Breastfeeding knowledge, intended practices, and maternal stress among Nigerian immigrant mothers in Kuala Lumpur: a cross-sectional study

Abstract

Background

Immigrant mothers, having a desire to breastfeed doesn’t necessarily mean they will do it, particularly when migration throws their traditional support networks into disarray and turns up the volume on daily stressors. Nigerian mothers in Malaysia are culturally inclined to breastfeed but face their own challenges as they negotiate motherhood thousands of miles away from home with no extended family or community support system.

Objective

This study examined breastfeeding knowledge, intended breastfeeding practices, and maternal stress among Nigerian immigrant mothers living in Kuala Lumpur, Malaysia.

Methods

A community-based cross-sectional study was conducted among 88 pregnant Nigerian immigrant women in their third trimester residing in Kuala Lumpur. Participants were recruited using purposive snowball sampling through community networks, religious organizations, student associations, social media groups, and referrals. Data were collected using structured questionnaires assessing socio-demographic characteristics, breastfeeding knowledge, intended breastfeeding practices, and maternal stress. Data were analyzed using descriptive statistics, ordinal logistic regression, and Spearman correlation analysis, with statistical significance set at p < 0.05.

Results

Participants were aged 18–45 years, with half (50.0%) aged 26–35 years. Although 92.0% of participants intended to breastfeed, only 8.0% planned to initiate breastfeeding within the first hour after birth and 39.8% intended to exclusively breastfeed for six months. Knowledge of infant-related breastfeeding benefits was relatively high, whereas knowledge of maternal benefits (43.2%) and breast milk expression techniques (26.1%) was considerably lower. Maternal stress was highest in the domains of household burden (mean = 2.75, SD = 0.96) and fatigue (mean = 2.69, SD = 0.86). Higher education was significantly associated with greater breastfeeding knowledge and intended breastfeeding exclusivity. Breastfeeding knowledge was positively correlated with intended exclusivity (r = 0.454, p < 0.001) and breastfeeding duration (r = 0.294, p = 0.006), while maternal stress was negatively associated with intended breastfeeding duration (r = -0.348, p = 0.001). Breastfeeding knowledge was also inversely correlated with maternal stress (r = -0.331, p = 0.002).

Conclusion

A clear disconnect exists between breastfeeding intention and planned practice among Nigerian immigrant mothers. This gap is driven by insufficient practical knowledge and elevated maternal stress- particularly from social isolation, household overload, and unsupportive environments. The findings of this study underscore the need for culturally grounded, stress-sensitive interventions that go beyond information delivery to include hands-on lactation support, peer networks, and integrated psychosocial care.

Background

Breastfeeding is widely recognized as one of the most effective public health strategies for improving infant and maternal health outcomes. The World Health Organization (WHO) recommends initiation of breastfeeding within the first hour after birth, exclusive breastfeeding for the first six months of life, and continued breastfeeding alongside complementary feeding for up to two years or beyond [1]. Adherence to these recommendations has been associated with reduced infant morbidity and mortality, improved cognitive development, and enhanced maternal health outcomes [2]. Despite these benefits, breastfeeding initiation, exclusivity, and duration remain suboptimal in many populations worldwide, particularly among immigrant mothers who often face unique social, cultural, and environmental challenges [3].

For many African women including Nigerian mothers, breastfeeding is traditionally regarded as the normative and culturally expected method of infant feeding [4]. In many Nigerian communities, breastfeeding practices are supported by strong family and cultural structures that encourage early initiation and prolonged breastfeeding. One important postpartum support practice is the Omugwo tradition, commonly observed among the Igbo ethnic group in southeastern Nigeria, where female relatives provide practical assistance with infant care, household responsibilities, and breastfeeding support during the postpartum period [5]. Such support systems help mothers recover physically, gain confidence in infant care, and establish successful breastfeeding practices.

Migration, however, can disrupt these traditional support networks. Nigerian mothers living abroad may find themselves separated from extended family members and culturally familiar sources of support during pregnancy and the postpartum period. Research among African immigrant populations has shown that migration-related challenges, including unfamiliar healthcare systems, limited social support, language barriers, financial constraints, and competing educational or employment responsibilities, may negatively influence breastfeeding experiences and practices [6, 7]. Although these challenges have been widely documented among immigrant populations in North America and Europe, evidence from Southeast Asia remains limited.

Malaysia has experienced increasing migration from African countries in recent years, yet relatively little is known about the maternal and child health experiences of African immigrant mothers living in the country. Immigrant families may encounter barriers to culturally responsive maternity services, limited access to breastfeeding support, and difficulties navigating unfamiliar healthcare systems [8]. These challenges may influence not only breastfeeding behaviour but also maternal psychological wellbeing during pregnancy and the postpartum period.

