An-Najah National University 

Faculty of Graduate Studies 

 

PSYCHOLOGICAL FACTORS, ATTITUDES, 

AND BEHAVIORS OF NURSING MOTHERS 

TOWARD EXCLUSIVE BREASTFEEDING: A 

CROSS-SECTIONAL STUDY 

 

 

By 

Esra’ Mahdi Mahmoud Sawalha 

 

 

 

Supervisors 

Dr. Adnan Sarhan 

Dr. Nihal Natour 

 

 

This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of 

Master of Community Mental Health Nursing, Faculty of Graduate Studies, An-Najah 

National University, Nablus - Palestine. 

2023 





III 

 

Dedication 

TO THE SNOWSTORM 

A special feeling of gratitude to my loving parents "Mahdi and Nahawat," my 

brothers "Yazan, Abdullah, and Bashar," and many friends especially “Ola Abu Zant”, 

who have never left my side and are very special to me, my best supporters. 

This thesis is dedicated to my dear uncle "Ali," who has meant and still means so much 

to me. My beloved uncle's memories still govern my life, even if he has passed away. 

 

Finally, to the people I hold in my heart. 

  



IV 

 

Acknowledgements 

Many thanks to the countless precious people who supported me to get my master's 

degree. They stood with me by their beautiful words, warm hearts, honest prayers, and 

deepest wishes of good luck to me. 

I would like to thank my supervisor, Dr. Adnan Sarhan, who has a pure soul and a warm 

heart for his efforts 

Many thanks to my co-supervisor, Dr. Nihal Natour, and to the defense committee 

members. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 





VI 

 

Table of Contents 

Dedication ....................................................................................................................... III 

Acknowledgements ......................................................................................................... IV 

Declaration ....................................................................................................................... V 

Table of Contents ............................................................................................................ VI 

List of Tables .................................................................................................................. IX 

List of Figures .................................................................................................................. X 

List of Appendices .......................................................................................................... XI 

Abstract ............................................................................................................................ X 

Chapter One: Introduction ................................................................................................ 1 

1.1 Overview .................................................................................................................... 1 

1.2 Conceptual and theoretical definitions ...................................................................... 4 

1.2.1 Postpartum period .................................................................................................... 4 

1.2.2 Exclusive breastfeeding ........................................................................................... 4 

1.2.3 Complementary feeding .......................................................................................... 4 

1.2.4 Formula feeding ...................................................................................................... 5 

1.2.5 Breastfeeding attitudes ............................................................................................ 5 

1.2.6 Breastfeeding behaviors .......................................................................................... 5 

1.3 Aim of the study ........................................................................................................ 5 

1.3.1 Objectives ................................................................................................................ 5 

1.4 Problem statement ..................................................................................................... 6 

1.5 Significance of the study ........................................................................................... 6 

1.6 Research questions ..................................................................................................... 7 

1.7 Hypotheses of the study ............................................................................................. 7 

Chapter Two: Literature Review ...................................................................................... 8 

2.1 Literature Review ...................................................................................................... 8 

2.1.1 Sociodemographic and EBF .................................................................................... 8 

2.1.2 Attitudes and behaviors ........................................................................................... 9 

2.1.3 Psychological factors ............................................................................................. 11 

2.1.4 Factors influencing EBF ........................................................................................ 12 

2.1.5 EBF in Palestine .................................................................................................... 14 

Chapter Three: Methodology .......................................................................................... 15 

3.1 Study design ............................................................................................................. 15 



VII 

 

3.2 Study population ...................................................................................................... 15 

3.3 Site and setting ......................................................................................................... 15 

3.4 Study time table ....................................................................................................... 16 

3.5 Sample size and sampling methods ......................................................................... 16 

3.5.1 Sample size ............................................................................................................ 16 

3.5.2 Sampling method ................................................................................................... 16 

3.6 Inclusion and Exclusion Criteria ............................................................................. 17 

3.6.1 The nursing mother should be ............................................................................... 17 

3.6.2 The following nursing mother were excluded ....................................................... 17 

3.7 Data collection process ............................................................................................ 17 

3.7.1 Study instruments .................................................................................................. 18 

3.7.1.1 Sociodemographic data ..................................................................................... 18 

3.7.1.2 Depression Anxiety Stress Scale-21 (DASS-21) .............................................. 18 

3.7.1.3 Breastfeeding Behavior Questionnaire (BBQ) ................................................. 19 

3.8 Variables .................................................................................................................. 20 

3.9 Data analysis ............................................................................................................ 20 

3.10 Ethical Consideration ............................................................................................... 20 

Chapter Four: Results ..................................................................................................... 21 

4.1 Sociodemographic data ............................................................................................ 21 

4.2 Prevalence of depression, anxiety and stress among nursing mothers .................... 23 

4.3 Ordinal logistic regression of the variables predicting depression .......................... 25 

4.4 Ordinal logistic regression of the variables predicting anxiety ............................... 25 

4.5 Ordinal logistic regression of the variables predicting stress .................................. 25 

4.6 Ordinal logistic regression of the variables predicting anxiety ............................... 27 

4.7 Ordinal logistic regression of the variables predicting stress .................................. 28 

4.8 Prevalence of positive and negative attitudes and behaviors toward exclusive 

breastfeeding ................................................................................................................... 30 

4.9 Logistic regression analysis of the association of attitudes and behaviors with the 

demographic characteristics for nursing women ............................................................ 31 

4.10  Discussion ............................................................................................................... 33 

4.11  Conclusion .............................................................................................................. 41 

4.12  Recommendations ................................................................................................... 42 

4.13  Strength of the study .............................................................................................. 44 



VIII 

 

4.14  Limitations of the study .......................................................................................... 45 

List of Abbreviations ...................................................................................................... 46 

References ....................................................................................................................... 47 

Appendices ...................................................................................................................... 61 

 ب ............................................................................................................................... الملخص 

 

 

  



IX 

 

List of Tables 

Table 1: Prevalence of sociodemographic data among nursing mothers ........................ 23 

Table 2: Prevalence of depression, anxiety and stress among nursing mothers ............. 24 

Table 3: Ordinal logistic regression of the variables predicting depression, anxiety, and 

stress (N = 368): ............................................................................................... 26 

Table 4: Ordinal logistic regression of the variables predicting anxiety (N = 368) ....... 28 

Table 5: Ordinal logistic regression of the variables predicting stress (N = 368) .......... 29 

Table 6: Prevalence of positive and negative attitudes and behaviors toward EBF ....... 30 

Table 7: Logistic regression of the association of attitude and behaviors with the 

demographic characteristics for nursing women: ............................................. 32 

 

 

 

 

 

 

 

 

 

 

 

 



X 

 

List of Figures 

Figure 1: Prevalence of depression, anxiety, and stress among nursing mothers ........... 24 

Figure 2: Prevalence of positive and negative attitudes and behaviors toward EBF ...... 30 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



XI 

 

List of Appendices 
Appendix A: Time Table ................................................................................................ 61 

Appendix B: Budget ....................................................................................................... 62 

Appendix C: Informed Consent ...................................................................................... 63 

Appendix D: Questionnaire in English ........................................................................... 64 

Appendix E: DASS-21 Scale in English ......................................................................... 65 

Appendix F: BBQ in English .......................................................................................... 67 

Appendix G: Questionnaire in Arabic ............................................................................ 70 

Appendix H: Arabic version of DASS-21 scale ............................................................. 71 

Appendix I: Arabic version of BBQ ............................................................................... 72 

Appendix J: Permission from the author to use BBQ ..................................................... 74 

Appendix K: IRB Approval ............................................................................................ 75 

Appendix L: IRB Certificate ........................................................................................... 76 

Appendix M: PMoH approval ........................................................................................ 77 

Appendix N: Key analysis of scales ............................................................................... 78 

 

 

 



X 

 

PSYCHOLOGICAL FACTORS, ATTITUDES, AND BEHAVIORS 

OF NURSING MOTHERS TOWARD EXCLUSIVE 

BREASTFEEDING: A CROSS-SECTIONAL STUDY 

By 

Esra’ Mahdi Mahmoud Sawalha 

Supervisors 

Dr. Adnan Sarhan 

Dr. Nihal Natour 

Abstract 

Background: According to the World Health Organization (WHO), EBF could save the 

lives of almost 220,000 children each year. The WHO recommends exclusively nursing 

newborns for the first six months of their lives.  

Aim: This study was intended to assess how psychological factors, attitudes, and 

behaviors influencing exclusively breastfeed among nursing mothers. 

Methods: A quantitative, cross-sectional study was conducted in the northern West Bank 

of Palestine at the maternal and child health clinics of the PMoH. A convenience sample 

used among 368 participants. A self-reported survey used, including the Arabic versions 

of the Depression and Anxiety Stress Scale (DASS-21) and the Breastfeeding Behavior 

Questionnaire (BBQ). The Statistical Package for Social Sciences (SPSS) version 24 was 

used for analysis.  

Results: A total of 368 participants responded and were included. The prevalence rates 

of postpartum depression, anxiety, and stress were 50.8%, 59.8%, and 68.5%, 

respectively. The current infant’s age between 2 and 4 months (P = 0.03, OR = 1.66, CI: 

1.03, 2.67) had a significant association with depression toward EBF among nursing 

mothers, as well as anxiety (P = 0.00, OR = 2.12, CI = 1.33, 3.39). The husbands between 

31 and 40 years old, mean age 35.5 years old, had a higher odd of having stress (P = 0.04, 

OR = 2.13, CI: 1.01, 4.49), same for mothers of less than 50 kg (P = 0.04, OR = 0.19, CI: 

0.19, 0.95). Also, 76.1% of the participants had negative attitudes and behaviors. Both of 

monthly incomes of less than $500 and between $500 and $800, and nursing mother age 

less than 18 years old had a significant association between EBF attitudes and behaviors 



XI 

 

(P = 0.01, OR = 0.82, CI: 0.71, 0.95, P = 0.02, OR = 0.85, CI: 0.74, 0.98, P = 0.00, OR = 

7.26, CI: 3.88, 13.60, respectively). 

Conclusion: The study revealed significant postpartum psychological problems among 

Palestinian nursing mothers, accompanied by unfavorable attitudes and behaviors 

towards EBF.  

Recommendations: Implementing the DASS-21 and the BBQ in PMoH clinics is 

strongly advised. Further researches is necessary to identify the factors contributing to 

these concerning findings. 

Keywords: Psychological factors, Anxiety, Depression, Stress, Exclusive Breastfeeding, 

Breastfeeding, EBF, Breastfeeding, BF, Attitudes, Behaviors, Palestine, Nablus. 





1 
 

Chapter One 

Introduction 
1.1 Overview 

Breastfeeding has a significant advantage for both the mother's and the baby's health 

(Stuebe, 2009). Accordingly, the World Health Organization (WHO) recommends six 

months of exclusive breastfeeding for all newborns and that they continue breastfeeding 

for at least two years with complementary breastfeeding (Lyons et al., 2018). Similarly, 

breastfeeding is recommended by both the Academy of Family Physicians (AAFP) 

(Stenchover, 2007) and the American Academy of Pediatrics (AAP) during at least the 

first year of a baby's life (Stuebe, 2009). 

