The relationship between postpartum women’s perceptions of insufficient milk and mother-baby attachment

Abstract

Background

This study was conducted to examine the relationship between postpartum women’s perceptions of insufficient milk and mother-baby attachment levels.

Methods

This descriptive and cross-sectional study was conducted between January 18, 2024, and May 1, 2024, at a university hospital with 235 postpartum women who had babies aged 0–6 months and were breastfeeding. Data were collected through face-to-face interviews using a Personal Information Form, The Perception of Insufficient Milk Scale (PIMS), and The Mother-to-Infant Bonding Scale (MIBS). In addition to descriptive statistics, parametric and non-parametric tests and correlation analysis were used in the analyses. A multivariable linear regression analysis with HC3 robust standard errors was also performed, with MIBS total score as the dependent variable and PIMS total score as the primary independent variable, adjusting for potential confounding factors. A statistical significance value of p < .05 was accepted.

Results

The mean age of the postpartum women was 28.53 ± 4.72 (min = 18, max = 43) years. It was determined that 80.9% of the women had planned pregnancies, 62.6% had cesarean deliveries, and 87.7% evaluated their last delivery positively. It was determined that 87.2% of postpartum women believed they produced enough milk to feed their babies. The mean total score for the PIMS was 35.65 ± 6.00 (5–46), and the median total score for the MIBS was 1.00 (0.00–2.00). A negative, moderate, and statistically significant relationship was found between the total scores of the PIMS and MIBS (rs= -0.437; p < .001). In the multivariable analysis, higher PIMS scores remained significantly associated with lower MIBS scores (B = − 0.122, 95% CI: −0.192 to − 0.052, p = .001), indicating that a stronger perception of milk adequacy was associated with fewer mother-infant bonding problems after adjustment for potential confounding factors. The model explained 49.5% of the variance in MIBS scores (R² = 0.495; adjusted R² = 0.472; p < .001).

Conclusion

Higher PIMS scores, indicating a stronger perception of milk adequacy, were associated with fewer mother-infant bonding problems, and this association remained significant after adjustment for potential confounding factors. Pregnancy planning status, employment status, and perception of the birth experience were also significantly associated with MIBS scores in the adjusted model, while educational status showed a non-linear pattern across categories. Regular monitoring of mothers’ perceptions of milk adequacy during the postpartum period and early support for mothers experiencing bonding difficulties are recommended.

Introduction

Breastfeeding constitutes the first and most critical stage of life, as it provides countless benefits for both maternal and infant health [1]. The World Health Organization (WHO) and other international health organizations strongly recommend exclusive breastfeeding for the first six months of life and breastfeeding for two years and beyond with appropriate complementary foods [1–3]. Despite this, one of the most common reasons for early breastfeeding cessation is the mother’s perception that her milk is insufficient [4, 5]. The perception of insufficient milk is the mother’s subjective belief that she cannot produce enough milk to meet her baby’s nutritional needs and is often independent of actual milk production [4, 6]. Various studies show that the perception of insufficient milk is a significant contributor to early cessation of breastfeeding and that a significant proportion of mothers stop breastfeeding because of this perception [5, 7, 8].

The postpartum period is a sensitive psychosocial transition period during which maternal identity is established. The mother-infant bond that develops during this process forms a vital foundation for the child’s social, emotional, and cognitive development. The mother’s emotional attachment to the baby has been reported to positively affect the child’s social-emotional development, especially in the postnatal period, and to be associated with psychosocial adjustment in later stages of life [9, 10]. Attachment is a pattern of emotional and behavioral interactions involving love, protection, and sensitivity that the mother develops toward her baby. This close relationship involves mutual interaction and responsive caregiving behaviors along with the emotional bonding process [11, 12]. The act of breastfeeding involves skin-to-skin contact, eye contact, and responding sensitively to the baby’s needs; in this respect, breastfeeding is a fundamental behavioral bridge that naturally supports the attachment process between mother and baby [13, 14]. However, the ‘perception of insufficient milk’, one of the mother’s biggest obstacles in this natural process, not only shortens the breastfeeding period but also undermines the mother’s self-confidence in her caregiving role, which may have implications for the emotional interaction between mother and infant. Limited studies in the literature, particularly those conducted during crisis periods (pandemics, etc.), have shown that mother-infant attachment scores are associated with breastfeeding self-efficacy [15]. Higher breastfeeding self-efficacy has also been reported to be associated with greater confidence in milk adequacy and more favorable maternal outcomes [16]. However, there is a need for more studies that comprehensively examine the association between perceptions of milk adequacy and mother-infant bonding. Despite the importance of both perceptions of insufficient milk and mother-infant bonding in the postpartum period, studies examining the relationship between these two variables remain limited, particularly in the Turkish population. This research was conducted to determine the relationship between postpartum women’s perceptions of insufficient milk and their mother-infant bonding. In this context, answers were sought to the following research questions.

