Psychosocial Influences on Breastfeeding Duration: Maternal, Paternal, and Infant Contributors

Abstract

Breastfeeding provides significant health benefits for infants and mothers, yet many families face challenges leading to early cessation. The role of maternal psychosocial factors, paternal psychosocial support, and parental perceptions of infant characteristics on breastfeeding duration remains underexplored. This narrative review aimed to synthesize recent literature on the psychosocial influences of maternal, paternal, and infant-related factors on breastfeeding duration. A literature search was conducted in the PubMed database to extract peer-reviewed studies between 2014 and 2024. The search terms include those relate to parents (e.g., “mother,” “father,” “maternal,” “paternal,”), infants (e.g., “infant,” “baby”), psychosocial factors (e.g., “mental health,” “self-efficacy,” “depression,” “anxiety”), and breastfeeding duration outcomes (e.g., “breastfeeding duration,” “continuation”) to identify relevant studies. A total of 447 articles were identified through the initial search, and 31 articles were included in the final qualitative analysis based on relevance to the inclusion criteria. The literature suggests that maternal mental well-being and lower self-efficacy are the most prominent predictors of breastfeeding duration and cessation. Additionally, fathers’ active participation, such as providing emotional support, can have a positive impact on breastfeeding duration. Variations in infant temperament were found to be associated with maternal breastfeeding and caregiving styles, which in turn influence breastfeeding duration. In summary, maternal, paternal, and infant psychosocial factors all contribute to variations in breastfeeding duration; however, paternal psychological factors and infant temperament are underrepresented in research on breastfeeding. A more holistic perspective is needed to guide future research and interventions aimed at supporting breastfeeding persistence.

Introduction

Health organizations, including the WHO and the UNICEF, recommend that infants be exclusively breastfed for ≥6 mo after birth and continue being breastfed until 12 mo or later [1,2]. Breastfeeding has both short- and long-term health benefits for mothers [3,4], infants [5,6], and even environmental and planetary health [7,8]. For mothers, breastfeeding is associated with a reduced risk of postpartum depression, breast cancer, osteoporosis, cardiovascular diseases, and diabetes [4,[9], [10], [11]]. Bidirectional influences of breastfeeding have also been documented, facilitating maternal mental health, mother–child bonding, and attachment relationships [12], which may positively impact breastfeeding initiation and duration [[13], [14], [15], [16]]. For infants, longer breastfeeding duration has been associated with protection against acute respiratory illness [17], diarrheal episodes, constipation, and childhood obesity [18,19]. It has also been reported that longer breastfeeding durations are associated with higher Intelligence Quotient and academic achievement, and this beneficial effect can persist through adulthood [20,21].

The 2023 Lancet Series on Breastfeeding emphasized that breastfeeding is not solely the responsibility of the lactating mother. Population-level improvements in breastfeeding practices require a collective societal approach that includes multilevel and multicomponent interventions across the socioecological model and different settings [22]. Supportive breastfeeding policies and practices, including the Baby-Friendly Hospital Initiative, have led to improvements in breastfeeding initiation [23]. Among infants born in 2019, most (83.2%) initially received some human milk. However, breastfeeding rates steadily decline from month to month, and by 6 mo, only 55.8% of infants were receiving any human milk, and just 24.9% were breastfed exclusively [24]. This can be partly attributed to the fact that the system-level efforts to support breastfeeding do not fully address the personal and situational factors that influence breastfeeding outcomes. Families may face challenges when breastfeeding, and many do not breastfeed for as long as they intend [25,26]. Accordingly, it is crucial to evaluate the salient, proximal factors in the home environment that are most strongly associated with breastfeeding duration and are amenable to interventions [27]. Although predictors of breastfeeding outcomes have been previously reviewed [[28], [29], [30]], the potentially modifiable, psychosocial determinants of breastfeeding duration within the proximal environment, including mothers, fathers, and infants, have not been collectively evaluated. This review aims to address the gap in our understanding by summarizing the literature on maternal psychosocial factors, paternal psychological and social support, and infant psychosocial and behavioral characteristics that may facilitate or reduce breastfeeding duration, with the goal of inspiring actionable pathways to improve breastfeeding outcomes. It should be noted that this review focuses on families where fathers are involved in the breastfeeding process, but we recognize the diversity of family structure within which breastfeeding decisions are made, and acknowledge the importance of examining breastfeeding duration within diverse families and living situations [31].

Methods

Search strategy

A literature search to inform this narrative review was performed in the PubMed database until March 2024. The search terms were selected with a focus on psychosocial factors influencing breastfeeding duration. Population terms included both Medical Subject Headings (MeSH) headings and free-text keywords for mothers, fathers, and infants to ensure broad coverage of relevant groups. Psychological terms were selected according to their relevance to the topic of the review and commonly studied constructs in mental health [32]. To capture contemporary trends and developments, while allowing for the inclusion of a substantial body of emerging research, the search focused on studies published over the past decade (2014–2024). The search terms include a combination of keywords and MeSH where applicable: Population terms: “Mothers [MeSH]” OR “mother∗” OR “maternal” OR “Fathers [MeSH]”“father∗” OR “paternal” OR Infant [MeSH] OR “infant∗” OR “baby” OR “babies”; Psychosocial terms: “Psychology [MeSH] OR “psychological” OR “Mental Health [MeSH]” OR “attitudes” OR “beliefs” OR self-efficacy” OR “emotion∗” OR “temperament” OR “depression” OR “’anxiety.” Outcome terms: (“Breast Feeding [MeSH]” OR “breastfeeding” OR “breastfeed∗”) AND (“duration” OR “length of breastfeeding” OR “continuation”).

Selection criteria

To maintain a focused scope for our narrative review, only studies that investigated psychosocial factors as a primary independent variable and breastfeeding duration as a primary outcome were included. Intervention studies were excluded to concentrate on research that explored natural associations among variables. The literature search yielded 447 articles in PubMed, which were then screened for titles and abstracts. Articles were removed if they were reviews or systematic reviews, were not written in English, or were not relevant to psychosocial factors associated with breastfeeding duration. At this step, 391 articles were filtered by YF. Full-text articles assessment was conducted for the remaining 56 articles, and another 25 articles were removed if psychosocial factors were not the primary assessment (n = 10), breastfeeding duration was not the primary outcome measure (n = 7), or were intervention studies (n = 8). After the full-text review, 31 articles related to maternal, paternal, and infant psychosocial aspects associated with breastfeeding duration outcomes were retained and are included in the current narrative review, as shown in the PRISMA flow diagram [33] (Figure 1). Abstract and full-text screening were conducted by 2 authors (YF and SMD), with support from the third author in case of disagreement (KFB).

FIGURE 1.

PRISMA 2009 Flow diagram for the literature selection process.

Results

Overview of included studies

The 31 included articles were categorized into 3 groups based on their primary study design: maternal psychosocial factors influencing breastfeeding duration (n = 25), paternal psychosocial factors impacting breastfeeding duration (n = 3), and infant psychosocial characteristics affecting maternal breastfeeding decisions and duration (n = 3). A summary of the maternal, paternal, and infant psychosocial factors, along with their positive and negative effects on breastfeeding duration, is presented in Figure 2.

FIGURE 2.

Summary of maternal, paternal, and infant psychosocial factors identified in the literature that exert effects on breastfeeding duration.

Maternal psychosocial factors affecting breastfeeding duration

The majority of included studies (n = 25) focused on maternal psychosocial factors, with maternal depression symptoms and breastfeeding self-efficacy emerging as the most studied constructs (Table 1) [[34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58]].

TABLE 1.

Effects of maternal psychosocial factors on breastfeeding durations.