Also, the WHO recommends that all newborns have six months of exclusive nursing and 

then continue breastfeeding for at least two years with complementary breastfeeding 

(Lyons et al., 2018). It is the process of feeding a baby food after six months of age 

because breastfeeding is insufficient and the baby needs more nutrition (Abeshu et al., 

2016). Between six months and 23 months is the optimal age for complementary feeding, 

and as the infant gets older and more nutritionally dependent, the need for it increases 

(Dewey, 2001). 

Although every mother's pregnancy and delivery experience different and unique phases 

(Namujju et al., 2018), but they are also brimming with psychological, physical, and 

social changes (Brockington, 2004; Machado et al., 2014). As a result, these alterations 

are strongly linked to psychological factors, leaving women more susceptible to 

depressive, anxiety, and stress disorders (Ahmadpour et al., 2023). The presence of these 

psychological symptoms negatively affects exclusive breastfeeding (De Jager et al., 2014; 

Jalal et al., 2017; Machado et al., 2014). 

Depression (sadness feelings affect feelings, thinking, and daily activity (National 

Institute of Mental Health, 2023)), which is estimated to affect from 10% to 15% of all 

postpartum mothers (Abdollahi et al., 2011), is marked beside anxiety and stress to 

influence the process of exclusive breastfeeding (Hurley et al., 2008).  

Pregnancy-related anxiety (discomfort, such as concern or fear, that can range from mild 

to severe, according to (Weisberg, 2009)) or distress is a discrete and identifiable 



2 
 

syndrome marked by increased fears or concerns about characteristics of pregnancy that 

are unique to it (e.g., medical treatment, physical symptoms, bodily changes, newborn 

health) (Blackmore et al., 2016). Accordingly, pregnancy-related anxiety showed that it 

impacts exclusive breastfeeding at weeks 6–8 postpartum (Horsley et al., 2019). 

Psychosocial factors (factors that influence or emerge in a person's mind) (Brazier, 2018) 

are expected to have a key role in ensuring breastfeeding exclusively for the first six 

months after birth (De Jager et al., 2014). Moreover, the duration (nursing over an 

extended period of time), initiation (starting breastfeeding early after birth), and 

exclusivity of breastfeeding are significantly linked with psychological aspects such as 

breastfeeding self-efficacy, proclivity optimism, belief in breastmilk, breastfeeding 

anticipations, anxiety, anticipated breastfeeding duration, and the decision related to the 

infant’s feeding time (O'Brien et al., 2008). 

Women with psychosocial problems, anxiety, or depression are more likely to experience 

a cessation of breastfeeding, and they need support to continue exclusive breastfeeding 

(Sharifi et al., 2016). Also, hormonal changes, psychological adjustment to parenting, and 

exhaustion may all play a role (Abdollahi et al., 2011). 

Likewise, postpartum psychological adjustment (the process of behavior by individuals 

that maintains a balance between their needs and the obstacles of the environment) (Asadi 

et al., 2020), early breastfeeding difficulties, support, increasing self-efficacy, and 

knowledge (Lyons et al., 2018) have also been reported to be important determinants of 

exclusive breastfeeding duration and intention (De Jager et al., 2014). Positive support 

perceptions have been shown to significantly influence adaptive maternal behavior, the 

transition to parenthood, and postpartum health (Hung & Chung, 2001).  

Prenatal interventions that aim to promote the duration of exclusive breastfeeding may 

benefit from the inclusion of strategies that assist in alleviating the anxieties and concerns 

that arise with being pregnant (Horsley et al., 2019). Therefore, this indicates the 

importance of psychological factors for improving breastfeeding behaviors. 

Breastfeeding, on the other hand, is a complex behavior impacted by a number of 

circumstances, including the mother's and the newborn's traits, healthcare systems, and 

family, community, and professional support (Gallegos et al., 2020). Non-modifiable and 



3 
 

modifiable determinants of breastfeeding include maternal age, socioeconomic status, 

geographic residence, parity, and the infant's birthweight, as well as modifiable factors 

like type of delivery, self-efficacy, attitudes (driven by religion), previous breastfeeding 

exposure, and social and professional support (Bernard et al., 2016). 

In addition, knowledge about breastfeeding, attitudes and behaviors toward breastfeeding 

play a significant role in the process of exclusively breastfeeding practices 

(Dukuzumuremyi et al., 2020) and the decision to breastfeed (Martens, 2001). 

However, childbearing and motherhood are intimately interlinked in the Palestinian 

setting with common cultural ideas and behaviors. Mothers, sisters, mother-in-law, and 

other female relatives typically help new mothers with all aspects of motherhood, 

including breastfeeding, bathing and physically caring for their children, learning about 

their cries, providing nutritional advice, and managing other aspects of health and well-

being, as well as family care (Taraki, 2006). 

In the State of Palestine "Palestine is a country divided into two parts, the West Bank and 

the Gaza Strip, because of the occupation from 1948 to present, according to (Efrat, 

2006)”, most women view breastfeeding as beneficial (Izhiman A., 2015). Initially, 

according to a 2014 Palestinian Multiple Indicator Cluster Survey, the percentage of 

children aged 0 to 23 months who were breastfed in Palestine was 96.6%, with 95.8% in 

the West Bank and 97.6% in Gaza. According to a survey conducted by the Palestinian 

Center for Statistics (PCBS), 38.6 percent of infants aged 0 to 5 months in the West Bank 

and 36.4 percent in Gaza were exclusively breastfed (PCBS, 2014). 

However, the rate drops over the next six months, with just 40% of exclusively breastfed 

babies reaching the age of six months (36 percent in the Gaza Strip and 41 percent in the 

West Bank). As a supplement to the nutritious maternal milk, infants are given formula, 

sugar water, or even herbal tea (Izhiman A., 2015). 

Despite the fact that UNRWA (United Nations Relief and Works Agency for Palestine 

Refugees in the Near East) clinics have been implementing a breastfeeding promotion 

program, reports on the prevalence of exclusive breastfeeding (EBF) among Palestinian 

refugee newborns receiving UNRWA facilities have only reached 32.7 percent (Musmar 

& Qanadeelu, 2012). Furthermore, pre-conception care, prenatal care, intra-natal care, 



4 
 

postnatal care, and family planning are among the reproductive health services provided 

by UNRWA (UNRWA, 2021). It encourages women to visit UNRWA health centers after 

giving birth to get postnatal care, which includes a full medical examination of the mother 

and the newborn, as well as counseling on family planning, breastfeeding, and newborn 

care (UNRWA, 2020). 

This study was conducted in Nablus clinics that provide Palestinian Ministry of Health 

services (PMoH), Asira Al-Shamliya, Ras Al-Ain, Balata, and central Nablus clinic. The 

purpose of this research is to assess the psychological factors, attitudes, and behaviors of 

nursing mothers towards exclusive breastfeeding.  

1.2 Conceptual and theoretical definitions 

1.2.1 Postpartum period 

The postpartum period is divided into three different but interconnected phases, 

commonly termed the "fourth stage of labor."  The initial phase (acute phase) begins 

within the first 6 hours of birth and lasts for 12 hours, followed by the second phase 

(subacute phase), which involves the first two to six weeks, and the last phase (delayed 

postpartum phase) for up to 6 months (Romano et al., 2010). 

1.2.2 Exclusive breastfeeding 

In the first six months of life, newborns are exclusively breastfed (also known as 

"exclusive breastfeeding"), which means that no other liquids, including water, tea, herbal 

medicines, or food (with the exception of prescription medications or dietary supplements 

such as minerals and vitamins), should be added to the breast milk (Motee A. & Jeewon 

R., 2014). 

1.2.3 Complementary feeding 

The WHO defines complementary feeding as the practice of meeting an infant's 

nutritional requirements with liquids and meals (meals include elements other than breast 

milk or formula) when breast milk is no longer sufficient. It's crucial to give newborns 

the nutrition they need for growth and development (Abeshu et al., 2016). 

 



5 
 

1.2.4 Formula feeding 

Formula, or bottle-feeding, is an artificial milk feeding for the baby instead of breastmilk 

(Maxwell et al., 2023). 

1.2.5 Breastfeeding attitudes 

Attitude is a multifaceted and frequently used notion. It could be evaluated in patients by 

health experts in order to attain the desired behavior. It includes four characteristics: 

making a judgment based on experience, behaviors, knowledge, and/or principles; 

feelings and ideas about a certain topic (e.g., nursing); agreeing, disagreeing, or remaining 

neutral; and exploring behavior and/or action modification (or a decision not to take 

action). Therefore, a breastfeeding attitude is the intention, initiation, and continuation of 

breastfeeding (Hamze L. et al., 2018).   

1.2.6 Breastfeeding behaviors 

It is a dyadic behavior in which an infant gets breast milk from his or her own mother. 

Breastfeeding behaviors include initiation, duration, and method of breast feeding, such 

as feeding the baby directly from the breast or using expressed breast milk (breast milk 

expression feeding is feeding breast milk that has been expressed by hand or pump to the 

infant by bottle feeding, with or without added infant formula or solid foods) (Rasmussen 

et al., 2017).  

1.3 Aim of the study 

To explore the psychological factors influencing attitudes and behaviors toward exclusive 

breastfeeding among Palestinian nursing mothers. 

1.3.1 Objectives 

1. Identify the prevalence of sociodemographic among exclusively nursing mothers. 

2. Identify the prevalence of psychological factors (depression, anxiety, stress) among 

exclusively nursing mothers. 

3. Identifying the prevalence of positive and negative attitudes and behaviors among 

nursing mothers.  

4. Assess if there are a significant difference between exclusive breastfeeding and 

depression, anxiety, and stress. 

5. Assess if there are a significant difference between exclusive breastfeeding and 

attitudes and behaviors among nursing mothers. 



6 
 

1.4 Problem statement 

Breastfeeding is an infant's preferred method of nutrition (Radwan, 2013). It is easier to 

digest in comparison with formula since it contains antibodies, and it helps in the 

prevention of allergies and protects from chronic conditions, but artificial feeding does 

not contain antibodies and cannot match the complexity of breast milk (Ben-Joseph E., 

2018). 

The World Health Organization (WHO) recommends breastfeeding for the baby until the 

age of 23 months as a target age (Abeshu et al., 2016),which is related to its benefits for 

the mother and baby since it helps the baby gain the right amount of weight, has 

appropriate growth and development, decreases the risk of chronic diseases, and has 

economic benefits (Yasser Abulreesh et al., 2021). Thus, formula feeding is expensive, 

might lead to overweight gain, and might increase the risk of chronic diseases (De Onis 

& Onyango, 2003). Also, for mothers, breastfeeding decreases the risk of breast and 

ovarian cancer (Prentice, 2022) and cardiovascular diseases (Tschiderer et al., 2022). 

However, in order to implement the WHO recommendation to breastfeed until a 

youngster is two years old, it is important to identify the psychological factors influencing 

breastfeeding attitudes, practices, behaviors, initiation, duration, and exclusive 

breastfeeding of nursing women (Kronborg & Vaeth, 2004). 

Moreover, there are not enough studies about the psychological factors influencing 

exclusive breastfeeding attitudes, practices, behaviors, initiation, and duration, even with 

all the recommendations and breastfeeding encouragement programs. This study aims to 

assess and identify these variables among Palestinian nursing mothers presenting to 

primary health care centers in Nablus city. 