Breastfeeding behaviour is influenced by multiple factors, including breastfeeding knowledge, maternal beliefs, social support, and maternal stress [9, 10]. Adequate breastfeeding knowledge has consistently been associated with positive breastfeeding outcomes, including earlier initiation, greater exclusivity, and longer breastfeeding duration [11]. Mothers who possess sufficient knowledge regarding the benefits of breastfeeding, appropriate feeding techniques, and management of common breastfeeding challenges are generally more confident and better prepared to implement recommended breastfeeding practices [12, 13]. Conversely, limited knowledge of practical breastfeeding skills, such as breast milk expression and management of breastfeeding difficulties, may hinder successful breastfeeding and contribute to uncertainty during the infant feeding period [14].

Maternal stress represents another important factor influencing breastfeeding behaviour. Previous studies have reported that elevated stress levels may negatively affect breastfeeding confidence, self-efficacy, and mothers’ ability to initiate and maintain breastfeeding as intended [10, 13]. Stress related to fatigue, childcare responsibilities, social isolation, and lack of support may reduce a mother’s capacity to engage in recommended breastfeeding practices. Among immigrant mothers, the absence of traditional family support systems and the challenges of adapting to a new environment may further increase vulnerability to maternal stress [15].

Importantly, breastfeeding knowledge and maternal stress may also be interconnected. Mothers with adequate breastfeeding knowledge may feel more prepared to manage infant feeding challenges, thereby reducing anxiety and enhancing confidence. In contrast, insufficient knowledge regarding breastfeeding techniques and infant feeding recommendations may contribute to uncertainty, stress, and reduced confidence in breastfeeding. Consequently, both breastfeeding knowledge and maternal stress may influence mothers’ intended breastfeeding practices, including breastfeeding initiation, exclusivity, and duration.

Although many immigrant mothers report strong intentions to breastfeed, intention alone does not guarantee adherence to recommended breastfeeding practices. The successful translation of breastfeeding intentions into actual behaviour may depend on a mother’s level of breastfeeding knowledge, access to support, and ability to cope with psychosocial stressors [10, 15, 16]. Understanding the relationships among breastfeeding knowledge, intended breastfeeding practices, and maternal stress is therefore important for identifying barriers that may prevent mothers from achieving their breastfeeding goals.

Despite growing research on breastfeeding among immigrant populations, studies examining these interrelated factors among African immigrant mothers in Southeast Asia remain scarce. In particular, little is known about breastfeeding knowledge, intended breastfeeding practices, and maternal stress among Nigerian immigrant mothers living in Malaysia. Addressing this gap is important for informing culturally responsive breastfeeding promotion strategies and maternal support interventions tailored to immigrant populations.

Therefore, this study aimed to examine breastfeeding knowledge, intended breastfeeding practices, and maternal stress among Nigerian immigrant mothers living in Kuala Lumpur, Malaysia. Specifically, the study sought to: (1) assess breastfeeding knowledge across key domains, including infant benefits, maternal benefits, and breast milk expression; (2) examine intended breastfeeding practices, including initiation, exclusivity, and planned duration; and (3) explore the relationships between maternal stress and selected socio-demographic characteristics and breastfeeding-related factors.

Method

Study design and setting

This community-based cross-sectional study examined breastfeeding knowledge, intended breastfeeding practices, and maternal stress among Nigerian immigrant mothers residing in Kuala Lumpur, Malaysia. The study was conducted between July and August 2024 among pregnant women in their third trimester.

Nigerian immigrants constitute a relatively small and geographically dispersed population in Malaysia. Furthermore, no centralized or publicly accessible registry of Nigerian pregnant women exists, as immigration, healthcare, and university records do not routinely capture or provide access to pregnancy-related information for research purposes. In addition, many Nigerian women residing in Malaysia are dependents of students or workers and are therefore not identifiable through official institutional databases. Consequently, a sampling frame could not be established, making probability sampling impractical.

Participants were therefore recruited using a non-probability purposive snowball sampling technique. Initial participants were identified through Nigerian community networks, including religious organizations, student associations, social media groups, and contacts facilitated through the Nigerian High Commission. Subsequently, eligible participants were encouraged to refer other pregnant Nigerian women within their social networks. This approach enabled access to a hard-to-reach population that would have been difficult to identify through conventional probability sampling methods [17].

Participants and sampling

This study included 88 pregnant Nigerian immigrant women aged 18–45 years who were residing in Kuala Lumpur, Malaysia, at least 32 weeks of gestation, and able to communicate in English. Women at ≥ 32 weeks gestation were selected because the study assessed intended breastfeeding practices rather than actual breastfeeding behaviours. At this stage of pregnancy, mothers are more likely to have established infant feeding intentions and plans and to have received antenatal education and counselling related to breastfeeding, thereby enabling a more informed assessment of breastfeeding knowledge, intended practices, and maternal stress.

