Abstract

Background

Breastfeeding self-efficacy signifies a mother鈥檚 confidence in her ability to breastfeed. Sleep quality, on the other hand, refers to the effectiveness of sleep. Low sleep quality is a common issue faced by new mothers during the postpartum period. It remains unclear whether there is a connection between a mother鈥檚 perception of breastfeeding self-efficacy, which has a positive effect on breastfeeding, and sleep quality during the postpartum period. This study aims to determine the relationship between sleep quality and breastfeeding self-efficacy among primiparous mothers during the postpartum period, while also examining the impact of different demographic factors.

Materials and methods

This descriptive study included 316 primiparous women who delivered babies in Damascus, Syria. Data were gathered using a questionnaire comprising 53 questions divided into three sections: demographic information, the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), and the Pittsburgh Sleep Quality Index (PSQI). Participants鈥� answers were collected via telephone interviews conducted by the authors, along with an electronic version of the questionnaire that was distributed online. IBM SPSS was used to perform descriptive statistics, independent t-tests, one-way ANOVA, MANOVA, post hoc tests, and Pearson correlation analyses. A P-value of <鈥�0.05 was considered to indicate statistical significance for all the analyses.

Results

A significant negative correlation emerged between maternal breastfeeding self-efficacy and PSQI scores. The gender distribution of the newborns yielded significant differences in maternal sleep quality as assessed using the PSQI but not in terms of the mean score on the BSES-SF. Maternal age was positively correlated with maternal breastfeeding self-efficacy and PSQI scores. Regarding education level and overall sleep quality, a significant difference was observed, as mothers with higher education levels tended to have lower overall sleep quality, but no relation to breastfeeding self-efficacy was detected. The multivariate analysis showed a positive correlation between breastfeeding self-efficiency and higher financial status. No significant differences were found in relation to type of delivery or infant age or residential factors.

Conclusions

Research findings indicated a positive correlation between the breastfeeding self-efficacy of postpartum women and their overall sleep quality, with an observed increase in breastfeeding self-efficacy as sleep quality improved.

Background

Childbearing encompasses the multifaceted journey of pregnancy, childbirth, and the transition to motherhood. During this time, women navigate a myriad of emotions and physiological changes [1]. The adaptation process commences immediately after delivery, as the family dynamic evolves with the introduction of a new member. This period signifies a substantial shift within the family structure characterized by the adoption of new roles, responsibilities, and the care of the infant [2]. Mothers, as primary caregivers, undergo significant psychological, physical, and social transformations [2, 3]. These alterations can present challenges that profoundly impact their quality of life, especially for first-time mothers, known as primiparas. Commonly reported postpartum issues include fatigue, breast complications, sleep disturbances, urinary or gastrointestinal problems, and emotional distress [2]. Fatigue is the predominant health concern among postpartum women and is intricately linked to sleep disruption [4]. Sleep serves as a crucial physiological necessity, mitigating both physical and mental exhaustion [2]. Buysse et al. conceptualized 鈥渟leep quality鈥� as sleep effectiveness, encompassing aspects such as subjective sleep quality, sleep duration, sleep latency, disturbances, medication use, habitual sleep efficiency, and daytime functionality [5]. Research indicates that suboptimal sleep or poor sleep quality during the postpartum phase detrimentally influences maternal health and can adversely affect newborn care [2].