Research questions

1. What are the levels of insufficient milk perception among postpartum women?

2. What are the levels of mother-infant bonding among postpartum women?

3. Is there a statistical relationship between postpartum women’s levels of perceptions of insufficient milk and their levels of mother-infant bonding?

4. Are postpartum women’s perceptions of insufficient milk associated with mother-infant bonding after adjustment for potential confounding factors?

Material and method

Type of study

The study is descriptive, cross-sectional, and correlational in design and was conducted between January 18, 2024, and May 1, 2024.

Population and sample

The study population consisted of postpartum women at a university hospital in the Central Black Sea Region. The sample size of the study was calculated using G*Power 3.1.9.7 software [17]. Işık and Küğcümen’s (2021) study, which reported the level of perceptions of insufficient milk among postpartum women as 38.71 ± 11.62, was used as a reference in determining the sample size [6]. In the a priori power analysis, it was determined that the study should be completed with at least 202 participants when the correlation effect size was set at r = .25, the margin of error at α = 0.05, and the test power at 0.95. No specific sampling method was used in the study. The sample consisted of 235 postpartum women who voluntarily agreed to participate in the study and who had babies aged 0–6 months and were exclusively breastfeeding their babies. In this study, “exclusively breastfeeding” refers to infants receiving only breast milk without any additional liquids, foods, or formula. These women were identified in the obstetrics and gynecology outpatient clinics, delivery rooms, gynecology wards, maternity wards, and pediatric wards of the relevant hospital during the specified dates.

Data collection tools

The data collection tools used were a personal data form to determine the mothers’ socio-demographic, descriptive, and obstetric characteristics, the Insufficient Milk Perception Scale (PIMS), and the Mother-Infant Bonding Scale (MIBS).

Personal data form

The form, developed by the researchers based on a review of the relevant literature, contained 15 questions to determine the participants’ socio-demographic and obstetric characteristics (age, educational status, employment status, number of pregnancies, number of living children, mode of delivery, etc.) [4–6, 13, 18].

PIMS

Developed by McCarter-Spaulding and Kearney in 2001, the PIMS contains 6 items aimed at determining the perception of insufficient breast milk. The first question, which asks whether the mother perceives her milk as sufficient, is answered with “yes” or “no.” [19]. The other 5 questions are aimed at measuring the perception of milk insufficiency and are scored on a scale of 0–10. “0” indicates that milk is perceived as completely insufficient, while “10” indicates that milk is perceived as completely sufficient. The scale is scored from 0 to 50. A high score indicates a higher perception of milk adequacy. The Cronbach alpha value in the original scale was determined to be 0.81 [19]. The validity and reliability of the scale in Turkish were established by Gökçeoğlu (2014), and the Cronbach alpha value in the study was found to be 0.82 [20]. Permission to use the scale in this study was obtained from the relevant author. The Cronbach’s alpha coefficient of the scale in this study was found to be 0.83.

MIBS

The MIBS, developed by Taylor et al., (2005), has been shown to continuously assess mother-infant bonding during the first 12 weeks after birth [21]. Therefore, the scale can be used to immediately assess the period after birth, as well as to reassess bonding within a short period of time. The adaptation, validity, and reliability study of the scale in our country was conducted by Karakulak-Aydemir and Alparslan (2009) [22]. The MIBS is an 8-item, 4-point Likert-type scale. Responses consisting of four options are scored between 0 and 3, with the lowest possible score being 0 and the highest possible score being 24. A higher score on the scale is considered an indicator of mother-infant attachment problems. In the assessment, items 1, 4, and 6 are positive emotion statements and are scored 0, 1, 2, 3, while items 2, 3, 5, 7, and 8 are negative emotion statements and are scored 3, 2, 1, 0, in reverse. The inter-rater reliability of the scale is reported to be 0.71 and the internal consistency reliability (Cronbach Alpha) is 0.66 [22]. The Cronbach alpha coefficient for this study was calculated as 0.67. Permission to use the scale in this study was obtained from the relevant author.

