PLOS ONE

RESEARCH ARTICLE

Determinants of breastfeeding attitudes of

mothers in Jordan: A cross-sectional study
Sireen M. Alkhaldi ID1*, Oqba Al-Kuran2, Mai M. AlAdwan ID3, Tala A. Dabbah ID3, Heyam
F. Dalky4, Eiman Badran5
1 Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman,
Jordan, 2 Department of Obstetrics and Gynecology, School of Medicine, The University of Jordan, Amman,
Jordan, 3 School of Medicine, The University of Jordan, Amman, Jordan, 4 Department of Community and
Mental Health Nursing, School of Nursing, Jordan University of Science and Technology, Irbid, Jordan,
5 Department of Pediatrics, School of Medicine, The University of Jordan, Amman, Jordan

a1111111111 * [email protected]
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Abstract
Breastfeeding provides the optimal nutrition for an infant. However, breastfeeding practice
is on decline globally. Attitude toward breastfeeding may determine the practice. This study
aimed to examine postnatal mothers’ attitude to breastfeeding and its determinants. A
OPEN ACCESS cross-sectional study was conducted, and data on attitude were collected using the Iowa
Citation: Alkhaldi SM, Al-Kuran O, AlAdwan MM, Infant Feeding Attitude Scale (IIFAS). A convenience sample of 301 postnatal women were
Dabbah TA, Dalky HF, Badran E (2023) recruited from a major referral hospital in Jordan. Data on sociodemographic characteristics,
Determinants of breastfeeding attitudes of mothers pregnancy and delivery outcomes were collected. SPSS was used to analyze the data and
in Jordan: A cross-sectional study. PLoS ONE
18(5): e0285436. https://doi.org/10.1371/journal.
identify the determinants of attitudes to breastfeeding. The mean total attitude score for par-
pone.0285436 ticipants was 65.0 ±7.15, which is close to the upper limit of the neutral attitude range. Fac-
Editor: Ghada Abdrabo Abdellatif Elshaarawy,
tors associated with attitude that is positive to breastfeeding were high income (p = 0.048),
National Research Centre, EGYPT pregnancy complications (p = 0.049), delivery complications (p = 0.008), prematurity (p =
Received: December 30, 2022
0.042), intention to breastfeed (p = 0.002) and willingness to breastfeed (p = 0.005). With
binary logistic regression modelling, determinants of attitude positive to breastfeeding were
Accepted: April 20, 2023
highest income level and willingness to breastfeed exclusively (OR = 14.77, 95%CI = 2.25–
Published: May 5, 2023 99.64 and OR = 3.41, 95%CI = 1.35–8.63 respectively). We conclude that mothers in Jordan
Peer Review History: PLOS recognizes the have neutral attitude to breastfeeding. Breastfeeding promotion programs and initiatives
benefits of transparency in the peer review should target low-income mothers and the general population. Policymakers and health
process; therefore, we enable the publication of
all of the content of peer review and author
care professionals can use the results of this study to encourage breastfeeding and improve
responses alongside final, published articles. The breastfeeding rate in Jordan.
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0285436

Copyright: © 2023 Alkhaldi et al. This is an open

access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
Introduction
reproduction in any medium, provided the original
author and source are credited. Breastfeeding enhances bonding between a mother and her infant after birth. It is the most
Data Availability Statement: All relevant data are
valuable gift a mother can offer to her newborn. The advantages of breastfeeding for both new-
within the manuscript and its Supporting borns and their mothers are well documented [1]. Increasing the rates of breastfeeding alone
Information files. can have the potential to save the lives of around a million children under age 5 worldwide [2,