The early postpartum stage is pivotal for initiating and sustaining breastfeeding [4]. Breast milk, as the optimal nutritional source, fosters healthy infant growth and development. Global health authorities, including the World Health Organization (WHO) and the United Nations Children鈥檚 Fund (UNICEF), advocate exclusive breastfeeding for the initial six months of an infant鈥檚 life, without supplementary food or water [2]. Breastfeeding duration is influenced by an array of demographic factors, such as maternal age, marital status, education level, and income. Additionally, psychological and social elements, including the mother鈥檚 breastfeeding intent and support from healthcare professionals and partners, are critical considerations [6]. Breastfeeding self-efficacy, rooted in Bandura鈥檚 social cognitive theory, is a key determinant of breastfeeding success. It reflects the mother鈥檚 confidence in her ability to breastfeed effectively and influences the initiation, effort invested, and response to breastfeeding challenges [3, 6]. The relationship between sleep quality and breastfeeding self-efficiency has been established in recent studies. Sleep quality positively correlates with BSE levels, as better sleep is associated with higher confidence in breastfeeding [2]. Similarly, low sleep quality among postpartum mothers negatively affects their BSE, probably due to stress, fatigue, and reduced ability to handle breastfeeding challenges [3]. Breastfeeding difficulties, often linked to lower BSE, may exacerbate sleep disturbances, which undermines mothers鈥� well-being [3]. Contrarily, some studies noted that breastfeeding during the early postpartum period may promote better maternal sleep patterns, underlining the bidirectional relationship between sleep and breastfeeding [1]. Studies have highlighted a notable prevalence of breastfeeding-associated sleep disorders among postpartum women [3]. The milk-producing hormones prolactin and oxytocin are secreted in accordance with the circadian rhythm. Sleep disruptions can interfere with the production of these hormones, potentially leading to reduced milk volume and supply issues [4]. Conversely, insufficient sleep, fatigue, and diminished concentration can impede the energy necessary for breastfeeding [2, 3], while other research suggests that breastfeeding may enhance sleep quality during postpartum recovery [1].

This study aimed to explore the correlation between sleep quality and breastfeeding self-efficacy in primipara mothers throughout their infants鈥� inaugural year in Damascus, Syria. It also examined the influence of demographic variables on these two critical aspects of postpartum well-being.

Methods

Study design and participants

This cross-sectional study was conducted from September 30 to November 30, 2023, aiming to explore the correlation between sleep quality and breastfeeding self-efficacy in postpartum primiparous women. The research employed telephone interviews and an electronic version of the questionnaire with eligible primiparous mothers who were currently breastfeeding; these interviews utilized reliable and validated questionnaires. To ensure the integrity and dependability of the research methodology, interviews were carried out by the investigators themselves.

Prior to the interviews, participants were provided with a consent form elucidating the study鈥檚 aims and methodologies. Their involvement was predicated on the return of the signed form, indicating compliance with the established inclusion criteria. Among the respondents, 90% (n鈥�=鈥�284) consented to participate, 8% (n鈥�=鈥�25) declined, and 2% (n鈥�=鈥�7) remained nonresponsive. The questionnaire was administered during the telephone interviews and via an electronic version of the questionnaire, with each session lasting approximately 10听min. Ethical approval for this study was granted by the Ethical Committee of Damascus University鈥檚 Faculty of Medicine, Syria, under serial number MD-160124-166. The study adhered to the ethical standards delineated in the Declaration of Helsinki.

This study recruited 316 female volunteers, 200 of whom were interviewed via telephone at the University Hospital of Obstetrics and Gynecology in Damascus, the city鈥檚 largest obstetrics hospital. An electronic version of the questionnaire was distributed to 116 primiparous mothers to ensure the representation of mothers who may have faced geographical or logistical barriers that might prevent them from participating in telephone interviews. This approach allowed us to include participants from diverse socioeconomic and regional backgrounds, ensuring a more inclusive participant pool. All participants received comprehensive information regarding the study鈥檚 objectives and were assured that their participation was strictly voluntary. Stringent protocols were established to maintain the confidentiality and anonymity of personal data throughout the research process. Inclusion criteria specified breastfeeding primiparous mothers aged between 15 and 46 years, with infants aged 1 to 365 days, and who expressed their willingness to provide informed consent. The exclusion criteria included multiparous women, those who declined participation, nonrespondents, individuals unable to complete the questionnaire, and mothers who had experienced neonatal loss.

Measures

The study鈥檚 data collection instrument was a comprehensive questionnaire comprising 53 items segmented into three sections: demographic information, the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), and the Pittsburgh Sleep Quality Index (PSQI).

Demographic information

The questionnaire solicited demographic information through 15 queries encompassing age, marital status, educational attainment, employment status, economic condition, domicile status (urban or rural), chronic or psychological health conditions, and particulars regarding pregnancy and the newborn (initial pregnancy, first childbirth, antecedent miscarriage, type of delivery, postnatal complications, interval since preceding pregnancy, and the neonate鈥檚 age and gender).