Data collection

Survey forms were distributed to mothers who agreed to participate in the study, and the forms were completed by the mothers themselves under the observation of the researchers in an average of 10–15 min. To reduce potential bias, standardized instructions were provided to all participants, and data collection was conducted in a consistent manner under similar conditions by the researchers.

Statistical analysis

The data obtained from the study were analyzed using the SPSS 22.0 software package. Numbers, percentages, arithmetic means, and standard deviations were used in the evaluation of the data. The normality of the data distribution was examined using the Kolmogorov-Smirnov test. The analysis revealed that the PIMS scores followed a normal distribution, while the MIBS scores did not. Accordingly, independent samples t-tests and one-way analysis of variance (ANOVA) were used to compare PIMS scores with demographic variables. Mann-Whitney U and Kruskal-Wallis tests were used to compare MIBS scores. When ANOVA revealed statistically significant differences between groups for certain variables, the homogeneity of variances was examined to determine the source of the difference; Tukey’s post-hoc test was applied for groups with homogeneous variances, and Tamhane’s T2 post-hoc test was applied for groups with non-homogeneous variances. In cases where the Kruskal-Wallis test revealed significant differences, the Dunn-Bonferroni test was preferred for multiple comparisons. Due to the inclusion of a variable (MIBS) that did not show a normal distribution, Spearman Correlation Analysis was applied to determine the relationship between the scales. Additionally, a multivariable linear regression analysis was conducted to assess the relationship between perceived milk adequacy and mother-infant bonding, while controlling for potential confounding factors. MIBS total score was specified as the dependent variable, and PIMS total score was specified as the primary independent variable. The model was adjusted for maternal age, educational status, employment status, pregnancy planning status, mode of delivery, perception of the last birth experience, difficulty during first breastfeeding, and timing of first breastfeeding. Heteroscedasticity-consistent (HC3) robust standard errors (SE) were used, and regression results were reported as unstandardized coefficients (B) with 95% confidence intervals (CIs). The internal consistency of the scales was tested using Cronbach’s Alpha coefficients, and the results were evaluated at a significance level of p < .05.

Ethical considerations

Ethical committee approval was obtained from the Ethics Committee of Social and Human Sciences Research at Tokat Gaziosmanpaşa University (Date: 26.12.2023, Number: 01–68) and approval from the relevant hospital (Date: 18.01.2024, No: E-21979232-020-387935) were obtained. Mothers who agreed to participate in the study were informed about the purpose of the study and were asked to declare their voluntary participation in the study verbally and in writing. Written informed consent was obtained from all participants before the start of the study. The study was conducted in accordance with the principles of the Helsinki Declaration.

Findings

Significant differences in PIMS and MIBS scores were observed across several sociodemographic and obstetric variables (Table 1).

Table 1.

Comparison of PIMS and MIBS total scores with number and percentage distributions according to women's descriptive characteristics

