half of the participants (51.2%) had no previous breastfeeding experience, and 22 participants (6.4%) had stopped breastfeeding in recent months for various reasons. The mean (SD) ages of the mothers and spouses were 30.83 (5.28) and 35.19 (5.57) years, respectively. In addition, the mean (SD) infant age was 4.28 (1.75) months. Table 1 presents other sociodemographic characteristics of the participants.

Table 1. Demographic characteristics of participants in the study and their relationship with breastfeeding empowerment (n=342).

Variable		N (%)	Breastfeeding empowermentMean±SD	P value
Education				0.311*
	Primary school	20 (5.8)	129.15±36.60
	guidance school	24 (7.0)	145.54±22.31
	High school	11 (3.2)	138.36±41.12
	Diploma	137 (40.1)	140.24±36.74
	University education	150 (43.9)	144.98±31.68
Husband education				0.195*
	Primary school	17 (5.0)	128.64±34.23
	High school	44 (12.8)	136.18±36.43
	Diploma	129 (37.7)	143.10±34.48
	University education	152 (44.4)	144.20±32.45
Income				0.010*
	Not sufficient	17 (5.0)	141.70±30.84
	To some extent sufficient	262 (76.6)	139.20±34.68
	Sufficient	63 (18.4)	153.58±29.19
Job				0.010*
	Employee	58 (17.0)	146.29±32.58	0.175†
	Working at home	17 (5.0)	153.35±24.72
	Housewife	267 (78.1)	140.32±34.58
Husbands job				0.539*
	Freelance	194 (56.7)	139.78±35.85
	Shopkeeper	11 (3.1)	144.09±25.14
	Employee	91 (26.6)	145.95±32.77
	Worker	35 (10.2)	140.08±31.38
	Workless	11 (3.2)	151.81±20.73
Living				0.181†
	Independent	328 (95.9)	142.16±34.14
	With own or husbands’ family	14 (4.1)	137.78±28.99
Pregnancy intention				0.741†
	Wanted	294 (86.0)	143.02±33.89
	Unwanted	48 (14.0)	135.60±33.78
Mothers' previous breastfeeding experience				0.088†
	Yes (has)	167 (48.8)	143.36±32.66
	No (has not)	175 (51.2)	140.66±35.13
Present breastfeeding				0.070†
	Yes	320 (93.6)	146.86±27.87
	No	22 (6.4)	71.00±35.31
Age		30.83	30.83±5.28	0.971‡
Husband age		35.19	35.19±5.57	0.882‡
Number of Gravids		1.69	1.69±0.75	0.770‡
Number of Paras		1.60	1.60±0.68	0.374‡
Living children (Number)		1.62	1.62±0.68	0.732‡
Pregnancy interval (years)		6.50	6.50±3.50	0.591‡
Infant age(by month)		4.28	4.28±1.75	0.275‡
Duration of previous breastfeeding(by month)		19.32	19.32±6.69	0.313‡

^*One-way ANOVA test;

^†: Independent Tt -test

^‡: Pearson coloration

The mean (SD) of breastfeeding empowerment, health literacy and partner support of participants was 141.98 (33.92) (range: 37–185), 126.08 (21.27) (range: 33–165) and 64.95 (12.62) (range: 20–100), respectively (table 2).

Table 2. Status of the study variables and their relationship with breastfeeding empowerment.

Variable	Mean (SD)	Obtainable score range	Obtained score range	Correlation with breastfeeding empowermentr (P)
Breastfeeding empowerment	141.98 (33.92)	37–185	37–185
Spousal support	64.95 (12.62)	20–80	29–80	0.28 (<0.001)
Health literacy level	126.08 (21.27)	33–165	64–165	0.23 (<0.001)

The results of the bivariate analysis and Pearson correlation test showed that the variable of breastfeeding empowerment had a significant direct correlation with health literacy (r=0.23, p<0.001) and perceived spousal support (r=0.28, p<0.001). In other words, the presence of higher maternal health literacy and partner support results in higher breastfeeding empowerment score. In addition, breastfeeding empowerment was significantly related to the variable of family income status (p=0.01) (table 2).