Women who were not of Nigerian nationality, were less than 32 weeks pregnant, or were unable to provide informed consent were excluded from the study.

Sample size calculation

Sample size was estimated using the formula for proportions in cross-sectional studies [18]. Based on an estimated pregnancy prevalence of 6.6% among the Nigerian urban population [19], a 90% confidence level (Z = 1.65) and 10% margin of error were applied. After applying finite population correction for the estimated 4,600 Nigerians residing in Malaysia, the minimum required sample size was 67 participants.

During recruitment, 92 women were approached through community networks, of whom 88 met the eligibility criteria and consented to participate, resulting in a response rate of 95.6%. All participants completed the questionnaire and were included in the final analysis.

Ethics consideration

Ethical approval for this study was obtained from Universiti Sultan Zainal Abidin Human Research Ethics Committee (UHREC with Ref No: UniSZA/UHREC/2023474) prior to the commencement of data collection. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki [20].

Written informed consent was obtained from all participants before they were provided with the questionnaire. An information sheet explaining the purpose of the study, procedures, researcher affiliation, potential benefits, and possible risks was provided to all participants. Privacy and confidentiality were ensured by omitting any personally identifiable information. Participants were informed of their right to withdraw from the study at any time without any consequences.

During the initial meeting, participants were verbally informed about the purpose, procedures, and benefits of the study. They were assured that participation would not expose them to any harm and that all information collected would be treated with strict confidentiality. To ensure a comfortable and neutral environment, participants were given adequate time to complete the questionnaire, and the researcher was available to provide clarification whenever necessary.

Instruments and data collection

Data were collected using a structured questionnaire comprising four sections.

The first section captured participants’ socio-demographic and obstetric characteristics, including age which was categorized into three reproductive age groups (18–25, 26–35, and 36–45 years) to facilitate comparison across younger, middle, and older reproductive-age women, marital status, employment status, educational attainment, monthly household income, length of stay in Malaysia, number of children, pregnancy planning status, and personal breastfeeding history.

Breastfeeding knowledge was assessed using an adapted version of the Breastfeeding Knowledge Questionnaire (BFKQ), a validated instrument originally developed in Malaysia [21]. The questionnaire measures six domains of breastfeeding knowledge, namely infant benefits, maternal benefits, colostrum, effective feeding techniques, breast milk expression, and breastfeeding duration. The instrument consists of 29 items with dichotomous “Yes” and “No” response options. However, findings from the pilot study indicated that some participants experienced difficulty selecting either response when they were uncertain of the correct answer. Therefore, an additional “Unsure” response option was incorporated following pilot testing and expert review to reduce forced responses and better capture participants’ actual level of knowledge. For scoring purposes, responses were coded dichotomously, with correct answers scored as 1 and both incorrect and “Unsure” responses scored as 0. Permission to adapt and use the instrument was obtained from the original developer.

Intended infant feeding practices were assessed using items adapted from the Infant Feeding Practices Questionnaire developed by Dunn et al. [14]. The questionnaire assessed breastfeeding intention, planned timing of breastfeeding initiation, intended exclusivity of breastfeeding, and intended breastfeeding duration.

Maternal stress was measured using the Maternal Postpartum Stress Scale (MPSS), a validated instrument developed by Nakić Radoš et al. [10]. The MPSS consists of 22 items assessing stress across three domains: infant nurturing, body changes and sexuality, and personal needs and fatigue. Responses are rated on a five-point Likert scale ranging from 0 (never) to 4 (very often).

All instruments were reviewed by a panel of seven experts comprising midwives, neonatal nurses, pediatric nutritionists, and researchers with expertise in lactation and maternal health to ensure content clarity, cultural appropriateness, and contextual relevance for Nigerian immigrant mothers living in Malaysia. Permission to use and adapt the relevant instruments was obtained from the original authors prior to data collection.

Prior to the main study, a pilot study was conducted among 35 Nigerian mothers residing in Selangor who had previously given birth in Malaysia. These participants were not included in the final study sample. The pilot study was undertaken to assess the clarity, feasibility, cultural appropriateness, and acceptability of the questionnaire. Internal consistency reliability was evaluated using Cronbach’s alpha, with coefficients ranging from 0.77 to 0.88 across the study instruments, indicating acceptable to good reliability.

Data analysis

Data were analyzed using IBM SPSS Statistics version 28. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participants’ socio-demographic characteristics, breastfeeding knowledge, intended breastfeeding practices, and maternal stress levels.