Citation	Study location	Year	Race/ethnicity	Study design	n	Psychological factor	Duration of breastfeeding	Measurement methods	Results
[34]	Viçosa, MG, Southeastern, Brazil	2014	NR	Longitudinal cohort study	168	•Postpartum depression symptoms (EPDS) •Emotional conditions during pregnancy and postpartum •Traumatic delivery	EBF duration analyzed using time-to-event (survival analysis) •1 mo cessation (53.6%, n = 90) •2 mo cessation (47.6%, n = 80) •4 mo cessation (69.6%, n = 117)	•Three interviews conducted when infants received scheduled vaccinations •30, 60, and 120 d postpartum	•Mothers who had a traumatic delivery (P = 0.035) and showed postpartum depression symptoms (EPDS ≥ 12, P = 0.002) were significantly more likely to cease EBF by 2 mo postpartum •Mothers who had negative emotional reaction to pregnancy (P = 0.002) and a lack of partner support (P = 0.023) were significantly more likely to cease EBF by 4 mo postpartum
[35]	Swansea, United Kingdom	2014	NR	Exploratory cross-sectional survey	602	•Maternal personality traits (10 item personality measure) •Attitudes toward breastfeeding	Breastfeeding duration assessed using time-point prevalence •At birth (83.2%, n = 501) •2 wk (53.2%, n = 320) •6 wk (38.0%, n = 229) •12 wk (28.1%, n = 169) •26 wk (25.7%, n = 155)	•Self-reported questionnaires with paper copy or online link (retrospective)	•Mothers who were still breastfeeding at birth, 2, 6, 12, and 26 wk had higher emotional stability (all P < 0.05) •Mothers who were still breastfeeding at birth, 2, and 6 wk had higher extraversion (all P < 0.05) •Higher extraversion, emotional stability, and conscientiousness were negatively associated with breastfeeding cessation (all P < 0.05)
[36]	Australia	2014	NR	Online, retrospective questionnaire	174	•Attitude toward pregnancy postpartum •Body attitude questionnaire •Breastfeeding intention •Breastfeeding self-efficacy •Coping style prior to pregnancy (Brief COPE) •Comfort breastfeeding in public •Depression Anxiety Stress Scale 21 •Fetal health locus control scale	•Average EBF duration: 4.0 ± 1.2 mos • EBF duration categories • <1 mo (7%, n = 13) - ≤2 mo (4%, n = 8) •2–4 mo (7%, n = 13) •>4 mo (49%, n = 85) •>6 mo (31%, n = 55)	Self-report questionnaires administered online	•Compared with mothers EBF <6 mo, mothers EBF >6 mo had higher scores in breastfeeding intention (P < 0.01), breastfeeding self-efficacy (P < 0.01), perceived postpartum strength (P < 0.01), and level of comfort breastfeeding in public (P < 0.001) •Breastfeeding self-efficacy was directly associated with EBF duration
[37]	Melbourne, Victoria, Australia	2015	NR	Longitudinal, prospective questionnaire-based study	125	•Attitude toward pregnancy •Body Attitude (BAQ) •EBF intention •Breastfeeding Self-Efficacy Scale (BSES-SF) •Psychological adjustment (DASS-21) •Motivation to EBF •Importance to EBF •Confidence to EBF	•EBF durations were scored based on the EBF status at each time ≤6 mo postpartum: 6.1 ± 1.4	• Self-administered questionnaire • 32 wk of gestation • 2 and 6 mo postpartum	At 32-wk pregnancy: •Confidence to maintain EBF was a direct positive predictor of EBF duration (β = 0.26, P < 0.05) At 2 mo postpartum: •Psychological adjustment was a direct negative predictor of EBF duration (β = –0.10, P < 0.01) •Breastfeeding self-efficacy was a direct positive predictor of EBF duration (β = 0.12, P < 0.01) At 3–6 mo postpartum: •Feeling fat (β = –0.27, P < 0.05) and psychological adjustment (β = –0.20, P < 0.01) were direct negative predictor of EBF duration •Breastfeeding self-efficacy (β = 0.24, P < 0.001) and confidence to maintain EBF (β = 0.44, P < 0.001) were direct positive predictor of EBF duration
[38]	Sabah, Malaysia	2015	•77.6% Indigenous •10.6 % Indonesian •4.7% Filipino •3.5% Chinese •3.2% Malay •0.4% Indian	Prospective cohort study	1078	Antenatal depression (EPDS)	Breastfeeding duration not reported	• Self-administered questionnaire completed at a private space • Baseline during pregnancy (EPDS) • 1, 3, and 6 mo postpartum (Breastfeeding practices)	Mothers with EPDS score >7 were more likely to cease breastfeeding by the end of 6 mo compared with mothers with EPDS score of ≤3 (HR = 1.95; 95% CI: 1.26, 3.01)
[39]	Korea	2015	NR	Cross-sectional web-based study	604	•Breastfeeding attitude •Breastfeeding knowledge •Interest toward breastfeeding	• Breastfeeding duration assessed as the duration that the last child was exclusively or mixed fed in categories • ≤ 3 mo (19.2%, n = 116) • 6 mo (30.5%, n = 184) • ≥ 12 mo (50.3%, n = 304)	Self-reported online questionnaires	•Breastfeeding knowledge was positively associated with longer breastfeeding duration (P < 0.001) •Breastfeeding attitude scores were positively associated with longer breastfeeding duration (P = 0.003) •Breastfeeding interest scores were not associated with breastfeeding duration (P = 0.80) •Mothers with optimal breastfeeding duration (≥6 mo) were more likely to be aware of the ease of milk simulation, emotional attachment build-up, and pleasure from breastfeeding, compared with mothers with <6 mo breastfeeding duration.
[40]	United Kingdom	2015	NR	Two-stage longitudinal questionnaire study	128	Body Image Questionnaire	BF duration assessed using time-point prevalence	Questionnaire completed via paper copy or via online survey •Prenatal (body image) •6 mo postpartum (breastfeeding practices)	•Higher pregnancy body image concerns (P = 0.004) were associated with shorter intended breastfeeding durations •Higher pregnancy body image concerns (P = 0.002) and prospective postnatal body image concerns (P = 0.01) were associated with shorter actual breastfeeding duration
[41]	Western Australia	2015	NR	Prospective cohort study	427	•Maternal–infant feeding attitude (IIFAS) •Perceived paternal feeding preference	Breastfeeding duration not reported	Self-report questionnaires •Baseline (Breastfeeding attitude) •Baseline, 4, 10, 16, 26, 32, 40, and 52 wk (breastfeeding practice)	•Mothers with positive attitude toward breastfeeding (IIFAS scores > 65) had a median of 11 more wk EBF compared with mothers with IIFAS score <65 (P < 0.0001) •Mothers with a positive attitude toward breastfeeding (IIFAS scores > 65) had a median of 26 more wk any BF compared with mothers with IIFAS score<65 (P < 0.001) •Mothers who perceived the infant’s father to be ambivalent about breastfeeding or prefer formula feeding were more likely to stop EBF (adjusted HR = 1.48; 95% CI: 1.11, 1.97) and any breastfeeding (adjusted HR = 1.71; 95% CI: 1.02, 2.85) at 26 wk postpartum
[42]	United States	2016	•84.1% White •7.2% Hispanic •4.0% Black •2.6% Asian/Pacific Islander •2.1% Other	Secondary data analysis	1271	•Postpartum depression symptoms (EPDS) •Prenatal breastfeeding intention •Breastfeeding self-efficacy	•Average EBF duration: 4.33 ± 7.10 wk •Average total breastfeeding duration: 20.75 ± 17.36 wk	Mailed survey questionnaires from the prenatal period through 12 mo postpartum	•Mothers with PDS had 2.37 wk shorter breastfeeding duration compared with mothers without PDS (P = 0.025) •Mothers who intended to breastfeed prenatally had 11.5 wk longer breastfeeding duration compared with mothers who did not intend to breastfeed exclusively (P < 0.001) •Prenatal intention to breastfeed predicted longer EBF duration (3.9 wk, P < 0.001) •PDS did not show a significant association with EBF after adjusting for covariates
[43]	Southwest Finland	2016	NR	Prospective follow-up for longitudinal cohort study	873	•Parental (maternal and paternal) postnatal depression (EPDS) •Parental marital distress (RDAS)	•Average EBF duration: 2.69 ± 2.1 mo •Average total breastfeeding duration 7.26 ± 4.5 mo	Self-reported questionnaires and self-administered follow-up diary •20 wk of gestation •4 mo postpartum	•Neither mother nor father's prenatal depression predicted EBF duration •Mothers with postnatal depression (EPDS ≥13) had shorter EBF (P = 0.001) •Mothers with persistent prenatal and postnatal depression had shorter EBF •Mothers with higher prenatal maternal marital distress had longer EBF duration (P = 0.029) •Father’s marital distress did not predict EBF duration
[44]	Melbourne, Australia	2016	NR	Prospective cohort study	1258	•Postpartum depression (EPDS)	Breastfeeding duration assessed using time-point prevalence •1 mo (84.6%, n = 1056) •2 mo (77.6%, n = 969) •3 mo (71.6%, n = 893) •4 mo (67.9%, n = 847) •5 mo (64.0%, n = 799) •6 mo (57.0%, n = 711)	Written questionnaires via mail •Baseline and 3 mo postpartum (EPDS) •Baseline, 3, and 6 mo postpartum (demographics and breastfeeding practice)	•Mothers reported depressive symptoms (EPDS ≥13) at 3 mo are less likely to breastfeed at 6 mo postpartum (49% vs. 61%, adjusted OR = 0.55; 95% CI: 0.34, 0.90) compared with mothers without depressive symptoms
[45]	Zagreb, Croatia	2016	NR	Cross-sectional observational study	303	•Maternal personality (International English Big Five Mini-Markers) •Mother–infant relationships (PBQ)	Breastfeeding duration not reported	Self-repot anonymous questionnaires	•Mother’s “agreeableness” (P = 0.002) and “openness” (P = 0.008) were positively correlated with breastfeeding duration •Mother’s “neuroticism” was positively correlated with breastfeeding duration (P = 0.047) •Mother’s “anxiety about care” was a negative predictor for breastfeeding duration (OR = 0.78; 95% CI: 0.65, 0.94)
[46]	United Kingdom	2017	NR	Nonexperimental one-group self-report survey	375	•Social-cognitive variables (attitude, subjective norm, perceived control, and self-efficacy) •Emotion variables (pride, regret, negative self-conscious emotions, and fear of inadequate nutrition and of breastfeeding damaging one’s physical appearance)	Average EBF duration: 4.46 ± 1.20 mo	Self-report questionnaires administered online	•EBF duration was positively correlated with attitude (P < 0.001), subjective norm (P < 0.01), perceived behavioral control (P < 0.001), self-efficacy (P < 0.001), and the emotions of pride (P < 0.001) and regret (P < 0.05) •EBF duration negatively correlated with fear of appearance damage (P< 0.01) and inadequate nutrition (p < 0.001) •EBF duration positively predicted by self-efficacy (P < 0.001), pride (P < 0.001) and regret (P < 0.1) •EBF duration negatively predicted by fear of inadequate nutrition (P < 0.001)
[47]	Across the United States	2018	•62% non-Hispanic Whit •13% non-Hispanic Black •9.4% non-Hispanic Other •15.6% Hispanic	Cross-sectional, retrospective analysis	62,483	•Prepregnancy depression	•Breastfeeding duration categorized as: •Never breastfed (16.0%) •Breastfed 8 wk or less (22.2%) •Breastfed >8 wk (61.8%)	Data taken from Pregnancy Risk Assessment Monitoring System	•Mothers with prepregnancy depression had 59% higher odds of never breastfeeding (adjusted OR = 1.59; 95% CI: 1.42, 1.77) and 50% higher odds of breastfeeding 8 weeks or less (adjusted OR = 1.5; 95% CI: 1.36, 1.66) •Different levels of associations between prepregnancy depression and breastfeeding duration were found at different maternal ages, with mothers aged 25–29 showing the most prominent effect
[48]	Idaho, United States	2019	94% White	Correlation design with moderated mediation models	94	•Stress (PSS) •Anxiety (PASS)- •Maternal perceptions of infant carrying (ICQ-R)	Average breastfeeding duration at 6 mo postpartum: 138 ± 69.13 d (4.4 mo)	• Interview and self-report questionnaire • Third trimester of pregnancy • 6 mo postpartum	•Model 1: prenatal stress (predictor), breastfeeding difficulties (mediator), and the perceptions of infant crying as spoiling (moderator) •Not statistically significant •Model 2: prenatal anxiety (predictor), breastfeeding difficulties (mediator) and the perceptions of infant crying as spoiling (moderator) •Overall model not statistically significant •Prenatal anxiety directly predicted breastfeeding duration (P = 0.022) •Independent sample t-test •Mothers above the clinical cutoff score (26) for prenatal anxiety had shorter breastfeeding duration (72.58 d less) compared with the mothers below clinical cutoff score (P < 0.0001) •ANCOVA •Positive association between postnatal anxiety and longer breastfeeding duration (P = 0.009)
[49]	Hunan Province, China	2019	NR	Prospective study	956	•Postpartum depression (EPDS)	•EBF duration: 3.90 ± 2.33 mo •Total breastfeeding duration not reported	•Survey collected via face-to-face interviews by trained investigators •4 wk postpartum (EPDS) •1, 3, 6, 8, and 12 mo postpartum (infant feeding practices)	•Mothers with depressive symptoms (EPDS ≥10) had 1.7 mo shorter total breastfeeding duration (8.02 compared with 6.32 mo, P = 0.008) compared with mothers without symptoms •Postpartum depressive symptoms were associated with increased risk of exclusive and partial breastfeeding cessation (P = 0.049 and 0.006, respectively)
[50]	Columbus, Ohio, United States	2019	• 52.8% White or other • 48.6% Black	Secondary analysis of longitudinal, nonexperimental cohort	70	•Breastfeeding beliefs (BBS) •Depressive symptoms (CES-D) •Perceived stress (PSS) •State anxiety (STAI) •Pregnancy-specific distress (NUPDQ)	•Breastfeeding duration assessed based on questionnaires about initiation and duration (categories) •Never initiated (12.9%, n = 9) •Early cessation of < 8 wk (34.3%, n = 24) •Continuing for ≥ 8 wk (52.9%, n = 37)	•Collected in person at Clinical Research Center at 3 study visits during pregnancy and 1 visit postpartum	•Mothers in the continued breastfeeding group had higher score in breastfeeding beliefs at the third trimester compared with early cessation (P < 0.01) and the never-initiated group (P < 0.01) •Mothers in the early cessation group had significantly higher pregnancy-specific distress in the first trimester compared with the never-initiated group (P ≤ 0.05) and the continued breastfeeding group (P ≤ 0.05) •Mothers who continued breastfeeding had fewer depressive symptoms postpartum compared with early cessation (P ≤ 0.04) and never-initiated group (P ≤ 0.05) •Mothers who continued breastfeeding had lower anxiety scores postpartum compared with early cessation (P = 0.04) and never-initiated group (P < 0.01)
[51]	Maldives	2019	NR	Prospective cohort study	458	•Antenatal and postnatal depression (EPDS) •Infant feeding attitude (Infant Feeding Attitudinal Scale)	•Breastfeeding duration assessed using survival analysis methods to estimate exclusive, full, and any breastfeeding duration	•Face-to-face interview and self-reported questionnaires •36-wk pregnancy •1, 3, and 6 mo postpartum	•Mothers with EPDS scores > 12: 23.6% at 36-wk pregnancy, 26.7% at 1 mo, 11.9% at 3 mo, and 2.6% at 5 mo •Mothers had antenatal EPDS > 12 was associated with late initiation of breastfeeding (adjusted OR = 3.0; 95% CI: 1.3, 6.8) •Mothers with 1-mo postnatal EPDS scores ≥12 had shorter EBF duration compared with mothers with an EPDS score <12 (P < 0.001) •Mothers with 1-mo postnatal EPDS scores ≥12 had shorter full breastfeeding duration compared with mothers with EPDS score <12 (P < 0.001) •Mothers with 1-mo postnatal EPDS scores ≥12 had shorter any breastfeeding duration compared with mothers with EPDS score <12 (P < 0.001)
[52]	Chapel Hill, North Carolina, United States	2019	•70% non-Hispanic White •12% African America •9% Hispanic/Latino	Prospective, longitudinal, 1-group observational nonexperimental study	192	•Maternal positive emotions (mDES)	•Breastfeeding duration assessed using time-to-event variable and survival analysis	• Interview and self-report questionnaires • Third trimester of pregnancy • 2,6, and 12 mo postpartum	•Maternal positive emotions during feeding 2 mo postpartum were associated with longer time to cessation of EBF (adjusted HR = 0.65; 95% CI: 0.46, 0.92) •Maternal positive emotions during feeding 2 mo postpartum were not associated with time to cessation of any BF during first year postpartum (adjusted HR = 0.94; 95% CI: 0.64, 1.31)
[53]	United States	2019	•85.2% non-Hispanic White •4.2% non-Hispanic Black •5.9% Hispanic •4.7% Others	Prospective cohort study	1198	•Breastfeeding intention •Breastfeeding self-efficacy	•Average EBF duration: 5.7 ± 8.3 wk •Average total breastfeeding duration 24.9 ± 19.7 wk	• Self-report questionnaires • Third trimester of pregnancy • Follow-up once a mo until 1 y postpartum	•Maternal breastfeeding intention was negatively associated with breastfeeding duration (P < 0.001) •Maternal breastfeeding self-efficacy was positively associated with breastfeeding duration (P < 0.001) •Workplace support was significantly associated with longer breastfeeding duration via the mediation of breastfeeding self-efficacy (P = 0.032)
[54]	West Yorkshire, United Kingdom	2022	95% White	Cross-sectional, quantitative study	91	•Intention to breastfeed •Self-efficacy scale •Perceived stress scale	•Breastfeeding duration assessed at 1 and 6 wk	•Online questionnaires •1 and 6 wk postpartum	•No significant predictors found for duration of breastfeeding at 1 wk and 6 wk
[55]	Anhui province, China	2022	NR	Prospective cohort study	3033	•Pregnancy-related anxiety (PrA questionnaire)	•Breastfeeding duration assessed using time-to-event variable	• Self-administered questionnaires under the supervision of graduate students • Second and third trimesters (PrA) • At 1, 2, 3, 4, 5, 6, and 12-mo postpartum (breastfeeding practices)	•Mothers with persistent PrA in both trimesters (PrA ≥24) had a higher risk of EBF cessation at 4 (adjusted OR = 1.38; 95% CI: 1.05, 1.82, P = 0.021) and 6 mo (adjusted OR = 1.86; 95% CI: 1.11, 3.12, P = 0.019) postpartum compared with those who never suffered PrA •Mothers with persistent PrA in both trimesters (PrA ≥24) had a higher risk of shorter breastfeeding duration (HR = 1.19; 95% CI: 1.01, 1.41, P = 0.041) compared with those who never suffered PrA
[56]	Hong Kong, China	2022	NR	Prospective cohort study	821	•Breastfeeding self-efficacy (BSES-SF)	•Breastfeeding duration assessed using survival analysis methods to estimate exclusive and any breastfeeding duration	• Self-administered questionnaires and telephone follow-up • Immediate postpartum (BSES-SF) • 6 mo or until weaning (breastfeeding practices)	•Higher maternal breastfeeding self-efficacy scores were associated with the continuation of any breastfeeding (adjusted OR = 1.07; 95% CI: 1.04, 1.09) and EBF (adjusted OR = 1.05; 95% CI: 1.03, 1.07) •Each 1-unit increase in BSES-SF score is associated with a 7%, 6%, and 4% increased odds of any breastfeeding continuation for 1.5, 3, and 6 mo postpartum
[57]	Thailand	2022	NR	Cross-sectional web-based study	390	•Fear of COVID-19 Scale •Attitude to COVID-19 (KAP) •COVID-19 vaccination acceptability •Maternal Anxiety (STAI-S) •Breastfeeding intention	•Average breastfeeding duration: 6.20 ± 2.5 mo	•Self-administered online surveys with closed-end questions	•Positive associations between breastfeeding intention and longer breastfeeding duration in the first year (P < 0.0001) •Positive associations between intention to vaccine and longer breastfeeding duration in the first year (P = 0.008) •Breastfeeding duration was positively predicted by breastfeeding intention (P < 0.05), vaccine intention (P < 0.05), and anxiety-related to COVID -19
[58]	Taif, Saudi Arabia	2023	NR	Descriptive correlational design	356	•Breastfeeding personal efficacy (BPEBI) •Infant feeding intention (MIFIS)	Two groups •Group 1 still breastfeeding at the time of data collection (mean = 4.1 mo) •Group 2 ceased breastfeeding at the time of data collection (mean = 6.83 mo)	•Questionnaires collected by researchers in clinics	• Two groups • Group 1: positive correlations between breastfeeding self-efficacy and breastfeeding duration; positive correlations between breastfeeding intention and breastfeeding duration (all P < 0.001) • Group 2: positive correlations between breastfeeding self-efficacy and breastfeeding duration; positive correlations between breastfeeding intention and breastfeeding duration (all P < 0.001)

