Midwifery 119 (2023) 103603

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/locate/midw

Which mothers’ breastfeeding behaviours within six weeks

postpartum do health workers need to notice? Developing an
indicator system based on the Delphi method and analytic hierarchy
process
Jing-Ling Wu a, Shu-Qin Pang a, Xiu-Min Jiang b,∗, Qing-Xiang Zheng b, Yan Lin c
a
School of Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
b
Department of Nursing, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
c
Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The six weeks postpartum is the high-incidence period of stopping breastfeeding. The clarity
Received 22 November 2021 of the internal mechanism of behaviour was an effective way to promote breastfeeding. The aim was to
Revised 4 June 2022
reach a consensus on indicators what should be used and prioritised in evaluating mothers’ breastfeeding
Accepted 22 January 2023
behaviour within six weeks postpartum in order to provide a theoretical reference for health workers to
take targeted strategies toward promoting breastfeeding practices.
Keywords: Design: Two rounds of Delphi method and analytic hierarchy process was conducted in this study. The
Mother two-rounds Delphi was performed to select essential indicators and collect revised suggestion. The an-
Breastfeeding alytic hierarchy process was adopted for pairwise comparison to rank the significance of primary and
Behaviour
secondary indicators.
Six weeks postpartum
Setting and participants: The panel included twenty experts with rich breastfeeding information and dif-
Indicators system
ferent general characteristics from China.
Findings: Consensus was achieved to include three primary indicators, seven secondary indicators, and
forty-five tertiary indicators in the final indicators system of the mothers’ breastfeeding behaviour within
six weeks postpartum. The weight sequence of primary indicators was self-regulation behaviour (0.401),
at-the-breast feeding behaviour (0.383), and resource utilisation behaviour (0.216). The rank of the sec-
ondary indicators was breastfeeding operation skills (0.267), self-decision behaviour (0.144), self-control
behaviour (0.130), self-coping behaviour (0.127), breastfeeding self-perception (0.116), resource acquisition
behaviour (0.115), and resource coordination behaviour (0.101).
Key conclusion: The study builds a new and reliable indicators system that intuitively reflects the con-
stituent elements of the mothers’ breastfeeding behaviour within six weeks postpartum and provides
priorities in primary indicators and secondary indicators.
Implications for practices: The study helps form a clear and scientific cognition on mothers’ breastfeeding
behaviour within six weeks postpartum and provides a new perspective and intuitive theoretical refer-
ence for health workers to take targeted measures to promote breastfeeding practices and achieve sub-
stantial public health gains.
© 2023 Elsevier Ltd. All rights reserved.

Introduction ommends that infants should be breastfed exclusively until the

first six months and continuously breastfed for a minimum of
Breastfeeding refers to mothers feed their infant at the two years (McGuire, 2015). However, recent estimates have indi-
breast, which has irreplaceable advantages in reducing infant cated that only 36% of global infants and 20.7% of Chinese infants
mortality, maintaining maternal health and saving healthy costs were exclusively breastfed until six months postpartum, these per-
(Rollins et al., 2016). The World Health Organization (WHO) rec- centages fell substantially short of the WHO global nutrition tar-
get for 2025 that exclusive breastfeeding rate of six-month-old in-
fants should be at least 50% (Duan et al., 2018; Geneva: World
∗
Corresponding author. Health Organization, 2017). The current situation is that breast-
E-mail address: jzc0427@163.com (X.-M. Jiang).

https://doi.org/10.1016/j.midw.2023.103603
0266-6138/© 2023 Elsevier Ltd. All rights reserved.
J.-L. Wu, S.-Q. Pang, X.-M. Jiang et al. Midwifery 119 (2023) 103603