1.5 Significance of the study 

The ideal infant's food is breast milk, which should be initiated within the first hour of a 

baby's life and last for at least six months of EBF (exclusive breastfeeding). It supplies 

all of the nutrition a newborn need throughout the first six months of life, as well as 

protecting the kid from sickness (Yasser Abulreesh et al., 2021). According to the World 

Health Organization, exclusive breastfeeding could save the lives of roughly 220,000 

children each year. 

There are a set of factors influencing the ability of women to breastfeed their babies (Krol 

& Grossmann, 2018).They are a mix of psychosocial, psychological, and medical 



7 
 

variables. The studies reviewed different factors affecting EBF, but a few of them 

determined that psychological factors affect EBF attitudes, practices, duration, behavior, 

and initiation. Accordingly, more studies are needed, and this study focused on the 

psychological factors, attitudes, and behaviors among Palestinian women and their 

impacts on exclusive breastfeeding. 

1.6 Research questions 

1. What is the prevalence of sociodemographic among exclusively nursing mother? 

2. What is the prevalence of psychological factors (Depression, Anxiety, Stress) among 

exclusively nursing mother? 

3. What is the prevalence of positive and negative attitudes and behaviors among nursing 

mothers? 

4. Are there significant differences between psychological factors and exclusive 

breastfeeding? 

5. Are there significant differences between psychological factors and breastfeeding 

attitudes? 

6. Is there a significant association between psychological factors and behaviors about 

breastfeeding? 

1.7 Hypotheses of the study 

H0: There are no significant differences between psychological factors (depression, 

anxiety and stress) and exclusive breastfeeding, at the level of p-value ≤ 0.05. 

H0: There is no relation between behaviors and attitudes and exclusive breastfeeding, at 

the level p-value ≤ 0.05. 

H1: There are no significant differences between psychological factors (depression, 

anxiety and stress) and exclusive breastfeeding, at the level of p-value ≤ 0.05 

H1: There are significant differences between behaviors and attitudes and exclusive 

breastfeeding, at the level p-value ≤ 0.05. 

 



8 
 

Chapter Two 

Literature Review 

2.1 Literature Review 

In this chapter, the researcher presents the studies related to the physiological factors 

influencing exclusive breastfeeding among nursing mothers worldwide, in Arab 

countries, and in Palestine. 

2.1.1 Sociodemographic and EBF 

In order to find out the association between breastfeeding practices in women with a body 

mass index (BMI) of 30 kg and any psychological issues, a systematic study was 

published in 2018. Researchers investigated 20 articles, and 16 psychological 

characteristics were reported. In this study, it was discovered that breastfeeding habits 

were related to nursing preferences, body image, social awareness, belief in nutritional 

adequacy, and the availability of enough breast milk. On the other side, researchers in this 

review recommended supporting breastfeeding, giving women knowledge to disprove 

specific myths, and addressing their self-image and social awareness (Lyons et al., 2018). 

To assess the degree of women's knowledge, attitudes, and practices related to exclusive 

breastfeeding and to offer recommendations on how to enhance it, an East African 

systematic review study was conducted in 2020. An inventory of English-language 

publications published between January 2000 and June 2019 was compiled by researchers 

using several databases. For the purpose of gathering data for the mentioned research (16 

studies), a survey of peer-reviewed literature was conducted. The results showed that 

84.4% of women recognized what EBF was, 49.2% knew it only lasted for the first six 

months, and 96.2% had heard of it.  Furthermore, 42.1% and 24% of mothers disagreed 

and strongly disagreed with the importance of breastfeeding the child during the first hour 

after birth and immediately, respectively, and 47.9% disagreed that discarding the 

colostrum is important. According to the statistics, 42% of mothers wanted to nurse their 

children exclusively for the first six months. In comparison, 55.9% of them had nursed 

their children exclusively for at least six months (Dukuzumuremyi et al., 2020). 



9 
 

A quantitative, cross-sectional study was conducted among young women in Nigeria to 

assess breastfeeding knowledge, practices, and attitudes. Researchers used the 

Knowledge, Attitude, and Intention (KAI) scale to evaluate 457 of the included 

participants. Study outcomes highlighted that 52.1% of women knew the benefit of 

starting nursing within the first hour after birth, while 37.8% of the respondents reported 

that breast milk is not enough for babies during the first 6 months of age and water should 

be introduced to them (Leshi et al., 2016). 

However, this published historical series aimed to monitor EBF's frequency for eight 

cross-sectional studies between 2004 and 2015 that conducted the annual vaccination in 

Primary Healthcare services. Results were obtained from 6027 infants with a mean age 

of 6.2 months. Findings showed a significant increase among infants aged four months or 

less in rates of breastfeeding (7.2%) and exclusive breastfeeding (9.5%), but there was a 

decline between 2010 and 2015 for infants aged four and five months (6.3%). While the 

prevalence increased up to 10.1% among infants aged between six and nine months old 

in comparison with no change for those aged between 10 and 11 months (Faustino-Silva 

et al., 2023). 

Another quantitative, cross-sectional study was conducted in Ghana to identify 

breastfeeding practices and sociodemographic characteristics that influence EBF. From 

May to June 2016, researchers utilized a simple random selection technique and a 

structured questionnaire to recruit 355 mothers of infants aged 0 to 24 months for the 

study. The findings of the study demonstrated a high level of awareness and 

comprehension of EBF. In addition, 63.4 percent of women started breastfeeding within 

an hour of giving birth, and 81 percent of mothers gave their newborns colostrum 

following delivery. Only 33.7 percent of 6- to 8-month-old infants have begun consuming 

supplemental foods. In addition, women between the ages of 20 and 24 were more likely 

to engage in EBF, as were less educated women as well (Asare et al., 2018). 

2.1.2 Attitudes and behaviors  

For the purpose of investigating breastfeeding knowledge, attitudes, and behavior among 

female undergraduate students as well as the variables that affect breastfeeding intention, 

a quantitative, cross-sectional study was carried out in the Middle East (Lebanon and 

Syria). A convenience sample of 293 individuals from four chosen universities in each 



10 
 

city—194 from Beirut and 199 from Damascus—completed a multi-part questionnaire. 

The results show a relationship between breastfeeding and knowledge, attitude, and 

behavior in Lebanon as well as in Syria (Hamade et al., 2014). 

To assess the attitudes and information about nursing held by working mothers, a quanti

tative, cross-sectional study was carried out. 400 working mothers were given an Arabic-

language self-report questionnaire by researchers at their places of employment. The 

survey was completed by 80% of participants. According to the findings, 20.9% of 

women breastfed their babies exclusively for six months, whereas 72.4% of women 

initiated nursing. Additionally, there was outstanding nursing expertise as well as 

supportive attitudes. Additionally, 30% of working women said their jobs were the reason 

for their child's early termination of nursing (Altamimi et al., 2017). 

In Ethiopia, the researchers used data from the 2019 Ethiopian Mini Demographic and 

Health Survey (2019 EMDHS) to determine factors influencing exclusive breastfeeding 

among infants six months of age or younger. The outcomes of a total of 566 participants 

were presented, of which 83% were EBF practices. There is a significant link between 

EBF under 6 months and education (higher education), residency place (urban), type of 

delivery, place of giving birth, and number of antenatal care visits (4 or more) (Mekebo 

et al., 2022). 

In India, a total of 441 participants with an infant age less than 12 months were 

interviewed prospectively and retrospectively to identify the prevalence of survival EBF 

practices and related factors. It was highlighted that EBF decreased after five months in 

comparison with its good survival rate up to three months. EBF practices were 69.4% and 

were significantly linked to education, region, birth weight, and maternal age (Sankar et 

al., 2023). 

In Changsha County, China, a cross-sectional study was conducted among 414 women 

who completed an online survey to identify the factors influencing exclusive 

breastfeeding practices. The study highlighted that 46.1% of the participants were 

exclusively breastfed. Also, results showed a significant relationship between EBF and 

self-efficacy and intention of EBF, while there was an indirect relationship with social 

support (Li et al., 2022). 



11 
 

2.1.3 Psychological factors 

Besides, psychosocial factors are likely to have a substantial influence in maintaining 

exclusive breastfeeding for six months. To identify the psychosocial factors linked with 

the ability to EBF for six months postpartum and to investigate a conceptual model of 

exclusive breastfeeding duration's psychological association s. A quantitative, cross-

sectional study was obtained among 174 women aged 18 years old or more who gave 

birth between 6 and 24 months and completed an online, retrospective survey. The 

Breastfeeding Self-Efficacy Scale (BSE), Body Attitude Questionnaire (BAQ), 

Depression, Anxiety, and Stress Scale (DASS), Fetal Health Locus of Control Scale, and 

the Brief Coping Orientation to Problems Experienced (COPE) scale were used to 

measure psychosocial factors (De Jager et al., 2014). 

The findings revealed that exclusive breastfeeding desire, duration, breastfeeding self-

efficacy, public nursing comfort, perceived physical strength, and reported less perceived 

breastfeeding difficulties were all significant predictors. Also, this study highlighted a 

significant relationship between maternal attitude towards pregnancy (both antenatal and 

postnatal), early breastfeeding difficulties, and psychological adjustment (De Jager et al., 

2014).  

Additionally, psychological factors may influence breastfeeding behavior, as literature 

suggests (Krol & Grossmann, 2018). In 2008, a quantitative, cross-sectional study aimed 

to identify the link between women’s psychological factors and breastfeeding duration 

after socio-demographic factors were controlled. Within 14 days of giving birth, 375 

postnatal inpatients at two hospitals completed the initial questionnaire, and at six months, 

complementary feeding was added. However, study results highlighted that nursing 

duration was statistically associated with psychological factors: breastfeeding 

expectations, breastfeeding self-efficacy, faith in breast milk, planned duration of 

breastfeeding, decision of infant feeding time, dispositional optimism, and anxiety. In 

addition, results showed that 44% of women experienced postnatal distress after giving 

birth (O'Brien et al., 2008). 

A published, quantitative, cross-sectional study aimed to explore the influence of 

depression symptoms during antenatal care on the women's intention to EBF. A self-

reported survey was completed by 393 pregnant women in China. This study's results 



12 
 

clarified that there is a negative relationship between EBF intention and antenatal 

depression symptoms, which means the EBF decreases when women experience 

antenatal depression symptoms without social support (Liu et al., 2023). 

Anxiety is more common among women than it is in men (Hoff et al., 2019). 

Approximately 7 to 10% of women in developed countries (Andersson et al., 2003) and 

25% of women in underdeveloped countries (Shahhosseini et al., 2015), experience 

anxiety during pregnancy. Also, the majority of diagnosed women were undiagnosed and 

untreated (Andersson et al., 2003). 

Also, to identify the relation between psychological aspects, social support, and the 

nursing process in Iran, a study was conducted among 465 women with infants aged 

between one and six months who were presented to healthcare centers from 2012 to 2016. 

Data were collected using self-reported questionnaires and other scales, including the 

Beck Depression Inventory, Spielberger's State-Trait Anxiety Inventory, Cohen's 

Perceived Stress Scale, and the Multidimensional Scale of Perceived Social Support. 

Findings showed the prevalence of EBF was 68.4%. Also, there was a significant link 

between anxiety and EBF (p = 0.004 and p = 0.006, respectively), which leads to 

decreased EBF chances. The study's suggestions centered on monitoring and controlling 

mothers’ anxiety during the postpartum period to encourage exclusive breastfeeding 

(Jalal et al., 2017). 