Breastfeeding Self-Efficacy Scale-Short form (BSES-SF)

The Arabic version of the 14-statement BSES-SF, which is a shortened form of the original, was utilized. Participants were asked to rate their level of agreement on a 5-point Likert scale, with 1 indicating a complete lack of confidence and 5 signifying unwavering confidence. The scores ranged from 14 to 70, with higher scores indicating greater confidence in breastfeeding. The BSES-SF was designed to identify mothers who are at increased risk, assess attitudes and thoughts about breastfeeding, develop strategies to boost confidence, evaluate the effectiveness of interventions, and inform future initiatives. The scale demonstrated a reliability coefficient of 0.95, and it showed strong discriminant validity and construct validity [7].

Pittsburgh sleep quality index (PSQI)

The Arabic version of the PSQI was utilized; it encompasses 19 items amalgamated into seven components: subjective sleep quality, sleep onset latency, sleep duration, sleep disruptions, habitual sleep efficiency, use of sleep medication, and diurnal dysfunction. The components were rated on a 0 to 3 scale, with 0 indicating no occurrence and 3 indicating a frequency of three or more times weekly. The cumulative score ranged from 0 to 21, with scores above 5 denoting poorer sleep quality. The PSQI reliability coefficient was 0.82 [8].

Statistical analysis

The data were recorded on a Google form and subsequently exported to an Excel spreadsheet for analysis. To analyse the data, IBM SPSS (version 23, SPSS, Inc., software package) was used to conduct descriptive statistics, including means, frequencies, percentages, and standard deviations for demographic variables. Independent sample t-tests, Pearson correlation tests, ANOVA and MANOVA were applied to investigate the relationships between various demographic factors and scores on the BSES-SF and PSQI. Additionally, post hoc tests were conducted to explore the association between education level and PSQI score. A significance level of <鈥�0.05 was employed for all analysis tests.

Results

Demographic characteristics

This study included 316 female participants, from whom comprehensive data pertaining to education, residency, pregnancy, childbirth, and financial status were obtained. The gender distribution of the newborns was 166 males (52.5%), 142 females (44.9%), and eight twins (2.5%). The participants鈥� ages ranged from 15 to 46 years, with a mean age of 24.31 years (SD鈥�=鈥�5.590). The newborns鈥� ages varied from 1 to 365 days, with an average age of 80.28 days (SD鈥�=鈥�102.901). These demographic characteristics offer a thorough representation of the study cohort and constitute crucial information for subsequent analyses and the formulation of meaningful conclusions. An additional file shows this in more detail [see Additional file 1].

The statistical exploration of factors influencing breastfeeding self-efficacy and sleep quality

The statistical analysis of a dataset of 316 participants aimed to explore the relationship between various factors and scores on the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) and Pittsburgh Sleep Quality Index (PSQI). The data were analysed using independent sample t-tests for different groups. The factors investigated included complications after childbirth, the gender of the newborn, the type of delivery, the history of psychological or chronic illness, previous miscarriage, and residential status.

Among the various factors examined, the gender of the newborn yielded significant differences in maternal sleep quality as assessed using the PSQI. Mothers of male newborns exhibited a significantly lower mean PSQI total score (M鈥�=鈥�1.33, SD鈥�=鈥�0.861) than mothers of female newborns did (M鈥�=鈥�1.31, SD鈥�=鈥�0.916), indicating better sleep quality in the former group (p鈥�=鈥�0.008). This finding suggested that the gender of the newborn may be associated with variations in maternal sleep patterns, potentially influenced by factors such as caregiving responsibilities or newborn-related sleep disruption.

Regarding complications after childbirth, the mean BSES-SF total score for participants who experienced complications was 49.39 (SD鈥�=鈥�11.804), while those without complications had a mean score of 51.10 (SD鈥�=鈥�12.716). The t-test results indicated no significant differences between the groups (p鈥�=鈥�0.347). Similarly, no significant difference was found in the total PSQI score between the groups (p鈥�=鈥�0.808). In terms of the gender of the newborns, the mean BSES-SF total score was 51.73 (SD鈥�=鈥�12.677) for mothers of male newborns and 49.72 (SD鈥�=鈥�12.220) for mothers of female newborns. A t-test showed no significant difference (p鈥�=鈥�0.158).

Regarding the type of delivery, no significant differences in the BSES-SF or PSQI scores were found between mothers who delivered naturally and those who delivered via cesarean section. Other factors, such as a history of psychological illness, chronic illness, previous miscarriage, and residential status, were also examined, and no significant differences were observed in the BSES-SF or PSQI scores between the relevant groups.