Prior to inferential analyses, the distribution of continuous variables was assessed using the Shapiro–Wilk test and visual inspection of histograms. Independent samples t-tests were used to compare mean scores between two groups, while one-way analysis of variance (ANOVA) was used for comparisons involving more than two groups. Welch’s ANOVA was applied when the assumption of homogeneity of variance was violated.

Associations between socio-demographic characteristics and breastfeeding knowledge and maternal stress were examined using independent samples t-tests and one-way ANOVA, as appropriate. Associations between socio-demographic characteristics and intended breastfeeding practices were examined using regression models appropriate to the level of measurement of each outcome variable.

For the binary outcome variable (intention to breastfeed), Fisher’s exact test was used because only 7 of the 88 participants reported that they did not intend to breastfeed, resulting in sparse cell counts that violated the assumptions required for logistic regression [22]. For ordinal outcome variables, including intended breastfeeding initiation timing, breastfeeding exclusivity, and intended breastfeeding duration, proportional odds logistic regression (ordinal logistic regression) was applied. Results are reported as odds ratios (ORs), 95% confidence intervals (CIs), and p-values.

Spearman rank-order correlation analysis was conducted to examine the relationships among breastfeeding knowledge, intended breastfeeding practices, and maternal stress.

Statistical significance was set at p < 0.05 for all analyses.

Result

A total of 88 pregnant Nigerian immigrant mothers residing in Kuala Lumpur were included in the final analysis. Most participants were aged 26–35 years (50%), followed by those aged 18–25 years (25%) and 36–45 years (25%). The majority were married (85.2%), while smaller proportions were separated (9.1%), divorced (2.3%), or widowed (2.3%).

Regarding employment status, 39.8% were students, 28.4% were homemakers, 18.2% worked part-time, and 13.6% were employed full-time. Most participants had post-secondary education (72.7%), while 27.3% had secondary education.

Although many mothers were highly educated, over half of the participants (53.4%) belonged to the lower-income (B40) category, earning below RM4,000 monthly. Most mothers had 0–2 children (67%), and 69.3% reported that their pregnancy was planned. In addition, 84.1% reported that they themselves had been breastfed during infancy.

Detailed demographic characteristics of the participants are presented in Table 1.

Table 1.

Sociodemographic and Clinical Characteristics of Participants (N = 88)

Variable	Category	n	%
Age Group	18–25 years	22	25
	26–35 years	44	50
	36–45 years	22	25
Marital Status	Married	75	85.2
	Separated	8	9.1
	Divorced	2	2.3
	Widowed	2	2.3
	No response	1	1.1
Employment Status	Full-time	12	13.6
	Part-time	16	18.2
	Homemaker	25	28.4
	Student	35	39.8
Education Level	Secondary	24	27.3
	Higher education	64	72.7
Monthly Income	< RM2,000	5	5.7
	RM2,000–RM4,000	42	47.7
	> RM4,000	40	45.5
	No response	1	1.1
Years in Malaysia	1–3 years	26	29.5
	4–6 years	33	37.5
	7–9 years	16	18.2
	≥ 10 years	13	14.8
Number of Children	0–2	59	67
	3–4	23	26.1
	> 4	6	6.8
Pregnancy Planned	Yes	61	69.3
	No	20	22.7
	Unsure	7	8
Breastfed as Infant	Yes	74	84.1
	Unsure	14	15.9

Breastfeeding knowledge

Participants demonstrated relatively high knowledge of infant-related breastfeeding benefits. For example, nearly 80% correctly identified that breastfeeding supports infant cognitive development, and 97.7% recognized proper latch and positioning as important components of effective breastfeeding.

However, knowledge was considerably lower for maternal benefits and practical breastfeeding skills. Only 43.2% recognized maternal health benefits such as reduced risk of postpartum hemorrhage or breast cancer, while 26.1% correctly identified appropriate breast milk expression techniques.

Associations between sociodemographic variables and breastfeeding knowledge are presented in Table 2. Higher education, employment status, and household income were significantly associated with greater breastfeeding knowledge across several domains.

Table 2.

Association Between Sociodemographic Factors and Breastfeeding Knowledge

Knowledge Domain	Age	Employment	Education	Income	Breastfed as Child
Infant benefits	0.57	2.42	2.53**	10.83***	1.7
Maternal benefits	1.86	4.50**	2.80**	3.13	2.00*
Colostrum knowledge	0.65	5.01**	3.49***	10.89**	2.95**
Effective feeding	0.02	1.53	1.90*	5.48*	0.34
Milk expression	4.27*	7.50***	2.12**	3.36*	4.36***
Duration knowledge	5.29**	2.2	3.77***	5.16**	1.9
Overall knowledge	2.28	6.88***	4.14***	8.50***	3.52***

*** p < 0.001, ** p < 0.01, * p < 0.05

Intended breastfeeding practices

Although 92% of mothers reported intending to breastfeed, their planned practices did not fully align with WHO breastfeeding recommendations.