Abbreviations: ANCOVA, analysis of covariance; BAQ, Body Attitudes Questionnaire; BBS, Breastfeeding Beliefs Scale; BPEBI, Breastfeeding Personal Efficacy Beliefs Inventory; BSES, Breastfeeding Self-Efficacy Scale; BSES-SF, Breastfeeding Self-Efficacy Scale-Short Form; CES-D, Center for Epidemiological Studies Depression Scale; CI, confidence interval; COPE, Coping Orientation to Problems Experienced; DASS-21, Depression Anxiety Stress Scale 21; EBF, exclusive breastfeeding; EPDS, Edinburgh Postpartum Depression Scale; HR, hazards ratio; ICQ-R, Infant Crying Questionnaire-Revised; IIFAS, Iowa Infant Feeding Attitude Scale; KAP, Knowledge, Attitudes, and Practice; mDES, Modified Differential Emotions Scale; MIFIS, Modified Infant Feeding Intention Scale; NR, not reported; NUPDQ, Revised Prenatal Distress Questionnaire; OR, odds ratio; PASS, Perinatal Anxiety Screening Scale; PBQ, Postpartum Bonding Questionnaire; PrA, pregnancy-related anxiety; PSS, Perceived Stress Scale; RDAS, Revised Dyadic Adjustment Scale; STAI, State-Trait Anxiety Inventory.