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Funding: The authors received no specific funding 3]. Yet, about 44% of infants 0–6 months old globally were exclusively breastfed over the
for this work. period of 2015–2020 [4].
Competing interests: The authors have declared Skin to skin contact and breastfeeding immediately after birth have been reported to mini-
that no competing interests exist. mize infant mortality and promote maternal health [1]. In addition, exclusive breast feeding
for six months, continued for two years and beyond with the provision of safe and appropriate
complementary foods are the most important strategies for promoting child survival and
health [5]. However, the benefits of breastfeeding are underestimated, and the proportion of
mothers who breastfeed their newborns is way below the recommended levels globally and
Jordan is no exception [4, 6]. The rates of breastfeeding (any breastfeeding) reported by the
UNICEF in 2022 for infants 0 to 5 months were 25% in Jordan, compared to 40% in Egypt,
35% in Morocco, 39% in Palestine, 29% in Syria, 14% in Tunisia, 29% in Algeria, 26% in Iraq,
and 53% in Iran [7].
Numerous factors influence both initiation and continuity of breastfeeding. These factors
include mothers’ age, income, education, mode of delivery and availability of breastfeeding
counseling before, during and after delivery, and past breastfeeding experience [8–14]. In
addition, health professional and birth attendant’s attitudes to breastfeeding have strong
impact on women’s breastfeeding practice, through their willingness and ability to help and
encourage the mother to initiate breastfeeding [15]. In addition, type of health care facility
where delivery occurred and admission of the infant in neonatal intensive care unit (NICU)
influence the process of breastfeeding by women [10, 15–18].
The decision about infant feeding seems to be made before childbirth [19].The literature
have shown that multiple factors at different levels determine breastfeeding practice including
demographic and socioeconomic factors, cultural norms, and perceptions to breastfeeding
[20, 21]. Studies have demonstrated that mothers’ attitude toward breastfeeding is a significant
predictor of their intention, initiation, and continuation of breastfeeding [14, 19, 22–26]. Atti-
tude is a mental position with regard to a fact or state, and the feeling or emotion toward the
fact or state. Attitude is traditionally structured along three dimensions: cognitive, affective,
and behavioral [27]. The breastfeeding behavior is directly determined by the intention to
breastfeed. Intention is formed through a combination of attitudes, motivation, subjective
norm, and perceived behavioral control [22]. Intention is a prior conscious decision to per-
form a behavior. Intention can reflect maternal commitment to infant’s health [28]. Research-
ers in Jordan demonstrated that a mother’s positive attitude toward breastfeeding is a
predictor of exclusive breastfeeding [24, 29]. The study population in Khasawneh et. al. [24]
was a randomly selected 344 women from the North of Jordan villages. Using questions
adapted from the IIFAS. While Khasawneh et. al. [29] interviewed healthy women attending
antenatal clinics in three hospitals in the North of Jordan too, using the IIFAS.
Nevertheless, women’s attitude toward breastfeeding worldwide is less than optimal [30].
Studies in Spain and in Canada found positive attitude to breastfeeding among women, while
more neutral attitude was noted in Poland and in Fiji [9, 31–33]. In the region, Naja et al.
showed that only 9.5% of women to have positive attitude to breastfeeding in Qatar and in
Lebanon. On the other hand, in Saudi Arabia, Mohammed et al found more positive attitude
toward breastfeeding [34], while Abulreesh et al. reported neutral attitude to breastfeeding
[35]. In Ethiopia, neutral attitude to breastfeeding was reported [36]. In Jordan, several
researchers found neutral attitude to breastfeeding (neither positive to breastfeeding nor to
bottle feeding) [23, 37, 38], while Khasawneh et.al. (2020) reported 72% of women to have pos-
itive attitude to breastfeeding [29].
A large body of literature indicated various factors to positively influence women’s attitude
to breastfeeding, including education, family income, employment, previous experience with
breastfeeding and intention to breastfeed exclusively [9, 11, 19, 31, 33–35, 39]. On the contrary,

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

maternal employment, mother’s illness, lack of father’s support, cesarean section delivery, pre-
term delivery, infant health status and neonatal intensive care unit NICU admission were
reported to adversely impact mothers’ attitude to breastfeeding [19, 23, 33–35]. Advancing bet-
ter understanding of the country-specific determinants and predictors of women’s attitudes
toward breastfeeding is critical for development of effective health care programs, and for
informing health care providers and policy makers in Jordan. However, there is scarcity in
research addressing factors that determine mothers’ attitude toward breastfeeding in Jordan.
Hence, in this study, we sought to assess factors that determine women’s attitude towards
breastfeeding in Jordan.

Methods
Study design and setting
This observational cross-sectional, hospital-based study was conducted to examine the atti-
tudes of mothers in Jordan toward breastfeeding. Postnatal mothers, attending the maternity
ward after delivery, were recruited from a referral tertiary teaching hospital in Amman, the
Capital city of Jordan, during the study period February 2021 to January 2022. This hospital is
an accredited Baby-friendly hospital since June 2018 and has approximately 3000 births
annually.
Despite the hospital’s high patient population, data collection restricted and was time-con-
suming because of the Covid-19 epidemic. During the pandemic, hospital admission and
patient access were regularly limited when infected patients or personnel were reported.

Population and sample

A convenience sample was selected from the target population for the current study, which
was all women attending the maternity ward after delivery, when the research team was avail-
able in the hospital, during the study period. Women who were still under the effect of anes-
thesia, or who seemed very tired at the time of data collection were excluded. The sample size
was calculated using a Raosoft, an online sample size calculator [40]. Confidence Interval was
set at 95% and margin of error at 5%. A sample size of at least 377 was needed. All women in
the maternity ward were eligible to participate in the study.

