{n “title”: “Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF)”,n “content”: “
Abstract
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The Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF) is a widely recognized, psychometrically robust self-report instrument engineered to quantify a mother\’s perceived maternal confidence and self-efficacy regarding her capacity to initiate and sustain breastfeeding. Originally derived from the 33-item Breastfeeding Self-Efficacy Scale (BSES) formulated by Dr. Cindy-Lee Dennis and Sandra Faux in 1999, the instrument assesses maternal expectations rooted in Albert Bandura\’s foundational Social Cognitive Theory. The scale captures two interrelated operational domains: technique (procedural, physiological, and biomechanical management of infant lactation, including latch, suckling mechanics, and positioning) and intrapersonal thoughts (cognitive appraisal, psychological coping, internal motivation, perceived autonomy, and affective regulation when confronting breastfeeding dilemmas).
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The shortened and standard operational forms of the BSES evaluate mothers across a 5-point Likert-type response scale ranging from 1 (\”not at all confident\”) to 5 (\”very confident\”). Across broad international cohorts, psychometric testing has evidenced exceptional internal consistency, yielding Cronbach\’s alpha coefficients typically spanning from 0.88 to 0.94. The scale demonstrates superior predictive validity for breastfeeding exclusivity and duration at 4, 8, 12, and 24 weeks postpartum, alongside strong construct and convergent validity when correlated with general self-efficacy, maternal anxiety, postpartum depression screening scores, and social support. Translated and validated in over thirty languages worldwide, the instrument functions as an indispensable clinical screening and research assessment metric to identify women at elevated risk for premature lactation cessation and to evaluate targeted clinical interventions designed to foster maternal competency.
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Keywords
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Breastfeeding Self-Efficacy, BSES-SF, Maternal Confidence, Social Cognitive Theory, Perceived Competence, Lactation Management, Postpartum Care, Psychometrics, Maternal-Infant Health, Predictive Validity
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Authors
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The Breastfeeding Self-Efficacy Scale and its psychometric variations were developed by Dr. Cindy-Lee Dennis, PhD, RN, FCAHS, in initial collaboration with Dr. Sandra Faux, PhD, RN.
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- Cindy-Lee Dennis, PhD, RN, FAAN, FCAHS: Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Senior Scientist, Lunenfeld-Tanenbaum Research Institute, Sinai Health System; Canada Research Chair in Perinatal Community Health, Toronto, Ontario, Canada.
- Sandra Faux, PhD, RN: Professor Emerita, Faculty of Nursing, University of Western Ontario, London, Ontario, Canada.
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Purpose
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The Breastfeeding Self-Efficacy Scale—Short Form was designed to satisfy a critical clinical and epidemiological objective: providing healthcare providers and behavioral researchers with an administratively efficient, theory-driven, and diagnostically sensitive instrument to measure a mother\’s situational confidence regarding her capacity to nurse her infant. Despite pervasive global public health guidelines promulgated by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommending exclusive breastfeeding for the first six months of life, a marked attrition in exclusive and partial breastfeeding occurs during the initial postpartum weeks. Many of the precipitating factors—such as perception of insufficient milk production, latching difficulties, infant fussiness, physical fatigue, and maternal distress—are profoundly mediated by psychological appraisals rather than unresolvable biological pathology.
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Bandura\’s behavioral paradigms suggest that self-efficacy represents a proximal cognitive determinant of behavioral execution, duration, effort expenditure, and resilience in the face of setbacks. Within the domain of lactation, mothers who harbor diminished self-efficacy are significantly more prone to interpret normative infant cues (such as growth spurts or cluster feeding) as definitive indicators of physiological lactation failure, prompting early supplementation with infant formula. The clinical purpose of the BSES-SF is therefore triadic:
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- Antenatal and Immediate Postpartum Triage: To screen and identify perinatal women exhibiting low confidence who require timely lactation consultations, behavioral reassurance, and tailored psychoeducation prior to hospital discharge or during initial community home visits.
- Intervention Formulation: To isolate idiosyncratic areas of maternal uncertainty—whether rooted in technical proficiency (e.g., assessing satiety, achieving an asymmetric latch) or intrapersonal cognitive dynamics (e.g., maintaining commitment amidst sleep deprivation and public scrutiny)—thereby enabling individualized clinical support.
- Empirical Research and Outcome Measurement: To serve as a standardized, reliable outcome metric in clinical trials assessing the efficacy of peer support systems, educational workshops, digital health applications, and clinical lactation interventions designed to elevate maternal competence and breastfeeding duration.