feeding practices in most countries and regions are not optimistic, tions of mothers’ breastfeeding behaviour within six weeks post-
even though breastfeeding is an assertive health-promoting be- partum. Accordingly, this study can provide a theoretical reference
haviour, and numerous policies and resources are proposed to for health workers to formulate targeted strategies towards pro-
promote breastfeeding. Factors influencing breastfeeding are com- moting breastfeeding practices.
plex and multi-dimensional, such as maternal mental and physical
states, social environment, social resources and infant behaviour. Methods
And those factors cause mother with different psychological reac-
tions or feeding actions, ultimately affecting breastfeeding prac- Two rounds of Delphi method and AHP were conducted in this
tices (Kim et al., 2021; Kortsmit et al., 2021; Taut et al., 2016; study to address issues related to mothers’ breastfeeding behaviour
Wake and Mittiku, 2021). That is, mothers are deemed the pri- that health workers should focus on. The Delphi method is a stan-
mary breastfeeding performers, and their role is the integrator and dard forecasting method that achieves consensus amongst a group
explainer for existing external conditions and internal reactions. of experts on an inconclusive issue, and is widely used to develop
Given the critical role of mothers in breastfeeding, this research at- an indicator system (Hooshmand et al., 2019). The reason for Del-
tempts to understand breastfeeding from the perspective of moth- phi’s appeal is its unique advantages, which avoid geographical
ers to address the low breastfeeding rate and short breastfeeding barriers and the dominance of authoritative experts, who collect
duration. extensive information and eventually converge scattered opinions
To be a mother brings extensive changes to women’s life, one (Shawahna et al., 2017). AHP is a general technique used to deal
of which is that they are given the responsibility of feeding their with multi-criteria decision-making problem, and it is constantly
babies after childbirth. In the first weeks and months after deliv- combined with the Delphi method to objectively reflect the im-
ery, mothers need adjust their subjective burden as caregivers and portance of indicators (Shawahna et al., 2017). Four steps were de-
overdraft time and energy for breastfeeding (Feligreras-Alcalá et al., signed to complete the study: organising a research team, building
2021; Xiao et al., 2020). Additionally, women in this new role have the indicator pool, composing the panel of Delphi expert, and im-
to cope with a series of challenges, such as facing health problems, plementing the Delphi expert consultation. Approval was granted
adapting to surrounding changes and transitioning to motherhood, by the medical ethics committee of Fujian Maternity and Children’s
thereby potentially making maternal physical and psychological Hospital [2019–153].
conditions in a vulnerable state (Henshaw et al., 2018). Although
breastfeeding is a natural process, it remains an overwhelming Organising a research team
challenge for new mothers. Wagner et al. (2013) confirmed a
constant high incidence of breastfeeding difficulties in the few The research group had eight members: two tutors, two gradu-
weeks postpartum, and peak incidence rate is up to 92% at three ate nursing students and four nurses specialising in maternal and
days postpartum. Thereafter, breastfeeding difficulties could trig- child healthcare. One tutor was a maternal nursing expert and the
ger some knock-on effects. Initial breastfeeding difficulties result in other was a scale expert. They were jointly responsible for research
mothers becoming lonely, confused or having other negative emo- guidance and inspection. One graduate nursing student conducted
tions. Moreover, mothers could doubt their ability to be a mother, the literature review, drafted the indicator pool, implemented the
feel insecure and hesitant about breastfeeding and eventually cease Delphi expert consultation, collect data and analysed the research
breastfeeding at an early period (Palmér, 2019; Palmér et al., result. Other members assisted in the construction of the indica-
2015; Peacock-Chambers et al., 2017). Brown et al. (2014) con- tor pool and data collection. Group meetings were held to reach a
firmed that 73.6% of mothers stop breastfeeding within the first six consensus on the expert consultation questionnaire and modified
weeks postpartum amongst 500 mothers who stopped breastfeed- programs on expert opinion.
ing before six months postpartum. A previous study in China has
also presented that approximately 67.9% of women stop exclusive Building the indicator pool
breastfeeding within the first six weeks postpartum (J.L. Wu et al.,
2021). Hence, six weeks postpartum, which represents a critical The indicator pool was built as the following process. (1) Con-
and thought-provoking period for breastfeeding, should be a con- cept analysis. Mothers’ breastfeeding behaviours within six weeks
siderable focus in promoting breastfeeding practices. postpartum was understood in two parts: behavioural subject (the
Puerperium is a variable period when all maternal organs re- main responsible person of social stereotype–mother) and be-
cover their pre-gestational state (except the breasts), and gener- havioural object (breastfeeding). The COM-B behaviour model (C:
ally refers to six weeks postpartum (Gómez-Carvajal et al., 2020). capability, O: opportunity, M: motivation, B: behaviour) was used
Mothers with six weeks postpartum are in the transitional period to analyse the general characteristics of breastfeeding behaviours.
for breastfeeding, need to change their original behaviour pattern Maternal role attainment theory and Meleis’s role transitions the-
and form a new behaviour pattern towards adapting the need for ory were used as theoretical bases to understand the breastfeeding
breastfeeding in early motherhood (Tsai and Wang, 2019). The new behaviour form the role of mothers within six weeks postpartum
behaviour pattern is likely to appear later in six months postpar- (Meleis et al., 20 0 0; Mercer, 1985). In our previous research, com-
tum and even in subsequent pregnancy as inherent behavioural bined with the preceding theories and papers, theoretical substruc-
characteristics (Huang et al., 2019). Michie et al. (2011) indicated tion was used to conceptualise. That is, mothers six weeks post-
that implementing evidence-based practice and public health pol- partum exhibited breastfeeding psychological reaction or move-
icy depends on behaviour change, and that the clarity of the in- ment influenced by internal regulation from capability, motiva-
ternal mechanism of behaviour could support a successful change tion and opportunity and external stimulation from the social en-
process. However, to the best of our knowledge, no study has fo- vironment, social resources and infant behaviour. (2) Literature
cused on breastfeeding behaviour within six weeks postpartum review. To further understand mothers’ breastfeeding behaviour
and no consensus has been reached on its essential components. within six weeks postpartum, the following electronic databases
Without clear cognition of mothers’ breastfeeding behaviour in were searched from inception to February 3, 2020: PubMed, Web
puerperium, evaluating or interfering with it will lack direction of Science, Embase, Cochrane Library, Wanfang Database, China Na-
in the future. Therefore, the Delphi method and analytic hierar- tional Knowledge Infrastructure Database, Chinese Scientific Jour-
chy process (AHP) were employed to form, develop and priori- nal Database and Chinese Biomedical Database. The search strat-
tise an indicator system reaching a consensus on the constitu- egy was in the title and abstract fields as follows: (breastfeeding