Characteristics	n	%	PIMS Total ScoreM±SD	Test value	MIBS Median (Q1-Q3)	Test value
Age
18-28	124	52.8	36.09±5.65	t=1.181; p = .239	1.00 (0.00-2.00)	Z=-1.710 p = .087
29-43	111	47.2	35.17±6.36		1.00 (0.00-2.00)
Educational status
Elementary school graduate	33	14.0	32.93±8.23a	F=4.580; p = .011 c>a; b > a	3.00 (1.00-5.00)a	KW=21.491 p < .001 a>b; a>c
High school graduate	117	49.8	35.74±5.12b		1.00 (0.00-2.00)b
University graduate and above	85	36.2	36.60±5.87c		1.00 (0.00–2.00)c
The place where they spent most of their life
Province/City	111	47.2	35.91±6.93	F=0.866; p = .671	1.00 (0.00-2.00)a	KW=10.696 p = .005 b>a
District	99	42.1	35.30±5.04		1.00 (0.00–1.00)b
Town/village	25	10.6	35.92±5.06		1.00 (0.00–3.00)c
Employment status
Yes	94	40.0	35.70±5.80	t=0.089 p = .930	1.00 (0.00-2.00)	Z = -2.596 p = .009
No	141	60.0	35.63±6.15		1.00 (0.00-3.00)
Pregnancy planning status
Planned	190	80.9	36.26±5.53	t=3.261 p = .001	1.00 (0.00-2.00)	Z = -4.476 p < .001
Unplanned	45	19.1	33.08±7.17		2.00 (1.00–4.00)
Last mode of delivery
Normal	88	37.4	37.02±5.78	t=2.731 p = .007	1.00 (0.00-2.00)	Z = -1.432 p = .152
Cesarean	147	62.6	34.84±6.00		1.00 (0.00–2.00)
Perception of the last birth experience
Positive	206	87.7	37.10±4.03	t=12.778 p < .001	1.00 (0.00-2.00)	Z = -6.787 p < .001
Negative	29	12.3	25.41±7.59		5.00 (3.00–7.00)
Previous breastfeeding experience
Yes	138	58.7	36.05±5.04	t=1.146 p = .254	1.00 (0.00-2.00)	Z = -1.337 p = .181
No	97	41.3	35.09±7.14		1.00 (0.00–2.00)
Breastfeeding education/information
Yes	126	53.6	35.24±6.69	t=1.136 p = .257	1.00 (0.00-2.25)	Z = -0.916 p = .360
No	109	46.4	36.13±5.06		1.00 (0.00–2.00)
Experiencing difficulties with initial breastfeeding after the last birth
Yes	49	20.9	28.61±8.87	t=11.567 p < .001	3.00 (1.00-5.00)	Z = -5.360 p < .001
No	186	79.1	37.51±2.91		1.00 (0.00–2.00)
Time of first breastfeeding after the last birth
Within the first half hour	206	87.7	37.25±3.42	t=8.578 p < .001	1.00 (0.00-2.00)	Z = -5.859 p < .001
Other	29	12.3	24.34±8.00		5.00 (2.00–5.00)
Age	M±SD (min-max)			28.53±4.72 (min=18, max=43)
Number of pregnancies	M±SD (min-max)			2.08±1.00 (min=1, max=6)
Number of births	M±SD (min-max)			1.80±0.89 (min=1, max=6)
Gestational age at birth of last baby	M±SD (min-max)			38.15±1.43 (min=35, max=41)
Birth weight of the last baby	M±SD (min-max)			3110.39±340.24 g (min=2400.00, max=4445.00)

n Number, % Frequency, F One-way ANOVA test value, t Student t test value, M Mean, SD Standard Deviation, Q1-Q3 Interquartile range, Z Mann-Whitney U test value, KW Kruskal–Wallis test

^a,b,cRepresent post-hoc analysis results

The distribution of total scale scores among postpartum women and their perceptions regarding milk production are presented in Table 2. 87.2% (n = 205) of the postpartum women included in the study stated that they believed they produced enough milk to feed their baby, while 12.8% (n = 30) stated that their milk production was insufficient. The mean total score for the PIMS among postpartum women was 35.65 ± 6.00, while the median total score for the MIBS was 1.00 (Q1-Q3: 0.00–2.00).

Table 2.

Postpartum women’s total scale mean scores

Scales
PIMS		Number (Percentage)
Do you believe you produce enough milk to satisfy your baby?
Yes		205 (87.2)
No		30 (12.8)
	Total Score	M ± SD (min-max) 35.65 ± 6.00 (5–46)
		Median (Q1 - Q3)
MIBS	Total Score	1.00 (0.00–2.00)

The results of the Spearman correlation analysis conducted to determine the relationship between participants’ PIMS and MIBS total scores are presented in Table 3. According to the analysis results, a statistically significant, negative, and moderate relationship was found between the total PIMS score and the total MIBS score (rs=-0.437; p< .001). This finding indicates that higher PIMS scores, reflecting a stronger perception of milk adequacy, are associated with lower MIBS scores, indicating fewer mother–infant bonding problems.

Table 3.

Correlation analyses between scales

Scales	MIBS Total Score
	Test Value (rs )	p
PIMS Total Score	− 0.437	< 0.001

r_s : Spearman correlation coefficient

To examine the association between perceived milk adequacy and mother–infant bonding after accounting for potential confounding factors, a multivariable linear regression analysis was performed with MIBS total score as the dependent variable and PIMS total score as the primary independent variable. The model was adjusted for maternal age, educational status, employment status, pregnancy planning status, mode of delivery, perception of the last birth experience, difficulty during first breastfeeding, and timing of first breastfeeding (Table 4).

Table 4.