Finally, the variables of family income status, educational qualifications, mother’s job, family lifestyle, breastfeeding experience, current breastfeeding status, perceived spousal support and health literacy, which all had significant associations with breastfeeding empowerment (p<0.2), were inserted into a GLM. The results showed that an increase in perceived spousal support was associated with higher breastfeeding empowerment score (B=0.54; 95% CI 0.29 to 0.79; p<0.001). In other words, for every one-unit increase in perceived spousal support, the breastfeeding empowerment score increases by 0.54 points. In addition, working mothers had a significantly higher breastfeeding empowerment score compared with mothers who were housewives (B=13.91; 95% CI 0.88 to 27.73; p=0.04), and currently breastfeeding mothers had a significantly higher score compared with mothers who were not currently breastfeeding (B=72.26; 95% CI 60.42 to 84.10; p<0.001) (table 3).

Table 3. Predictors of breastfeeding empowerment based on the general linear model (n=342).

Variable	B (95% CI)	P value
Total partner support	0.55 (0.29 to 0.79)	<0.001
Total health literacy	0.15 (−0.1 to 0.32)	0.081
Income (Reference: sufficient)
Not sufficient	−0.43 (−15.77 to 14.90)	0.95
To some extent sufficient	−7.31 (−15.46 to 0.83)	0.07
Husband education (Reference: collegiate)
Primary	4.22 (−11.18 to 19.63)	0.59
High school	−0.33 (−10.30 to 9.64)	0.94
Diploma	5.03 (−2.03 to 12.10)	0.16
Job (Reference: housewife)
Working	13.91 (0.88 to 27.73)	0.04
Living (Reference: with husbands’ family)Independent	3.35 (−11.43 to 18.13)	0.65
Breastfeeding experience (Reference: no) Yes	3.07 (−3.03 to 9.17)	0.32
Present breastfeeding (Reference: no)Yes	72.26 (60.42 to 84.10)	<0.001

Discussion

The study investigated the relationships of breastfeeding empowerment with health literacy and perceived spousal support among mothers with 6-month-old or younger infants during the postpartum period. The mean scores of breastfeeding empowerments, health literacy and perceived spousal support of participants were all above average. In addition, the adjusted GLM results showed that the variables of perceived spousal support, mother’s job and current breastfeeding status had a significant relationship with breastfeeding empowerment.

The mean (SD) of breastfeeding empowerment of mothers was above average. This is consistent with the findings of a recent study in Iran.³² The findings of another study showed that an increase in breastfeeding empowerment increases the level of exclusive breastfeeding in women.³³ Many psychological and social factors influence breastfeeding success. For example, mothers’ knowledge, skills and self-efficacy substantially influence their ability to breastfeed their infants.³⁴ Recently, a qualitative study was conducted to assess Iranian women’s perception of breastfeeding empowerment. The results indicated that breastfeeding empowerment requires adequate breastfeeding knowledge and skills and a high level of breastfeeding self-efficacy.³⁵ Mothers’ perceived insufficient milk supply is a common reason why mothers feel unable to breastfeed and therefore stop breastfeeding prematurely. Perceived insufficient milk supply is also associated with low confidence in breastfeeding.³⁶ In this regard, healthcare providers can play a vital role by teaching mothers how to ensure the adequacy of their milk supply.

The findings of this study highlight the significant role of spousal support in enhancing breastfeeding empowerment among Iranian women. The results indicate that greater perceived spousal support is associated with higher score of breastfeeding empowerment. This aligns with the cultural emphasis placed on spousal support during the postpartum period in Iran. The high levels of spousal support reported by the participants in this study underscore the importance of this form of support in the Iranian context. These findings are consistent with a study conducted in Turkey, which found that mothers who exclusively breastfed their infants received notably high levels of support from their husbands.¹³ The results of this study also highlight the importance of spousal attitudes towards breastfeeding in influencing mothers’ decisions to initiate and continue breastfeeding.³⁷ This is consistent with findings from a study conducted in China, which revealed that spouses who received breastfeeding education demonstrated more positive attitudes towards infant feeding, which in turn enhanced their support for breastfeeding.³⁸ Overall, men’s positive attitudes towards breastfeeding and their active support for their wives strongly encourage women to breastfeed their children.³⁷ Therefore, attending educational classes at health centres about the significance of breastfeeding and breastfeeding principles can improve husbands’ attitudes towards breastfeeding and increase the support they provide to their wives in the postpartum period. These findings underscore the need for targeted educational initiatives aimed at partners in Iran to foster a supportive environment for breastfeeding.