2.1.4 Factors influencing EBF 

Moreover, in the context of acculturation (the process of adopting another culture's 

practices and behaviors) and exclusive breastfeeding, in 2016, a qualitative study 

investigated the acculturation levels and advantages and disadvantages of exclusive 

breastfeeding among Mexican American mothers. The sample size was 21 women who 

were interviewed using Pender’s Health Promotion Model concepts and the revised 

Acculturation Rating Scale. More than half of the sample (66%) were women who were 

"Very Mexican-oriented". Study outcomes showed the majority of participants 

exclusively breastfed, with less use of compulsory feeding for "inadequate breastmilk." 

Three main themes emerged: the woman's natural ability to give birth; encouragement, 

tradition, and guidance influencing her decision to breastfeed; and the preference for 

breast milk influenced by life events (Wambach et al., 2016). 



13 
 

In United Arab Emirates, a quantitative, cross-sectional study was conducted to examine 

the factors influencing various infant feeding methods. interviews included 593 women 

with children aged two years or less. Results showed 99% of women initiated 

breastfeeding, with a mean duration of 8.6 months. Age, education, parity, nipple issues, 

and contraception use influenced initiation and duration of BF. A significant relationship 

between EBF and feeding patterns was presented, including feeding on demand, more 

frequently at night, and rooming in. Percentages of newborns used complementary 

feeding, exclusively breastfed, mostly breastfed since birth were, 24.1%, 25%, and 

49.4%, respectively. Non-milk fluids were given to 30% of infants before 3 months, while 

solid food was given to 83.5% before 6 months. Reasons for breastfeeding termination 

include new pregnancy, inadequate milk production, and the infant weaning process 

(Radwan, 2013). 

Moreover, in 2017, a quantitative, cross-sectional study investigated variables linked with 

cessation of EBF in the first and second months of the postpartum period. Researchers 

interviewed 1077 postnatal women in the first and second months of the postpartum 

period in Taiwan. Outcomes showed that 40.1% of participants maintained exclusive 

breastfeeding, and at 2 months, 29.3% maintained EBF. Premature exclusive 

breastfeeding cessation is linked with education level, primiparity, perceived poor milk 

amount, and return to work (Chang et al., 2019). 

The Global Strategy for Infant and Young Child Feeding highlights the critical actions 

that must be implemented in order to promote, protect, and encourage breastfeeding. 

When a kid is nursed exclusively, their immune system is improved, allowing them to 

avoid life-threatening infections such as pneumonia and diarrhea, among others (Nassar, 

2019; santé et al., 2003). 

According to studies, newborns who are not nursed exclusively for the first six months of 

life are 15 times more likely to die from pneumonia than those who are exclusively 

breastfed for the first six months of life. Moreover, 220,000 children could be saved every 

year with EBF, as the WHO estimated (Nassar, 2019; WHO, 2023). 

 

 



14 
 

2.1.5 EBF in Palestine 

Meanwhile, in Palestine, according to the outcomes of a study conducted in 2013, the 

percentage of exclusive breastfeeding in the Gaza Strip and West Bank was 55% and 

52.9%, respectively, and 53.9% in the state of Palestine (Nassar, 2019). 

In 2010, a quantitative, cross-sectional, retrospective study conducted in Nablus refugee 

camps (Balata, Askar, and Ein Beit el Ma) aimed to investigate the relationship between 

selected mothers' and newborns' sociodemographic characteristics and the infants' 

feeding patterns during the first six months of life. Researchers reviewed 690 files in 2007 

for women receiving health care services in one of three of The United Nations Relief 

and Works Agency (UNRWA) clinics in Nablus. Results showed 70% of women 

exclusively breastfeed during the first six months of a child's life, 16% for partial 

breastfeeding, and 14% for exclusive formula feeding. There was a significant 

relationship between EBF (p = 0.05) and both the mother and infant sociodemographic 

factors: mothers aged 22–28 years old at marriage and at delivery, those with high parity 

(more than 4), mothers with basic and secondary levels of education, fathers who were 

not educated, vaginal delivery, and female infants (Qanadelo, 2010). 

In summary, exclusive breastfeeding is important for the infant’s life, growth and 

development. And many factors influence the duration, initiation, attitudes, practices, 

behaviors and the pattern of breastfeeding. In order to these factors, a set of studies 

discussed them to encourage EBF for six months and a complementary feeding from 6 

months to 2 years old of child life, as a recommendation from the World Health 

Organization (WHO), The United Nations Relief and Works Agency (UNRWA), and 

United Nations International Children's Emergency Fund (UNICEF). 

 

 

 

 

 



15 
 

Chapter Three 

Methodology 

3.1  Study design  

To obtain the primary objective of this study, which aimed to examine the psychological 

factors influencing attitudes and behaviors toward exclusive breastfeeding among 

Palestinian nursing mothers, the researcher used a quantitative, cross-sectional, and 

descriptive research design. Moreover, the study sought to address associated research 

questions and sub-questions while evaluating the hypotheses posited by the researcher for 

acceptance or rejection. 

In this study design, the researcher collected data at a single point in time, specifically 

during the postpartum period from the time of delivery up to six months. This approach 

aimed to describe the characteristics of a phenomenon within a specific population of 

nursing mothers. Utilizing numerical data predominantly gathered through surveys or 

questionnaires, the researcher in this study used a questionnaire comprising two scales 

and demographic data-related questions. This quantitative methodology allowed for the 

analysis of patterns, relationships, and trends, ultimately offering a snapshot view of the 

subject under investigation. 

3.2 Study population 

The population consisted of postpartum nursing mothers presenting to get postpartum 

services from Palestinian Ministry of Health (PMoH) primary health care clinics in 

Nablus city/ North of the West Bank. 

3.3 Site and setting 

The study was conducted at the primary health care clinics which provide Maternal and 

Child Health (MCH) services in Nablus city/ North of West Bank. The total number of 

clinics was four, Ras Al-Ain camp clinic, Nablus central clinic, Balata clinic, and Asira 

Al-Shamliya clinic.   

 

 



16 
 

3.4  Study time table 

After receiving IRB (Institutional Review Board) approval from An-Najah National 

University (NNU), and approval from the Palestinian Ministry of Health's Research 

Ethics Committee Department, the study began in January 2022. From January to March 

2022, data was collected and entered. In addition, data analysis started in September 2022, 

while the literature review and writing study results were completed by the end of October 

2022 as shown in appendix A. 

3.5  Sample size and sampling methods 

3.5.1 Sample size 

By using the Stephen Thompson Equation formula to determine the sample size 

(Thompson k.,1945), the population size is 8494  (PMoH, 2021)”, the sample size is 368 

at a minimum and the respond rate was 100%, the number of the participants who were 

completed the questionnaire was 368. 

That is according to the following formula: 

 ………………………(1) 

 

n: Sample size.    

N: Population size.   

z: Confidence level at 95% = (1.96). 

d: Error proportion = (0.05).    

p: Population proportion (expressed as a decimal) = 0.50. 

3.5.2 Sampling method 

The researcher in this study used a convenience sampling technique. It is one of the forms 

of non-probability sampling methods that focuses on gathering data from individuals of 

the community who are readily available to participate in the study (Polit and Beck, 

2004). 

( )
( )  ( ) ppzdN

ppN
n

−+−

−
=

11

1
22



17 
 

3.6 Inclusion and Exclusion Criteria 

3.6.1 The nursing mother should be 

1. Postpartum nursing mothers presenting to primary health care clinics to get the 

services during first six months of giving birth. 

2. Without breast problems. 

3. With healthy baby. 

4. With gestational age more than 37 weeks. 

3.6.2 The following nursing mother were excluded 

1. Postpartum nursing mother presenting to primary health care clinics to get the 

services after six months of giving birth because the EBF is up to six months only. 

2. Diagnosed with mental illnesses.  

3. Having a medical disease. 

4. With breast problems. 

5. Who have died or ill baby. 

6. With premature babies, gestational age less than 37 weeks. 

3.7 Data collection process 

Data were collected within the first six months of giving birth by using a self-reported 

questionnaire. The time needed to complete the survey was five to ten minutes for each 

participant at the PMoH clinics. 

1. The researcher visited the PMoH clinics on a daily basis to engage with the 

participants included in the study. 

2. All participant who were in the clinic and met the inclusion criteria on the day that 

researcher went to collect data were included in the study. 

3. The study's objectives and the participants' rights were elucidated by the researcher. 

4. After obtaining oral permission, participants provided written informed consent by 

their signature. 

5. Each participant independently completed the questionnaire in a serene, solitary 

setting devoid of disruptions. 

6. In instances where questions required clarification, participants received the 

necessary elucidation without any hints to ensure unbiased responses. 



18 
 

7. Before participants left, the researcher conducted a quick review of the questionnaire 

to confirm comprehensive responses; any missed items were addressed and 

completed by the participant after informing her. 

8. Instances of unanswered questions arose, prompting some participants to decline 

responses; such cases resulted in the exclusion of the respective questionnaire 

9. The researcher undertook daily data review, subsequently inputting the data into the 

SPSS program 

10. Upon achieving the designated sample size, data collection ceased, and researchers 

moved on to the next phase of data analysis. 

3.7.1 Study instruments 

The data was collected from January, 2022, to February, 2022, by a self-reported 

questionnaire that included the sociodemographic data, the Depression, Anxiety, and 

Stress Scale (DASS-21) to assess psychological factors affecting the duration of exclusive 

breastfeeding and a Breastfeeding Behavior Questionnaire (BBQ) scale to evaluate 

nursing mothers' behaviors and factors affecting the duration of exclusive breastfeeding. 

The needed time to fill out the questionnaire and scales is 5 to 10 minutes. 

3.7.1.1 Sociodemographic data 

This part of the questionnaire consists of 11 items, including the mother's age, marital 

status, husband's age, residency place, monthly income, level of education, work status, 

the number of current kids, the current child’s age, type of delivery, and the current weight 

of the mother region. Which were found to have associations with the factors influencing 

exclusive breastfeeding. 

3.7.1.2 Depression Anxiety Stress Scale-21 (DASS-21) 

The DASS-21 consists of 21 items divided into three subscales, each with seven items. 

They inquire about depressed symptoms (for example, feeling down and out), anxiety 

symptoms (for example, feeling on the verge of panic), and other stress-related symptoms 

(e.g., having a tendency to over-react to situations). The relevant questions are graded on 

a four-point scale (0 = did not belong to me at all, 1 = apply to me a little, 2 = apply to 

me at sometimes, 3 = apply to me the majority of the time). More psychological distress 

is indicated by higher scores (Ali and Green, 2019). 



19 
 

The DASS is a well-known and reliable instrument for assessing depression, anxiety, and 

stress. Individual experience and emotional expression may be influenced by cultural 

differences. As a result, when academics and practitioners use Western-based 

assessments with Asian people without properly validating them, the process can be 

difficult (Oei et al., 2013). However, the Arabic version of the DASS-21 scale was tested 

among Egyptian drug users and has good validity and reliability (reliability was high at 

0.88) (Ali and Green, 2019). 

3.7.1.3 Breastfeeding Behavior Questionnaire (BBQ) 

The third questionnaire part included BBQ scale which used to assess the women's 

opinions about their own breastfeeding behaviors and attitudes. It's a valid and reliable 

scale that can be translated into a variety of languages and used in a variety of settings. 