Study instrument
The questionnaire for this study consisted of three parts. The first part is the Iowa Infant Feed-
ing Attitude Scale (IIFAS) [28], a pre-validated tool used to measure attitudes of mothers
toward infant feeding. An infant is defined as a child who is less than one year of age. It
includes 17 items with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly
agree). Eight statements indicate positive attitude toward breastfeeding and nine statements
indicate positive attitude toward formula feeding. The statements indicating positive attitude
to breastfeeding were reverse-scored before calculating the total scores of all items. An example
for attitude is: “Formula-feeding is more convenient than breastfeeding”, and “Breastfeeding
increases mother-infant bonding”. The total IIFAS score can range from 17 to 85 with higher
scores reflecting more positive attitude towards breastfeeding. The total IIFAS is further classi-
fied as positive to breastfeeding (a score of 70–85), neutral (a score of 49–69) and positive to
formula feeding (a score of 17–48). The researcher used a validated Arabic version of the
IIFAS after permission from the author [41]. The tool was pilot tested on 30 participants to
check for clarity, response time, any potential problems with the questionnaire in addition to

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

reliability. Cronbach’s alpha analysis revealed good reliability of the IIFAS, with coefficient
equals to 0.72. No major changes were made based on the pilot test results.
Additionally, sociodemographic characteristics of mothers, and pregnancy and delivery
information which includes mode of delivery, gestational age, the presence of complications
during pregnancy or delivery, admission of the baby to neonatal intensive care unit (NICU),
and receiving antenatal counseling for breastfeeding were all collected. The last part consisted
of five questions to assess breastfeeding practices, which was created by the researcher based
on the Centers for Disease Control and Prevention (CDC) guidelines [42]. These include
items about intention to breastfeed, willingness to breastfeed exclusively (feeding the baby
only breastmilk), receiving counselling for breastfeeding and time of initiation of breastfeed-
ing. All data collected were quantitative.

Data collection procedure

The research team were trained in interviewing procedures. They collected data from postpar-
tum mothers who attended the hospital’s maternity ward after delivery. Data collection took
place in the period between February 2021 and January 2022, using a structured interviewer-
administered questionnaire.
The research team attended the maternity ward whenever they were allowed to do so. They
approached all mothers available in the ward at the time of their visit. They introduced them-
selves, and offered women the opportunity to participate in the research study. Women who
were willing to participate were given further details and a verbal consent was obtained. Medi-
cal students were responsible for data collection, where they asked mothers questions and
mothers responded. In compliance with infection control procedures, and for avoiding paper-
based questionnaires, medical students entered the answers electronically immediately, using
their mobile phones or tablets. It took 10 minutes to complete each questionnaire. The
response rate was 95% with 301 mothers completing the questionnaires to collect sociodemo-
graphic information and the IIFAS questions. Data related to the pregnancy and delivery out-
comes were collected from the medical record. Each mother’s electronic medical record was
searched for information pertaining to the pregnancy and birth outcomes. Every questionnaire
was checked for completeness before the research team left the ward. During data collection,
appropriate infection prevention control measures and principles relevant to COVID-19 were
also addressed.
Data collection required a very long time, because of the Covid-19 pandemic-related
restrictions for access of the research team, recurrent closures, and because of the limited num-
ber of women admitted for delivery compared to the usual number before Covid-19 pandemic.
Data collection continued for 12 months, ending up with a sample of 301 participants by Janu-
ary 2022.

Ethical considerations
The ethical committee (IRB) in the University of Jordan Hospital approved this study (no.
2019–229). All study protocols complied with the guidelines established by the institution’s
committee on research ethics. Participation in the study was voluntary, and verbal consent was
obtained from participating mothers. Mothers were assured that the service they receive would
not be affected by their decision to participate in the study. Data obtained were kept confiden-
tial, and were used strictly for the purpose of this research. Confidentiality of the data was pre-
served, data were stored in password-protected files in the computers of the research team,
and were used only for the purpose of this research.

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Analysis
The collected data were examined for completeness and consistency, and then data was
cleaned. Statistical analysis were performed using Statistical Package for Social Sciences (SPSS)
version 21 [43]. Descriptive statistics were used to summarize the sociodemographic personal
characteristics, pregnancy and delivery variables, and infant breastfeeding-related variables. In
addition, the mean and standard deviation for individual items of IIFAS, and total score for
the attitude toward breastfeeding for each respondent were calculated. Independent t-test and
one-way ANOVA tests were performed to assess if the total attitude score towards breastfeed-
ing different significantly across each of the measured patient characteristics Additionally,
binary logistic regression was used to detect predictors of attitude of mothers toward infant
feeding. The results were expressed as adjusted odds ratio (AOR) with 95% confidence inter-
vals (CI) and p-values. P-values of <0.05 were considered statistically significant.