Correlational insights into maternal age, infant age, breastfeeding self-efficacy, and sleep quality

Correlation analysis aimed to explore the relationships among maternal age, infant age, maternal breastfeeding self-efficacy (BSES-SF total), and Pittsburgh Sleep Quality Index (PSQI) total score. The results revealed significant correlations in the dataset. Mothers鈥� age was significantly positively correlated with maternal breastfeeding self-efficacy (r鈥�=鈥�0.207, p鈥�<鈥�0.01) and PSQI scores (r鈥�=鈥�0.170, p鈥�<鈥�0.01). This suggested that as mothers鈥� age increased, their confidence in breastfeeding increased, while overall sleep quality tended to decrease (higher PSQI scores indicate poorer sleep quality). However, no significant correlations were found between infant age and maternal breastfeeding self-efficacy (r = -0.031, p鈥�=鈥�0.585) or overall sleep quality (r = -0.064, p鈥�=鈥�0.257). Additionally, a negative correlation emerged between maternal breastfeeding self-efficacy and PSQI scores (r = -0.162, p鈥�<鈥�0.01), indicating that maternal confidence in breastfeeding tended to increase as overall sleep quality increased (lower PSQI scores indicate good sleep quality). These findings underscore the intricate interplay between maternal age, infant age, breastfeeding self-efficacy, and sleep quality, highlighting the need for further exploration in the context of breastfeeding and sleep. We conducted an analysis stratified by infant age groups (neonatal period: 1鈥�28 days, early infancy: 1鈥�3 months, and later infancy: 4鈥�12 months) to examine differences in breastfeeding self-efficacy, sleep quality, and postpartum bonding. Although this analysis was completed, no statistically significant differences were found across the age groups for any of these variables.

Exploring the impact of education and financial status on maternal well-being

One-way analysis of variance (ANOVA) was used to investigate the influence of education level and financial status on maternal breastfeeding self-efficacy (BSES-SF total) and Pittsburgh Sleep Quality Index (PSQI) total scores. There were no significant differences in the relationship between education level and breastfeeding self-efficacy (F鈥�=鈥�1.079, p鈥�=鈥�0.348). Similarly, financial status did not significantly impact breastfeeding self-efficacy (F鈥�=鈥�1.185, p鈥�=鈥�0.206). However, when exploring the relationship between education level and overall sleep quality, a significant difference was observed (F鈥�=鈥�2.775, p鈥�=鈥�0.042). Post hoc tests using Tukey鈥檚 honest significant difference (HSD) test revealed specific group differences. Notably, individuals with higher education levels tended to have lower overall sleep quality than did those with lower education levels (mean difference = -0.618, p鈥�=鈥�0.042). Additionally, a detailed breakdown of homogeneous subsets indicated variations in the PSQI total means across educational levels. This analysis provides valuable insights into the interplay between education, financial status, breastfeeding self-efficacy, and sleep quality in the context of maternal well-being.

Additional statistical insights on financial and residential factors

Further statistical analysis was conducted using multivariate analysis of variance (MANOVA), Pearson correlation, and independent sample t-tests to further elucidate the relationships between financial status, residential factors, and maternal outcomes. MANOVA results indicated that urban residence was associated with slightly better sleep quality (lower PSQI scores) compared to rural residence; however, the observed differences were not statistically significant (Wilks鈥� Lambda鈥�=鈥�0.985, F(1, 314)鈥�=鈥�3.441, p鈥�=鈥�0.065, 畏虏 = 0.01, small effect). Financial status, examined through Pearson correlation, exhibited a weak but statistically significant positive correlation with breastfeeding self-efficacy (r鈥�=鈥�0.110, p鈥�=鈥�0.048, small effect), implying that mothers with greater financial resources might feel more confident in their breastfeeding abilities. Independent sample t-tests revealed that urban mothers had a mean PSQI score of 1.28 (SD鈥�=鈥�0.842) compared to 1.40 (SD鈥�=鈥�0.911) for rural mothers, aligning with the overall trend but not achieving statistical significance (t(314) = -1.842, p鈥�=鈥�0.066, Cohen鈥檚 d鈥�=鈥�0.14, small effect). These findings underscore the multifaceted influences of socioeconomic and environmental factors on maternal health and well-being and highlight areas for further investigation using more nuanced and longitudinal methodologies.