According to a study of Lebanese women, the Arabic version of BBQ-A has strong 

internal consistency reliability (Cronbach's alpha = 0.78), and can determine whether a 

baby will nurse exclusively at one, three, and six months. On 354 pregnant, the internal 

consistency, reliability, and construct validity of the Arabic BBQ (BBQ-A) were 

investigated. The ability of the tool to predict breastfeeding outcomes was tested by 

comparing the women's BBQ-A scores to their breastfeeding outcomes at one, three, and 

six months after birth (Charafeddine et al., 2020). 

However, the BBQ-A scale consisted of 12 scenarios. For each one, participants are asked 

whether or not they agree with the woman’s choice via a six-point scale called Likert; 1 

= Very Strongly Agree, 2 = Strongly Agree, 3 = Agree, 4 = Disagree, 5 = Strongly 

Disagree, and 6 = Very Strongly Disagree (Charafeddine et al., 2020). 

It is unidimensional, according to exploratory factor analysis. The inter-item association 

s ranged from 0.016 to 0.934, while the corrected-item total association s ranged from 

0.273 to 0.678. Positive breastfeeding attitudes, adequate breastfeeding knowledge, and 

stronger nursing intention were all linked to perceived positive breastfeeding behavior 

and attitudes, indicating that it had external validity (Charafeddine et al., 2020). 

 

 



20 
 

3.8 Variables 

 Dependent variables: Depression, anxiety, stress, attitudes, and behaviors. 

 Independent Variables: sociodemographic.  

3.9 Data analysis 

The data analyzed using the Statistical Package for Social Science (SPSS) version 24. 

Frequency and regressions tests were used to identify the relation between variables. 

To determine the prevalence of stress, depression, and anxiety among Palestinian 

exclusively nursing mothers, a frequency test was applied. Additionally, it was utilized 

to determine the prevalence of both negative and positive attitudes and behaviors 

regarding exclusive breastfeeding. An ordinal logistic regression analysis test was used 

to define relationships between variables, specifically to identify association between 

sociodemographic data and psychological factors such as depression, stress, and anxiety. 

This same analytical approach was used to explore the associations between 

sociodemographic data and attitudes as well as behaviors among Palestinian exclusively 

nursing mothers. 

3.10 Ethical Consideration 

Approval to perform the study was obtained from the Palestinian Ministry of Health 

(Annex 8.13), and the college of Graduate Studies and An-Najah National University's 

Institutional Review Boards (IRB) committee the reference number was Mas. Jan. 

2022/6 (Annex 8.12). The following steps were taken into consideration while collecting 

data to keep privacy and confidentiality: 

For the study's data management, numerical codes were applied to label the questionnaire 

papers. A clear elucidation of the study's aim and objectives was provided to all 

participants, followed by the collection of informed consent from each individual. 

Participants individually completed the questionnaires within a single, calm, and private 

room to ensure privacy. Subsequently, the completed surveys were securely stored in a 

closed drawer under the exclusive supervision of the researcher, who maintained access 

to the data. The collected data was meticulously inputted into Excel and SPSS programs 

as numerical entries by the researcher. Once the data analysis was completed, the 

researcher ensured the proper disposal of the papers in a secure manner. 

 



21 
 

Chapter Four 

Results 

In this chapter, the researcher presents the study's outcomes, obtained from data analysis, 

in tables accompanied by explanations. These tables encompass a range of information, 

including demographic data, the prevalence of depression, anxiety, and stress among 

nursing mothers, the association between these mental health factors and the 

demographics of the mothers, the prevalence of positive and negative attitudes and 

behaviors towards exclusive breastfeeding, and ultimately, the association of these 

attitudes and behaviors with the demographic characteristics of the nursing mothers. 

4.1 Sociodemographic data 

Table 1 displays the sociodemographic of the 368 participants included in this study. 

Among the mothers' age groups, the highest percentage was observed among nursing 

mothers aged between 19 and 29 years old, accounting for 67.1% (n = 247). As for the 

highest percentage among fathers' age groups, it was found among husbands aged 

between 31 and 40 years old, comprising 52.4% (n = 193). Furthermore, the percentages 

for nursing mothers aged between 30 and 40 years old, 41 years old or more, and less 

than 18 years old were 25% (n = 92), 8% (n = 26), and 7.1% (n = 3), respectively. 

Similarly, for husbands, the percentages were 36.7% (n = 135) for those aged 30 years or 

less and 10.9% (n = 40) for those aged 41 years or more. 

Based on the results, it was found that 86.7% (n = 319) of nursing mothers reside in urban 

areas, while 13.3% (n = 49) live in camps and villages. In terms of monthly income, the 

majority of participants, 48.9% (n = 180), have an income ranging from 500 to 800 

dollars. This is followed by 38.6% (n = 142) who earn less than 500 dollars, and 12.5% 

(n = 45) who earn more than 800 dollars. 

Among nursing mothers, there was an equal percentage of 48.9% (n = 180) for both 

educational levels: high school or less and a bachelor's degree. Additionally, 2.2% (n = 

8) of nursing mothers possessed a master's degree or higher. Out of the total 368 

participants, 83.7% (n = 308) were unemployed, indicating that 16.3% (n = 60) were 

employed as working mothers. 



22 
 

Furthermore, among the breastfeeding mothers in this study, it was found that 74.5% (n 

= 274) had one to three children, followed by 23.6% (n = 87) who had four to six children, 

and 1.9% (n = 7) who had more than six children. Regarding the distribution of 

participants based on the age of their current child, it was observed that 28% (n = 103) 

had a child under two months old, 30.2% (n = 111) had a child between two and four 

months old, and 41.8% (n = 154) had a child between four and six months old. 

Regarding the type of giving birth, women who had a cesarean section birth 51.9% (n = 

191) outnumbered those who gave normal vaginal birth 48.1% (n = 177). 

Lastly, in terms of participant body weight, women with a body weight ranged from 51 

kilograms to 65 kilograms had by far the highest percentage, 48.6% (n = 179), which 

means that the other half was approximately divided between mothers who had a body 

weight of less than 50 kilograms, 11.4% (n = 42), followed by those with a body weight 

between 66 and 80 kilograms, 26.9% (n = 99), and more than 80 kilograms, 13% (n = 

48). 

 

 

 

 

 

 

 

 

 

 

 



23 
 

Table 1  

Prevalence of sociodemographic data among nursing mothers 

 

Item 

Sociodemographic data 

 Frequency Percent (%) 

 

Age 

Less than 18 

19 to 29 

30 to 40 

41 or more 

26 

247 

92 

3 

7.1 

67.1 

25 

8 

 

Husband age 

30 or less 

31 to 40 

41 or more 

135 

193 

40 

36.7 

52.4 

10.9 

 

Residency 

Camp or village 

City 

49 

319 

13.3 

86.7 

 

Monthly income 

Less than 500$ 

500$ to 800$ or 

more 

More than 800$ 

142 

180 

45 

38.6 

48.9 

12.5 

 

Level of education 

High school or 

less 

Bachelor degree 

or more 

180 

188 

48.9 

51.1 

Work 
I work 

I do not work 

60 

308 

16.3 

83.7 

The number of current 

kids 

1 to 3 

4 to 6 or more 

274 

94 

74.5 

25.5 

Current child's age 

Less than 2 

months 

2 to 4 months 

4 to 6 months 

103 

11 

154 

28 

30.2 

41.8 

Type of delivery 
Normal delivery 

Cesarean section 

177 

191 

48.1 

51.9 

Current weight 

Less than 50 kg 

51 to 65 kg 

66 to 80 kg 

More than 80 kg 

42 

179 

99 

48 

11.4 

48.6 

26.9 

13 
 

4.2 Prevalence of depression, anxiety and stress among nursing mothers 

Table 2 provides an overview of the prevalence of psychological factors, including 

depression, anxiety, and stress, across various intensity levels ranging from mild to 

extremely severe.  

Approximately half of the participants, 49.2% (n = 181), did not exhibit any signs of 

depression. The remaining distribution included individuals with mild depression, 



24 
 

accounting for 14.9% (n = 55); moderate depression, accounting for 20.1% (n = 74); 

severe depression, accounting for 9.2% (n = 34); and extremely severe depression, 

accounting for 6.5% (n = 24). 

In terms of anxiety, nearly 40.2% (n = 148) of nursing mothers did not experience any 

anxiety. Among those who did, 8.7% (n = 32) reported mild anxiety, 24.7% (n = 91) 

experienced moderate anxiety, 7.6% (n = 28) reported severe anxiety, and 18.8% (n = 69) 

reported extremely severe anxiety. 

Furthermore, the table indicates that 31.5% (n = 116) of nursing mothers did not 

experience stress. Slightly higher than this, 33.4% (n = 123) reported mild stress. The 

percentages for participants experiencing moderate stress (n = 75), severe stress (n = 43), 

and extremely severe stress (n = 11) were 20.4%, 11.7%, and 3% respectively. 

Table 2 

Prevalence of depression, anxiety and stress among nursing mothers 

 
Depression 

N (%) 

Anxiety 

N (%) 

Stress 

N (%) 

Normal 181 (49.2%) 148 (40.2%) 116 (31.5%) 

Mild 55 (14.9%) 32 (8.7%) 123 (33.4%) 

Moderate 74  (20.1%) 91 (24.7%) 75 (20.4%) 

Severe 34 (9.2%) 28 (7.6%) 43 (11.7%) 

Extremely severe 24 (6.5 %) 69 (18.8%) 11 (3%) 

Total 368 (100%) 368 (100%) 368 (100%) 
 

Figure 1 

Prevalence of depression, anxiety, and stress among nursing mothers 

 

49.20%

14.90%

20.10%

9.20%
6.50%

40.20%

8.70%

24.70%

7.60%

18.80%

31.50% 33.40%

20.40%

11.70%

3%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Normal Mild Moderate Severe Extremely severe

Prevalence of depression, anxiety and stress among nursing 
mothers

Depression Anxiety Stress



25 
 

4.3 Ordinal logistic regression of the variables predicting depression 

Table 3 in this study presented the association results between nursing mothers' 

demographics and different levels of depression, including normal, mild, moderate, 

severe, and extremely severe. The findings of the table reveal a significant relation 

between depression and the age of the current child, specifically within the range of 2 to 

6 months (P = 0.03, OR = 1.66, CI: 1.03, 2.67). 

4.4 Ordinal logistic regression of the variables predicting anxiety 

The association results between nursing mothers' demographics and various levels of 

anxiety, including normal, mild, moderate, severe, and extremely severe, was presented 

in Table 3 of this study.  

The table's findings indicate a significant association between anxiety and the age of the 

current child, particularly between 2 to 4 months (P = 0.00, OR = 2.12, CI: 1.33, 3.39). 

4.5 Ordinal logistic regression of the variables predicting stress 

Table 3 in this study showcases the association findings between nursing mothers' 

demographics and various levels of stress, encompassing normal, mild, moderate, severe, 

and extremely severe.  

The results of the table indicate a noteworthy association between stress and the age of 

the mothers' husbands, specifically within the range of 31 and 40 years old (P = 0.04, OR 

= 2.13, CI: 1.01, 4.49). Additionally, a significant relationship was observed between the 

current weight of the nursing mothers and their level of stress (P = 0.04, OR = 0.19, CI: 

0.19, 0.95). 

