The Malay Version of Antenatal and Postnatal Breastfeeding Self-Efficacy Scale-Short Form: Reliability and Validity Assessment

Background

Breastfeeding confers well-established benefits for both infant and maternal health, including reduced risk of infectious diseases, improved cognitive development, and lower rates of breast and ovarian cancer in mothers. Despite these recognised advantages and Malaysia’s national policy promoting exclusive breastfeeding for the first six months of life, exclusive breastfeeding rates in the country have remained below targets. Understanding the modifiable factors that influence breastfeeding outcomes is therefore a priority for maternal and child health programmes.

Breastfeeding self-efficacy — a mother’s confidence in her ability to breastfeed her infant successfully — has been consistently identified in the international literature as one of the strongest modifiable predictors of breastfeeding initiation, exclusivity, and duration. Mothers with higher breastfeeding self-efficacy are more likely to initiate breastfeeding, persist through early challenges, and maintain exclusive breastfeeding for longer periods. Conversely, low self-efficacy is a significant risk factor for early breastfeeding cessation and supplementation with formula.

The Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), originally developed in English by Cindy-Lee Dennis, is a widely used 14-item instrument that measures maternal confidence across key breastfeeding domains. For the instrument to be used effectively in the Malaysian healthcare context, where Malay is the primary language for many mothers, a linguistically and culturally validated Malay version was needed. This study undertook the systematic translation, cultural adaptation, and psychometric evaluation of the BSES-SF for use among Malaysian mothers.

Study Methodology

The translation process followed established international guidelines for cross-cultural adaptation of health measurement instruments. The original English BSES-SF was translated into Malay through a rigorous back-to-back translation process involving independent forward translation, synthesis, back-translation, expert committee review, and pre-testing. This systematic approach ensured that the translated version maintained conceptual equivalence with the original while being linguistically natural and culturally appropriate for Malaysian respondents.

The validated Malay version was then administered to two samples: 101 pregnant women in their third trimester (for the antenatal version) and 104 women in their first week postpartum (for the postnatal version). Participants were recruited from healthcare facilities, and the questionnaire captured socio-demographic information, antenatal history, breastfeeding information, and BSES-SF responses. Follow-up data on infant feeding method were collected via telephone at four weeks postpartum to assess the predictive validity of the scale.

Psychometric Properties

Reliability

The Malay version of the BSES-SF demonstrated excellent internal consistency reliability. The Cronbach’s alpha coefficient for the antenatal version was 0.94, indicating strong internal consistency among the 14 items. The postnatal version similarly demonstrated high reliability. These values exceed the commonly accepted threshold of 0.70 for acceptable internal consistency and are comparable to validation studies of the BSES-SF in other languages and cultural contexts, including Persian, Chinese, Portuguese, and Turkish versions.

Validity

Content validity was established through expert panel review during the translation and adaptation process. The expert panel assessed each item for semantic equivalence, idiomatic equivalence, experiential equivalence, and conceptual equivalence between the English original and the Malay translation. Face validity was evaluated through pre-testing with a sample of target respondents, who were asked to rephrase items in their own words to assess comprehension.

Construct validity was assessed through the relationship between BSES-SF scores and actual breastfeeding behaviour. The scale demonstrated the expected pattern of associations: higher self-efficacy scores were associated with greater likelihood of exclusive breastfeeding at four weeks postpartum, supporting the theoretical framework underlying the instrument.

Clinical Implications

The availability of a validated Malay-language breastfeeding self-efficacy instrument has important practical applications for maternal and child health services in Malaysia. Healthcare providers at antenatal clinics, postnatal wards, and primary care settings can use the instrument as a screening tool to identify women who may be at risk of low breastfeeding self-efficacy and, consequently, early breastfeeding discontinuation.

Early identification allows for targeted intervention during the antenatal period, when self-efficacy-enhancing strategies — including peer support, skills-based breastfeeding education, observational learning through contact with successfully breastfeeding mothers, and physiological and affective state management — can be most effectively implemented. Such interventions align with Bandura’s self-efficacy theory, which identifies four primary sources of efficacy information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states.

The instrument also provides a standardised outcome measure for evaluating the effectiveness of breastfeeding promotion programmes and interventions, enabling evidence-based assessment of whether specific strategies are successfully improving maternal confidence in breastfeeding.

Broader Research Context

This validation study contributes to a growing international portfolio of culturally adapted versions of the BSES-SF. Systematic reviews of the BSES and BSES-SF have confirmed that these instruments demonstrate consistently strong psychometric properties across diverse cultural and linguistic settings, supporting their utility as global measures of breastfeeding self-efficacy. The Malay version extends this evidence base to the Malaysian and broader Malay-speaking population.

The study also contributes to the broader effort to strengthen evidence-based maternal and child health practice in Malaysia. By providing a validated tool for identifying modifiable predictors of breastfeeding behaviour, the research supports the development of targeted, theory-informed interventions that can improve breastfeeding outcomes at the population level.

Limitations

The study was conducted at specific healthcare facilities and may not capture the full diversity of the Malaysian population. The sample sizes, while adequate for initial psychometric evaluation, were relatively modest, and larger-scale validation with diverse populations across different Malaysian states would strengthen confidence in the instrument’s generalisability. The follow-up period for predictive validity assessment was limited to four weeks postpartum; longer follow-up would be valuable for assessing the instrument’s ability to predict sustained breastfeeding behaviour.

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