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Psychological Construct
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The construct assessed by the BSES-SF is Breastfeeding Self-Efficacy, operationalized as a woman\’s perceived capability to execute the cognitive, affective, physical, and interpersonal behaviors required to successfully breastfeed her child. Within modern psychometric and behavioral science paradigms, breastfeeding self-efficacy is differentiated from generalized self-efficacy or global maternal confidence by its strict domain specificity. General self-efficacy measures broad optimism across generalized life demands, whereas breastfeeding self-efficacy directly models the complex micro-behaviors, somatic assessments, and psychological coping mechanisms required in the lactation relationship.
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The Technique Dimension
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The technical dimension encompasses the practical, procedural, and sensorimotor facets of breastfeeding management. In this domain, maternal efficacy centers on mastery of motor skills and physiological interpretations:
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- Biomechanical Positioning and Latch Optimization: The capability to align the infant correctly at the breast, ensure deep latching where the areola is deeply grasped, and sustain optimal oral biomechanics without experiencing maternal nipple trauma or pain.
- Monitoring Nutritional Adequacy: The mother\’s subjective confidence in evaluating physiological indicators of milk transfer, such as auditory swallowing patterns, contentment post-feeding, urine output, and bowel movements, rather than succumbing to subjective milk-insufficiency panic.
- Physiological Milk Supply Regulation: Confidence in applying biological principles of lactation physiology, such as supply-and-demand mechanics, alternating or draining breasts effectively, and feeding responsive to infant hunger cues without premature supplemental feeding.
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The Intrapersonal Dimension
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The intrapersonal dimension assesses maternal emotional regulation, cognitive attribution, and resilience under stressors intrinsic to newborn care:
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- Cognitive Reframing and Stress Tolerance: Maternal capacity to adaptively cope with the time-intensive demands of exclusive breastfeeding, sleep disruption, and the temporary attenuation of personal autonomy without disengaging from the behavioral commitment.
- Internal Motivation and Goal Commitment: The strength of the internal psychological drive to sustain breastfeeding even during difficult developmental periods (e.g., infant colic, prolonged crying episodes, illness).
- Social Confidence and Stigma Management: Perceived competence in maintaining nursing behaviors within social settings, managing family interactions, navigating public breastfeeding comfort, and soliciting interpersonal encouragement from interpersonal support systems.
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Theoretical Framework
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The foundational underpinning of the Breastfeeding Self-Efficacy Scale is rooted in Social Cognitive Theory formulated by Albert Bandura (1977, 1986, 1997). Central to Bandura\’s formulation is the tenet that human functioning is governed by a reciprocal interaction between cognitive/personal factors, environmental influences, and behavioral patterns. Perceived self-efficacy—defined as beliefs in one\’s capabilities to organize and execute the courses of action required to produce given attainments—influences how people feel, think, motivate themselves, and behave.
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Bandura conceptualized self-efficacy expectations as being dynamically informed and altered by four principal informational sources, each of which Dennis (1999) operationalized into perinatal lactation processes:
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- Performance Accomplishments (Enactive Mastery Experiences): Recognized by Bandura as the most potent source of efficacy information because it provides authentic evidence that one possesses the capability to succeed. In lactation, successful prior experiences—such as feeling milk letdown, calming a crying infant at the breast, or witnessing infant weight gain without formula supplementation—firmly establish high self-efficacy. Conversely, early technical failures, unmanaged cracked nipples, or difficulties achieving a pain-free latch erode self-efficacy beliefs.
- Vicarious Experiences: Observing social models perform a behavior informs the observer of appropriate methods and instills confidence that the observer can also master comparable tasks. For breastfeeding women, observational learning historically occurred within familial and community settings. In modern nuclear societies, vicarious learning often occurs through exposure to peers, lactation educators, and nursing role models. Seeing peers surmount lactation challenges significantly elevates maternal confidence.
- Verbal and Social Persuasion: Encouragement and constructive counsel from healthcare providers, partners, and peer counselors can bolster a mother\’s conviction that she possesses the skills to manage breastfeeding. Bandura argued that persuasion is particularly critical when individuals confront unexpected obstacles; discouraging messages or premature suggestions to introduce formula immediately undermine maternal self-belief.