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J.-L. Wu, S.-Q. Pang, X.-M. Jiang et al. Midwifery 119 (2023) 103603

OR breastfeed OR lactation) and (maternal OR women OR mother) and insight’. Weighted mean of the four options was called judge-
and (postpartum OR primipara OR puerperium) and (behaviour OR ment coefficient (Ca) (Wang et al., 2021). Thirdly, experts’ con-
behaviour). Additionally, breastfeeding as the primary term was tent familiarity was investigated via the question ‘Are you familiar
searched in breastfeeding-related websites, such as WHO, United with this consultation content?’ Five possible responses were pro-
Nations International Children’s Fund, National Health Commission vided, ranging from ‘very familiar’ (5 points) to ‘very unfamiliar’
of the People’s Republic of China, China Health Education Net- (1 point), and their weights were 1.0, 0.8, 0.6, 0.4 and 0.2, respec-
work and Breastfeeding Mums. (3) Drafting the indicator pool. tively (Zhou et al., 2021). Average familiarity degree of all experts
One researcher summarised behavioural characteristics based on was called familiarity coefficient (Cs). The second round of the Del-
the conception and literature review to form the primary indi- phi expert consultation questionnaire included four parts, and the
cators (self-regulation behaviours, resource utilisation behaviours first three parts were similar to the first round. The fourth part was
and at-the-breast feeding behaviours) and their corresponding sec- designed to determine the weights of the primary and secondary
ondary indicators (self-decision behaviours, self-coping behaviours, indicators by hierarchising the importance of the same level indi-
self-control behaviours, resource coordination behaviours, resource cators using the 1 to 9 AHP Saaty scale (Sirakaya et al., 2020). The
acquisition behaviours, breastfeeding operation skills and breast- same level indicators were inserted in each row and column and
feeding self-perception). Tertiary indicators were designed based compared with one another, ranging from 1 (equally important) to
on the preceding findings and existing scales. Thereafter, research 9 (absolutely important).
group meetings were held to modify the drafting indicator pool
until a consensus was reached. Statistical methods