Maternal depression and anxiety

Prenatal and postnatal depressive symptoms (PDSs) were consistently predictive of both shorter exclusive breastfeeding (EBF) and any breastfeeding durations. The Edinburgh Postpartum Depression Scale (EPDS) is a commonly used tool for investigating maternal depressive symptoms across the globe. The EPDS is a 10-item self-administered questionnaire that provides a score ranging from 0 to 30 [59]. A cutoff score for the EPDS is typically used as a threshold to detect major depression; however, various cutoff scores have been employed by different researchers in different study settings [60]. Seven articles in our review used EPDS to measure maternal depressive symptoms, with the studies administered at different geographic locations across the world. A prospective study conducted in Hunan Province, China, recruited 956 mothers and collected data on breastfeeding duration through face-to-face interviews with trained researchers from 1 mo to 1 y postpartum [49]. A revised Chinese version of the EPDS was employed at 1 mo postpartum. A cutoff of ≥10 was used to determine the presence of postnatal depression (PND) symptoms. The results suggested that mothers with PND symptoms had 1.7 mo shorter (P = 0.008) breastfeeding duration compared with mothers who did not present PND symptoms. In terms of EBF, mothers without PND symptoms had a higher rate of EBF in the first month compared with those with PND symptoms (70% compared with 57.1%, P = 0.006) [49]. Another prospective study with a similar setting (n = 1258) was conducted in Melbourne, Australia by Woolhouse et al. [44]. The EPDS was collected at baseline and 3 mo postpartum, and breastfeeding duration was collected ≤6 mo postpartum. A EPDS score of ≥13 was used as an indicator for possible major depression. The authors found that compared with mothers without PND symptoms, mothers who reported PND symptoms at 3 mo postpartum had significantly lower rates of breastfeeding at 4, 5, and 6 mo postpartum, suggesting shorter breastfeeding duration. The association between maternal depressive symptoms and lower breastfeeding rates at 6 mo remained significant after adjusting for covariates [44].

In the United States, a secondary data analysis of longitudinal research conducted by the Food and Drug Administration and the Centers for Disease Control and Prevention used an EPDS cutoff of 9 to identify mild depression symptoms at 2-mo postpartum [42]. Among the 1271 mothers, those who showed PDS had 2.37 wk shorter breastfeeding duration compared with mothers without PDS. Also, mothers who intended to breastfeed had longer EBF duration and total breastfeeding duration [42]. Furthermore, a verified Malay version of EPDS was performed in a large cohort (n = 1078) in Sabah, Malaysia, to investigate maternal depression and breastfeeding duration. Unlike other studies that examined the effects of postpartum depression on breastfeeding, this study specifically analyzed the depression symptoms during the antenatal period [38]. The distribution of antenatal EPDS scores was categorized into tertiles, with scores ranging from 0 to 3, 4 to 7, and 8 to 30, respectively. The results suggested that mothers with an antenatal EPDS score > 7 were twice as likely to discontinue breastfeeding by 6 mo postpartum compared with mothers with an EPDS score of 3 or lower [38]. Thus, this study highlighted the importance of maternal mental health prior to delivery on breastfeeding duration. A prospective cohort study in the Maldives further confirmed the contributions of maternal depressive symptoms in the antenatal period to breastfeeding outcomes [51] using a translated EPDS, where a score of >12 was considered as major depression. The authors reported that antenatal depression symptoms were associated with late initiation of breastfeeding, whereas PND was found to be negatively associated with breastfeeding durations. However, the direct association between antenatal depression and breastfeeding duration was not assessed in the design [51].