 

 

 

 

 



26 
 

Table 3 

 Ordinal logistic regression of the variables predicting depression, anxiety, and stress (N = 368): 

Variable B SE 
P 

value 
OR 

CI (95%) 

Lower Upper 

Depression 

Normal -2.66 1.84 0.14 0.06 0.00 2.59 

Mild -2.02 1.84 0.27 0.13 0.00 4.93 

Moderate -0.88 1.84 0.63 0.41 0.01 15.24 

Severe 0.14 1.83 0.93 1.15 0.03 42.11 

Extremely sever 0a 0a 0a 1 0a 0a 

Age 

Less than 18  

19 to 29  

30 to 40  

41 or more  

-1.01 

-1.21 

-1.45 

0a 

1.19 

1.14 

1.15 

0a 

0.39 

0.29 

0.21 

0a 

0.36 

0.29 

0.24 

1 

0.04 

0.03 

0.03 

0a 

3.76 

2.79 

2.24 

0a 

Husband 

age 

30 or less 

31 to 40  

41 or more  

-0.28 

-0.01 

0a 

0.41 

0.37 

0a 

0.49 

0.98 

0a 

0.76 

0.98 

1 

0.34 

0.48 

0a 

1.69 

2.05 

0a 

Residenc

y 

Camp or village 

City 

0.37 

0a 

0.66 

0a 

0.58 

0a 

1.44 

1 

0.39 

0a 

5.25 

0a 

Monthly 

income 

Less than 500$ 

500$ to 800$ 

800$ or more 

-0.07 

0.16 

0a 

0.35 

0.33 

0a 

0.83 

0.62 

0a 

0.92 

1.17 

1 

0.47 

0.62 

0a 

1.83 

2.22 

0a 

Level of 

education 

High school or less 

Bachelor degree or 

more 

0.40 

0a 

0.81 

0a 

0.62 

0a 

1.49 

1 

0.31 

0a 

7.34 

0a 

Work 
I work 

I do not work 

-0.08 

0a 

0.31 

0a 

0.79 

0a 

0.92 

1 

0.51 

0a 

1.68 

0a 

The 

number of 

current 

kids 

1 to 3 

4 to 6 or more 

-0.46 

0a 

0.76 

0a 

0.55 

0a 

0.63 

1 

0.14 

0a 

2.81 

0a 

Current 

child's age 

Less than 2 months 

2 to 4 months  

2 to 6 months 

-0.08 

0.51 

0a 

0.25 

0.24 

0a 

0.76 

*0.03 

0a 

0.92 

1.66 

1 

0.57 

1.03 

0a 

1.51 

2.67 

0a 

Type of 

delivery 

Normal delivery 

Cesarean section 

0.01 

0a 

0.21 

0a 

0.98 

0a 

1.01 

1 

0.67 

0a 

1.50 

0a 

Current 

weight 

Less than 50 kg 

51 to 65 kg 

66 to 80 kg 

More than 80 kg 

-0.80 

0.32 

0.29 

0a 

0.45 

0.31 

0.34 

0a 

0.07 

0.31 

0.39 

0a 

0.45 

1.38 

1.34 

1 

0.19 

0.74 

0.68 

0a 

1.08 

2.57 

2.63 

0a 

 

 

 



27 
 

4.6 Ordinal logistic regression of the variables predicting anxiety 

The association results between nursing mothers' demographics and various levels of 

anxiety, including normal, mild, moderate, severe, and extremely severe, was presented 

in Table 4 of this study.  

The table's findings indicate a significant association between anxiety and the age of the 

current child, particularly between 2 to 4 months (P = 0.00, OR = 2.12, CI: 1.33, 3.39). 

The results of the table indicate a noteworthy association between stress and the age of 

the mothers' husbands, specifically within the range of 31 and 40 years old (P = 0.04, OR 

= 2.13, CI: 1.01, 4.49). Additionally, a significant relationship was observed between the 

current weight of the nursing mothers and their level of stress (P = 0.04, OR = 0.19, CI: 

0.19, 0.95). 

 

 

 

 

 

 

 

 

 

 

 

 

 



28 
 

Table 4 

Ordinal logistic regression of the variables predicting anxiety (N = 368) 

Variable B SE 
P 

value 
OR 

CI (95%) 

Lower Upper 

 

Anxiety  

Normal -0.78 1.89 0.68 0.46 0.01 18.68 

Mild -0.41 1.89 0.83 0.67 0.02 27.26 

Moderate 0.75 1.89 0.69 2.11 0.05 86.29 

Severe 1.22 1.89 0.52 3.38 0.08 138.01 

Extremely sever 0a 0a 0a 0a 0a 0a 

Age 

Less than 18  

19 to 29  

30 to 40  

41 or more  

1.57 

1.09 

0.95 

0a 

1.35 

1.30 

1.30 

0a 

0.25 

0.40 

0.47 

0a 

4.79 

2.98 

2.58 

1 

0.34 

0.23 

0.20 

0a 

67.15 

38.33 

33.24 

0a 

Husband 

age 

30 or less 

31 to 40  

41 or more  

0.43 

0.65 

0a 

0.40 

0.36 

0a 

0.29 

0.07 

0a 

1.53 

1.91 

1 

0.69 

0.94 

0a 

3.38 

3.88 

0a 

Residency 
Camp or village 

City 

0.15 

0a 

0.65 

0a 

0.82 

0a 

1.16 

1 

0.33 

0a 

4.10 

0a 

Monthly 

income 

Less than 500$ 

500$ to 800$ 

800$ or more 

-0.00 

-0.14 

0a 

0.34 

0.32 

0a 

0.99 

0.64 

0a 

0.99 

0.86 

1 

0.52 

0.46 

0a 

1.93 

1.61 

0a 

Level of 

education 

High school or less 

Bachelor degree or more 

0.19 

0a 

0.74 

0a 

0.79 

0a 

1.21 

1 

0.29 

0a 

5.15 

0a 

Work 
I work 

I do not work 

0.25 

0a 

0.29 

0a 

0.38 

0a 

1.29 

1 

0.73 

0a 

2.27 

0a 

The 

number of 

current 

kids 

1 to 3 

4 to 6 or more 

-1.32 

0a 

0.93 

0a 

0.16 

0a 

0.27 

1 

0.04 

0a 

1.64 

0a 

Current 

child's age 

Less than 2 months 

2 to 4 months  

2 to 6 months 

0.00 

0.75 

0a 

0.24 

0.24 

0a 

0.99 

*0.00 

0a 

1.00 

2.12 

1 

0.63 

1.33 

0a 

1.61 

3.39 

0a 

Type of 

delivery 

Normal delivery 

Cesarean section 

-0.09 

0a 

0.20 

0a 

0.63 

0a 

0.91 

1 

0.61 

0a 

1.35 

0a 

Current 

weight 

Less than 50 kg 

51 to 65 kg 

66 to 80 kg 

More than 80 kg 

-0.58 

0.45 

0.19 

0a 

0.41 

0.32 

0.34 

0a 

0.16 

0.16 

0.59 

0a 

0.56 

1.57 

1.21 

1 

0.25 

0.83 

0.62 

0a 

1.26 

2.95 

2.36 

0a 

 

4.7 Ordinal logistic regression of the variables predicting stress 

Table 5 in this study showcases the association findings between nursing mothers' 

demographics and various levels of stress, encompassing normal, mild, moderate, severe, 

and extremely severe.  

 



29 
 

Table 5 

Ordinal logistic regression of the variables predicting stress (N = 368) 

Variable B SE 
P 

value 
OR 

CI (95%) 

Lower Upper 

 

Stress 

Normal -2.63 1.65 0.11 0.07 0.00 1.82 

Mild -1.15 1.65 0.49 0.32 0.01 7.99 

Moderate 0.05 1.65 0.97 1.06 0.04 26.48 

Severe 1.79 1.66 0.28 6.04 0.23 
156.8

6 

Extremely sever 0a 0a 0a 0a 0a 0a 

Age 

Less than 18  

19 to 29  

30 to 40  

41 or more  

0.24 

0.72 

0.63 

0a 

1.09 

1.03 

1.03 

0a 

0.83 

0.48 

0.55 

0a 

1.27 

2.06 

1.87 

1 

0.15 

0.27 

0.25 

0a 

10.82 

15.67 

14.27 

0a 

Husband age 

30 or less 

31 to 40  

41 or more  

0.52 

0.76 

0a 

0.42 

0.38 

0a 

0.22 

*0.04 

0a 

1.68 

2.13 

1 

0.74 

1.01 

0a 

3.82 

4.49 

0a 

Residency 
Camp or village 

City 

0.54 

0a 

0.63 

0a 

0.39 

0a 

1.72 

1 

0.49 

0a 

5.99 

0a 

Monthly income 

Less than 500$ 

500$ to 800$ 

800$ or more 

-0.45 

-0.26 

0a 

0.33 

0.31 

0a 

0.17 

0.39 

0a 

0.64 

0.77 

1 

0.34 

0.42 

0a 

1.21 

1.40 

0a 

Level of 

education 

High school or less 

Bachelor degree or 

more 

0.10 

0a 

0.68 

0a 

0.88 

0a 

1.11 

1 

0.29 

0a 

4.20 

0a 

Work 
I work 

I do not work 

-0.32 

0a 

0.28 

0a 

0.26 

0a 

0.73 

1 

0.42 

0a 

1.3 

0a 

The number of 

current kids 

1 to 3 

4 to 6 or more 

-1.10 

0a 

0.74 

0a 

0.14 

0a 

0.33 

1 

0.08 

0a 

1.41 

0a 

Current child's 

age 

Less than 2 months 

2 to 4 months  

2 to 6 months 

-0.11 

0.34 

0a 

0.24 

0.24 

0a 

0.65 

0.12 

0a 

0.89 

1.44 

1 

0.56 

0.91 

0a 

1.43 

2.29 

0a 

Type of delivery 
Normal delivery 

Cesarean section 

0.17 

0a 

0.19 

0a 

0.39 

0a 

1.18 

1 

0.80 

0a 

1.74 

0a 

Current weight 

Less than 50 kg 

51 to 65 kg 

66 to 80 kg 

More than 80 kg 

-0.84 

-0.24 

-0.36 

0a 

0.40 

0.31 

0.34 

0a 

*0.04 

0.44 

0.28 

0a 

0.19 

0.79 

0.69

00a 

0.19 

0.43 

0.36 

0a 

0.95 

1.44 

1.35 

0a 

B: coefficient; SE: standard error; *statistically significant difference at p ≤ 0.05, 0a: 

reference category, OR: odds ratio. 

 

 



30 
 

4.8 Prevalence of positive and negative attitudes and behaviors toward exclusive 

breastfeeding 

According to the findings in table 6, the majority of nursing mothers, specifically 76.1% 

(n = 280), held negative attitudes and behaviors regarding exclusive breastfeeding. On 

the other hand, Figure 1 demonstrated that the remaining participants, accounting for 

23.9% (n = 88), had positive attitudes and behaviors. 