Results
Data collected from 301 mothers after delivery were included in the analysis. Table 1 presents
the sociodemographic characteristics of participants in addition to pregnancy and delivery
information. More than 40% of the study population were 30 years of age or older and more
than 70% had up to three children (including the recently delivered infant). Over 75% of par-
ticipants had a university degree or higher. A large proportion of the sample were employed
(43.2%). More than 60% of mothers had a monthly family income of 450 Jordan Dinar or less,
and the vast majority (93%) had health insurance. The most common pregnancy complication
among mothers was gestational diabetes (16%), and 26% of mothers had preterm deliveries.
More than half of all deliveries were by a cesarean section (56.2%) and 18% of infants were
admitted to NICU (Table 1).
Findings regarding breastfeeding-related variables are presented in Table 2. Almost all
(95.7%) of mothers intended to breastfeed their infants, but only 35.2% of them were willing to
breastfeed exclusively. Only 40% of mothers received any breastfeeding counselling before or
after delivery. Nevertheless, only 43% of mothers initiated breastfeeding during the first day
after birth, while 28.6% did not initiate breastfeeding before discharge (Table 2).
The attitude of participants to infant feeding, as measured using the IIFAS after delivery,
are demonstrated in Table 3. The statements with the highest mean were “Breastfeeding
increases mother-infant bonding” and “Breast milk is more easily digested than formula”. The
statements with the lowest means were “Mothers who occasionally drinks alcohol should not
breastfeed” and “Women should not breastfeed in public places”. Overall mean attitude
toward infant feeding was 4.0 ± 1.0, measured using a 5-point likert scale, and the overall total
(summed) attitude score for participants was 65±7.2 (out of 85). This an attitude score that is
close to the upper limit of the neutral range (49–69), indicating tendency toward a positive atti-
tude to breastfeeding. Only 24.3% of mothers in this study demonstrating positive attitude to
breastfeeding after childbirth (total attitude score �70 out of 85) (Table 3).
Table 4 displays the relationship between mother’s total attitude toward breastfeeding and
personal characteristics, pregnancy and delivery variables, using t-test and ANOVA. Results
show that total attitude score toward breastfeeding was significantly higher among women
with higher income (p = 0.05), who had pregnancy complications (p = 0.05), with delivery
complications (p = 0.01), who had preterm infants (p = 0.04), who intended to breastfeed
(p = 0.00) and who were willing to breastfeed exclusively (p = 0.01).
Table 5 presents result of logistic regression carried out to assess the factors associated with
positive attitude toward breastfeeding. The overall model was statistically significant when
compared to the null model, (χ2 (9) = 21.7, p = 0.01). This model explained 28.4% (Nagelkerke

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Table 1. Sociodemographic characteristics, pregnancy and delivery variables of mothers participating in this
study of attitudes toward breastfeeding (N = 301).
Variable Categories N %
Age <24 25 8
24–30 105 35
31–35 103 34
>35 68 23
Parity 1 84 27.9
2–3 131 43.5
>=4 86 28.6
Level of Education Primary or lower 10 3.3
Secondary level 61 20.3
University degree or above 137 45.5
Graduate degree 93 30.9
Smoking (n = 291) Non-smoker 238 82
smoker 15 5
Previous smoker 38 13
Working status Employed 130 43.2
Unemployed 171 56.8
Monthly family income a (n = 179) 0–300 JD 32 17.9
301–450 JD 79 44.1
451–650 JD 53 29.6
>651 JD 15 8.4
Health Insurance Yes 279 93
No 21 7
Pregnancy Complications No 205 68.1
Gestational diabetes 44 16.4
Hypertension 17 5.7
Preeclampsia 11 3.7
Other complications 24 8
Delivery Complications No 271 90
Yes 30 10
Gestational Age (mean = 41.4 week) Preterm 78 26
Term 222 74
Mode of Delivery Vaginal birth 132 43.9
Cesarean Section Delivery 169 56.1
Admission to NICU No admission to NICU 247 82.0
Admission to NICU 54 18.0
a
1 JD equals US$ 1.4

https://doi.org/10.1371/journal.pone.0285436.t001

R square) of the variance in the attitude to breastfeeding and correctly classified 82% of cases.
Logistic regression results indicated that, holding other variables constant, mothers with sec-
ond income level (301–450 JD’s) and mothers with highest family income (>650 JD’s) had
4.88 and 14.77 times the odds of having positive attitude toward breastfeeding compared to
women with lowest income level (95%CI = 1.12–23.8 and, 95%CI = 2.25–99.64 respectively).
Furthermore, holding other variables constant, the odds of having positive attitude toward
breastfeeding was 3.4times higher among mothers who were willing to breastfeed exclusively,
compared to women who were not willing to breastfeed exclusively (p = 0.01, 95%CI = 1.35–
8.63).