Discussion

The postpartum period is a critical phase in a mother鈥檚 life and is marked by various mental, social, and physical challenges [3]. During this time, mothers endeavor to adjust to their new roles and address the needs that arise with the addition of a new family member [2]. Consequently, it is essential to examine the factors influencing women鈥檚 quality of life in the postpartum period, such as sleep quality and breastfeeding self-efficacy, along with their associated variables. In our study, we explored the connection between breastfeeding self-efficacy and sleep quality among first-time mothers during the postpartum period. The mothers in our study achieved an average score of 50.78鈥壜扁��12.551 on the breastfeeding self-efficacy scale. Comparatively, in Izmir, the scores were 51.21鈥壜扁��6.95 at week 1 postpartum and 64.54鈥壜扁��9.65 at week 8 postpartum [9], while another Turkish study reported an average BSES-SF score of 55.5鈥壜扁��8.8 [10]. A Colombian study reported an average score of 55.88鈥壜扁��10.85 [11]. We hypothesize that the lower observed breastfeeding self-efficacy may be attributed to the sample consisting of first-time mothers, who may lack sufficient education and knowledge about breastfeeding practices. The average score from the PSQI scale in our research was 8.71鈥壜扁��3.554. This contrasts with a Turkish study鈥檚 average score of 10.1鈥壜扁��3.5 [12]; a southern Taiwanese study鈥檚 22.82鈥壜扁��8.16 [13], and a Korean postpartum study鈥檚 17.5鈥壜扁��6.9 [14]. Our findings suggested a relatively greater sleep quality among mothers compared to other studies. Possible explanations for these differences could include inadequate adaptation to hormonal and physical changes, as well as the challenges of caregiving and meeting an infant鈥檚 needs [2, 15]. The differences in sleep quality observed in our study compared to the other studies may also be attributed to variations in maternal and infant characteristics. For instance, the mean maternal age in our study was 24.31 years, while in the other studies, it was approximately 30 years. Additionally, the broad age range of infants in our study (1鈥�365 days) differs from the other studies that focused on narrower age groups, such as 6 weeks or 6 months. Furthermore, cultural practices in Syria, such as receiving postpartum support from family members, may help alleviate caregiving burdens and enhance maternal sleep quality. This support system could partly explain the relatively better sleep quality observed in our sample compared to other populations. Our analysis revealed a negative correlation between the BSES-SF score and PSQI score (r = -0.162, p鈥�<鈥�0.01), suggesting that as mothers鈥� sleep quality improves, so does their breastfeeding self-efficacy in the postpartum period. This is consistent with the findings of Aksu & Y谋lmaz and Bay et al. [2, 3]. In Bay et al.鈥榮 study, the authors investigated the impact of sleep quality on the breastfeeding self-efficacy of 52 new mothers during the first, sixth, and 12th weeks postbirth. Their findings indicated that mothers with good sleep quality had increased BSES scores at each follow-up, while those with poor sleep quality experienced a decrease [3], thus supporting our study鈥檚 results. It is well documented that prolactin levels typically rise during sleep, and sleep deprivation can hinder the proper release of prolactin into the bloodstream, negatively affecting lactation and, consequently, mothers鈥� breastfeeding self-efficacy [16]. In this context, it is inferred that mothers with high-quality sleep are likely to produce an adequate milk supply, and their energy and enthusiasm for breastfeeding are bolstered, leading to increased satisfaction and perceived self-efficacy [2]. Although our findings indicate a relationship between maternal breastfeeding self-efficacy and sleep quality, this relationship may partially reflect breastfeeding exclusivity status. However, our study did not record data on breastfeeding exclusivity (exclusive, mixed, or formula feeding), which is a limitation. Exclusive breastfeeding has been associated with improved maternal sleep quality due to hormonal and behavioral factors. It is possible that breastfeeding self-efficacy serves as a marker for exclusivity, which may explain its association with sleep quality. Furthermore, our study did not collect data on specific feeding methods, limiting our ability to analyze whether breastfeeding self-efficacy translated into tangible changes in feeding practices. Future research should prioritize collecting feeding method data to explore how maternal self-efficacy impacts actual feeding practices and whether these practices influence maternal sleep quality and well-being. Additionally, future studies should investigate the potential mediation of feeding practices in the relationship between self-efficacy and sleep quality. Interventions aimed at improving breastfeeding self-efficacy should also consider the influence of breastfeeding exclusivity on maternal well-being. We believe that recommendations for exclusive breastfeeding for infants under 6 months of age may lead to increased maternal stress, particularly during the early postpartum period. Achieving exclusive breastfeeding goals during this period may pose unique challenges. Interventions should address the increased stress associated with exclusive breastfeeding, and provide targeted support to improve maternal health and breastfeeding outcomes.

