Abstract

Background: Maternal competence in infant feeding is important to foster infant growth and development; however, maternal competence has been defined inconsistently using a variety of terms in relation to different contexts. Aim: This work provides an analysis of the concept of maternal competence in the context of infant feeding. Methods: The concept was analyzed using Walker and Avant's eight-step concept analysis method. Results: Maternal competence in infant feeding is defined as the possession of the knowledge, skills, abilities, responsiveness, and sensitivity that are required to provide optimal infant feeding. The concept's antecedents are the mother-infant relationship, maternal expectations, and support systems. The consequences are optimal nutrients intake, maternal confidence, infant's self-regulation and infant’s healthy growth and development. Conclusions: This concept analysis identified all related attributes and provided a clear definition of maternal competence in infant feeding. Information from this analysis can be used to develop a conceptual framework for maternal competence in infant feeding.

1. Background

The role of mothers in promoting healthy infants growth and development is challenging. Maternal competence is one of the important variables to achieve the ideal maternal role ¹. The concept of maternal competence has been used to describe different aspects of the maternal role including infant feeding. While a lack of maternal competence in infant feeding can put infants at risk for poor health outcomes, this concept has been defined inconsistently using a variety of terms within different contexts. This work comes to elucidate the concept of maternal competence in the context of infant feeding to allow for its precise usage in research and clinical practice.

Maternal self-efficacy has been used interchangeably with maternal competence, necessitating clear delineation of these two concepts. Johnston and Mash ² defined self-efficacy as a parent's feelings of being confident and competent in dealing with their children's problems. According to de Montigny and Lacharite ³, the difference between parental competence and parental efficacy is based on who assesses the capability. Accordingly, parental competence was described as others’ judgment about the parents’ ability to do something, while parental efficacy refers to parents’ judgement about their own ability to do something ³.

Self-efficacy reflects the beliefs of performing the behavior, but does not reflect the actual ability ⁴. Hence, the concept of maternal competence is broader than self-efficacy because it combines aspects of perception and behavior. It can be perceived by mothers and appraised by someone else to assess the quality of maternal behaviors ⁵.

The purpose of this concept analysis was to help researchers and clinicians understand the meaning of maternal competence in the context of infant feeding. Specifically, the aim was to analyze the concept of maternal competence in the context of infant feeding by going through the steps of Walker and Avant's ⁶ concept analysis methods.

2. Methods

Walker and Avant's eight-step concept analysis method was used to analyze this concept ⁶. The steps includes selecting a concept, determining the purpose of the analysis, identifying all uses of the concept, determining the defining attributes, constructing a model case, identifying a borderline case, identifying antecedents and consequences, and defining empirical referents ⁶.

A literature search of electronic databases was conducted to find studies that addressed maternal competence. Electronic databases included the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Medline, PsychInfo, and Google Scholar. Manual Internet searches were also undertaken to search in the online dictionaries. The search processes were limited to English-language articles. Search terms included competence, maternal self-efficacy, maternal confidence, maternal competence, parental competence, breastfeeding, infant feeding, and formula feeding.

The Oxford Dictionaries define competence as the ability to do something well ⁷. This word is used extensively as a noun, adjective, or phrase to describe persons, practices, or cultures. In psychology, competence is described as the continuously developed knowledge, skills, and values related to clinical practice ⁸. Likewise, in business competence is described as a quality that combines the skills, knowledge, and attitudes needed to complete a task successfully ⁹. In the legal profession, the term competence is used to describe a person who has the characteristics needed to consent or be a witness—a sound mind and sufficient maturity, and understanding—or the mental status required for legal accountability ¹⁰. Taken in total, the literature implies that competence is an essential component for successful outcomes in any practice or profession.

The concept of competence has been commonly used in health-related literature. The usages of the concept varied depending on the context, especially regarding the competence of healthcare providers ¹¹. For example, cultural competence is used to describe a healthcare provider's ability to work effectively with individuals from varying cultural backgrounds ¹². Additionally, competence can describe the ability of preterm infants to generate a specific numbers of sucks during feeding ¹³.

The concept of maternal competence has been used in various ways. Competence is used in nursing research to describe a mother's ability to feed a low-birth-weight infant in relation to the influences of infant, maternal, and family conditions ¹⁴. Furthermore, maternal competence has been identified as an antecedent of maternal ability to make autonomous decisions in breastfeeding ¹⁵.

The concept of competence is a complex term that comprised of several qualities such as maturity, knowledge, personal insightfulness ¹¹, as well as physical, intellectual, and emotional capability ¹⁵. Maternal competence often is described in relation to different aspects of infant care. The major domains of parental competencies was identified by Pridham, Limbo, Schroeder, Thoyre, and Van Riper ¹⁶ as expressing comfort, satisfaction, and skill in being with the infant; knowing the infant; providing infant care; communicating with others about the infant's needs; and solving infant-care problems.