Multivariable linear regression analysis of the association between PIMS and MIBS (n = 235)

Variables	B	Robust SE	95% CI	p
PIMS total score	−0.122	0.036	−0.192 to − 0.052	0.001
Age (years)	−0.009	0.021	−0.051 to 0.033	0.677
Educational status
Elementary school	Ref.	—	—	—
High school	−0.937	0.334	−1.591 to − 0.282	0.005
University and above	−0.571	0.391	−1.337 to 0.195	0.144
Employment status
Employed	Ref.	—	—	—
Not employed	0.524	0.223	0.088 to 0.961	0.019
P regnancy planning status
Planned	Ref.	—	—	—
Unplanned	0.680	0.269	0.153 to 1.207	0.011
Last mode of delivery
Normal	Ref.	—	—	—
Cesarean	−0.167	0.197	−0.554 to 0.219	0.396
Perception of the last birth experience
Positive	Ref.	—	—	—
Negative	1.201	0.540	0.142 to 2.260	0.026
Difficulty during first breastfeeding
Yes	Ref.	—	—	—
No	−0.473	0.470	−1.394 to 0.448	0.314
Timing of first breastfeeding
Within the first 30 min	Ref.	—	—	—
Other	−0.148	0.615	−1.352 to 1.056	0.810

MIBS total score was entered as the dependent variable and PIMS total score as the primary independent variable. The model was adjusted for maternal age, educational status, employment status, pregnancy planning status, mode of delivery, perception of the last birth experience, difficulty during first breastfeeding, and timing of first breastfeeding. Heteroscedasticity-consistent (HC3) robust standard errors were used

B  unstandardized regression coefficient, SE  Standard error, CI  Confidence interval, Ref reference category

Model statistics: R² = 0.495; Adjusted R² = 0.472; overall model p < .001

After adjustment, higher PIMS scores remained significantly associated with lower MIBS scores (B = − 0.122, 95% CI: −0.192 to − 0.052, p = .001), indicating that greater perceived milk adequacy was independently associated with fewer mother–infant bonding problems. The overall model was statistically significant and explained 49.5% of the variance in MIBS scores (R² = 0.495; adjusted R² = 0.472; p < .001).

Discussion

The findings obtained from this study, which aimed to determine the relationship between postpartum women’s perception of insufficient milk and mother-infant bonding levels, were discussed in line with the relevant literature. The results of the study indicated a relatively strong perception of milk adequacy among the participants, suggesting that the majority of mothers perceived their milk as sufficient. Indeed, the fact that 87.2% of participants stated that they believed they produced enough milk to feed their baby supports this finding. The literature also reports that mothers’ negative perceptions of milk production are one of the most common reasons for early cessation of breastfeeding; on the other hand, low levels of perceived milk insufficiency support the continuation of breastfeeding [23, 24].

The study found a statistically significant, negative, and moderately strong relationship between total PIMS and MIBS scores. More importantly, multivariable regression analysis showed that this association remained statistically significant after adjustment for maternal age, educational status, employment status, pregnancy planning status, mode of delivery, perception of the last birth experience, difficulty during first breastfeeding, and timing of first breastfeeding. Higher PIMS scores, indicating a stronger perception of milk adequacy, were independently associated with lower MIBS scores and fewer mother–infant bonding problems (B = − 0.122, 95% CI: −0.192 to − 0.052, p = .001). A review of the literature reveals numerous studies supporting the positive effects of breastfeeding on mother-infant bonding [12, 13]. However, the success of this process and the quality of the bond largely depend on the mother’s perception of milk adequacy and her psychological comfort during this process. Indeed, a recent study by Küçükoğlu et al. (2025) reported a significant relationship between mothers’ levels of maternal attachment and their perceptions of milk adequacy; this finding is consistent with the association observed in our study [15]. Similarly, Kim et al. (2024) point to the critical role of breastfeeding experiences on maternal emotional availability and secure attachment [14].