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Table 2. Breastfeeding- related variables of mothers participating in this study of attitudes toward breastfeeding
(N = 301).
Variable Categories N %
Intention to breastfeed Yes 288 95.7
No 10 3.3
Undetermined 3 1.0
Willingness to breastfeed exclusively Yes 106 35.2
No 146 48.5
Undetermined 49 16.3
Breastfeeding counseling received Yes/ prenatal 60 20
Yes/ postnatal 60 20
No 181 60
Time of Initiation of breastfeeding Day 1 130 43.2
Day 2 53 17.6
Day 3 32 10.6
Did not initiate 86 28.6
https://doi.org/10.1371/journal.pone.0285436.t002

Discussion
The rates of breastfeeding are on decline globally including Jordan. Mothers’ attitude toward
breastfeeding is a vital factor that influences breastfeeding practice. This study aimed to assess
mothers’ attitude toward breastfeeding in Jordan, and to identify the determinants and predic-
tors of this attitude. Results of this study exhibit that a small proportion (24.3%) of mothers in
Jordan have positive attitude toward breastfeeding. This may be due to the belief that formula

Table 3. Item scores of mothers’ postnatal attitudes to breastfeeding using the IIFAS (N = 301).
Attitude statement Likert Scale Responses* (%) Item Mean ±SD
1 2 3 4 5
Benefit of breast milk last only until weaning ** 48.8 4.0 11.6 7.3 27.2 3.4±1.7
Formula milk is more convenient than breastfeeding ** 39.8 4.3 8.3 4.7 29.2 3.5±1.8
Breastfeeding increases mother-infant bonding 1.0 0.0 1.3 0.7 96.0 4.9±0.6
Breast milk is lacking in iron ** 49.2 6.6 22.6 5.6 15.9 3.7±1.5
Formula-fed babies are more likely to be overfed 6.0 3.0 10.3 4.3 73.0 4.3±1.3
Formula-feeding is the better choice if a mother plans to work outside to work ** 12.3 3.0 19.3 12.3 43.5 2.3±1.4
Mothers who formula feed miss one of the greatest joys of motherhood 5.6 1.0 3.7 7.3 79.0 4.5±1.1
Women should not breastfeed in public places ** 10.9 5.0 12.3 4.3 63.0 2.0±1.5
Babies fed breast milk are healthier 4.3 1.3 3.7 5.7 84.0 4.6±1.0
Breastfed babies are more likely to be overfed ** 76.7 6.6 8.6 2.7 5.3 4.5±1.1
Fathers feel left out if a mother breastfeeds ** 45.5 8.0 19.6 8.6 14.2 3.7±1.5
Breast milk is the ideal food for babies 1.7 0.0 1.3 2.3 94.3 3.9±0.6
Breast milk is more easily digested than formula 2.0 1.3 4.3 2.7 89.0 4.7±0.8
Formula is as healthy for an infant as breast milk ** 73.1 9.3 12.6 2.7 2.3 4.5±01.0
Breastfeeding is more convenient than formula feeding 26.2 6.3 11.3 5.0 51.1 3.5±1.7
Breast milk is less expensive than formula 6.3 1.7 3.0 2.2 86.7 4.6±1.7
Mothers who occasionally drinks alcohol should not breastfeed** 7.0 1.7 3.3 2.7 85.4 1.4±1.1
Overall mean score on attitude toward infant feeding = 4.0 ± 1.0
Total (summed) attitude score for participants was 65±7.2 (out of 85)

* 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree

**Statement with reverse score

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Table 4. Relationship between sociodemographic characteristics, pregnancy and delivery outcomes and total attitudes score of mothers toward breastfeeding
(N = 301).
Variable Categories N % Total Attitude Score a P-value
Age (mean = 29.67, sd =) <24 25 8 67.9 0.16b
24–30 105 35 64.9
31–35 103 34 64.3
>35 68 23 65.0
Parity 1 84 27.9 65.4
2–3 131 43.5 64.7 0.42 b
�4 86 28.6 66.5
Level of Education Primary or lower 10 3.3 60.6
Secondary level 61 20.3 64.0 0.12 b
University degree or above 137 45.5 65.2
Graduate degree 93 30.9 65.7
Working status Employed 130 43.2 65.07 0.84c
Unemployed 171 56.8 64.9
Monthly family income (n = 179) 0–300 JD 32 17.9 62.5
301–450 JD 79 44.1 64.6 0.05 b
451–650 JD 53 29.6 65.5
>651 JD 15 8.4 68.1
Pregnancy Complications No 205 68.1 64.5 0.05 c
Yes 96 31.9 66.1
Delivery Complications No 271 90 64.6 0.01 c
Yes 30 10 68.0
Gestational Age (mean = 41.4 week) Preterm 78 26 66.4 0.04 c
Full term 222 74 64.5
Mode of Delivery Vaginal birth 132 43.9 64.5 0.41 b
Planned CS 81 26.9 64.9
Emergency CS 88 29.2 65.8
Admission to NICU No admission to NICU 247 82.0 64.8 0.36 b
Admission to NICU 54 18.0 65.6
Intention to Breastfeed Yes 288 95.7 65.2 0.00 b
No 10 3.3 57.2
Undetermined d 3 1.0 65.3
Willingness to Breastfeed Exclusively Yes 106 35.2 66.7 0.01 b
No 146 48.5 63.8
Undetermined 49 16.3 64.9
Breastfeeding counseling during antenatal care Yes/ prenatal 60 20 64.9 0.99 b
Yes/ postnatal 60 20 64.9
No 181 60 64.9
Time of Initiation of Breastfeeding Day 1 130 43.2 65.3 0.51 b
Day 2 53 17.6 65.6
Day 3 32 10.6 64.4
Did not initiate 86 28.6 64.0
Mean for the sum of attitude score = 65.0 ± 7.2 out of 85 (range 37–81)
a
Total attitude score is the sum of all items scores (range from 17 to 85). It was classified as positive to breastfeeding (a score of 70–85), neutral (a score of 49–69) and
positive to formula feeding (a score of 17–48).
b
One-way ANOVA
c
Independent Sample t-test
d
Undetermined refers to the case when the answer is neither yes nor no.