Consistent with several studies, the mean (SD) health literacy of participants was above average. The results of a study conducted in 2017 in Qazvin, Iran, indicated that the level of health literacy of 46.8% of mothers was adequate.³⁹ Moreover, the findings of another study in Iran showed that mothers with infants had desirable levels of health literacy.⁴⁰ In a study in the United States, only 24% of mothers had inadequate health literacy.⁴¹ The results of a study in Spain showed that mothers had adequate levels of health literacy in the postpartum period before hospital discharge. The authors also concluded that adequate health literacy serves as a protective factor against early cessation of breastfeeding.⁴² In contrast to these findings, the results of another study in Spain revealed that the health literacy of more than half of breastfeeding mothers with 6-month-old infants was inadequate.²² This discrepancy is probably because these studies used different tools to measure various variables. The present study used the HELIA scale, which is designed for the general population, to measure levels of health literacy.

In bivariate analysis, the variable of health literacy was significantly related to breastfeeding empowerment; however, this relationship was not significant in the final model. A recent study in Indonesia found that high health literacy prepares mothers for exclusive breastfeeding, as mothers with higher health literacy are more likely to exclusively breastfeed their infants.² Findings of similar studies in Spain showed a significant association between inadequate health literacy and cessation of exclusive breastfeeding in infants younger than 6 months. These studies considered health literacy as a protective factor against early cessation of breastfeeding.^{22 43} To obtain more reliable results, researchers are suggested to use a tool that specifically measures maternal health literacy during breastfeeding in future studies.

Breastfeeding empowerment was significantly higher among working mothers than among housewives. A study conducted in the United States examined the demographic and personal characteristics of women who breastfed their infants compared with those who did not. The findings indicated that women who breastfed were significantly more likely to have a professional job or be employed. The study’s results suggest that working women are more likely to initiate breastfeeding and less likely to discontinue breastfeeding compared with women who are not employed, which is consistent with our study’s findings.⁴² In contrast to the results of the present study, in a study in Erbil, Iraq, exclusive breastfeeding rates were higher in housewives than in working women. However, there was no significant relationship between maternal employment status and exclusive breastfeeding.⁴³ High breastfeeding continuation and breastfeeding empowerment rates in working women can be attributed to their high educational qualifications. Women who have professional jobs usually have high educational qualifications and are therefore more aware of the benefits of breastfeeding and more willing to breastfeed their infants.

In the present study, breastfeeding empowerment rates were higher among mothers who exclusively breastfed their infants than among those who stopped breastfeeding before the infant was 6 months old or those who used both formula and breast milk. The findings of a similar study that examined the relationship between breastfeeding empowerment and exclusive breastfeeding indicated that mothers who scored higher in various domains of breastfeeding empowerment breastfed exclusively longer than others.³² As mentioned in recent similar studies, breastfeeding empowerment influences breastfeeding initiation and continuation,^{10 32} and mothers who have higher breastfeeding empowerment usually continue breastfeeding more.

This study presents several methodological limitations that warrant consideration. The cross-sectional design restricts our ability to establish causal relationships, as data were collected at a single point in time. Additionally, the use of self-report questionnaires may introduce bias, as participants might provide responses that align with social expectations rather than their true experiences. Furthermore, while job status and current breastfeeding status were included in our models based on their statistical significance in preliminary analyses, this approach may result in biased estimates since these variables were not predetermined as primary exposures. Lastly, the small sample size led to wide confidence intervals for certain estimates, which could limit the generalizability of our findings.

The way forward

To address these limitations, future research should consider qualitative methodologies, such as in-depth interviews with breastfeeding mothers and their partners, to provide richer insights into their experiences. Additionally, conducting studies with larger sample sizes will be essential to validate our conclusions and improve the reliability of the findings. By employing these strategies, researchers can contribute to a more nuanced understanding of the interplay between these variables and inform targeted interventions to support breastfeeding mothers effectively.

Conclusion

This study highlights the critical role of spousal support in enhancing breastfeeding empowerment among Iranian women. The findings contribute to the existing body of research by demonstrating how perceived spousal support positively influences mothers' breastfeeding empowerment. Nurses and midwives can play a key role in improving new mothers’ breastfeeding skills and their spouses’ attitudes towards breastfeeding. Encouraging partners to attend educational classes can be especially beneficial, as they can learn how to provide practical and emotional support to their wives during the breastfeeding process. By promoting the importance of partners/spouses in supporting breastfeeding, we can help create a culture that supports and values breastfeeding as a normal and natural part of motherhood. Additionally, since employment and current breastfeeding status were found to be associated with breastfeeding empowerment, implementing breastfeeding-friendly policies in the workplace can further enhance breastfeeding rates.

Data availability statement

Data are available upon reasonable request.