A mother’s perception of insufficient milk can transform the breastfeeding process from a biological act into a source of psychological stress. Güngör Çalışkan and Altınkaynak (2019) and Huang et al. (2022) state that mothers’ anxiety about insufficient milk is one of the fundamental psychological factors that disrupts the breastfeeding process and causes early cessation of breastfeeding [4, 5]. Such concerns may also be associated with difficulties in the emotional interaction between the mother and her infant. Indeed, Kafcı and Yılmaz (2025) emphasize that feelings of inadequacy experienced during breastfeeding can weaken the quality of attachment [12]. Mothers who experience stress because they perceive their milk as insufficient may have greater difficulty during mother–infant interaction, which may be associated with increased bonding problems. The quality of attachment formed in the early stages has the potential to affect not only the current process but also the child’s future development. Indeed, Waal et al. (2023) found that the level of mother- baby attachment in the postpartum period plays a decisive role in the child’s socio-emotional development in later stages [9]. These findings indicate that closer monitoring of mothers’ perceptions of milk adequacy in the early postpartum period and timely support by midwives may contribute to improved mother–infant attachment. However, because of the cross-sectional design of the present study, the direction of this association cannot be established and the findings should not be interpreted as evidence of a causal effect. The persistence of the association between PIMS and MIBS scores after adjustment for potential confounding factors nevertheless highlights the importance of perceived milk adequacy in relation to mother–infant bonding.

Educational status was significantly associated with mother–infant bonding in the adjusted analysis; however, this association did not show a consistent pattern across all educational levels. Compared with mothers with elementary school education, mothers with high school education had significantly lower MIBS scores (B = − 0.937, 95% CI: −1.591 to − 0.282, p = .005), whereas the difference for mothers with university education or above was not statistically significant. The literature contains conflicting findings regarding the effect of educational level on milk perception. While Işık and Küğcümen (2021) found that mothers with primary school education or below had higher perceptions of milk adequacy than university graduates, our findings are consistent with those of Koç, Rüzgar & Altınayak (2024) [6, 8]. Similarly, recent studies have reported that maternal educational level and related sociodemographic factors may influence perceptions of milk adequacy and breastfeeding confidence [25]. These findings suggest that the relationship between educational status and mother–infant bonding may be complex and may not follow a simple linear pattern across increasing levels of education. Therefore, educational status should be considered together with other maternal and psychosocial factors when evaluating mother–infant bonding during the postpartum period.

The study found statistically significant differences in both PIMS and MIBS scores based on whether the pregnancy was planned. Mothers with planned pregnancies were found to have a more positive perception of milk adequacy and higher levels of mother-infant attachment. Gökçeoğlu and Küçükoğlu (2017) reported that planned pregnancy positively affected breastfeeding self-efficacy and perception of milk adequacy [26]. Similarly, Candan and Çağlayan Keleş (2024) reported that planned pregnancy is among the factors supporting breastfeeding self-efficacy and perceived milk adequacy; these findings are consistent with the significant difference between pregnancy planning status and PIMS scores in our study [16]. A planned pregnancy may be associated with greater psychological preparedness for breastfeeding and the postpartum mother–infant bonding process. Importantly, this association with mother–infant bonding remained statistically significant in the adjusted analysis. Mothers with unplanned pregnancies had higher MIBS scores than those with planned pregnancies (B = 0.680, 95% CI: 0.153 to 1.207, p = .011), indicating greater bonding problems after adjustment for the other variables included in the model. Şahin and Bayrı Bingöl (2021) stated that attachment problems with the baby are more common in mothers who experience unplanned pregnancies [27]. Similarly, Kınık and Özcan (2020) emphasized that planned pregnancy is an important factor affecting maternal attachment and that maternal attachment is weaker in unplanned pregnancies [28]. Furthermore, in unplanned pregnancies, the mother’s feeling of being caught unprepared and the mixed emotions accompanying the process can overshadow feelings of closeness to the baby, making the bonding process more difficult. Taken together, these findings suggest that pregnancy planning status is an important psychosocial factor associated with mother–infant bonding during the postpartum period.