Two other studies investigated both PND and emotional distress and their impact on EBF duration. One study was a longitudinal cohort in Southeastern Brazil (n = 168), where the effects of postpartum depression on EBF duration were examined [34]. EPDS was administered at 30 and 60 d postpartum. The analysis revealed that depressive symptoms, as suggested by an EPDS score ≥12, were associated with discontinuing EBF at 2 mo postpartum. At 4 mo postpartum, mothers’ negative emotional reaction to the news of pregnancy and lack of partner support were significant predictors for EBF cessation [34]. However, the total or any breastfeeding duration was not investigated in this study. Another study conducted in Southwest Finland followed up 873 families and investigated the impact of depression and marital distress of both parents [43]. The results suggested that mothers’ PDSs (EPDS ≥13) were associated with shorter EBF duration. Also, mothers with persistent depression prenatally (EPDS ≥15) and postnatally (EPDS ≥13) had the shortest EBF duration compared with those who had depressive symptoms at only 1 point. However, paternal depressive symptoms and marital distress were not significant predictors of EBF duration. Interestingly, higher prenatal maternal marital distress was associated with longer EBF duration [43]. Building on prior work that examined the effects of depressive symptoms during and after giving birth, 1 study across the United States (n = 62,483) explored whether depressive symptoms preceding pregnancy affected breastfeeding behaviors postpartum [47]. Findings from this large cohort suggested that mothers with prepregnancy depression were more likely to breastfeed for a shorter time compared with those who did not have depressive symptoms before pregnancy [47], which indicates the importance of considering maternal mental health even before conception.

Similarly, the impact of maternal anxiety on breastfeeding duration and exclusivity has gained attention from researchers in different geographic regions. In the United States, a group of 94 mothers residing in the state of Idaho was followed from the third trimester to 6 mo postpartum to investigate the associations between maternal perinatal/postnatal stress and anxiety and breastfeeding duration [48]. Maternal stress was assessed using a 14-item self-report Perceived Stress Scale, and maternal anxiety was measured with a 31-item self-report questionnaire, Perinatal Anxiety Screening Scale (PASS) [48]. It was documented that only prenatal anxiety was a negative predictor of breastfeeding duration. To be specific, mothers with anxiety scores at or above the clinical cutoff of 26 had 72.6 d shorter breastfeeding duration compared with mothers below the clinical cutoff (PASS <26) [48]. Beyond prenatal anxiety, maternal anxiety during pregnancy was explored in a prospective cohort study (n = 3033) in Anhui province, China. The results highlighted that mothers who suffered anxiety persistently during the second and third trimesters of pregnancy had a significantly higher risk of early EBF cessation and shorter total breastfeeding duration [55]. Likewise, a smaller cohort (n = 70) in Ohio, United States, examined the effects of several psychological distresses during pregnancy and early postpartum periods on breastfeeding duration [50]. The findings demonstrated that mothers with early breastfeeding cessation (<8 wk postpartum) had higher pregnancy-related distress in early pregnancy compared with those who never initiated breastfeeding and those who breastfed longer. In addition, mothers who ceased breastfeeding early also had higher early postpartum anxiety and depressive symptoms [50].

Maternal personality and self-efficacy

In addition to maternal depression and anxiety, maternal personality can also influence breastfeeding behaviors. Studies examining personality usually assess the Big Five traits that include openness, conscientiousness, extraversion, agreeableness, and neuroticism, which are typically measured using standard and validated self-report questionnaires such as the Neuroticism-Extraversion-Openness personality inventory [61] or the Big Five Inventory [62].

An exploratory cross-sectional study investigated the associations between maternal personalities, attitudes, and breastfeeding duration [35]. The findings revealed that mothers who reported higher levels of emotional stability [35] and extraversion had longer breastfeeding duration. At the same time, those mothers who had greater emotional stability, extraversion, and conscientiousness also showed a more positive attitude toward breastfeeding. The positive attitudes, including aspects like believing breastfeeding to be healthier, could be potential promoting factors for longer breastfeeding as well. Conversely, mothers who were more introverted and anxious had a greater tendency to stop breastfeeding earlier due to factors such as feeling embarrassed about breastfeeding and the lack of support [35]. Similarly, Keller et al. [45] found consistent patterns in the association between maternal personality and breastfeeding duration in a Croatian cohort (n = 303), where “openness” and “agreeableness” were positively correlated with breastfeeding duration, and “neuroticism” was negatively correlated with breastfeeding duration.

Notably, a longitudinal study in Australia involving 125 mothers investigated various psychological factors collectively and their effects on EBF duration, including EBF intention, motivation, and confidence, attitude toward pregnancy and body, self-efficacy, and depression [37]. During the antenatal period at 32 wk of gestation, mothers’ confidence in achieving EBF was a positive predictor of EBF duration to 6 mo postpartum. At postpartum periods, maternal self-efficacy was positively associated with longer EBF duration, whereas combined depression, anxiety, and stress were negative predictors for EBF duration [37]. Beyond maternal personality traits, maternal self-efficacy, described as the mothers’ confidence in their ability to successfully breastfeed [63], has emerged as another key factor that is worth investigating. Fan et al. [56] evaluated the associations between maternal self-efficacy and infant feeding mode in a prospective cohort in Hong Kong, China. The results from 821 healthy mothers suggested that a higher score for breastfeeding self-efficacy was associated with higher odds of breastfeeding continuation over a 6-mo postpartum period, and a lower risk of using expressed human milk feeding [56]. A retrospective study in Australia (n = 174) evaluated several psychosocial factors related to EBF duration, including maternal self-efficacy. An online survey was employed, and those women who exclusively breastfed for 6 mo or longer scored higher in intention to breastfeed, breastfeeding self-efficacy, and level of comfort for feeding in public. Breastfeeding self-efficacy was a strong predictor of both EBF intention and duration [36]. Furthermore, positive effects of higher maternal self-efficacy were also seen in other populations. In the United States, mothers’ (n = 1198) self-efficacy was a direct predictor of longer breastfeeding duration and a significant mediator in the relations between workplace support on breastfeeding duration [53]. In Saudi Arabia (n = 356), strong positive correlations were found between breastfeeding self-efficacy and breastfeeding duration, as well as between breastfeeding intention and breastfeeding duration [58]. However, in the United Kingdom (n = 91), maternal self-efficacy was not found to be a significant predictor of breastfeeding duration at 1 and 6 wk postpartum [54].

Maternal attitudes and emotions

Although self-efficacy reflects mothers’ confidence in their breastfeeding ability, their underlying attitudes may also influence their breastfeeding decisions and practices. A prospective cohort in rural Western Australia (n = 427) was evaluated to examine the influence of infant feeding attitudes on breastfeeding duration [41]. The Iowa Infant Feeding Attitude Scale (IIFAS) was used to measure mothers' attitudes toward breastfeeding, and a score of 65 (of 85) was used as the threshold for positivity toward breastfeeding. The analysis suggested that mothers with a positive attitude toward breastfeeding (IIFAS >65) had a longer EBF duration and any breastfeeding duration [41]. In another cross-sectional study in Korea, a convenience sample of 604 mothers of children aged 24 mo or younger were recruited to investigate breastfeeding knowledge, attitudes, and beliefs of its usefulness, and their effect on breastfeeding duration [39]. Results highlighted that mothers with more positive attitudes and greater interest toward breastfeeding were more likely to have longer breastfeeding durations, and those who had a duration of longer than 6 mo were more aware of the pleasure of breastfeeding and the development of maternal–child attachment [39].

Additionally, maternal positive emotions during breastfeeding sessions can be influential on the breastfeeding process. Wouk et al. [52] measured maternal emotions during breastfeeding at 2 mo postpartum and the associations with breastfeeding outcomes and overall breastfeeding experiences. They used a Modified Differential Emotions Scale to evaluate maternal emotions at 2 mo and collected breastfeeding outcomes on a monthly basis through 12 mo postpartum. The analysis revealed that positive emotions during breastfeeding at 2 mo were associated with a longer time to EBF cessation and better breastfeeding experiences. Although positive emotions during EBF at 2 mo predicted longer EBF duration; this association was not significant for any breastfeeding duration across the first year [52]. Furthermore, positive emotion at 2 mo postpartum was associated with higher levels of antenatal attachment, social support, skin-to-skin contact, and fewer early breastfeeding problems [52], all of which contributed to better breastfeeding experiences.

Various negative emotions experienced by mothers have also been investigated. Brown et al. [40] explored mothers’ body image concerns during pregnancy and their impact on breastfeeding practices in the United Kingdom (n = 128). The findings suggested that higher pregnancy body image concerns and prospective postnatal body image concerns were associated with both shorter intended breastfeeding duration and actual breastfeeding duration. The body image concerns consisted of negative emotions such as embarrassment, concerns about public feeding, and fear of the impact of breastfeeding on body appearance [40]. Mothers’ negative emotions can also come from external or environmental factors. For example, a study carried out in Thailand examined mothers’ fear and anxiety during the COVID-19 pandemic. A group of 390 mothers was recruited and asked to complete an online questionnaire regarding psychological factors and breastfeeding practices. Mothers with the intention to breastfeed and the intention to vaccinate against COVID-19 had significantly longer breastfeeding durations in the first year postpartum [57]. Interestingly, the authors reported that mothers’ anxiety toward COVID-19 infection was a positive predictor of longer breastfeeding duration within the first year of life, possibly to protect their infants. In this context, maternal anxiety related to COVID-19 might have motivated the prolonged breastfeeding behavior as a protective measure.