Only 8% of mothers planned to initiate breastfeeding within the first hour after birth, while most mothers intended to begin breastfeeding after 6 h or the following day.

Similarly, only 39.8% of participants intended to breastfeed exclusively for six months, whereas 58% planned to introduce supplementary feeding earlier, including formula, herbal teas, water, or complementary foods. Detailed breastfeeding intentions and planned practices are presented in Table 3.

Table 3.

Intended Breastfeeding Practices (N = 88)

Practice	Category	n	%
Plan to Breastfeed	Yes	81	92
	No	7	8
Initiation Time	Within 1 h	7	8
	1–6 h	23	26
	> 6 h	32	36
	Next day	25	28
	Unsure	1	1.1
Hospital Staff Support	Yes	75	85
	No	13	15
Age of Introducing Supplements	< 1 week	29	33
	First month	12	14
	2–5 months	10	11
	≥ 6 months	35	40
	Not sure	2	2.2
Intended Breastfeeding Duration	≤ 12 months	39	44
	13–18 months	12	14
	19–24 months	37	42
Can Breastfeed as Long as Desired	Yes	38	43
	No	27	31
	Unsure	23	26

Sociodemographic factors associations with breastfeeding practices

Ordinal logistic regression analyses were conducted to examine the association between socio-demographic characteristics and intended breastfeeding practices. These associations are presented in Table 4. Marital status was significantly associated with intended breastfeeding initiation timing (OR = 1.61, 95% CI: 1.03–2.53, p <0.05), indicating increased odds of later initiation among higher marital-status categories.

Table 4.

Association Between Sociodemographic Factors and Breastfeeding Practices

	Age	Marital Status	Employment	Education	Planned Pregnancy
Plan to Breastfeeda	1.07	1.37	2.81	0.74	0.99
Intended time of initiationb	1.09	1.61*	0.95	1.01	0.99
Exclusivityb	1.31	0.72	1.26	17.85***	0.45**
Duration of Breastfeedingb	0.99	0.53*	1.57*	2.23	0.52

*** p < 0.001, ** p < 0.01, * p < 0.05 (* = significance level)

a = chi-square statistics reported

b = odd-ratio for univariate ordinal logistic regression

For breastfeeding exclusivity, education (OR = 17.85, 95% CI: 5.73-55.77, p < 0.001), and pregnancy planning status (OR = 0.45, 95% CI: 0.24-0.87, p < 0.05) were significant predictors. Education demonstrated the strongest association with breastfeeding exclusivity.

Regarding intended breastfeeding duration, employment (OR = 1.57, 95% CI:1.05-2.35. p < 0.05) was positively associated with longer intended breastfeeding duration, whereas marital status (OR = 0.53, 95% CI: 0.30-0.93 p <  0.05) was negatively associated with intended breastfeeding duration. Age was not significantly associated with intended breastfeeding duration (p =  0.977).

Maternal stress levels

Maternal stress levels were assessed across three domains of the Maternal Postpartum Stress Scale (MPSS): infant nurturing, body changes and sexuality, and personal needs and fatigue.

Overall, stress levels were lowest in the infant nurturing domain, suggesting that most mothers felt relatively confident about caring for their infants. Concerns about infant development and feeding were reported infrequently.

In contrast, higher stress levels were observed in the domain of personal needs and fatigue. Mothers reported feeling overwhelmed by household responsibilities, persistent fatigue, and limited personal time. Feelings of social isolation were also reported, including a lack of time for social interaction and loneliness while caring for the baby at home.

Moderate stress levels were observed in the body changes and sexuality domain, particularly regarding concerns about physical appearance and returning to pre-pregnancy weight.

Detailed MPSS scores are presented in Table 5.

Table 5.

Mean, Standard Deviation and Mode of Maternal Stress Level

Domain	Item	Mean	SD
Infant Nurturing	Difficulty soothing baby when crying	1.56	1.09
	Baby irregular feeding	1.36	0.99
	Concern about insufficient milk supply	0.94	1.02
	Difficulty recognizing baby’s needs	0.69	0.91
	Baby health problems	0.66	0.95
	Concern about baby’s development	0.38	0.78
	Worry about choosing feeding method	0.36	0.57
Body Changes and Sexuality	Concern about physical appearance after birth	2.03	1.21
	Returning to pre-pregnancy weight	1.94	1.1
	Partner returning home late from work	1.39	1.2
	Uncertainty about resuming sexual activity	1.34	1.07
	Reduced frequency of sexual intercourse	1.2	1.08
	Concern partner may find mother unattractive	1.14	1.06
Personal Needs and Fatigue	Overwhelmed by household chores	2.75	0.96
	Fatigue and exhaustion	2.69	0.86
	Lack of help with baby and housework	2.69	1.02
	Lack of personal time	2.63	0.98
	Frequent night waking	2.59	0.85
	Lack of time for social interaction	2.56	1.05
	Baby irregular sleep pattern	2.32	0.99
	Feeling lonely at home with baby	2.29	1.18
	Unable to talk to someone about concerns	1.84	1.19