Composing the panel of Delphi expert SPSS 25.0 was used for analysing descriptive statistics. Reliabil-
ity of experts was comprehensively evaluated by expert positivity
The Delphi method is a standard method used to achieve con- coefficient, expert authority coefficient and expert coordination de-
sensus on inconclusive issues. This method was used in this study gree. Questionnaire response rate expressed the expert positivity
to develop the indicator system of breastfeeding behaviour of coefficient, and over 70% was considered high. Authority coefficient
mothers within six weeks postpartum (Shawahna, 2017). Selec- (Cr) was the mean of Ca and Cs, and the panellists had excellent
tion of qualified panellists was vital in ensuring the validity of the authority when Cr was above 0.7 (Wang et al., 2021). Expert co-
Delphi expert consultation (Okoli and Pawlowski, 2004). Experts ordination degree was judged using coefficient of variation (CV)
should fulfil the following inclusion criteria: (1) possessing a senior and Kendall’s W consistency coefficient. Expert coordination was
professional title or master’s degree or above; (2) over five years of acceptable when the CV value was below 0.25, and the result of
practising, teaching, or managing experience; (3) possessing prior Kendall’s W was P < 0.05 (Field, 2005; Y. Wu et al., 2021). After
knowledge of maternal and child nursing and (4) volunteering to identifying that the experts were reliable, indicators were screened
participate in at least two rounds of expert consultations. Poten- using the following criteria: (1) total score rate > 0.20, (2) mean of
tial experts who meet the first three criteria were contacted with importance score ≥ 3.50 and (3) CV < 0.25 (Y. Wu et al., 2021).
an initial introduction of the study aims, significance of the study If any of the preceding criteria was not met, then the research
and their responsibilities. Moreover, experts who agreed were in- group would combine the experts’ suggestions and clinical prac-
vited to participate in this panel. With reference to previous stud- tice to make the final decision on whether or not an item was ex-
ies (Okoli and Pawlowski, 2004; Parker et al., 2020), 20 experts en- cluded. AHP was conducted to determine the significance of pri-
roled to become panellists in this study. mary and secondary indicators assessing mothers’ breastfeeding
behaviour within six weeks postpartum. The software of Yaahp
Implementing the Delphi expert consultation 12.5 was used to build a hierarchical analysis structure, construct a
judgement matrix, obtain weights value and calculate consistency
Expert consultation questionnaires were individually delivered ratio (CR). If the CR value was below 0.1, then it was considered
via e-mail to the panel members of the Delphi expert consulta- that the experts’ judgements was logically sound (Saaty, 1994).
tion, and panellists did not know one another. The research group
summarised and analysed the experts’ feedback when all ques- Findings
tionnaires were completed in this round. Indicators achieving pre-
established retention criteria were reserved or revised to form the Characteristics of experts
following expert consultation questionnaire. Thereafter, the new
questionnaire was distributed, and the time interval for each round A total of 20 experts from Beijing, Fujian and Hubei provinces
was two weeks. The process was repeated until the expert opin- in China were invited to the Delphi expert panel, and 17 experts
ions are coordinated. In this study, two-round Delphi expert con- eventually completed two-round expert consultations. The panel-
sultations were conducted from February 2020 to April 2020. The lists were all women from different age groups and had different
first-round consultation questionnaire included three sections. (1) work experiences, academic degrees and professional titles in spe-
Introduction of the present study: Background, significance, pur- cialised variable fields incorporated into maternity care, paediatric
pose, theoretical model and concept were introduced. (2) Semi- care, nursing management and nursing education. A total of 12
open consultation form: A 5-point Likert scale was used to as- experts worked in clinical settings, including clinical nursing and
sess the importance of all level indicators, from ‘very important’ nursing management. One expert has a certification as a lactation
(5 points) to ‘very unimportant’ (1 point). Moreover, correspond- consultant, 10 experts have professional experience at the mater-
ing blank areas behind each indicator were given for suggest- nity ward for >20 years and another expert was invited to pro-
ing experts’ decisions and recommendations as necessary. (3) Ex- vide the perspective of a paediatric nurse. Additionally, five experts
pert authority form: Firstly, expert’s general information and work- were engaged in maternity education, consisting of authoritative
ing details were investigated, such as gender, age, education level, experts (e.g. professional experience teaching maternity nursing
working years and major fields. Secondly, experts were invited to for >20 years) and middle-aged experts (e.g. professional experi-
provide the influence degree amongst the three options of ‘large, ence teaching maternity nursing for >5 years), thereby ensuring
medium and small’ when they made important judgements based a combination of authority and foresight. The experts’ mean age
on ‘theoretical analysis, practical experience, peer understanding was 44.71 years (SD = 6.58), ranging from 32 to 59 years. Their

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Table 1
The Characteristics of experts completed two-rounds consultation.

Items Total experts (N = 17) Items Total experts (N = 17)

Gender Work experience (years)

Female 17 (100.00%) 5∼15 3 (17.65%)
Male 0(0.00%) 16∼29 11 (64.71%)
Age (years) >30 3 (17.65%)
30∼39 4 (23.53%) Academic degree
40∼49 11 (64.71%) Ph.D. 3 (17.65%)
≥50 2 (11.76%) Master 4 (23.53%%)
Major fields Bachelor 10 (58.82)
Maternity care 6 (35.29%) Job title
Paediatric care 1 (5.89%) Senior 5 (29.41%)
Nursing education 5 (29.41%) Associate senior 8 (47.06%)
Nursing management 5 (29.41%) Intermediate 4 (23.53%)

mean working experience years was 22.47 years (SD = 6.58), with indicators was modified. Eventually, the formal indicator system
a range of 5 to 36 years. Amongst them, 7 experts (41.18%) hold was formed, including three primary, seven secondary, and forty-
master’s degrees or above, and 13 experts (76.47%) hold titles of five tertiary indicators (see Table 2).
associate senior or higher. The detailed general characteristics are
presented in Table 1. Final indicator system with weights