A wide range of attributes has been associated with the concept of maternal competence. However, only the attributes of maternal competences specifically related to infant feeding practices either by breast or formula were identified for this analysis. The attributes consistently found in the definitions of maternal competence (see Table 1) were knowledge, skills, abilities, responsiveness, and sensitivity.

Knowledge has been defined as the information a mother should know to provide infant care ¹⁷. Maternal knowledge about infant feeding includes understanding of types of feeding, frequency, preparation, provision, and during and after feeding care (e.g., burping, positioning). It is crucial that the mother knows what to feed her infant in each different developmental stage. According to Baker, McGrath, Pickler, Jallo, and Cohen ¹⁸, the essence of maternal competence is that the mother know how, why, when, and what to do for her infant.

Maternal knowledge and skills are both important to ensure optimal feeding practices. Skills can be defined as completing tasks effectively and efficiently with a high degree of certainty ¹⁹. Infant feeding practices require mastering several skills; for instance, recognizing infant cues ²⁰, and supporting infant in feeding position ²¹. Maternal knowledge and skills need ability in order to perform feeding tasks successfully. Ability is defined as having the power to perform something under different circumstances ²². Maternal competence in infant feeding requires not only abilities to fulfill infant's nutritional needs, but also problem solving and decision making abilities ¹⁶. Maternal ability of performing infant feeding practices is an important attribute that distinguish maternal competence from self-efficacy.

Maternal responsiveness and maternal sensitivity are important attributes of maternal competence that shape mother-infant relationships. Maternal responsiveness is defined as recognizing and responding to infant cues ²³. Maternal responsiveness and maternal sensitivity are related concepts. However, maternal responsiveness takes into account the promptness of the maternal behavior whereas maternal sensitivity is a broad concept that encompasses the quality of such behavior ^{24, 25}. A recent systematic literature review revealed positive relationships between maternal responsiveness and appropriate infant feeding practices ²⁶.

A model case is used to demonstrate the concept and reflect all related attributes ⁶. In this model case, a 24-year-old mother lives with her husband and three-month-old infant. She has read some educational materials on infant feeding practices. Through her reading, she became knowledgeable about infant's hunger cues. She practiced breastfeeding during which she was able to identify and respond to her infant's hunger cues. During a well-infant visit, the healthcare provider assured her that her infant was growing and was at an appropriate weight and height for his age.

Walker and Avant ⁶ defined antecedents as the events that must exist prior to the concept's occurrence. Antecedents for maternal competence in infant feeding are the mother-infant relationship, maternal expectations, and maternal support systems. The mother-infant relationship can develop through early skin-to-skin contact, maternal responsiveness to infant cues, and breastfeeding ²⁷. Mother-infant interactions improve an infant's secure attachment and build maternal competence in meeting the infant's nutritional needs. A poor mother-infant relationship negatively influences infant physical health ²⁸.

Personal expectations play an essential role in determining, initiating, and sustaining behaviors ²². According to Bandura's self-efficacy theory, expectations for a behavior can be derived from four information sources: accomplishments, vicarious experiences, physiological states, and verbal encouragement from others ²². Maternal expectations are formed of experiences, culture, beliefs, assumptions, and ideas about infant needs. Maternal expectations inform thoughts and actions in adopting a competent mothering role, and were found to be positively associated with maternal practices ²⁹.

Social support includes any form of assistance or resources received from others or perceived as available including emotional, instrumental, and informational support ^{30, 31}. After childbirth, mothers need support from healthcare providers, friends, and family members. Receiving support in the postpartum period strengthens a mother's ability to competently practice her maternal role and overcome any barriers to that role. Support from family members (ie, the child's father, siblings, and grandparents) was identified as a predictor of maternal competence ³². A recent systematic review concluded that all forms of support decrease the incidence of breastfeeding cessation ³³. Thus, social support is an important factor that enables mothers to continue practicing competent infant feeding.

According to Walker and Avant ⁶, consequences are the outcomes that occur after the occurrence of the concept. This analysis identified four consequences of maternal competence: optimal nutrients intake, maternal confidence, infant's self-regulation and infant's healthy growth and development (Figure 1). Maternal confidence is defined as a mother's perception about her ability to provide infant care ^{34, 35}. While the concept of maternal confidence is related to a persons' strength of belief about their ability to perform a behavior, it does not reflect the persons' ability to accomplish the behavior ^{4, 22}. The behaviors associated with maternal competence promote positive beliefs about successfully performing these same behaviors. These beliefs, in turn, reinforce a sense of maternal confidence. In contrast, mothers with a low level of maternal competence report having more difficulties regarding their feelings about being a mother ³⁶.