In this study, we included 8 twins, as their small number (representing only less than 3% of the total sample) did not significantly affect the overall results. The large sample size of singleton births ensured the robustness of our findings. However, given the unique challenges faced by mothers of twins, further research specifically focusing on this subgroup is warranted to better understand how twin pregnancies may influence breastfeeding efficacy and sleep quality.

We also discovered a significant positive correlation between mothers鈥� age and both breastfeeding self-efficacy (r鈥�=鈥�0.207, p鈥�<鈥�0.01) and PSQI scores (r鈥�=鈥�0.170, p鈥�<鈥�0.01), indicating that older mothers tend to have greater breastfeeding self-efficacy but poorer sleep quality. Our observations regarding breastfeeding self-efficacy are in line with various studies [17, 18, 19, 20], yet they contrast with findings from other studies [21, 22, 11]. The observed variation in breastfeeding self-efficacy may be attributed to differences in the study samples. Eslami et al. reported that among 460 mothers, those older than 35 years exhibited greater breastfeeding self-efficacy, which tended to increase with age. This could be due to older mothers having more breastfeeding experience, which in turn may enhance their proficiency in breastfeeding practices [23]. Considering that our sample consisted solely of first-time mothers with no prior breastfeeding experience, we suggest that the improved breastfeeding self-efficacy of older mothers may be linked to their greater maturity and problem-solving capabilities. Furthermore, our study revealed a positive and significant correlation between maternal age and PSQI scores, indicating that older mothers tend to have poorer sleep quality. Wen et al.鈥榮 cross-sectional study indicated that women older than 35 years were three times more likely to suffer from poor sleep quality three months after delivery than younger women were, possibly because natural aging affects sleep disturbance and efficiency [24]. Similarly, a meta-analysis by Yang et al. reported a higher incidence of poor sleep quality among older women, which may result from increased physical discomfort, slower postpartum recovery, and heavier domestic responsibilities [25]. These findings align with our research.

Intriguingly, our study also revealed a significant association between maternal education level and sleep quality. Mothers with higher education levels experienced worse overall sleep quality than did those with lower education levels, contrary to a Northwest Ethiopian study in which women with secondary education had poorer sleep quality compared to those with higher education [26]. It is hypothesized that educated mothers, particularly in economically challenging environments, face increased responsibilities that may exacerbate sleep disturbances and anxiety. Nonetheless, our study did not find a significant relationship between maternal education and breastfeeding self-efficacy, which is consistent with the findings of other relevant studies [11, 23] but contrasts with the findings of Monteiro et al., who suggested that educated women have better access to breastfeeding information [21]. Regarding the gender of the newborns, our study revealed that mothers with male infants had a marginally lower mean PSQI total score (M鈥�=鈥�1.33, SD鈥�=鈥�0.861) than mothers with female infants (M鈥�=鈥�1.31, SD鈥�=鈥�0.916). This suggested that newborn gender may influence maternal sleep patterns, possibly due to caregiving responsibilities or sleep disruptions. In contrast to our results, Thomas et al. reported that mothers of male infants had shorter total sleep time and sleep periods, which was attributed to the different feeding and sleep-wake patterns of male infants, who typically have shorter primary sleep durations, more frequent feedings, and less quiet sleep than female infants [27]. Our study posits that female infants may require more attention due to their sensitivity and irritability. However, these observations were based on self-reported experiences from the participants, and further research is needed to better understand the potential role of infant temperament in shaping maternal sleep patterns.

We found no correlation between the type of delivery and sleep quality, echoing the findings of Ko et al. [13]. In contrast, Lee et al. reported poorer sleep quality in the hospital for mothers after cesarean section compared to those sleeping at home after vaginal birth [28]. Similarly, no link was established between delivery method and breastfeeding self-efficacy, aligning with Benli et al.鈥檚 results [29]. However, other research has shown that cesarean deliveries are associated with lower breastfeeding self-efficacy scores [23, 30, 21], possibly due to pain, delayed maternal-infant contact, and lactation issues postcesarean [29]. Our literature review revealed a gap in studies addressing the impact of these complications on breastfeeding self-efficacy.