- Physiological and Affective States: Somatic cues provide immediate diagnostic feedback regarding potential failure or success. A mother who experiences severe pain, physical exhaustion, postpartum fatigue, or autonomic signs of acute anxiety (e.g., palpitations, muscle tension) may cognitively misinterpret these visceral symptoms as indicators of biological inadequacy or insufficient milk production. Bandura noted that reducing somatic distress and reframing physiological responses fundamentally strengthens self-efficacy beliefs.
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Validity
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The construct, criterion, convergent, and discriminant validity of the Breastfeeding Self-Efficacy Scale and its short form have been rigorously substantiated across numerous clinical investigations, epidemiological cohorts, and international psychometric evaluations.
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Content and Construct Validity
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During the primary scale development, Dennis and Faux (1999) established robust content validity through systematic literature reviews, clinical observations of postpartum dyads, and formal evaluation by an expert panel of international lactation consultants, maternal-infant nurse researchers, and perinatal behavioral scientists. The content validity index (CVI) exceeded recommended academic thresholds (CVI > 0.90), confirming that items comprehensively covered the operational spectrum of lactation demands.
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Predictive and Criterion Validity
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Predictive validity is the definitive clinical hallmark of the BSES and BSES-SF. Extensive longitudinal studies consistently demonstrate that baseline postpartum BSES-SF scores directly predict both the duration and exclusivity of breastfeeding across subsequent follow-up intervals:
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- Dennis (2003) demonstrated that maternal BSES-SF scores recorded in the early postpartum period significantly differentiated between mothers who were exclusively breastfeeding, partially breastfeeding, or fully bottle-feeding at 4 and 8 weeks postpartum (p < .001).
- Subsequent multi-center studies internationally have revealed that for every 1-point increase in the total BSES-SF score, the odds of exclusive breastfeeding at 6 weeks postpartum increase by approximately 5% to 10% after controlling for confounding sociodemographic factors such as maternal age, parity, education, delivery mode, and household income.
- Mothers categorized into the lowest quartile of baseline self-efficacy exhibit hazard ratios exceeding 2.5 for premature cessation of breastfeeding within the initial month post-discharge relative to women in the upper quartile.
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Convergent and Discriminant Validity
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Convergent validity has been evaluated through correlations with theoretically congruent psychological constructs. Studies routinely identify significant, moderate-to-strong positive correlations between the BSES-SF and generalized maternal self-efficacy, perceived social support (such as scores on the Multidimensional Scale of Perceived Social Support), and maternal-infant attachment indices. Conversely, discriminant validity has been evidenced by moderate negative correlations with postpartum depressive symptoms (measured via the Edinburgh Postnatal Depression Scale [EPDS]) and state-trait anxiety metrics (e.g., the State-Trait Anxiety Inventory [STAI]). Women experiencing clinical anxiety and depressive affect systematically exhibit depressed breastfeeding self-efficacy ratings.
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Reliability
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The psychometric reliability of the BSES-SF has been demonstrated across diverse demographic cohorts, language translations, and clinical environments.
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Internal Consistency
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In the original validation study of the 14-item short form by Dennis (2003), the instrument yielded a Cronbach\’s alpha coefficient of α = 0.94, reflecting superior internal consistency without redundant item inflation. Subsequent international translations have yielded concordant metrics:
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- Portuguese Validation: Cronbach\’s α = 0.89 to 0.92 across postpartum cohorts.
- Chinese Validation: Cronbach\’s α = 0.93 among inpatient and outpatient mother cohorts in Hong Kong and mainland China.
- Spanish Translation: Cronbach\’s α = 0.92 across European and Latin American studies.
- Turkish Translation: Cronbach\’s α = 0.86 to 0.91.
- Persian and Arabic Adaptations: Cronbach\’s α typically ranging between 0.88 and 0.94.
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Item-total correlation coefficients in psychometric studies uniformly surpass the conventional methodological threshold of 0.30, with most items ranging between 0.45 and 0.78, demonstrating that every individual item contributes robust variance to the unified latent construct.
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Temporal Stability (Test-Retest Reliability)
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Test-retest reliability evaluations, conducted over short intervals (e.g., 2 to 4 weeks postpartum) among mothers whose clinical parameters remained stable, revealed intraclass correlation coefficients (ICC) ranging between 0.80 and 0.88. Because self-efficacy is a dynamic, learning-sensitive cognitive construct designed to change in response to physiological feedback and practical experience, moderate-to-high temporal stability over stable phases confirms measurement precision without masking responsiveness to clinical interventions.