Our study found that mothers who had a positive birth experience had significantly higher PIMS and lower MIBS scores compared to those who had a negative birth experience. Thus, mothers who perceived their birth experience positively had a stronger perception of milk adequacy and fewer mother–infant bonding problems. In particular, attachment problem scores were substantially higher among mothers who perceived the birth negatively than among those who perceived it positively, indicating a strong association between these two variables. Importantly, this association remained statistically significant in the multivariable analysis. Mothers who reported a negative birth experience had higher MIBS scores than those who reported a positive birth experience (B = 1.201, 95% CI: 0.142 to 2.260, p = .026), indicating greater mother–infant bonding problems after adjustment for the other variables included in the model. There are also studies in the literature examining the relationships between the perception of the birth experience and milk perception and breastfeeding success. For example, it has been reported that mothers with a more positive perception of birth breastfeed their children for longer [29]. In a study conducted by Çankaya and Ocaktan (2022) with primiparous mothers, it was found that perceiving the birth experience as traumatic negatively affected mothers’ attitudes toward breastfeeding and could be an inhibiting factor on breastfeeding success in the early postpartum period [30]. Similar to our study, Çimen and Varol (2021), in their research examining maternal attachment levels, found that maternal attachment was significantly higher in mothers whose birth process was not difficult but rather easy and comfortable [31]. Furthermore, a study by Aydın, Aktaş, and Binici (2022) found that an increased perception of birth-related trauma negatively affected maternal attachment levels [32]. When the aforementioned literature and research findings are evaluated together, the findings suggest that mothers’ subjective assessments of the birth process may be associated with both their perception of milk adequacy and the quality of the emotional bond they form with their babies. In particular, the association between a negative birth experience and greater mother–infant bonding problems persisted after adjustment for potential confounding factors. However, given the cross-sectional design of the present study, a causal relationship cannot be established.

The study determined that mothers’ perceptions of milk adequacy and mother-infant bonding problems differed depending on whether they experienced problems during the first breastfeeding process after birth and the timing of the initiation of breastfeeding. It was found that mothers who completed the first breastfeeding process without problems and started breastfeeding within the first half hour after birth had higher PIMS scores, indicating a stronger perception of milk adequacy, and lower MIBS scores, indicating fewer mother–infant bonding problems, in the unadjusted comparisons. However, in the multivariable analysis, neither difficulty during first breastfeeding nor timing of first breastfeeding was significantly associated with MIBS scores after adjustment for the other variables included in the model (p = .314 and p = .810, respectively). In the literature, Işık and Küğcümen (2021) and Koç et al. (2024) have reported that early breastfeeding reduces the perception of insufficient milk [6, 8]. Similarly, studies have emphasized the importance of early mother-infant contact and breastfeeding in the development of mother-infant bonding [18, 33]. However, findings regarding the relationship between the timing of breastfeeding initiation and mother–infant bonding are not entirely consistent. Çankaya et al. (2017) reported no significant relationship between breastfeeding initiation time and maternal attachment [34]. This finding is consistent with our adjusted analysis, in which the timing of first breastfeeding was not significantly associated with MIBS scores after controlling for the other variables in the model. Similarly, difficulty during first breastfeeding did not remain significantly associated with MIBS scores in the adjusted analysis. Therefore, although the unadjusted comparisons showed more favorable PIMS and MIBS scores among mothers who initiated breastfeeding earlier and experienced no difficulty during first breastfeeding, these factors did not show independent associations with mother–infant bonding after adjustment for potential confounding factors.

The study found that mothers who had a normal delivery had higher PIMS scores, indicating a stronger perception of milk adequacy, compared to mothers who had a cesarean section. The literature indicates that the mode of delivery may affect the breastfeeding process. According to the WHO (2023), early initiation of breastfeeding and skin-to-skin contact are important for successful breastfeeding [1]. Cesarean delivery may be associated with difficulties in the early breastfeeding process due to factors such as postoperative pain, delayed mobilization, and delayed mother–infant contact [4]. Işık and Küğcümen (2021) and Candan and Çağlayan Keleş (2024) reported findings supporting differences in breastfeeding-related outcomes according to mode of delivery [6, 16]. However, Koç et al. (2024) reported no significant difference in perceived milk adequacy according to mode of delivery [8]. In the present study, although mode of delivery was associated with PIMS scores in the unadjusted comparison, it was not significantly associated with MIBS scores in the multivariable analysis (p = .396). Thus, after adjustment for the other variables included in the model, cesarean delivery was not independently associated with greater mother–infant bonding problems. This finding suggests that mothers’ subjective perceptions of their birth experience may be more closely associated with bonding problems than mode of delivery itself, as negative birth experience remained significantly associated with higher MIBS scores in the adjusted model.