Although it is not uncommon for mothers to continue breastfeeding until 6 mo postpartum, most women stop EBF after 6 wk [64]. To better understand the effects of social-cognitive and emotional factors on the duration of EBF, an online survey was conducted with 375 mothers in the United Kingdom. Mothers’ responses revealed that maternal self-efficacy, pride toward breastfeeding, and the possibility of regret for not breastfeeding their infant were positive predictors of EBF duration; however, the fear of damaging one’s appearance and the fear of inadequate nutrition to support lactation were negative predictors [46].

In summary, multiple maternal psychological factors, including maternal emotional well-being, personality dimensions, and breastfeeding intentions, attitudes, and self-efficacy, were shown to influence breastfeeding duration and experiences. Maternal stress, anxiety, and depressive symptoms were consistently linked to early breastfeeding cessation and shorter breastfeeding duration. Maternal personality traits, such as emotional stability, conscientiousness, and openness, were positively associated with prolonged breastfeeding practices. Furthermore, mothers’ intention to breastfeed, confidence in feeding, and positive attitudes can all positively enhance the length of breastfeeding postpartum.

Paternal psychosocial contributions to breastfeeding duration

Family support can play a crucial role in the duration of breastfeeding, and 3 studies examining paternal psychosocial contributions to breastfeeding duration were identified in this review (Table 2) [[65], [66], [67]]. Fathers are ideal candidates for providing emotional, practical, and informational support that may directly impact a mother’s confidence and ability to sustain breastfeeding [68]. Emotional support and understanding from fathers potentially help mothers cope with the challenges of breastfeeding, thereby enhancing maternal well-being by reducing stress [69]. This interpersonal interaction between parents can be particularly vital in the early postpartum period, when mothers are adjusting to the demands of breastfeeding and potential physical discomfort or self-doubt [70]. However, recent research on psychosocial support provided by fathers, specific to breastfeeding, is rather limited.

TABLE 2.

Effects of paternal psychosocial involvement on breastfeeding durations.

Citation	Study location	Year	Race/ethnicity	Study design	n	Psychological factor	Duration of breastfeeding	Measurement methods	Results
[65]	Monroe County, Indiana, United States	2014	NR	Cross-sectional, retrospective survey	146	•Breastfeeding intention •Breastfeeding plans •Postpartum breastfeeding support	•Breastfeeding duration not reported	•Self-administered questionnaires	•EBF prevalence at 6 mo was higher among mothers with father involvement early postpartum •Mothers who had father involvement in breastfeeding were more likely to continue breastfeeding after leaving the hospital
[66]	Ontario, Canada	2018	NR	Longitudinal, prospective, and multicenter cohort study	222	•Maternal Depression Symptoms (EPDS) •Relationship satisfaction •Dissatisfaction with father involvement (CAQ)	• Breastfeeding durations reported by mothers and categorized into a dichotomized variable • EBF at 3 mo • Any breastfeeding at 6 mo	• Self-administered questionnaires • 3, 8, 16, and 24 mo postpartum	•Among mothers who were EBF at 3 mo, mothers’ dissatisfaction with father involvement at 6 mo was a significant predictor for breastfeeding discontinuation from 3 to 6 mo (P = 0.006)
[67]	Chiang Mai province, Thailand	2022	NR	Cross-sectional, descriptive quantitative design	205	•Breastfeeding self-efficacy (BSES-SF) •Father’s Attitude toward Exclusive Breastfeeding questionnaire (FAEB)	•Average EBF duration: 4.74 mo	•Self-administered questionnaires	•Positive correlation between maternal BSES and EBF duration (P < 0.01) • Positive correlation between paternal BSES and EBF duration (P < 0.01) • Positive correlation between paternal FAEB scores and EBF duration (P < 0.05) • Paternal BSES did not moderate the relationship between maternal BSES and EBF duration

Abbreviations: CAQ, Childbearing Attitude Questionnaire; BSES, Breastfeeding Self-Efficacy Scale; BSES-SF, Breastfeeding Self-Efficacy Scale-Short Form; EBF, exclusive breastfeeding; EPDS, Edinburgh Postpartum Depression Scale; FAEB, Father’s Attitude toward Exclusive Breastfeeding questionnaire; NR, not reported.

Hunter and Cattelona [65] investigated the impact of father involvement, and their physical and emotional support in the early postpartum period on breastfeeding initiation and duration. A cross-sectional cohort of 146 first-time mothers was recruited from Monroe County, Indiana, United States, and a self-reported questionnaire about breastfeeding status and partner’s support was completed by the mothers during the postpartum period. The results highlighted that receiving support from fathers during the early postpartum period was associated with significantly higher EBF breastfeeding prevalence and breastfeeding continuation after leaving the hospital up to over 6 mo [65]. Thus, breastfeeding, which is often viewed as a maternal responsibility, may be influenced by a father’s active involvement and support. Fathers’ encouragement and advocacy may provide emotional reinforcement, helping to counteract maternal self-doubts. On the contrary, optimal involvement of the fathers to meet the needs of breastfeeding mothers might be challenging, and maternal dissatisfaction with the partner’s involvement can have negative effects on breastfeeding outcomes. A multicenter study in Ontario, Canada, followed 222 mothers until 24 mo postpartum and asked them to rate satisfaction levels with father involvement in the breastfeeding practices [66]. The data revealed that a higher level of maternal dissatisfaction with father’s involvement predicted breastfeeding discontinuation from 3 to 6 mo postpartum [66].

Earlier in this review, the importance of maternal self-efficacy in breastfeeding behavior was summarized. Expanding this focus beyond mothers, a study conducted in Thailand investigated the contribution of fathers’ self-efficacy on breastfeeding outcomes with 205 couples. The results indicated that the fathers’ self-efficacy for supporting breastfeeding and their attitudes toward EBF were both positively correlated with EBF duration [67]. Antenatal class attendance by both parents was also positively correlated with EBF. Furthermore, the paternal number of children was positively correlated with the duration of EBF [67]. Hence, paternal education on practices that are specific to increasing fathers’ confidence in supporting their partners’ breastfeeding can be an important component of breastfeeding support. Fathers’ involvement in the process might also help ease the physical and psychological barriers to breastfeeding by providing emotional support that potentially enhances mothers’ confidence in reaching breastfeeding goals.

Infant psychosocial factors and breastfeeding duration

Mother–child interactions and their influences are bidirectional, and as such, the infant plays an active role in the breastfeeding process and duration. Three observational studies were identified in this review (Table 3) [[71], [72], [73]]. Various psychosocial and behavioral factors were incorporated in the search criteria, including infant emotions and temperament. Temperament, defined as individual differences in emotional and behavioral styles [74], varies among infants and can influence the process of breastfeeding. Moreover, the infant characteristics tend to impact breastfeeding status indirectly via the parents’ perception of the infant traits. A large cohort study (n = 5955) carried out in Ireland investigated the associations between infant temperament and breastfeeding duration [73]. They reported that infant fussiness/difficulty, characterized by high negative affectivity and reactivity, was negatively associated with breastfeeding duration, whereas higher infant unpredictability was positively associated with breastfeeding duration [73]. The unpredictability dimension of the Infant Characteristics Questionnaire used in this study refers to irregular behavioral/biological patterns and rhythms such as irregular sleeping routines and unpredictable crying. Although this dimension is part of a more reactive temperament profile, it was positively associated with breastfeeding duration. It may be that mothers respond to unpredictability with more attempts to sooth or regulate their infant with continued breastfeeding (CBF), and this finding highlights the need to examine multiple dimensions of temperament, and both direct and indirect associations between infant temperament and breastfeeding duration.

TABLE 3.

Influence of infant psychosocial characteristics on breastfeeding durations.