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Table 5. Determinants of positive attitude of mothers toward breastfeeding, results of logistic regression of family income, gestational age, intention to breastfeed,
willingness to breastfeed exclusively, pregnancy complication, and delivery complications (N = 301)a.
Variable Categories p-value OR 95%CIb
Monthly family income (n = 179) 0–300 JD (reference)
301–450 JD 0.05c 4.88 1.12–23.8
451–650 JD 0.30 2.42 0.59–12.81
>651 JD 0.00c 14.77 2.25–99.64
Gestational Age Preterm (reference)
Full term 0.27 0.60 0.25–1.48
Pregnancy Complications No (reference)
Yes 0.51 0.75 0.32–1.77
Delivery Complications No (reference)
Yes 0.26 0.52 0.16–1.64
Intention to Breastfeed No (reference)
Yes 0.98 1.04 0.25–1.49
Undetermined 0.99 1.05 0.22–1.56
Willingness to Breastfeed Exclusively No (reference)
Yes 0.01c 3.41 1.35–8.63
Undetermined 0.91 1.09 0.36–3.31
a
Model’s Chi-square (df) = 21.7 (9), p = .01, Nagelkerke R2 = 28.4.
b
Confidence Interval
c
Statistically significant, p < .05

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milk is an advanced combination of nutrients and that it is as good as breastmilk. This propor-
tion is high compared to 9.2% having positive attitude to breastfeeding in Lebanon and Qatar
[19], but considerably lower than 72% having positive attitude in Jordan in 2020 [29], and 55%
in India [44]. Khasawneh et al (2020) have overestimated the proportion of mothers with posi-
tive attitude to breastfeeding. They offered the choice of only agree or disagree for the IIFAS
scale, and agreement with more than half of the items was considered as positive attitude to
breastfeeding.
Despite the fact that this hospital is a baby friendly hospital, only 43% of mothers initiated
breastfeeding in the first day after childbirth, and 60% of mothers did not receive any counsel-
ling of advice related to breastfeeding. This may be explained by the hospital being a tertiary
referral one, receiving a large volume of complicated cases requiring cesarean section, and
inducing delay in initiation of breastfeeding. On the other hand, the role of this hospital in
promoting positive breastfeeding behavior is suboptimal. It seems that many factors influence
weather mothers’ intentions are reflected into actual practice.
The mean total attitude score in this study was 65.0 ± 7.2, which is very similar to the mean
total IIFAS score (63.5 ± 4.67) reported previously by Shoosha et.al. among Jordanian mothers
[23]. Yet, this score is low compared to the very positive attitude with a total score of
81.39 ± 8.35 in Jeddah, Saudi Arabia [34], and to 69.76 ± 7.75 in Spain. On the other hand,
lower total scores were reported in Poland (63.12 ± 7.34), in Saudi Arabia (59.6 ± 7.3) [35],
and neutral attitude to breastfeeding (30 out of 50) in Fiji [9]. This indicates the multifaceted
nature of the attitude toward breastfeeding, involving a wide array of social norms, culture and
health care environment factors.
Findings of this study pointed out multiple sociodemographic characteristics and delivery
characteristics that were associated with mother’s attitudes to infant feeding. In accordance
with other studies, socioeconomic status and particularly higher income, was associated with