Sociodemographic factors associated with maternal stress

Analysis of variance showed that several socio-demographic factors were associated with maternal stress. Age was significantly associated with stress in the infant nurturing domain, while marital status was associated with stress related to body changes and overall stress levels. Mothers with unplanned pregnancies reported significantly higher stress levels, particularly in the domain of personal needs and fatigue.

In addition, mothers who reported being breastfed during infancy experienced lower levels of stress related to personal fatigue compared with those who were unsure of their breastfeeding history.

These associations are presented in Table 6.

Table 6.

Association Between Sociodemographic Factors and Maternal Stress

Maternal stress level	Age	Marital status	No of child(ren)	Planned pregnancy	Breastfed as a child
Infant Nurturing	6.49**	1.73	1.94	0.97	0.04
Body changes and Sexuality	2.51	12.61*	3.20*	0.47	1.58
Personal needs and Fatigue	1.68	10.62	4.58*	7.87**	2.59**
All Stress	2.51	10.86*	0.29	3.32	2.11*

*** p < 0.001, ** p < 0.01, * p < 0.05 (*, **, *** = significance level)

Relationships among breastfeeding knowledge, practices, and maternal stress

Spearman correlation analysis was conducted to examine the relationships among breastfeeding knowledge, intended breastfeeding practices, and maternal stress (Table 7).

Table 7.

Spearman correlations among Breastfeeding Knowledge, Intended practices and maternal stress

Spearman correlations	Breastfeeding Knowledge		Maternal stress
Breastfeeding Practices	r	p-value	r	p-value
Plan to Breastfeed	-0.016	0.884	0.226	0.034
Intended time of initiation	0.130	0.227	-0.019	0.864
Exclusivity	0.454	< 0.001	-0.199	0.066
Duration of Breastfeeding	0.294	0.006	-0.348	0.001
Breastfeeding knowledge	-		-0.331	0.002

Breastfeeding knowledge was significantly and positively associated with intended breastfeeding exclusivity (r = 0.454, p < 0.001) and intended breastfeeding duration (r = 0.294, p = 0.006). These findings indicate that mothers with higher levels of breastfeeding knowledge were more likely to intend exclusive breastfeeding and to plan longer breastfeeding durations. However, breastfeeding knowledge was not significantly associated with intention to breastfeed (r = -0.016, p = 0.884) or intended timing of breastfeeding initiation (r = 0.130, p = 0.227).

Maternal stress was significantly associated with intention to breastfeed (r = 0.226, p = 0.034) and intended breastfeeding duration (r = -0.348, p = 0.001). Higher maternal stress was associated with a lower likelihood of intending to breastfeed and with shorter intended breastfeeding duration. No significant associations were observed between maternal stress and intended breastfeeding initiation timing (r = -0.019, p = 0.864) or breastfeeding exclusivity (r = -0.199, p = 0.066).

A significant negative correlation was observed between breastfeeding knowledge and maternal stress (r = -0.331, p = 0.002), indicating that mothers with greater breastfeeding knowledge tended to report lower levels of maternal stress. This finding suggests that adequate breastfeeding knowledge may enhance maternal confidence and preparedness for infant feeding, thereby reducing stress related to breastfeeding and postpartum adjustment.

Overall, the findings demonstrate that breastfeeding knowledge, intended breastfeeding practices, and maternal stress are interrelated. Mothers with greater breastfeeding knowledge were more likely to report favorable intended breastfeeding practices and lower levels of maternal stress, whereas higher maternal stress was associated with less favorable breastfeeding intentions and shorter intended breastfeeding duration.

Overall, the findings suggest that while breastfeeding intention among Nigerian immigrant mothers was high, several gaps remain in planned breastfeeding practices. Lower knowledge of maternal breastfeeding benefits and milk expression, combined with elevated levels of maternal fatigue and social isolation, may influence the ability of mothers to follow recommended breastfeeding practices.