Table 6 

Prevalence of positive and negative attitudes and behaviors toward EBF 

 Frequency (n) Percent (%) 

 

Positive 

 

88 

 

23.9 

 

Negative 

 

280 

 

76.1 

 

Total 

 

368 

 

100.0 

 

Figure 2 

Prevalence of positive and negative attitudes and behaviors toward EBF 

 



31 
 

4.9 Logistic regression analysis of the association of attitudes and behaviors with the 

demographic characteristics for nursing women 

Table 7 in this study presented the association of the results between nursing mothers' 

demographics and their attitudes and behaviors. 

Notably, a significant relationship was observed between nursing mothers' attitudes and 

behaviors and three specific demographic factors. These factors include the age of the 

nursing mothers less than 18 years old (P = 0.00, OR = 7.26, CI: 3.88, 13.60), monthly 

income less than 500$ (P = 0.01, OR = 0.82, CI: 0.71, 1.41), and monthly income ranging 

from 500$ to 800$ (P = 0.02, OR = 0.85, CI: 0.74, 0.98). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



32 
 

Table 7 

Logistic regression of the association of attitude and behaviors with the demographic 

characteristics for nursing women: 

 B SE P Value OR 
C. I (95%) 

Lower Upper 

Age 

Less than 18 

19 to 29 

30 to 40 

41 or more 

1.98 

0.03 

0.09 

0a 

0.32 

0.10 

0.06 

0a 

*0.00 

0.81 

0.12 

0a 

7.26 

1.03 

1.10 

1 

3.88 

0.84 

0.98 

0a 

13.60 

1.26 

1.25 

0a 

Husband 

age 

30 or less 

31 to 40 

41 or more 

0.03 

0.02 

0a 

0.09 

0.08 

0a 

0.77 

0.83 

0a 

1.03 

1.02 

1 

0.86 

0.87 

0a 

1.23 

1.19 

0a 

Residency 
Camp or village 

City 

0.05 

0a 

0.15 

0a 

0.77 

0a 

1.05 

1 

0.78 

0a 

1.41 

0a 

Monthly 

income 

Less than 500$ 

500$ to 800$ 

More than 800$ 

-0.19 

-0.16 

0a 

0.08 

0.07 

0a 

* 0.01 

* 0.02 

0a 

0.82 

0.85 

1 

0.71 

0.74 

0a 

0.95 

0.98 

0a 

Level of 

education 

High school or less 

Bachelor degree or 

more 

-0.24 

0a 

0.16 

0a 

0.15 

0a 

0.79 

1 

0.57 

0a 

1.09 

0a 

Work 
I work 

I do not work 

-0.05 

0a 

0.06 

0a 

0.48 

0a 

0.96 

1 

0.84 

0a 

1.08 

0a 

The number 

of current 

kids 

1 to 3 

4 to 6 or more 

0.02 

0a 

0.17 

0a 

0.91 

0a 

1.02 

1 

0.73 

0a 

1.42 

0a 

Current 

child’s age 

Less than 2 months 

2 to 4 months 

4 to 6 months 

-0.03 

-0.06 

0a 

0.05 

0.05 

0a 

0.57 

0.27 

0a 

0.97 

0.94 

1 

0.87 

0.85 

0a 

1.08 

 1.05 

0a 

Type of 

delivery 

Normal delivery 

Cesarean section 

-0.02 

0a 

0.05 

0a 

0.60 

0a 

0.98 

1 

0.89 

0a 

1.07 

0a 

Current 

weight 

Less than 50 kg 

51 to 65 kg 

66 to 80 kg 

More than 80 kg 

-0.04 

-0.01 

-0.02 

0a 

0.09 

0.07 

0.08 

0a 

0.66 

0.91 

0.76 

0a 

0.96 

0.99 

0.98 

1 

0.80 

0.86 

0.84 

0a 

1.15 

1.14 

1.13 

0a 

B: coefficient; SE: standard error; *statistically significant difference at p ≤ 0.05, 0a: 

reference category, OR: odds ratio. 

 

 

 

 

 

 

 



33 
 

4.10 Discussion 

In this chapter, regarding to comprehensive analysis of the research results, the researcher 

examined the study's findings in light of existing literature, making comparisons to derive 

the key findings. Also, the researcher addressed hypothesis rejections, conclusion, 

recommendations, limitations of the study, strength of the study, and potential implication 

of the study.  

Based on the study findings, the researchers rejected both null hypotheses that posited no 

significant association between psychological factors (depression, anxiety, and stress) 

and exclusive breastfeeding, with a significance level of p-value ≤ 0.05. Furthermore, the 

study also demonstrated the rejection of the null hypothesis indicating the absence of a 

significant association between behaviors, attitudes, and exclusive breastfeeding, with a 

significance level of p-value ≤ 0.05. 

In Palestine, breastfeeding plays a vital role in the well-being of both mothers and infants. 

However, the term "exclusive breastfeeding" is not commonly used, and there is a lack of 

understanding about its significance, which subsequently influences the attitudes and 

behaviors of nursing mothers. Moreover, the association between breastfeeding practices 

and mental health has yielded diverse findings, emphasizing the importance of exploring 

this relationship further. 

With the importance of breastfeeding and its potential impact on mental health 

established, it is essential to delve into the prevalence of depression among nursing 

mothers in Palestine. Understanding the prevalence rates and risk factors for depression 

in this particular community will help shed light on the challenges they face and 

encourage the development of focused interventions to promote their well-being. 

It is important to compare and contrast our findings in this study with those of comparable 

research carried out in other areas and cultural contexts in order to put the prevalence of 

depression among nursing mothers in Palestine into context. 

In this particular study, the prevalence of depression symptoms among participants was 

noteworthy, with approximately more than half of them (50.8%) experiencing depression, 

classified into four severity levels ranging from mild to extremely severe. When 

compared to the global mapping of postpartum depression prevalence among nursing 



34 
 

mothers, the worldwide prevalence was found to be 17.22% (Wang et al., 2021). 

Interestingly, the highest prevalence was observed in Southern Africa (39.96%), while 

high-income countries and developing countries had the lowest prevalence rates (Wang 

et al., 2021), in addition to the Western countries since the prevalence ranged between 

10% and 15% (Faisal-Cury et al., 2013).  

The result of (Glasser et al., 2011) in Bedouin Palestinians, (Green et al., 2006) in United 

Arab Emiratis, and in Kazakhstan (Abenova et al., 2022) were consistent with our study, 

where the prevalence among exclusively nursing mothers was 43% , 44.2%, and 59.4%, 

respectively. Similarly, a high prevalence of postpartum depression among nursing 

mothers was observed in Egypt (73.7%), although the small sample size (n = 57) should 

be considered (Mohamed et al., 2014).  

On the contrary, high-income countries exhibited lower prevalence rates of postpartum 

depression compared to the findings of this study. Countries such as the China (6.7%) 

(Hegde et al., 2012), India (16%) (Hegde et al., 2012), Australia (20%) (Adhikari & 

Cooper-Stanbury, 2012), and Southern Brazil (14%) (Hartmann et al., 2017), reported 

similar lower prevalence rates. The observed variations and similarities between countries 

can be attributed to shared cultural contexts, socio-demographic factors, and economic 

conditions. 

Similarly, when examining the prevalence of anxiety among postpartum mothers, our 

study's findings warrant comparison with other research conducted in different countries. 

On one hand, high-income countries have reported lower prevalence rates of postpartum 

anxiety compared to our study's results. Anxiety prevalence varies between developed 

and developing countries, with rates ranging from 7% to 10% in developed nations 

(Andersson et al., 2003) and reaching 25% in developing countries (Shahhosseini et al., 

2015) among nursing mothers.  

The prevalence rate of anxiety in this study was 59.8%, with participants experiencing 

varying levels of anxiety, ranging from mild to moderate to severe and extremely severe. 

This finding closely aligns with the prevalence rates of postpartum anxiety reported in 

Iran (54.2%) (Alipour et al., 2018), Lebanon (67.7%) (Hobeika et al., 2023), and Saudi 

Arabia (67.6%) (Radwan et al., 2021). The similarities in prevalence rates between our 



35 
 

study and these Middle Eastern countries suggest a significant burden of postpartum 

anxiety in the region. 

Furthermore, upon comparing our results with other global studies, where prevalence 

rates were slightly lower, we found that Iraq had a rate of 37.5% of  postpartum anxiety 

among nursing women (Mishkin et al., 2018), in Egypt (32.85%) (Wassif et al., 2019), in 

Pakistan (28.8%) (N. S. Ali et al., 2009), in Brazil (20.2%) (Faisal-Cury et al., 2009), in 

Havana Cuba (20%) (Esquivel Lauzurique et al., 2022), in Italy (13.2%) (Giardinelli et 

al., 2012), and in Australia (12.7%) (Yelland et al., 2010). 

Researchers investigating mother mental health are becoming increasingly interested in 

and concerned about the prevalence of stress among postpartum nursing mothers. 

Globally, 44% of postnatal women experience stress. For instance, the prevalence rate of 

postpartum stress among Palestinian exclusively breastfeeding mothers was found to be 

68.5%. A comparison with other international studies reveals varying prevalence rates 

across different regions. In Lebanon, the reported prevalence was 50% (Hamade et al., 

2013), while in Jordan, it was as high as 75% (Moh'd Yehia et al., 2013). Similarly, among 

Mexican women during the COVID-19 pandemic, the prevalence of postpartum stress 

was reported to be 46.1% (Suárez-Rico et al., 2021), and in New Zealand, it reached 55% 

(Signal et al., 2017). Understanding the prevalence of postpartum stress globally can 

assist in developing targeted interventions and support systems to address the unique 

needs of postpartum nursing mothers especially in Palestine. 

The sociodemographic elements on mental well-being, including depression, anxiety, and 

stress, significantly impact on the patterns and practices of exclusive breastfeeding.  

 In our study by using a regression analysis to find the relationship, there was a significant 

relation between postpartum depression among Palestinian nursing women and the age 

of the current child, particularly within the range of 2 to 6 months (P = 0.03, OR = 1.66, 

CI: 1.03, 2.67).  

Studies highlighted a significant link between psychological factors such as depression, 

anxiety, and stress with the sociodemographic data such as residency place, place of 

delivery, and child’s age (Mekebo et al., 2022). According to the studies, postpartum 

depression may vary in frequency and severity depending on the age of the child at the 



36 
 

time of assessment. That is indicated and supported by (Liu et al., 2023) in a study which 

concluded that postpartum depression among breastfeeding mothers has an impact on 

exclusive breastfeeding. Regardless, studies provide evidence for the immediate 

influence of postpartum depression on infant, while indicating a lack of enduring effects 

over an extended period (Stewart et al., 2003).  

In Italy, a study supported our findings; researchers concluded that breastfeeding mothers 

exhibited high scores of postpartum depression, particularly when the infant age was three 

months old up to six months of age (Vismara et al., 2016). Agreed with a study conducted 

in the United Kingdom and Taiwan, taking into consideration the notably higher quality 

of care in the United Kingdom (Huang & Mathers, 2001). While in a study in the 

University of Minnesota in United State of America which investigated the severity of 

postpartum depression severity from 0 to 9 months, the prevelnace of severity was 7% at 

two months of age which alighn with our study findings, in comaprsion with the highest 

prevelance at 0 to 1 months of age (12.5%) (Gjerdingen et al., 2011).  