The study found significant differences in mother-infant bonding levels based on where mothers spent most of their lives and their employment status. In the unadjusted comparisons, differences in MIBS scores were observed according to these sociodemographic characteristics. However, employment status showed a different pattern after adjustment for the other variables included in the multivariable model. Mothers who were not employed had significantly higher MIBS scores than employed mothers (B = 0.524, 95% CI: 0.088 to 0.961, p = .019), indicating greater mother–infant bonding problems. Social support and the mother’s social environment may play an important role in the mother-infant bonding process. Alan and Ege (2013) reported that social support was associated with maternal-infant bonding [35]. Similarly, Hopkins et al. (2018) emphasized the relationship between social support, psychological distress, and maternal attachment [36]. Employment status may reflect differences in social, economic, and support-related circumstances; however, these mechanisms were not directly assessed in the present study. Therefore, the adjusted association between employment status and MIBS scores should be interpreted cautiously and should not be considered evidence that employment itself improves mother–infant bonding. In addition, because place of residence was not included in the multivariable model, the observed residence-related difference should be interpreted only as an unadjusted finding.

Conclusion and recommendations

The study found a statistically significant, negative, and moderate relationship between PIMS and MIBS scores. More importantly, this association remained statistically significant after adjustment for potential confounding factors. Higher PIMS scores, indicating a stronger perception of milk adequacy, were associated with lower MIBS scores, indicating fewer mother–infant bonding problems.

In the adjusted analysis, pregnancy planning status, employment status, and perception of the last birth experience were significantly associated with MIBS scores. Mothers with unplanned pregnancies and those who perceived their last birth experience negatively had higher MIBS scores, indicating greater mother–infant bonding problems. Mothers who were not employed also had higher MIBS scores than employed mothers; however, this association should be interpreted cautiously and should not be considered evidence that employment itself improves mother–infant bonding. Educational status was also associated with MIBS scores, although the pattern was not consistent across all educational levels. In contrast, maternal age, mode of delivery, difficulty during first breastfeeding, and timing of first breastfeeding were not significantly associated with MIBS scores in the adjusted model.

Based on the findings, it is recommended that mothers’ perceptions of milk adequacy be routinely assessed during the postpartum care process and that mothers with lower perceived milk adequacy and greater bonding problems receive appropriate breastfeeding and psychosocial support. Particular attention may be given to mothers with unplanned pregnancies and those who report negative birth experiences, as these characteristics were associated with greater mother–infant bonding problems after adjustment for potential confounding factors. Midwives and other healthcare professionals may play an important role in identifying breastfeeding-related concerns and bonding difficulties and providing individualized support during the postpartum period.

Given the cross-sectional design of the study, these recommendations should be interpreted in the context of observed associations rather than causal relationships. Future longitudinal and multicenter studies are recommended to further investigate the direction and mechanisms of the relationship between perceived milk adequacy and mother–infant bonding.

Abbreviations

PIMS

The Perception of Insufficient Milk Scale

MIBS

The Mother-to-Infant Bonding Scale

WHO

World Health Organization

CDC

Center for Disease Control and Prevention

UNICEF

United Nations Children’s Fund

SD

Standard Deviation

HC3

Heteroscedasticity-consistent type 3

SE

Standard error

CI

Confidence interval

Authors’ contributions

A.Ç.: Conceptualization; data curation; formal analysis; resources; investigation; writing–original draft; methodology; validation; visualization; writing – review and editing; software.F.N.A.: Conceptualization; data curation; writing – review and editing.K.B.: Conceptualization; data curation; writing – review and editing.

Funding

Not applicable.

Data availability

The dataset is available from the corresponding author upon reasonable request.The dataset supporting the conclusions of this research can be obtained from the corresponding author upon reasonable request.1. Access to the data is subject to the following guidelines: Interested researchers must provide a comprehensive application, clearly stating the purpose of their research, how they intend to use the data, and a declaration of confidentiality.2. The data will be made available strictly for the intended academic use described in the application. It may not be utilized for commercial gain or for any form of unauthorized secondary analysis.3. Proper citation of this study is required in any subsequent publications or presentations based on the shared data.Details for data access: Repository: author’s archiveContact for data request: [ayse.mete@gop.edu.tr, Asst. Prof. Ayşe ÇATALOLUK]

Declarations

Ethics approval and consent to participate

Ethical committee approval was obtained from the Ethics Committee of Social and Human Sciences Research at Tokat Gaziosmanpaşa University (Date: 26.12.2023, Number: 01–68) and approval from the relevant hospital (Date: 18.01.2024, No: E-21979232-020-387935) were obtained. Mothers who agreed to participate in the study were informed about the purpose of the study and were asked to declare their voluntary participation in the study verbally and in writing. The study was conducted in accordance with the principles of the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.