Citation	Study location	Year	Race/ethnicity	Study design	n	Psychological factor	Duration of breastfeeding	Measurement methods	Results
[71]	Swansea and Durham, United Kingdom	2014	NR	Cross-sectional study	508	•Maternal parenting style (IPSQ)	•Breastfeeding duration not reported	•Self-report questionnaire via paper or online	•Mothers who were breastfeeding at 2, 6, 12, and 26 wk scored lower on parent-led routine compared with mothers who were not breastfeeding
[72]	North Carolina, United States	2014	•50% non-Hispanic European American •47% African American •3% Others	Longitudinal cohort study	237	•Adult Attachment Interview •Infant Crying Questionnaire •Infant temperament (IBQ-RVS)	•Median breastfeeding duration: 3 mo (IQR = 7)	• Interview and mailed questionnaires • Third trimester (interview and infant crying questionnaire) • 6 mo postpartum (breastfeeding practices)	•Maternal attachment and beliefs about infant crying were not associated with breastfeeding duration after correcting for covariates •Infants rated high on negative affect are at greater risk of early breastfeeding cessation when mothers score d high on spoiling beliefs (HR = 1.71, P < 0.01) •Infants rated high on negative affect are at lower risk of early breastfeeding cessation when mothers scored moderate or low on spoiling beliefs (HR = 0.53, P < 0.01)
[73]	Ireland	2016	Irish	Longitudinal cohort study	5955	•Infant temperament (ICQ)	• Breastfeeding duration assessed using categories • <1 wk (n= 1019) • 1 wk–1 mo (n = 808) • 1–3 mo (n = 1292) • 3–6 mo (n = 1229) • >6 mo (n = 1607)	•Retrospective surveys administered by trained interviewers	•Fussy infants had significantly lower odds of being breastfed ≥90 d (OR = 0.98; 95% CI: 0.97, 0.99) •Unpredictable infants had significantly higher odds of being breastfed ≥90 d (OR = 1.04; 95% CI: 1.02, 1.07)

Abbreviations: CI, confidence interval; IPSQ, Infant Parenting Questionnaire; ICQ, Infant Characteristics Questionnaire; IBQ-RVS, Infant Behaviour Questionnaire-Revised Very Short; NR, not reported; OR, odds ratio; HR, hazard ratio.

Another study by Mathews et al. [72] also investigated the associations between infant temperament, maternal beliefs, and breastfeeding duration. The longitudinal cohort involved 237 participants in North Carolina, United States. Breastfeeding duration was negatively associated with prenatal beliefs about controlling infant cries, negative infant affect, and the belief that responding to infant cries can increase attachment. Infant negative affectivity is 1 dimension of infant temperament, describing high reactivity and difficulty in being soothed or calmed down [75]. Notably, the result indicated a complex interplay between infant temperament and maternal beliefs, particularly regarding the practice of responding to infant cries. An interaction effect suggested that mothers who perceived their infants as having high levels of negative affectivity and simultaneously hold the belief that comforting a crying baby will “spoil” them were at greater risk of earlier breastfeeding cessation [72]. This interaction suggests that beliefs about spoiling may amplify the perceived breastfeeding challenges with an infant who is relatively high on negative affectivity, ultimately shortening breastfeeding duration.

A cross-sectional study in the United Kingdom [71] examined infant-led approaches to breastfeeding in response to cues of hunger and their impact on breastfeeding outcomes in 508 families. Maternal age ranged from 17 to 44 y, and associations were found between age and parenting behaviors. Older mothers were more likely to show higher levels of anxiety and lower levels of affectionate care and attention toward their infants compared with younger mothers. In addition, greater levels of anxiety and more frequent use of a parent-led breastfeeding routine were associated with shorter breastfeeding duration. On the other hand, the use of an infant-led breastfeeding routine, where mothers were responsive to the cues from infants, was associated with longer breastfeeding duration [71]. This study suggested the importance of infant behavior and parents’ awareness of and responsiveness to their infants’ signals for optimal breastfeeding outcomes.

Discussion

Herein, we focused on psychosocial factors influencing breastfeeding duration, as current clinical and epidemiological data suggest that breastfeeding initiation rates in the United States are close to recommendations [46], although still suboptimal in low- and middle-income countries [76]. However, few mothers meet the recommendations for breastfeeding exclusivity and duration in both the United States [77] and globally [78]. A longer breastfeeding duration benefits infants by supporting their nutritional and physiological needs, and also plays a role in their overall immune, cognitive, and psychological development [79,80]. In particular, exclusive and prolonged breastfeeding lowers risk of infections [81], protects infants from excessive weight gain early in life [82], and fosters a stronger immune system and healthier microbiota in infants [83]. Longer breastfeeding duration can also have long-term implications for parental caregiving styles into toddlerhood. A longitudinal study conducted in Southeast Norway investigated the associations between breastfeeding duration in the first year and parenting behaviors. The path analysis revealed that a longer breastfeeding duration was associated with more supportive paternal parenting, which appeared to be mediated by maternal supportive parenting [84]. This suggests that the positive effects of extended breastfeeding on maternal behaviors might indirectly enhance paternal involvement in caregiving at the same time.

This review specifically focused on the psychosocial factors of the mother, the psychological and social/emotional support from the father, and infant temperamental and behavioral characteristics, and their impact on breastfeeding duration. By summarizing these 3 domains, we aimed to provide a more comprehensive understanding of the salient psychosocial correlates of breastfeeding duration. Those insights could potentially inform future strategies to facilitate a more successful breastfeeding process as most psychosocial factors have been suggested to be modifiable [27], such as self-efficacy [85] and depressive symptoms [86,87].

Maternal stress and depression are associated with both maternal and infant health [88] and are commonly reported in pregnancy [89]. Alterations in psychological function often occur over the course of pregnancy [90]. Even following childbirth, postpartum depression affects 17.2% of women globally [91]. PND symptoms can negatively influence breastfeeding outcomes [92]. The direct and indirect relations between maternal psychological well-being and breastfeeding duration were evident in the studies included in the current review. For example, 7 studies reported that maternal depressive symptoms and sadness were significantly associated with reduced EBF and any breastfeeding duration [34,38,[42], [43], [44],49,51]. These overall findings are consistent with recent research that also suggests the importance of considering the comorbid and possible differential effects of postpartum depression and anxiety symptoms on EBF and CBF. The comorbid presence of postpartum depression and anxiety predicted lower odds of EBF, but decreased odds of CBF were associated with anxiety symptoms [93]. Taken together, these findings highlight the importance of providing psychological support to mothers from both families and health care providers, including the time before planning to conceive, during pregnancy, and postpartum.

Breastfeeding self-efficacy, or a mother’s confidence in her ability to breastfeed [94], emerged as another crucial factor in extending the duration of breastfeeding, as reported by studies across various geographic locations [36,37,53,58]. Also, mothers’ concern about body image during pregnancy and postpartum was an additional source of distress [40]. Mothers’ concerns, such as negative perceptions about body appearance postpartum or discomfort with public feeding, can further impact maternal self-efficacy. To address this, strategies to increase EBF duration should not only include breastfeeding education but also incorporate positive counseling to improve mothers’ confidence. For example, a telephone intervention targeting postpartum mothers in Brazil revealed that education and motivational interviews provided by trained nurses improved maternal breastfeeding self-efficacy [95]. Thus, similar strategies could potentially be applied as a regular component of postnatal care.

Moreover, maternal personality traits such as emotional stability, extraversion, and conscientiousness were associated with breastfeeding attitude and positive breastfeeding outcomes [35]. Mothers who scored higher on these traits were more likely to breastfeed for longer durations, whereas mothers who were introverted and anxious faced more challenges such as embarrassment or lack of social support [35]. Together, these findings suggest that personalized support that considers individual differences in personality traits, especially for mothers who are elevated on introversion and anxiety, could assist with breastfeeding maintenance.

Beyond psychological factors themselves, physical discomfort and pain related to breastfeeding can be important predictors of PND and breastfeeding cessation [96]. Many mothers experienced breastfeeding-associated discomfort [97], such as nipple pain [98], breast engorgement [99], and mastitis [100], that can all contribute to frustration and emotional distress. In turn, additional stress can impact the breastfeeding experience, self-efficacy, and ultimately reduce the length of breastfeeding. Therefore, it is vital to address the physical aspects of breastfeeding as a part of postpartum support for maternal mental wellness. Providing adequate assistance, such as pain-relief products, latching techniques, and positioning instructions [101], can be useful in helping mothers sustain breastfeeding and increase self-efficacy.

There are several ways to support maternal psychological well-being, one of which is the quality of maternal–infant interaction [40,102], with positive interactions fostering stronger emotional connection and longer breastfeeding. These interactions encompass a range of behaviors, including physical closeness [103], emotional bonding [104], and responsive caregiving [105,106], all of which contribute to a supportive breastfeeding environment. The WHO recommends skin-to-skin contact immediately after birth as the standard of practice to improve both short- and long-term health outcomes for infants [107]. It has also been suggested that skin-to-skin contact may have positive effects on the development of preterm infants [108].