In contrast, in a meta anlysis the prevlenace of postpartum depression were higher in 

childrean aged six months up to one year of age (21.9%) (Gaynes et al., 2005). Same in 

another studies counducted by (Netsi et al., 2018) in England (6.8%), and in Greece 

(12.9%) up to one year (Gonidakis et al., 2008).  

Similar patterns emerged concerning the relation between the assessment timing during 

the postpartum phase, reflecting the child's age, and the presence of postpartum anxiety 

symptoms. Within our study, a significant association was identified solely between 

postpartum anxiety among Palestinian exclusively breastfeeding mothers and infants 

aged two to four months (P = 0.00, OR = 2.12, CI: 1.33, 3.39). 

For instance, in Pakistan the highest prevalence of postpartum anxiety was at age one 

year (13.1%) while it was less among women after six months (10.1%), and slightly lower 

and similar at ages one to two months (5.2%) (Ali et al., 2009). Agreed with a systematic 

review (OR = 2.64, CI: 2.02, 3.46), and in Grand Fork in United State of America the 

prevalence of postpartum anxiety at eight weeks were the highest (56%).  

Despite the varying prevalence rates in the relationship between postpartum anxiety and 

the assessment timing, which corresponds to the child's age, a significant connection 



37 
 

persists. Our study specifically zoomed in on the age range of two to four months, as no 

other associations were observed with different time points. 

Within this context, our study's identification of significant associations between 

postpartum stress and specific sociodemographic variables is essential for a deeper 

understanding of how various factors influence exclusively nursing mothers. In this study, 

a significant association was presented between postpartum stress and the age of the 

mothers' husbands, specifically within the range of 31 and 40 years old (P = 0.04, OR = 

2.13, CI: 1.01, 4.49).  

The association between the husband's age and postpartum stress, as found in this study 

among Palestinian exclusively breastfeeding women, appears to be a unique, as no 

previous studies have identified or discussed this specific relationship. However, many 

studies have focused on parental adjustments and adaptation and the stress experienced 

by parents following the birth of a child. 

Additionally, a significant relationship was observed between the current weight less than 

50 kg of Palestinian nursing mothers and postpartum stress (P = 0.04, OR = 0.19, CI: 

0.19, 0.95). In a study by (Leonard, 2017) a consistent results were identified about the 

significant relation between postnatal mothers’ weight and postpartum stress, in Leonard 

study no specific weight mentioned. Also, same results appeared among American 

women between six months up to one year postpartum in a study conducted by (Whitaker 

et al., 2014). 

An examination of the prevalence rates of positive and negative attitudes and behaviors 

towards breastfeeding in Palestine identifies an important relationship between attitudes, 

behaviors, and factors such as sociodemographic characteristics, cultural norms, and 

different practices. 

Despite the fact that 53.9% of Palestinian women exclusively breastfeed their infants 

(55% in Gaza Strip and 52.9% in the West Bank), according to Nassar's 2019 study 

(Nassar, 2019), this supported by a study conducted by Qanadelo in 2010 in Nablus city 

in West Bank that 70% of nursing women believes breastfeeding and they are exclusively 

breastfeed (Qanadelo, 2010). 



38 
 

However, in Palestine, the prevalence rates of positive and negative attitudes and 

behaviors toward exclusively nursing mothers were found to be 23.9% and 76.1%, 

respectively, according to the findings of this study. Consistent with these outcomes, 

researcher found another instance of elevated prevalence concerning extremely negative 

attitudes toward exclusive breastfeeding in Lebanon (90.8%) while only 9.2% was the 

prevalence of positive part (Naja et al., 2022). 

Poland was in the middle, exhibiting a prevalence rate of 46.6% for negative attitudes and 

behaviors toward exclusive breastfeeding (Olejnik et al., 2020). Similarly, among 

Chinese women, a rate of 54.7% was observed for negative attitudes and behaviors 

associated with insufficient knowledge about breastfeeding (Zhou et al., 2010). This 

observation aligns with a study conducted in Honolulu, United States of America, where 

approximately half of the participants exhibited both positive and negative attitudes and 

behaviors regarding exclusive breastfeeding (Mitchell-Box et al., 2013). Also agreed with 

a study in Nigeria with a rate of 52.1% for positive one (Leshi et al., 2016). 

In contrast of this study findings, results were observed in a different context, where 

researchers identified notably low prevalence of negative attitudes toward exclusive 

breastfeeding in Northwest Ethiopia (24%), with a contrasting prevalence of positive 

attitudes at 76% (Alamirew et al., 2017). Corroborating this finding, a study undertaken 

at King Saud University Medical Center in Saudi Arabia reported a significant rate of 

80.8% for positive behaviors and attitudes (Alnasser et al., 2018).  

Attitudes and behaviors toward exclusive breastfeeding are not only influenced by 

individual preferences but also by multiple factors, including sociodemographic 

characteristics, that shape cultural norms and values. In the context of Palestine, 

understanding the relationship between these sociodemographic factors and the 

prevalence of positive and negative attitudes towards exclusive breastfeeding is 

important. 

Providing a comprehensive comparison among various studies conducted in both low- 

and middle-income (LMIC) and high-income countries and comparing them with this 

study gives an important insight into the factors influencing and their relationship with 

exclusive breastfeeding. 



39 
 

Notably, a significant relationship was observed between nursing mothers' attitudes and 

behaviors and the age of the nursing mothers (P = 0.00, OR = 7.26, CI: 3.88, 13.60). This 

result aligns with a study conducted in four European countries (Scotland, Spain, Sweden, 

and Italy) using Lowa Infant Feeding Attitude Scale (LIFAS) (P= 0.038) (Scott et al., 

2015). Same in Saudi Arabia in a study conducted among Mothers in Princess Nourah 

Bint Abdulrahman University (P = 0.006).  

Also, the age had a significant association of sociodemographic characteristics and birth 

in relation to exclusive breastfeeding attitudes and behaviors among Qatari and Lebanese 

women (OR = 3.47, CI: 1.07.11.21) (Naja et al., 2022). Similar in Northwest Ethiopia 

women aged 45 years or older exhibited 1.44 times higher odds (OR = 1.44, CI: 1.12, 

5.59; P < 0.05) compared to those under the age of 25 with a significant relation between 

nursing mothers age and the positive or negative attitudes and behaviors toward exclusive 

breastfeeding (Chekol Abebe et al., 2022). Among Polish women aged less than 25 years 

old, negative attitudes and behaviors towards exclusive breastfeeding were three times 

higher than those of older women (OR = 3.05, 95% CI: 1.82, 5.12) (Olejnik et al., 2020). 

Additionally, the monthly income in this study was found to be significantly associated 

with the attitudes and behaviors toward exclusive breastfeeding among Palestinian 

women, particularly those with a monthly income of less than $500 and those with 

incomes ranging from $500 to $800, with a significance level of (P = 0.01, OR = 0.82, 

CI: 0.71, 1.41) and (P = 0.02, OR = 0.85, CI: 0.74, 0.98) respectively. In an Indonesian 

study, a consistent result was noted, highlighting the significance of monthly income in 

relation to exclusive breastfeeding, with a P value of 0.047 (Shofiya et al., 2020). 

Also, a study in Somaliland showed same significance of family income ranged from 

100$ to 200$ (OR = 0.35, CI: 0.18, 0.68) (Jama et al., 2020). Another study conducted in 

the Fafan zone of the Somali Regional State in Ethiopia corroborated the findings of the 

previous studies. The results indicated that a monthly income ranging from 500 birr to 

2000 birr (equivalent to $9.07 to $36.27) and a monthly income ranging from 2001 birr 

to 3500 birr (equivalent to $36.29 to $63.47) exhibited statistical significance, with odds 

ratios of (OR = 2.7, CI: 1.4, 5.2) and (OR = 2.2, CI: 1.2, 4), respectively (Tadesse et al., 

2019). 



40 
 

In contrast, no significant relationship was identified between sociodemographic 

characteristics, including monthly income and nursing mother age, and attitudes and 

behaviors about exclusive breastfeeding, as presented in a study conducted at the 

University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia (Ishak et al., 

2014). 

However, no other significant demographic factors in this study were found to have a 

relationship with attitudes and behaviors toward exclusive breastfeeding among 

Palestinians, such as parity, level of education, residency place, husband age, number of 

current children, or weight.  

In summary, the study found that there were high prevalence rates of depression, stress, 

and anxiety among Palestinian nursing mothers who practiced exclusive breastfeeding. 

Additionally, the study revealed that both negative and positive attitudes and behaviors 

towards exclusive breastfeeding were prevalent among these mothers. The majority of 

the studies' in different countries findings were consistent, showing a significant link 

between breastfeeding and mental health outcomes including depression, stress, and 

anxiety and with positive and negative attitudes and behaviors. However, a few of the 

studies' results showed slightly different trends when compared to the overall findings of 

the study.  

In addition, regarding the relationship between sociodemographic characteristics and 

depression, anxiety, stress, as well as attitudes and behaviors among Palestinian women 

exclusively practicing nursing, a significant relationship emerged during the discussion. 

Depression and anxiety exhibited a significant association with the age of the last baby, 

while stress demonstrated links with both maternal weight and the age of their husbands. 

Maternal age and monthly income were found to influence attitudes and behaviors. 

The overwhelming majority of studies supported these associations, although one study 

showed no relationship between attitudes and behaviors toward exclusive breastfeeding 

and the mother's age or family's monthly income. 

 

 



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4.11 Conclusion 

Breastfeeding is essential for the health of Palestinian mothers and infants. However, the 

concept of "exclusive breastfeeding" is not well understood, which results in a lack of 

knowledge about its importance. Nursing mothers' attitudes and behaviors are 

subsequently impacted by this. Different findings on the association between 

breastfeeding practices and outcomes related to mental health highlight the need for 

additional research. 

Understanding the frequency of depression among nursing mothers in Palestine is 

essential, given the significance of breastfeeding's impact on mental health. Insights into 

the difficulties these mothers confront can be gained by determining depression 

prevalence rates and risk factors among Palestinian nursing mothers, enabling focused 

interventions to improve their well-being. 

A comparison with comparable studies from other areas and cultural situations was 

important to contextualize the prevalence of depression among nursing mothers in 

Palestine. Significantly, the prevalence of depression was significant in this study, with 

over half of the participants experiencing various levels of severity from mild to 

extremely severe. When compared to global figures, the worldwide prevalence was lower, 

highlighting a specific concern within the Palestinian context. 

Similar findings were observed regarding anxiety among postpartum nursing mothers. 

This study’s prevalence finding aligned with rates reported in other Middle Eastern 

countries, indicating a notable burden of postpartum anxiety in the region. Although there 

are regional variations in prevalence, a worldwide understanding of anxiety prevalence 

will enhance the interventions for women. 

Sociodemographic factors significantly influence mental well-being, impacting exclusive 

breastfeeding patterns. A significant relationship was identified between postpartum 

depression and anxiety and the age of the last child. Studies corroborated this link, with 

some studies highlighting the immediate impact of postpartum depression on infants from 

the feeding point. 

Furthermore, a significant relationship emerged between postpartum stress and 

sociodemographic factors, such as the age of mothers' husbands and maternal weight. 



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This association was distinct and previously unexplored, offering novel insights into the 

stress experienced by postpartum nursing mothers. 

Attitudes and behaviors toward exclusive breastfeeding are molded by sociodemographic 

factors and cultural norms. In this study, the prevalence rates of positive and neg