Reliability of the Delphi expert panel Weight values and significant ranks of the primary and sec-
ondary indicators according to the AHP model are presented
In the first round, 17 valid questionnaires were returned in 20 in Table 3. In the primary indicators, weight sequence was
questionnaires, with a response rate of 85.0%. In the second round, self-regulation behaviour (0.401), at-the-breast feeding behaviour
17 questionnaires were e-mailed with a response rate of 100%. (0.383) and resource utilisation behaviour (0.216). The combined
Moreover, 14 experts presented professional revision recommen- weight rank of the secondary dimensions was breastfeeding op-
dations during the two-round consultations. After calculation, the eration skills (0.267), self-decision behaviour (0.144), self-control
Ca, Cs and Cr values of 17 experts were 0.95, 0.92 and 0.93, re- behaviour (0.130), self-coping behaviour (0.127), breastfeeding self-
spectively. In the first round, the range of CV values was 0.00 to perception (0.116), resource acquisition behaviour (0.115) and re-
0.31, and 4 tertiary indicators were over 0.25. In the second round, source coordination behaviour (0.101). CR values of all judgement
all CV values of the primary-, secondary- and tertiary indicators matrices involved in this study were calculated. CR values of 17 ex-
were below 0.25. The two-round Kendall’s W consistency coeffi- perts’ original judgement matrices were between 0.0 0 0 and 0.071,
cients were 0.217 and 0.235 (P < 0.001). and CR values for the assembled judgement matrices were be-
tween 0.0 0 0 and 0.0 02, which falls in the acceptable range.
Indicator screening and revision
Discussion
The indicators pool had 3 primary indicators, 7 secondary indi-
cators and 45 tertiary indicators. In the first round, the full score In the present study, an indicator system for evaluating moth-
rates for the primary-, secondary- and tertiary indicators range ers’ breastfeeding behaviour within six weeks postpartum was
from 52.94% to 76.47%, 58.82% to 76.47% and 35.29% to 10 0.0 0%, firstly built using the Delphi method, compared pairwise thereafter
respectively. Means of the importance scores for the primary-, and ranked the significance of the same level on the AHP model.
secondary- and tertiary indicators varied from 4.29 to 4.76, 4.35 to This section discusses the reliability of the building indicator sys-
4.88 and 4.06 to 5.00, respectively, with CV values of 0.09 to 0.19, tem, explains the possible reason for indicators that obtain the cor-
0.07 to 0.19 and 0.00 to 0.31, respectively. Four tertiary indicators, responding ranking in each of the domains and presents implica-
namely, ‘Stopping breastfeeding when experiencing problems’, ‘Some- tions of promoting breastfeeding practices in the future.
times do breastfeeding risk things’, ‘Not bear the hardship of breast-
feeding’ and ‘Breastfeeding made life worse’, were deleted because Reliability of building indicator system
the CV values were 0.26, 0.27, 0.27 and 0.31, respectively, which
were over 0.25. Moreover, 14 experts posed their specific questions A scientific indicator pool is a foundation for forming a reliable
and modified suggestions for tertiary indicators. Lastly, combining indicator system. In this study, it was built depending on a specific
the experts’ recommendations and research group discussions, 11 conceptual model developed by in-depth theoretical analysis and
tertiary indicators were revised, 5 tertiary indicators were added extensive literature review of authoritative opinions from official
and 2 tertiary indicators were merged into one to form an up- websites. These extensive and reliable information sources ensure
graded version of the indicator system, which includes 3 primary, that the researcher had a systematic and profound understanding
7 secondary and 45 tertiary indicators. In the second round, the of mothers’ breastfeeding behaviour within six weeks postpartum.
full score rates for the primary-, secondary- and tertiary indica- Meanwhile, individuals with adequate experience on breastfeeding
tors ranged from 58.82% to 10 0.0 0%, 58.82% to 88.24% and 47.06% or scale development were selected as members of the research
to 10 0.0 0%, respectively. Means of the importance scores for the group to revise the manuscript of the indicator pool. Hence, the
primary-, secondary- and tertiary indicators varied from 4.35 to drafter’s limitation had the opportunity to be corrected by other
4.82, 4.35 to 4.88 and 4.35 to 5.00, respectively, with CV values members. In the Delphi consultation stage, 17 experts completed
of 0.08 to 0.19, 0.07 to 0.19 and 0.00 to 0.26, respectively. All indi- two-round questionnaires, of which 76.47% of the experts hold an
cators met the remaining criteria, and no indicators needed to be associate senior professional title or higher, and 41.18% of them
deleted, added or merged. Five experts suggested revised sugges- hold master’s degree or above, indicating the good academic au-
tions, and the equivocal or ambiguous expression in eight tertiary thority of this expert panel. Additionally, all experts had exten-