High-quality maternal–infant interactions not only facilitate infants’ effective sucking [109], but also stimulate milk production through the maternal hormonal feedback involving oxytocin and prolactin [110,111]. Moreover, a strong maternal–infant bond can enhance a mother’s confidence, self-efficacy, and commitment to breastfeeding, reducing the likelihood of early weaning [112]. A systematic review and meta-analysis found that immediate skin-to-skin contact increased breastfeeding duration compared with separation at birth [113]. However, there are potential barriers to enabling skin-to-skin contact immediately after birth, such as interference with clinical routines, lack of supporting personnel, and concerns about the safety of newborns falling [114,115]. Although immediate skin-to-skin contact may be challenging for mothers, the importance of these interactions cannot be overstated, as they establish the foundation for a successful breastfeeding experience and a healthy developmental trajectory for infants [116]. For example, institutional practice may support the successful establishment of early breastfeeding practices. The Baby-Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding provides an evidence-based framework to assist mothers in breastfeeding initiation and continuation [117,118]. Support and education on maternal–infant bonding provided by hospitals have also been shown to be effective [[119], [120], [121]]. Expanding those efforts can be particularly helpful in addressing both psychological and physical barriers to breastfeeding.

Maternal employment and the need to return to work postpartum can disrupt maternal–infant bonding, affect maternal psychological well-being, and may contribute to earlier cessation of breastfeeding [[122], [123], [124], [125], [126], [127]]. Thus, emotional distress from employment may influence both breastfeeding duration and workforce participation [124]. Therefore, policies supporting extended maternity leave and flexible work arrangements may prolong breastfeeding duration [128,129].

Paternal support is another crucial, yet often underemphasized, factor in shaping breastfeeding duration and experiences [130]. Paternal involvement, knowledge, and attitudes about breastfeeding can significantly impact a mother’s breastfeeding experience and should be carefully considered [131,132]. For example, studies showed that fathers’ attitudes toward breastfeeding [133], their participation in support programs [134], and their involvement in childcare [135], are associated with longer breastfeeding duration. It has also been reported that one of the most significant factors in a mother’s decision about breastfeeding compared with bottle feeding was the father’s preference [133]. Similarly, another study of first-time mothers showed that their partners’ breastfeeding beliefs predicted breastfeeding duration, and were a stronger predictor than the mothers’ own beliefs [136], suggesting the importance of fathers in shaping breastfeeding behaviors. Just as maternal self-efficacy is critical, fathers’ self-efficacy in breastfeeding support can be equally important. Thus, the need for the partners to be well-educated about breastfeeding is crucial to enhance breastfeeding duration and reduce the chance of early cessation.

Intervention studies have explored methods to enhance paternal support for breastfeeding, which generally improved breastfeeding outcomes [137]. An intervention study in Vietnam investigated the effectiveness of fathers’ involvement on breastfeeding outcomes [135]. In the intervention group, fathers were actively responsible for supporting their mothers by assisting them and being responsive to their needs. All forms of supportive behavior by the fathers collectively predicted longer breastfeeding duration. The father’s involvement in the postpartum period also improved the quality of father–infant relationships and improved later infant development [135]. To understand the mothers’ perception of partner support, Lundquist et al. [138] interviewed first-time mothers to understand their perspective about their partners’ involvement in supporting breastfeeding. The researchers reported that fathers’ involvement and support improved the mothers’ experience with breastfeeding and increased breastfeeding duration [138].

Given that maternal psychological distress was one of the main barriers to longer breastfeeding duration, the psychological support provided by fathers is especially important when considering strategies to promote longer breastfeeding. Paternal emotional support can play a crucial role in reducing maternal stress, improving confidence, and encouraging EBF and any breastfeeding [139]. Despite the potential impact of fathers’ psychological support on breastfeeding outcomes, research in this area remains limited. More studies are needed to explore supportive ways to incorporate paternal behavior into breastfeeding routines.

Although many studies have investigated parental psychological factors in facilitating breastfeeding duration, fewer studies have examined infant characteristics. Understanding how infant temperament, feeding cues, and emotions influence breastfeeding can provide additional insights into optimizing breastfeeding practices. The behavioral traits of infants can potentially affect the caregiver’s choice of feeding practices. A systematic review highlighted that infant cues, such as crying and fussiness, are often perceived as problematic by caregivers and may be associated with formula introduction, lactation difficulties, and early breastfeeding cessation [140]. Although research in this domain is still emerging, the available evidence suggests that infants who were perceived as fussy or difficult were more likely to be weaned early from breastfeeding [73], possibly due to the increased stress and frustration experienced by mothers. On the other hand, more unpredictable infants may support longer breastfeeding periods, possibly through the mother’s adaptability and flexibility in breastfeeding, as well as more responsive mother–infant interaction. Additionally, the timing of introducing solid foods to infants may interact with their temperament. Earlier introduction of solids has been reported to be associated with negative infant temperament traits, such as fussiness [141], which may further complicate the breastfeeding process, as the earlier introduction of solid food will likely reduce the length of EBF at the same time [142]. A similar effect was observed in 3- to 5-mo-old infants, where mothers who perceived their infants as having higher extroversion and negative affect were more likely to use food to calm them [143]. However, an opposite relationship was observed in a longitudinal cohort from the United Kingdom, where earlier introduction of solids was negatively associated with temperament traits like smiling and laughter [144]. This suggests that careful consideration of infant cues and temperamental traits is crucial when making breastfeeding decisions and the timing of solid food introduction. However, the limited literature on infant characteristics reveals a gap in research regarding psychological factors impacting breastfeeding duration. Although some studies suggest that infant temperament and hunger cues can influence breastfeeding practices, many are limited in scope and fail to consider a broad range of infant behaviors and characteristics. This suggests a need for more comprehensive investigations into how various infant traits and behaviors, beyond temperament, impact breastfeeding experiences. For example, other infant characteristics related to illness or prematurity [145] would be important to consider as they can be related to breastfeeding difficulties. A deeper understanding of the infant’s role could inform strategies to better support breastfeeding continuation.

Our current review has several limitations. As a narrative review, a systematic approach was not employed in the literature search, which may introduce selection bias into the selection process. Additionally, the literature search was conducted solely in the PubMed database. Although the scope of the PubMed engine aligns well with the topic, this might exclude relevant studies indexed in other databases. Additionally, the specific focus on paternal psychosocial factors related to breastfeeding duration might underrepresent the impact of other determinants and diverse family structures.

In conclusion, breastfeeding is a multifaceted process influenced by a range of determinants, including individual, interpersonal, societal, environmental, and structural factors. Within the household environment, maternal psychological well-being, paternal emotional and practical support, and infant characteristics can significantly influence breastfeeding decisions and duration. Understanding the interplay of the 3 parties can be informative for public policy such as longer paid parental leave, in particular paternal leave, to support longer breastfeeding duration and exclusivity [146,147]. Among these factors, maternal psychological well-being appears to play a crucial role in determining breastfeeding duration. Thus, it would be beneficial to design strategies and provide education that support mothers emotionally, especially during the immediate postpartum period. More tailored programs should be developed for both parents to better understand the most suitable breastfeeding practices and ways to properly respond to infant feeding and emotional cues, as well as coping strategies that help to mitigate breastfeeding difficulties. Additionally, establishing broader social support networks, including family members, healthcare providers, and community resources, can further help parents navigate breastfeeding challenges. Future research should continue to explore the parental and infant factors, especially in diverse cultural settings and family structures, to enhance the effectiveness of breastfeeding and to provide infants with the best start in life.

Author contributions

The authors’ responsibilities were as follows – YF, KFB: designed search criteria; YF: conducted literature review and summarized findings and wrote draft of the article; SMD, KFB: primary responsibility for final content; and all authors: read and approved the final manuscript.

Data availability statement

Data described in the manuscript, codebook, and analytic code will be made available on request pending application and approval.

Funding

This research was funded by the National Dairy Council, the NIH (R01 DK107561, R01 DK138032), and USDA Hatch funding. YF was supported by the Jeanette Chu and Winston Y. Lo Endowed Fellowship from the Department of Food Science and Human Nutrition and a Dissertation Completion Fellowship from the Graduate College at the University of Illinois Urbana-Champaign.

Conflicts of interest

SMD reports that financial support was provided by NIH and National Dairy Council; reports relationships ByHeart that includes board membership; Nestle Nutrition Institute that includes funding grants, speaking and lecture fees, and travel reimbursement; and DSM that includes speaking and lecture fees and travel reimbursement. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.