Competent mothers foster healthy infant growth and development by responding to infant cues and providing optimal nutrients intake in the critical period of infancy. Maternal responsiveness promotes infants' self-regulation of food intake ^{37, 38}, which in turns may reduce the risk of rapid infant weight gain ³⁹. Moreover, Mercer's Theory of Maternal Role Attainment indicates that maternal competence can improve child's health and cognitive development ⁴⁰. Further longitudinal research is warranted to understand the relationship between maternal competence and long-term infant health outcomes.

Based on the defining attributes, antecedents, and consequences obtained from the literature, maternal competence in the context of infant feeding is defined as the possession of knowledge, skills, abilities, responsiveness, and sensitivity that are required to provide optimal infant feeding.

Empirical referents are real-life phenomena that allow for the recognition and measurement of a concept ⁶. The above conceptual definition of maternal competence in infant feeding suggests that competence can be perceived and performed ^{3, 5}. Hence, it should be assessed through someone other than the mother to evaluate the quality of feeding behaviors ²⁶.

The empirical referents or practices that demonstrate maternal competence in infant feeding include recognizing and responding to infant hunger cues, providing a sufficient amount and frequency of feeding, and positioning an infant appropriately during and after feeding. Additional empirical referents for formula feeding include selecting an appropriate age-specific formula, preparing formula properly, and cleaning bottles adequately.

In Holditch-Davis et al. ⁵ study, maternal competence was assessed subjectively through interviews and objectively by observations of mother behaviors and interactions with her infant. Furthermore, Brown et al. ²¹ developed an observational tool to assess the regularity of mother-infant feeding interactions, which includes the following categories of maternal behaviors: mother's observation of feeding, supporting of infant feeding position, verbal communication, vestibular stimulation, touching, and active feeding.

3. Discussion and Recommendations

Maternal competence in infant feeding is one of the essential components that allow mothers to achieve positive infant health outcomes ¹. This analysis resulted in a conceptual definition that distinguishes the concept from other related concepts. The antecedents and consequences of maternal competence were supported by Mercer's Maternal Role Attainment (MRA) Theory ⁴⁰. The main concepts in the MRA theory are maternal factors, infant variables, maternal role identity (maternal competence), and child outcomes. Maternal factors include sensitivity to infant cues, and birth experiences related to having prior knowledge and skills that shape maternal expectations. The mother-infant interaction, maternal expectation, and social support can lead to maternal competence and confidence in her role, as well as infant growth and development.

The level of maternal competence is amendable to change if appropriate support and customized interventions are provided. However, determining the level of maternal competence may differ depending on the criteria and person who judges the competence. Therefore, it is recommended to assess maternal competence in infant feeding externally through expert's observations of maternal feeding behaviors.

The information from this conceptual analysis has several implications for nursing practice. It is important for clinicians to help mothers establish a strong relationship with their infants by facilitating early mother-infant interaction. Nurses can integrate knowledge from this analysis into clinical practice by offering mothers education and resources that help them develop the knowledge and skills required for maternal competence in infant feeding. Moreover, during well-child visits, nurses can use the information about infant growth to reinforce maternal competence in providing infant feeding.

Maternal competence is a multidimensional concept combining a wide range of attributes. While this concept has been examined broadly in the literature, there are few specifications about the context in which it was being measured or the tasks involved. This concept analysis was necessarily limited by the lack of literature concerning the conceptual and operational definitions and specific attributes of maternal competence in the specific context of infant feeding. Therefore, future research could help identify additional attributes of the concepts and further refine the conceptual relationships illustrated in Figure 1.

An additional limitation is related to the scant information available on the maternal factors—including socioeconomic, marital, age, physical, and psychological status—that can influence maternal competence in fulfilling an infant's nutritional needs. For example, single mothers have been shown to have lower maternal competence than do married mothers ²⁰. Furthermore, physical pain after caesarean section can influence the choice of infant feeding practice ⁴¹. Therefore, it is recommended that future research be undertaken to determine other maternal factors that could influence competence in infant feeding.

Mother's level of maternal competence can improve over time as she practices her role. Previous infant care experiences also can inform maternal actions and beliefs. Therefore, future research on this concept should examine the improvement of maternal competence that happens over time. Furthermore, researchers should consider developing a task-specific tool to assess all the defining attributes of maternal competence in infant feeding.

4. Conclusion

Maternal competence in infant feeding plays an important role in promoting healthy infant growth and development. It encompasses cognitive and behavioral traits that work together in order to provide optimal nutrients intake. This concept analysis expands the state of knowledge related to mother and infant health outcomes, and provides foundation for future research. Further research is needed to continue building the conceptual framework and assessment tools for this important concept.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

References