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Factor Analysis
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The latent dimensionality of the Breastfeeding Self-Efficacy Scale has been an area of active psychometric inquiry, with structural investigations yielding both unidimensional and two-factor models depending on the extraction techniques, rotations, and analytical frameworks utilized.
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Exploratory Factor Analysis (EFA)
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In the initial development of the comprehensive 33-item scale, Dennis and Faux (1999) utilized principal components analysis with varimax rotation. This procedure initially isolated three factors—termed Technique, Intrapersonal Thoughts, and Support. However, subsequent empirical evaluations demonstrated that the \”Support\” items behaved erratically as an internal efficacy metric because external support relies upon third-party agency rather than personal capability. Consequently, during the derivation of the 14-item short form (Dennis, 2003), items representing pure external support were removed or reframed, and factor analyses converged toward a dominant single-factor model accounting for roughly 53% to 60% of the total variance, with all 14 items displaying primary factor loadings spanning from 0.54 to 0.82.
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Confirmatory Factor Analysis (CFA)
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Subsequent psychometric validation studies employing structural equation modeling (SEM) have systematically tested competing structural paradigms. While Dennis conceptualized the BSES-SF as a parsimonious unidimensional scale suitable for rapid clinical computation, several international psychometric evaluations identify a superior empirical fit for a correlated two-factor model differentiating:
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- Factor 1: Technique Skills (items assessing mechanical, sensory, and procedural execution such as latching, feeding signs, and position).
- Factor 2: Intrapersonal Thoughts and Coping (items measuring internal motivation, situational tolerance, satisfaction, and self-regulation).
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CFA fit indices across multi-ethnic cohorts frequently demonstrate acceptable-to-excellent values for the unidimensional and correlated two-factor structures:
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- Comparative Fit Index (CFI): 0.92 – 0.97
- Tucker-Lewis Index (TLI): 0.91 – 0.96
- Root Mean Square Error of Approximation (RMSEA): 0.045 – 0.068 (90% CI: [0.038, 0.075])
- Standardized Root Mean Square Residual (SRMR): 0.035 – 0.052
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Because the inter-factor correlation between Technique and Intrapersonal dimensions typically exceeds r = 0.70, researchers and clinicians commonly employ the BSES-SF as a single composite score, while retaining the subscale scores for nuanced behavioral profiling.
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Instrument / Measurement Tool
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- Instrument Name: Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF)
- Original Scale Antecedent: Breastfeeding Self-Efficacy Scale (BSES; 33 items)
- Construct Assessed: Maternal perceived self-efficacy and confidence regarding breastfeeding capability
- Administration Format: Self-administered paper-and-pencil questionnaire, structured face-to-face clinical interview, or secure digital web/mobile interface
- Target Population: Antenatal expectant mothers in the third trimester, inpatient immediate postpartum mothers, and outpatient postpartum lactating women
- Administration Duration: Approximately 3 to 7 minutes
- Response Format: 5-point Likert rating scale:
- 1 = Not at all confident
- 2 = Not very confident
- 3 = Sometimes confident
- 4 = Confident
- 5 = Very confident
- Scoring Mechanism: All items are framed positively (no reverse-coded items). Individual item responses (1 through 5) are summed to generate a total scale score.
- Score Range:
- BSES-SF (14 items): Possible score range from 14 to 70.
- Comprehensive Research Scale (33 items): Possible score range from 33 to 165.
- Clinical Interpretation Guidelines (BSES-SF):
- 14 – 32: Low breastfeeding self-efficacy. High risk for premature supplementation, lactation crisis, and early cessation. Urgent indication for targeted clinical lactation intervention, technical support, and psychosocial follow-up.
- 33 – 50: Moderate breastfeeding self-efficacy. Requires focused monitoring, positive reinforcement of infant feeding cues, and reinforcement of maternal confidence.
- 51 – 70: High breastfeeding self-efficacy. Mother possesses robust perceived self-efficacy and psychological coping reserves for navigating standard infant feeding demands.
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Permissions & Fee and Test Year
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The Breastfeeding Self-Efficacy Scale was initially developed and published by Dr. Cindy-Lee Dennis and Dr. Sandra Faux in 1999, followed by the psychometric evaluation and release of the Short Form (BSES-SF) in 2003. The scale is protected by academic copyright owned by Dr. Cindy-Lee Dennis.