Regarding psychological health, we did not find significant differences in BSES-SF or PSQI scores among the groups. However, an Ethiopian study indicated that mothers with a history of depression are more susceptible to sleep disruptions [31], and another study suggested a greater incidence of sleep issues among women with a family history of depression [26]. A Turkish study also noted a weak positive correlation between psychological health and breastfeeding self-efficacy, consistent with research showing that depression can diminish confidence in breastfeeding abilities [18]. A Brazilian study proposed that depression might affect women鈥檚 self-esteem and self-perception of the maternal role [32]. Our study鈥檚 low incidence of depression (3.5%) among postpartum women may explain our results, which differ from those of other studies. Regarding the economic status, when we took one variable into account, financial status did not significantly impact breastfeeding self-efficacy. However, when we included all the variables together, financial status showed a weak but statistically significant positive correlation with breastfeeding self-efficacy, implying that mothers with greater financial resources might feel more confident in their breastfeeding abilities.

Limitations

This study employed a cross-sectional design, implying that the data were collected at a single point in time. Consequently, this design did not definitively establish a causal relationship between breastfeeding self-efficacy and sleep quality. Moreover, the study was unable to evaluate potential modifications in mothers鈥� behaviour over time. The use of an online questionnaire might introduce biases, as individuals may not always provide entirely accurate answers and may tend to select responses aligning more with societal expectations. It is worth noting that similar limitations apply to phone interviews, where participants may also be influenced by social desirability bias. Additionally, the use of an online questionnaire may have excluded women of lower socioeconomic status (SES) who lack access to digital devices. Our study did not collect data on breastfeeding exclusivity (exclusive, mixed, or formula feeding), which limits our ability to assess how exclusivity may influence the relationship between breastfeeding self-efficacy and maternal sleep quality. Exclusive breastfeeding has been associated with improved maternal sleep quality due to hormonal and behavioral factors, and breastfeeding self-efficacy may serve as a marker for exclusivity, potentially explaining its association with sleep quality. In addition, the study did not include data on specific feeding methods, preventing an analysis of whether breastfeeding self-efficacy translated into tangible changes in feeding practices. This limitation also hinders our understanding of how maternal self-efficacy impacts actual feeding behaviors and whether these practices affect maternal sleep quality and well-being. Another limitation of this study is the inability to fully explore the experiences of mothers of twins, as we were unable to access a larger number of twin participants. This small sample size (8 twins) limited our capacity to conduct a more detailed analysis of their unique challenges. Additional research with a larger sample size is needed to generalize these findings.

Conclusion

Our study revealed that postpartum women鈥檚 breastfeeding self-efficacy improved in tandem with their overall sleep quality. It was also observed that older mothers exhibited higher levels of breastfeeding self-efficacy and but poorer sleep quality. Furthermore, we discovered an inverse relationship between maternal education level and sleep quality, with higher education correlated with lower sleep quality. Additionally, our findings indicated that mothers with male infants generally experienced superior sleep quality compared to mothers with female infants. Given these insights, we underscore the importance of enhancing maternal awareness about modifiable factors, such as sleep hygiene and breastfeeding techniques, to improve their postpartum experience. Implementing training programs and counselling services is crucial for equipping mothers with effective strategies for managing and overcoming the new challenges they face. Moreover, involving healthcare professionals鈥攕uch as lactation consultants, nurses, and OB/GYNs鈥攄uring prenatal and postpartum visits is essential. These professionals can provide tailored education and support, guiding mothers on breastfeeding practices, sleep management, and the importance of seeking assistance from social and professional networks. Such efforts are crucial for addressing the challenges of the postpartum period and fostering maternal well-being. Additionally, Future studies should address gaps related to Breastfeeding exclusivity and Feeding Method by incorporating data on feeding methods and exploring the potential mediation of feeding practices in the relationship between self-efficacy and sleep quality. Additionally, the influence of breastfeeding exclusivity on maternal well-being should be considered in interventions aimed at improving breastfeeding self-efficacy.