Discussion

This study examined breastfeeding knowledge, intended breastfeeding practices, and maternal stress among Nigerian immigrant mothers residing in Kuala Lumpur, Malaysia. Although most participants expressed an intention to breastfeed, substantial gaps were observed between breastfeeding intentions and planned breastfeeding practices. While 92% of mothers intended to breastfeed, only 8% planned to initiate breastfeeding within the first hour after birth and fewer than half intended to exclusively breastfeed for six months. These findings suggest that positive breastfeeding intentions alone may be insufficient to ensure adherence to recommended breastfeeding practices. Similar discrepancies between breastfeeding intention and practice have been reported among immigrant mothers in other settings, where cultural support for breastfeeding exists but practical, social, and environmental barriers interfere with implementation [6, 9].

One of the most important findings of this study was the uneven distribution of breastfeeding knowledge across different domains. Participants demonstrated relatively good knowledge of infant-related benefits of breastfeeding and effective feeding techniques. However, knowledge regarding maternal benefits and practical breastfeeding skills, particularly breast milk expression, was considerably lower. This finding is important because mothers who migrate may face challenges that require practical breastfeeding skills, including separation from infants due to work or study commitments, limited family support, and difficulties accessing culturally appropriate breastfeeding assistance. Previous studies have similarly reported that knowledge of breastfeeding benefits does not necessarily translate into confidence in managing practical breastfeeding challenges [11, 23].

The present study further demonstrated that breastfeeding knowledge was significantly associated with intended breastfeeding practices. Mothers with higher breastfeeding knowledge were more likely to intend exclusive breastfeeding and longer breastfeeding duration. In addition, breastfeeding knowledge was inversely associated with maternal stress, indicating that mothers with greater knowledge reported lower levels of stress. These findings support the view that breastfeeding knowledge extends beyond information acquisition and may contribute to maternal confidence, preparedness, and perceived ability to cope with infant feeding demand [24]. Adequate knowledge may therefore serve as a protective factor that helps mothers navigate breastfeeding challenges while reducing uncertainty and anxiety during the perinatal period [25].

Education emerged as one of the strongest factors associated with breastfeeding knowledge and intended breastfeeding practices. Mothers with higher educational attainment demonstrated significantly greater breastfeeding knowledge and were substantially more likely to intend exclusive breastfeeding. Higher education was also positively associated with longer intended breastfeeding duration. These findings are consistent with previous studies suggesting that educational attainment enhances health literacy, access to health information, and the ability to understand and apply breastfeeding recommendations [26, 27]. The strong association observed in this study highlights the potential role of educational and informational interventions in promoting optimal breastfeeding practices among immigrant mothers.

Maternal stress constituted another important finding of the study. The highest stress levels were observed in the domains of personal needs and fatigue, particularly feelings of exhaustion, household burden, lack of assistance with childcare, limited personal time, and social isolation. In contrast, stress related to infant nurturing was comparatively low. This pattern suggests that the primary challenges experienced by these mothers were not concerns about caring for the infant but rather difficulties associated with balancing childcare responsibilities, domestic demands, and personal wellbeing [28].

The elevated stress levels observed in this study may be partly explained by the migration experience. Traditionally, many Nigerian mothers receive postpartum support through the Omugwo system, in which female relatives assist with childcare, household responsibilities, and maternal recovery following childbirth. Migration frequently disrupts access to these support networks, leaving mothers to manage infant care and household responsibilities with limited assistance. Similar findings have been reported among immigrant mothers in other countries, where the loss of culturally familiar support systems contributes to increased stress, loneliness, and challenges in adapting to motherhood [29, 30].

Importantly, maternal stress was significantly associated with intended breastfeeding practices. Mothers reporting higher stress levels were less likely to intend to breastfeed and tended to report shorter intended breastfeeding duration. Furthermore, maternal stress was negatively associated with breastfeeding knowledge, suggesting that knowledge and stress may interact in shaping breastfeeding intentions and behaviours. Although the cross-sectional design precludes causal inference, these findings support previous research demonstrating that psychosocial wellbeing plays an important role in breastfeeding decision-making and maintenance [31, 32]. Mothers experiencing elevated stress may find it more difficult to sustain confidence and motivation regarding breastfeeding, particularly in the absence of adequate social support.

Another notable finding from this study was the influence of pregnancy planning status. Mothers with planned pregnancies generally reported lower levels of stress and more favorable intended breastfeeding practices than those with unplanned or uncertain pregnancies. Planned pregnancy may provide mothers with greater opportunity to prepare emotionally, psychologically, and practically for infant feeding and motherhood. Previous studies have similarly reported associations between pregnancy planning, maternal wellbeing, and positive health behaviours during pregnancy and the postpartum period [33].