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Dr. Dennis makes the BSES and BSES-SF accessible for academic research, health service evaluations, clinical audits, and non-commercial educational practice, provided that appropriate citation and copyright attribution are maintained. Formal user registration, translation licensing, and commercial permissions are administered through Dr. Dennis\’s official institutional research portal (cindyleedennis.ca). Commercial entities, sponsored pharmaceutical trials, and proprietary software developers must obtain written authorization and negotiate formal licensing agreements prior to deploying the scale in commercial enterprises.
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References
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- Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
- Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
- Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
- Dennis, C. L. (2003). The Breastfeeding Self-Efficacy Scale: Psychometric assessment of the short form. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(6), 734–744. https://doi.org/10.1177/0884217503258459
- Dennis, C. L. (2006). Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period. Research in Nursing & Health, 29(4), 256–268. https://doi.org/10.1002/nur.20140
- Dennis, C. L. (2010). Clinical utility of the Breastfeeding Self-Efficacy Scale. Retrieved from http://www.cindyleedennis.ca/research/1-breastfeeding/clinical-utility-of-the-breastfeeding-self-efficacy-scale
- Dennis, C. L., & Faux, S. (1999). Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Research in Nursing & Health, 22(5), 399–409. https://doi.org/10.1002/(sici)1098-240x(199910)22:5<399::aid-nur6>3.0.co;2-4
- Gregory, A., Westerland, L., & Dennis, C. L. (2008). Breastfeeding self-efficacy and infant feeding outcomes in an ethnically diverse cohort. Journal of Human Lactation, 24(4), 415–424. https://doi.org/10.1177/0890334408323547
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Items of the Scale
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Response Format:
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- I can always determine that my baby is getting enough milk
- I can always successfully cope with breastfeeding like I have with other challenging tasks
- I can always breastfeed my baby without using formula as a supplement
- I can always ensure that my baby is properly latched on for the whole feeding
- I can always manage the breastfeeding situation to my satisfaction
- I can always manage to breastfeed even if my baby is crying
- I can always keep wanting to breastfeed
- I can always comfortably breastfeed with my family members present
- I can always be satisfied with my breastfeeding experience
- I can always deal with the fact that breastfeeding can be time consuming
- I can always finish feeding my baby on one breast before switching to the other breast
- I can always continue to breastfeed my baby for every feeding
- I can always manage to keep up with my baby’s breastfeeding demands
- I can always tell when my baby is finished Breastfeeding
- Keep my baby awake at my breast during a feeding
- Maintain my milk supply by using the “supply and demand” rule
- Refrain from bottle feeding for the first 4 weeks
- Feed my baby with breast milk only
- Stay motivated to breastfeed my baby
- Count on my friends to support my decision to breastfeed
- Keep wanting to breastfeed
- Feed my baby every 2–3 hours
- Keep feeling that I really want to breastfeed my baby for at least 6 weeks
- Comfortably breastfeed with my family members present
- Be satisfied with my breastfeeding experience
- Comfortably breastfeed in public places
- Deal with the fact that breastfeeding can be time consuming
- Finish feeding my baby on one breast before switching to the other breast
- Continue to breastfeed my baby for every feeding .65
- Feel if my baby is sucking properly at my breast
- Accept the fact that breastfeeding may temporarily limit my freedom
- Manage to keep up with my baby’s breastfeeding demands
- Recognize when my baby is finished breastfeeding [Tell when my baby is finished breastfeeding]
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“,n “excerpt”: “The Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF) is a standardized psychometric instrument developed by Dr. Cindy-Lee Dennis to measure maternal confidence in breastfeeding. Based on Bandura’s Social Cognitive Theory, it reliably predicts breastfeeding exclusivity and duration.”,n “slug”: “breastfeeding-self-efficacy-scale-short-form-bses-sf”,n “categories”: [n “Maternal & Child Health”,n “Psychological Assessment”,n “Clinical Psychometrics”,n “Perinatal Psychology”n ],n “tags”: [n “Breastfeeding Self-Efficacy”,n “BSES-SF”,n “Cindy-Lee Dennis”,n “Maternal Confidence”,n “Social Cognitive Theory”,n “Lactation”,n “Postpartum Health”,n “Psychometrics”n ],n “seo_title”: “Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF): Psychometrics & Clinical Use”,n “seo_description”: “Explore the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF): theoretical framework, construct validity, psychometric reliability, clinical scoring, and full scale items.”,n “focus_keyword”: “Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF)”n}