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

more positive attitude to breastfeeding in Saudi Arabia [34], Fiji [9], Lebanon and Qatar [19].
In fact, higher family income continued to be a predictor of more positive attitude to breast-
feeding, even after controlling for all other variables. Mothers with higher income level seem
to care more about the quality of food they provide for their families, including choosing
breastfeeding for their infants. Mothers with lowest income level demonstrated more positive
attitude to formula milk feeding. These women cannot afford the price of formula milk, and
have no choice but to breastfeed. This may explain why they favor formula milk more, and
may perceive it as an ideal nutritious food for their infants.
On the other hand, mothers with higher education did not show more positive attitude to
breastfeeding. This was consistent with results of other studies in the literature, where higher
education was significantly associated with less positive attitude to breastfeeding, or had no
association [9, 19, 29, 34, 35]. This may be explained by the fact that mothers with higher edu-
cation are working or planning to work. For these mothers, bottle-feeding may be considered
a more convenient option for infant feeding, since it is less time consuming and can be pro-
vided by any caregiver. These mothers may also value freedom, and prefer to choose infant
feeding method that will not restrict their daily activities.
Interestingly, mothers who had pregnancy and delivery complications did not have signifi-
cantly more positive attitude to breastfeeding. Similarly, positive attitude to breastfeeding was
not associated with preterm delivery in this study. This comes in line with earlier findings in
Jordan, where mothers of preterm infants were less likely to have positive attitude to breast-
feeding [23]. On the other hand, other studies reported no association Saudi Arabia, Qater,
Lebanon and in Jordan [19, 29, 34]. In addition, our results indicated that NICU admission
did not influence postpartum attitude to breastfeeding as expected, which implies that NICU
of the baby was not a barrier to breastfeeding among mothers in this study. Although admis-
sion to NICU was associated with a significant delay in the initiation of breastfeeding to second
or third day after childbirth, it did not prevent initiation. This may be because this hospital is
baby-friendly, and the healthcare providers do encourage and support mothers to initiate
breastfeeding after birth.
Despite the fact that no association was found in this study between working status or
employment and attitude to breastfeeding, other studies reported a negative association, where
employment was a barrier to breastfeeding Saudi Arabia, Bangladesh, Qatar, Lebanon, and in
Jordan [8, 14, 19, 29, 34, 35, 39, 45]. According to Al Tamimi et.al., 30% of the mothers in their
study in Jordan, attributed premature cessation of breastfeeding to work [39]. In addition,
Khasawneh et.al. indicated the short maternity leave as a prominent reason for non-exclusive
feeding in Jordan [45]. The majority of mothers in the current study believed that mothers
who were going back to their employment after childbirth, should choose formula feeding.
Nevertheless, there was no difference in the mean attitude score between mothers who work
and those who do not work, nor in their time of initiation of breastfeeding before discharge
from hospital. This may suggest the more or less breastfeeding-friendly behavior that mothers
perceive in many workplaces in Jordan.
We did not find any difference between mothers who received prenatal or postnatal coun-
selling about breastfeeding and those who did not receive any counselling. In addition, no
association was found between attitude and early initiation of breastfeeding. This is in line
with findings of Khasawneh et.al. where counselling about breastfeeding by healthcare provid-
ers did not influence breastfeeding practice [29]. This may suggest that education and provid-
ing information about breastfeeding during pregnancy or just after delivery is not enough to
influence mothers’ attitude to breastfeeding.
This study demonstrated that mothers who were willing to breastfeed exclusively had more
positive attitude to breastfeeding. This contradicts the findings from Lebanon, Qatar, Saudi

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Arabia and from Jordan [8, 19, 29], where associations were reported between planning and
intending to breastfeed.
To shape attitude to breastfeeding in mothers, it is essential to build more positive attitude
to breastfeeding among husbands, mothers, mothers in law and friends of pregnant women
[46]. Friends and family, among others in the community have a critical role in supporting,
assisting, encouraging and motivating mothers to initiate and continue breastfeeding after
childbirth. Their own attitudes to breastfeeding positively influence mothers’ breastfeeding
decisions and practices. They can effectively help mothers conquer barriers that may arise
along the breastfeeding journey.
This study is the first to explore postnatal mothers’ attitudes to breastfeeding in Jordan in
addition to the influence of validated pregnancy and delivery outcomes on this attitude.
Results of this study added insight to the evolving body of literature about mothers’ breastfeed-
ing attitudes in Jordan.

Limitations
Nevertheless, there are some limitations of this study. First, the main challenge was that data collec-
tion started just before Covid-19 pandemic, which interrupted and delayed the process of data col-
lection. There was the lock down initially, followed by limitation to admissions to the wards during
that period. Additionally, temporary closure of the ward when cases were identified limited access
of the research team for data collection. Thus, the sample size is less than planned beforehand. Sec-
ond, results may not be generalizable to mothers in Jordan, since our sample did not include moth-
ers with no health insurance who gave birth in private hospitals. In addition, the study was carried
out in a teaching hospital, which is certified as a baby-friendly hospital. Therefore, results may have
restricted generalizability to the population of mothers in Jordan who receive services in non-
baby-friendly facilities. Furthermore, the sample was selected from mothers attending this referral
teaching hospital in the capital Amman. The sample was selected from mothers attending this
referral teaching hospital in the capital Amman. Many of women who receive service in this hospi-
tal are university employees and their families. This explains the high level of education among the
participants. These women may not be representative of all women in Jordan.
Third, the interviewer-administered way of data collection for the attitude, may have resulted
in social desirability bias in responses, despite the training provided for the interviewers to reduce
this bias. Additionally, cultural beliefs about breastfeeding were not addressed as factors that may
influence women’s attitude toward breastfeeding in Jordan, which may be the focus of future
research. Finally, data about initiation of breastfeeding in the first hour after birth is not available,
which makes the data less useful for calculating the rate of early initiation of breastfeeding.