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Table 2
The indicator pool of mothers’ breastfeeding behaviour within six weeks postpartum.

Primary indicators Secondary indicators Tertiary indicators

Self- Self-decision behaviour 1 Breastfeeding for health

regulation 2 Breastfeeding for enhancing mother-child relationship
behaviour 3 Breastfeeding for other expectations
4 Expecting breastfeeding
5 Confident of exclusive breastfeeding within 42 days
6 Planning exclusive breastfeeding to 6 months
Self-coping behaviour 7 Making adequate preparation
8 Self-encouragements
9 Seeking solutions for breastfeeding problems
10 Continuing feeding when experiencing problem
11 Accepting breastfeeding in the public place
Self-control behaviour 12 Having the ability to control negative emotions
13 Paying attention to diet
14 Paying attention to lifestyle
15 Adjusting sleep patterns for uninterrupted breastfeeding
16 Receiving breastfeeding restricts freedom
17 Body changes do not affect continued breastfeeding
Resource Resource coordination behaviour 18 Asking for external help proactively
util- 19 Expressing demands objectively and accurately
i- 20 Expressing gratitude to people who helped me
sa- 21 Coordinating conflicts from surroundings
tion 22 Considering the reliability of the information
behaviour Resource acquisition behaviour 23 Someone to help with child care or household chores
24 Demands can be timely and effective responses
25 Someone to take responsibility for breastfeeding together
26 Breastfeeding decision was respected and affirmed
27 Family and friends helped me encounter breastfeeding problems

Primary indicators Secondary indicators Tertiary indicators

At-the-breast feeding behaviour Breastfeeding operation skills 28 Be able to recognise signs of infant hunger
29 Aligning the tip of the baby’s nose at my nipple
30 The body of the baby faced and closed me
31 The head of baby and body into a straight line
32 Supporting the baby’s whole body well
33 Supporting the breast with a C-shape
34 Most of the areola was contained in the mouth
35 Feeling gentle and regular swallowing movement
36 Slow and rhythmic sucking after a few quick sucking
37 Breastfeeding position is comfortable and relaxing
Breastfeeding self-perception 38 No nipple pain or other discomfort
39 Relaxed during breastfeeding
40 Good cooperation with baby
41 Baby was satisfied and sleepy after breastfeeding
42 Breastfeeding made baby gain a healthy weight
43 Sufficient milk to meet baby demand
44 Enough energies to breastfeed
45 Breastfeeding made me feel like a good mother

Table 3
The weight for indicators system of breastfeeding behaviour of mothers within six weeks postpartum.

Primary indicators Secondary indicators

Name Weight Rank Name Weight Combined weight Rank

Self-regulation behaviour 0.401 1 Self-decision behaviour 0.359 0.144 2

Self-coping behaviour 0.318 0.127 4
Self-control behaviour 0.324 0.130 3
At-the-breast feeding 0.383 2 Breastfeeding operation skills 0.696 0.267 1
behaviour Breastfeeding self-perception 0.304 0.116 5
Resource utilisation 0.216 3 Resource coordination behaviour 0.469 0.101 7
behaviour Resource acquisition behaviour 0.531 0.115 6

sive information on breastfeeding and engaged in different mater- fessional recommendations, which confirmed that they had high
nal and child nursing research, including postpartum nursing, mid- positivity from another perspective. The Cr value of expert consul-
wife, breastfeeding health education and paediatric nursing. Such a tation was 0.93, which was above 0.7, indicating that the experts
background ensured that the panellists could propose constructive had high certainty to the research content in this study. Kendall’s
suggestions from different departments and angles. W consistency coefficient test showed proper coordination in the
The experts’ reliability is expressed in terms of their positiv- two-round experts’ consultation (P < 0.001). CV values of all indi-
ity, authority and coordination. Both response rates of two-round cators did not reach the retention standard until the second round,
expert consultation were over 70%, reflecting the experts’ positive indicating that there was initial disagreement amongst experts, al-
attitude towards this study. Moreover, most experts proposed pro- though a consensus was eventually achieved in the second round.