Taken together, the findings indicate that breastfeeding knowledge, intended breastfeeding practices, and maternal stress are closely interconnected. Mothers with greater breastfeeding knowledge tended to report lower stress levels and more favorable breastfeeding intentions, whereas elevated stress was associated with less favorable breastfeeding intentions and shorter intended breastfeeding duration. These findings suggest that interventions designed to improve breastfeeding outcomes among immigrant mothers should address not only breastfeeding knowledge but also the psychosocial and structural challenges that influence maternal wellbeing.

Therefore, efforts to improve breastfeeding outcomes among Nigerian immigrant mothers should extend beyond the provision of breastfeeding information alone. Community-based breastfeeding support programmes, culturally responsive counselling services, peer-support networks, and interventions aimed at reducing maternal stress may be particularly beneficial. Such approaches may help compensate for the disruption of traditional support systems following migration and provide mothers with the practical and emotional resources required to successfully initiate and sustain breastfeeding.

Limitations and strengths

This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design precludes the establishment of causal relationships among breastfeeding knowledge, maternal stress, and intended breastfeeding practices. Consequently, the observed associations should not be interpreted as evidence of cause-and-effect relationships.

Second, the use of purposive snowball sampling and the relatively small sample size may limit the generalizability of the findings beyond Nigerian immigrant mothers residing in Kuala Lumpur. Nevertheless, this sampling approach was appropriate for accessing a dispersed and hard-to-reach immigrant population for which no formal sampling frame existed.

Third, the study assessed intended breastfeeding practices during late pregnancy rather than actual breastfeeding behaviours after childbirth. Although breastfeeding intentions are important predictors of future behaviour, intentions may change following delivery due to factors such as birth experiences, maternal health, infant health, family support, employment demands, and access to breastfeeding assistance. Therefore, the findings should be interpreted as reflecting planned rather than actual breastfeeding practices.

A major strength of this study is that it addresses an important gap in the literature by focusing on Nigerian immigrant mothers in Malaysia, a population that has received limited research attention despite the growing African immigrant community in the country. The study also provides a more comprehensive understanding of breastfeeding among immigrant mothers by simultaneously examining breastfeeding knowledge, intended breastfeeding practices, and maternal stress. Furthermore, the inclusion of correlation and regression analyses enabled the identification of key factors associated with intended breastfeeding practices, including educational attainment, pregnancy planning status, and maternal stress.

Although the study focused specifically on Nigerian immigrant mothers in Kuala Lumpur, the findings may provide useful insights for healthcare providers, policymakers, and researchers working with other African immigrant populations living in similar migration contexts.

Conclusion

This study found that although Nigerian immigrant mothers in Kuala Lumpur expressed strong intentions to breastfeed, their planned breastfeeding practices did not consistently align with recommended breastfeeding guidelines. Knowledge of infant-related breastfeeding benefits was generally high; however, important gaps were identified in knowledge of maternal benefits and practical breastfeeding skills, particularly breast milk expression. Maternal stress was primarily related to fatigue, household responsibilities, and social isolation, reflecting the challenges of motherhood in the absence of traditional family support systems.

Breastfeeding knowledge was positively associated with intended breastfeeding exclusivity and duration, while maternal stress was associated with less favorable breastfeeding intentions and shorter intended breastfeeding duration. Furthermore, mothers with higher breastfeeding knowledge reported lower levels of maternal stress, highlighting the interconnected nature of breastfeeding knowledge, intended practices, and maternal wellbeing.

These findings suggest that improving breastfeeding outcomes among immigrant mothers requires more than promoting breastfeeding intentions alone. Interventions should strengthen practical breastfeeding knowledge while addressing the psychosocial challenges associated with migration and limited social support. Such efforts may help mothers translate positive breastfeeding intentions into sustained breastfeeding practices.

Abbreviations

WHO

World Health Organization

BFKQ

Breastfeeding Knowledge Questionnaire

MPSS

Maternal Postpartum Stress Scale

SPSS

Statistical Package for Social Science

ANOVA

Analysis of Variance

Authors’ contributions

Study design: BBO, OSL, KLA, IMA, Data Collection: BBOData Analysis: BBO, ZUO, OSLManuscript writing: BBO, OSL, KLA ZUO, IMACritical revisions for important intellectual content: OSL, KLA, IMA, BBO, ZUO.

Funding

This study receives no funding.

Data availability

The data used and/or analysed will be provided upon reasonable request from the corresponding author.

Declarations

Ethics approval and consent to participate

This study was approved by the Universiti Sultan Zainal Abidin Human Research Ethics Committee (UHREC) with a Ref No: UniSZA/UHREC/2023474. All potential participants were informed of the purpose, confidentiality and affiliation of the study. Written inform consent were obtained from all the participant before collecting the data.

Consent for publication

Not applicable. This study does not include any identifiable personal data, images, or clinical details of participants.

Competing interests

The authors declare no competing interests.