Recommendations
Future research may explore women’s attitudes before pregnancy, during pregnancy, and after
delivery in order to investigate the effect of pregnancy and delivery experience on breastfeed-
ing attitude. We also recommend more research targeting knowledge about breastfeeding.
More qualitative studies can be of great benefit in exploring breastfeeding attitudes in the pop-
ulation in Jordan. We suggest that future studies look at whether the IIFAS is associated with
breastfeeding practices in Jordan, controlling for other factors such as hospital breastfeeding
routines (early initiation of breastfeeding, rooming-in, etc.), newborn characteristics (prema-
turity, birth weight, birth by cesarean section, etc.) and maternal characteristics (educational
level, work status, income, etc.). We also recommend that future studies be conducted on a
representative population sample with a prospective design so that results can contribute to
policy recommendations for the Jordanian population.

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

There is an immediate need for interventions in Jordan to improve the rate of breastfeed-
ing. Public policies can be implemented to increase the availability of designated breastfeeding
places in workplaces, public places, parks, shopping malls, restaurants and health care facilities
that are breastfeeding-friendly, prepared with a suitable place for breastfeeding. Policies and
laws on marketing formula milk and breastmilk substitutes, paid maternity leave, availability
of day care facilities, breastfeeding breaks for employed mothers, should all be enforced.
Workplaces should encourage mothers to breastfeed their infants, and even reward them for
adhering to this practice. Since the majority of women in Jordan give birth in private hospitals,
more private hospitals better be encouraged to join the Baby Friendly Hospitals initiative. In
addition, hospitals that are designated as baby friendly, must audit their procedures related to
encouraging breastfeeding practice, and make sure that related policies are properly imple-
mented. Interventions are specially needed to positively impact attitude to breastfeeding in
low income communities, targeting women, their husbands, families and friends. Their sup-
port and encouragement is necessary for mothers to start and continue breastfeeding.
Health care students in all disciplines must be educated on breastfeeding. In addition, pub-
lic education is essential to support and encourage woman’s decision to breastfeed. To achieve
that, initiatives must clearly communicate the benefits and importance of breastfeeding to the
people [47], against the strong marketing for breastmilk substitutes by the companies.
Well-designed interventions for improving breastfeeding counselling by health care provid-
ers after birth is vital. Maternity nurses can be very effective in educating, supporting and
encouraging women to breastfeed for the benefit of both the infant and the mother. Policies
and laws on marketing formula milk and breastmilk substitutes, paid maternity leave, avail-
ability of day care facilities, breastfeeding breaks for employed mothers, should all be enforced.
Workplaces should encourage mothers to breastfeed their infants, and even reward them for
adhering to this practice.

Conclusion
To conclude, this study found that the mothers in Jordan have neutral (attitude was close to
the upper limit of the neutral range) attitude toward breastfeeding. In addition, it revealed the
need for adopting various strategies for stimulating more positive attitude to breastfeeding,
and especially people with low income, to optimize breastfeeding rates in Jordan. Healthcare
professionals at all levels of the health care system must play their vital role in promoting
breastfeeding, starting with prenatal counselling, and ending with immediate postnatal coun-
selling and supporting mothers to initiate breastfeeding their infants. All this in the attempt to
increase to the rates of breastfeeding among women in Jordan. Findings of this study can be
instrumental for health care providers and policy makers in Jordan in their intentional efforts
to boost breastfeeding on the population level.

Supporting information
S1 Dataset.
(SAV)

Acknowledgments
We would like to acknowledge Salameh Halaseh, Murad Haddad and Dima Nasrieh for data
entry, management and cleaning. Also, Bdour Abdallat, Layan Ayesh, and Donia Jaber for
their valuable efforts in data collection.

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PLOS ONE Determinants of breastfeeding attitudes of mothers in Jordan

Author Contributions
Conceptualization: Sireen M. Alkhaldi, Oqba Al-Kuran, Mai M. AlAdwan, Tala A. Dabbah,
Heyam F. Dalky, Eiman Badran.
Data curation: Sireen M. Alkhaldi, Mai M. AlAdwan, Tala A. Dabbah.
Formal analysis: Sireen M. Alkhaldi.
Investigation: Sireen M. Alkhaldi, Oqba Al-Kuran, Heyam F. Dalky, Eiman Badran.
Methodology: Sireen M. Alkhaldi, Oqba Al-Kuran, Heyam F. Dalky, Eiman Badran.
Project administration: Sireen M. Alkhaldi, Oqba Al-Kuran, Mai M. AlAdwan, Tala A.
Dabbah.
Supervision: Sireen M. Alkhaldi, Eiman Badran.
Writing – original draft: Sireen M. Alkhaldi, Mai M. AlAdwan, Tala A. Dabbah, Heyam F.
Dalky.
Writing – review & editing: Sireen M. Alkhaldi, Oqba Al-Kuran, Mai M. AlAdwan, Tala A.
Dabbah, Heyam F. Dalky, Eiman Badran.

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