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In the AHP stage, CR values of all judgement matrices were below feeding self-perception were favourable conditions. Additionally,
0.1. That is, consistency on weight allocation is high and the result resource acquisition and resource coordination behaviours were es-
is reliable. sential supplements to promote best breastfeeding practices for
mothers within six weeks postpartum.
Ranking of indicators’ weight
Implications and limitation
AHP is a multi-criteria decision-making method, which was of-
ten resolved with the Delphi expert consultation to determine the
Comprehensive and practical support requires clear and scien-
priority of the indicators system because the combination could
tific cognition of mothers’ breastfeeding behaviour in the puer-
involve quantitative and qualitative analysis. In the primary indi-
perium. If not integrated with inner essence, then current breast-
cators, self-regulation behaviour has the highest weight, which is
feeding issues on puerperium were hardly addressed in the tar-
considered the behaviour of resolving and balancing the incom-
get measures. The present study builds a new indicator system
patibility by themselves between the current situation and the
that intuitively reflects the constituent elements and their priority
breastfeeding goal in this study. That is, maternal subjective initia-
in evaluating mothers’ breastfeeding behaviour within six weeks
tive on achieving breastfeeding goals was the necessary condition
postpartum. This system provides a new perspective and theoret-
for achieving breastfeeding. Puerperium is a transitional period for
ical reference for health workers to promote optimal breastfeed-
breastfeeding practice, thereby placing mothers in a complicated
ing practices and achieve substantial public health gains. In clinical
and volatile situation. Mothers are leading implementers of breast-
practice, more integrated and coherent health education courses,
feeding, and their ability or willingness to make positive adjust-
continuous care programs and intervention programs for promot-
ments and reactions is associated with breastfeeding success when
ing mothers’ breastfeeding behaviour within six weeks postpartum
they face changes and challenges (Tsai and Wang, 2019). If moth-
could be designed by breastfeeding educators, nurses, midwives or
ers did not manage to regulate their behaviour accordingly, then
community health workers based on the present study. Meanwhile,
negative situations would happen, such as perceiving role pressure,
priority could be appropriately allocated when making the sup-
producing anxiety, feeling privacy invasion or being unwilling to
porting plan, and high-weight behaviours should be preferentially
breastfeed at night, any of which could be a reason why mothers
considered when time and conditions are limited.
eventually give up breastfeeding (Gila-Díaz et al., 2020; Lau et al.,
We also acknowledge that some limitations should be consid-
2017; Rosen-Carole et al., 2018; Shepherd et al., 2017). The second
ered in this study. Firstly, although the Delphi method is a com-
score pertains to at-the-breast feeding behaviour, which is defined
mon method to determine an indicator system, it has inherent
as mothers’ breastfeeding skills and relational psychological reac-
limitations in presenting a thorough scientific study to obtain ad-
tion in the current study. Mothers are likely to successfully and
ditional sufficient data. Secondly, in the AHP stage, priority was
sustainably breastfeed their infants when they have adept breast-
formed on the bases of opinions from invited experts. Undeniably,
feeding skills and positive psychological reactions to breastfeeding
different experts could obtain different results, thereby reflecting
(Senna et al., 2020; Lau et al., 2015). Weight of resource utilisa-
the preferences of the expert panel only. Thirdly, although the for-
tion behaviour was ranked third, in which mothers uses available
mation of indictors was based on theoretical analysis and literature
resources in their social network to achieve the breastfeeding goal
review with repeating revisions by research and expert groups, its
in this study. Using resources effectively in the information explo-
weaknesses in terms of comprehensiveness and authority in ob-
sion society is essential, which is no exception for mothers deal-
tained knowledge compared to form indictors directly based on
ing with breastfeeding issues. Previous studies have shown that
existing paradigms. Given these limitations, if there are more ma-
mothers could receive breastfeeding knowledge, decision-making,
ture conditions, then more rigorous research should be designed
practical or emotional support from their social support network,
to overcome the inherent limitations of the Delphi method. Alter-
which is an essential guarantee for breastfeeding (Emmot et al.,
natively, the scope and scale of Delphi expert consultation could
2020; Sherriff et al., 2014; Wallenborn et al., 2019).
be expanded to further improve representation in subsequent re-
In the secondary indicators, the combined weight of breastfeed-
search. Evaluation process of the relative significance of indicators
ing operation skills was ranked first, indicating that breastfeed-
has to be re-performed when the objective participants and indi-
ing operation skills were the vital part of achieving breastfeed-
cators’ structures change. Paradigms should be evolved as the im-
ing. This outcome was consistent with the emphasis on teaching
provement of the research results on mothers’ breastfeeding be-
breastfeeding skills in China. Self-decision behaviour was ranked
haviours within six weeks postpartum to provide more robust ref-
second, revealing that mothers as the main body of breast-
erences for decision makers.
feeding were essential for breastfeeding decision-making, simi-
lar to Kuswara et al. (2020). Self-control behaviour was ranked
third, expressing that new behaviours formed by adjusting ac- Conclusion
tions and emotions were conducive to breastfeeding promotion
(Iacovou et al., 2020). Self-coping behaviour was ranked fourth, A study combining the Delphi method and AHP was used to
showing that mothers’ active coping behaviour was key to con- construct a new and reliable indicator system that intuitively re-
tinuing breastfeeding when experiencing breastfeeding difficulties flects the constituent elements of mothers’ breastfeeding behaviour
(Lucchini et al., 2017). The rank of breastfeeding self-perception within six weeks postpartum and provides priorities in primary in-
was fifth, which was mothers’ direct feedback on breastfeeding. dicators and secondary indicators. The result of this study helps
The negative self-perception will hinder mothers’ breastfeeding form a clear and scientific cognition and provides a new per-
plans (Morns et al., 2021; Yate, 2017). The ranks of resource acqui- spective and intuitive theoretical framework for health workers
sition and resource coordination behaviours were sixth and sev- to improve breastfeeding practices by more targeted interventions
enth, respectively, implying that mothers’ availability and coor- for mothers within six weeks postpartum in future clinical study.
dination for resources were the support helping mothers solve Lastly, further research is needed to better gather information
breastfeeding problems (Demirci et al., 2018). Overall, importance from mothers within six weeks postpartum, thereby understanding
ranking of indicators was similar to the research assumptions. the validity and reliability of the indicator system and developing
Breastfeeding operation skill was the basis, and self-decision be- strategies related to mothers’ breastfeeding behaviour within six
haviour, self-control behaviour, self-coping behaviour and breast- weeks postpartum to solve breastfeeding problems.

6
J.-L. Wu, S.-Q. Pang, X.-M. Jiang et al. Midwifery 119 (2023) 103603

Ethical approval Henshaw, E.J., Cooper, M.A., Jaramillo, M., Lamp, J.M., Jones, A.L., Wood, T.L., 2018.
"Trying to figure out if you’re doing things right, and where to get the info":
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jian Maternity and Child Health Hospital [YCXMH20-03] and Inno- Kortsmit, K., Li, R., Cox, S., Shapiro-Mendoza, C.K., Perrine, C.G., D’Angelo, D.V.,
vation and Entrepreneurship Training Program for College Students Barfield, W.D., Shulman, H.B., Garfield, C.F., Warner, L., 2021. Workplace leave
in Fujian Province [202010393021]. and breastfeeding duration among postpartum women, 2016-2018. Am. J. Pub-
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measurement properties of the Chinese breastfeeding self-regulation question-
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the first manuscript, and is the first author of the final manuscript my baby: unvealing the experiences of women who lived process difficulties
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Declaration of Competing Interest Morns, M.A., Steel, A.E., Burns, E., McIntyre, E., 2021. Women who experience feel-
ings of aversion while breastfeeding: a meta-ethnographic review. Women Birth
34, 128–135. doi:10.1016/j.wombi.2020. 02.013.
The authors declare that they have no known competing finan- Okoli, C., Pawlowski, S.D., 2004. The Delphi method as a research tool: an exam-
cial interests or personal relationships that could have appeared to ple, design considerations and applications - ScienceDirect. Inform. Manag. 42,
15–29.
influence the work reported in this paper.
Palmér, L., 2019. Previous breastfeeding difficulties: an existential breastfeeding
trauma with two intertwined pathways for future breastfeeding-fear and long-
Acknowledgements ing. Int. J. Qual. Stud. Health Well-being 14, 1588034. doi:10.1080/17482631.
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Palmér, L., Carlsson, G., Brunt, D., Nyström, M., 2015. Existential security is a
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study for their valuable suggestions. ties: a lifeworld hermeneutical study. Int. Breastfeed J. 10, 17. doi:10.1186/
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