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Introduction

Breastfeeding, which is quite beneficial for the mother and infant, is the most preferred method for infant feeding in the postpartum period [1]. The fact that infants are exclusively breastfed during the first six months after birth, and then, the infant is continued to be breastfed along with complementary food for at least two years is very important for the physical and psychological development [2].

Many factors are effective in the successful continuation of breastfeeding [3]. In addition to these factors, maternal attachment regarding communication between the mother and infant, and breastfeeding self-efficacy affecting the mother’s thoughts about breastfeeding are also very important [4-6]. In accordance with this aim, it is emphasized that supporting postpartum women and the strengthening of health systems are quite important for the continuation of breastfeeding [2]. Yoga, which is one of the practices that support the women in this period, is the oldest system in the world that emphasizes the importance of physical, mental and psychological balance in human development [7,8]. With this study, it is considered that yoga practice will help mothers to cope with negative thoughts about breastfeeding and will increase maternal attachment.

Materials and Methods

This quasi-experimental study with pre-test and post-test control groups was carried out with the mothers who were registered to Family Health Centers No.1 and No.14 affiliated to a province’s Public Health Directorate in the pregnant education class located in FHC No.14 between September 11, 2017.

December 18, 2018. Primiparous breastfeeding mothers with 20-40-day old infants, who were registered to FHCs No.1 and No.14 constituted the population of the study. In the power analysis performed to determine the sample size, based on the study on women’s breastfeeding self-efficacy carried out by Ekşioğlu & Ceber (2011) [9] in the literature, the sample size was calculated as 124 mothers, consisting of 62 mothers in the experimental group and 62 mothers in the control group, with an effect size of 0.7, an error level of 0.05, and a population representation power of 0.95. The study was started with 130 mothers including 65 mothers in the experimental group and 65 mothers in the control group, by considering the possibility that mothers could not continue the study for different reasons during the study. The inclusion criteria for the study were determined as being at the age of 20-35 years, having term vaginal delivery, having only one infant who is exclusively breastfed, having no previous yoga practice, being at least a primary school graduate, and having no communication problem. The exclusion criteria for the study were determined as having cesarean delivery, having an infant who started receiving complementary food, and the absence of any health problem in the mother and infant. The criteria for the termination of the study were determined as the mother’s desire to withdraw from the study, the occurrence of any complication related to the health of the mother and the infant during the study, and the initiation of complementary food for the infant.

Data Collection

An information interview was conducted with the mothers who applied to the pregnant education class before and after the initiation of study and who met the study criteria, and their phone numbers and names were recorded. The data were collected by the researcher using face-to-face interview method in the lactation room of FHCs. The flow chart of the study is presented in Figure 1: Application Plan of the Study. The data of the study were collected using the Individual Identification Form, the Breastfeeding Self-Efficacy Scale (BSES) and the Maternal Attachment Scale (MAS).

Individual Identification Form: This form prepared by the researcher consists of 10 questions.

Breastfeeding Self-Efficacy Scale: This scale, which was developed by Cindy Lee Dennis to determine breastfeeding self-efficacy, consists of 2 sub-dimensions (“Technical scale”, “Scale for personal thoughts”) and 33 items. The minimum and maximum scores to be obtained from the scale are 33 and 165, respectively, and breastfeeding self-efficacy increases as the total score increases (19). Turkish validity and reliability of the scale was examined by Ekşioğlu and its Cronbach’s alpha value was calculated as 0.95 (Ekşioğlu & Ceber, 2011). In our study, Cronbach’s alpha value was calculated as 0.95. The mean application time of the scale is 20 minutes.

Maternal Attachment Scale (MAS): This scale, which was developed by Mary E. Muller, is applied to postpartum women with 1-4-year-old infants in order to determine maternal feelings and behaviors [10]. The scale consists of 26 questions in 4-point likert type. The minimum and maximum scores to be obtained from the total of questions range from 26 to 104. High score indicates a good maternal attachment. The scale was adapted to Turkish by Kavlak & Şirin (2009), and its Cronbach’s alpha internal consistency reliability coefficient was calculated as 0.82. In our study, Cronbach’s alpha value was calculated as 0.95.

Intervention

The pregnant education class, where the study would be carried out, was arranged to have women do postpartum yoga practice (Nagendra, Nagarathna & Gurelman, 2014; Ratfisch, 2015) [11,12]. The researcher made mothers practice yoga on certain days of the week and at certain times. In each session, the steps of postpartum yoga practice were performed respectively.

Steps of Postpartum Yoga Practice: Breath awareness practice (for 5 minutes), practice of postpartum yoga asanas (for 45 minutes), mother-infant communication and meditation (for 10 minutes).

Evaluation of Data: The coding and statistical analyses of the data were performed on computer using the SPSS (Statistical Package for Social Science) package program. Shapiro-Wilk normality test was used to determine whether the data on quantitative variables showed normal distribution (p>0.05). Significance level was accepted as at least p<0.05. Percentage, arithmetic mean and standard deviation, Chi square test, analysis of variance in repeated measures, Bonferroni test, and t test in independent groups were used in the evaluation of data with normal distribution.

Ethical considerations: Approval of Malatya Health Sciences Scientific Research and Publication Ethics Committee was obtained for the study (No: 2017/19-8). The consent form was filled out by the mothers who agreed to participate in the study.

Results

The distribution of socio-demographic and obstetric characteristics of mothers is presented in Table 1. It was determined that there was no statistically significant difference between the mothers in the control and experimental groups in terms of sociodemographic and obstetric characteristics (p> 0.05).

The comparison of pre-test, intermediate test and post-test mean scores of the mothers in the experimental group in terms of breastfeeding self-efficacy and maternal attachment is presented in Table

The difference between the total mean scores for the BSES “scale for personal thoughts” and BSES “technical scale” sub-dimensions and the MAS that the mothers in the experimental group received from pre-test, intermediate test and post-test was found to be statistically significant (p<0.05). The comparison of pre-test, intermediate test and post-test mean scores of the mothers in the control group in terms of breastfeeding self-efficacy and maternal attachment is presented in Table 2. The difference between the total mean scores for the BSES “scale for personal thoughts” and BSES “technical scale” sub-dimenexsions and the MAS that the mothers in the control group received from pre-test, intermediate test and post-test was found to be statistically significant (p<0.05).

The comparison of pre-test, intermediate test and post-test mean scores of the mothers in the experimental and control groups in terms of breastfeeding self-efficacy and maternal attachment is presented in Table 3. When mothers in the experimental and control groups were compared in terms of total mean scores for the BSES and the MAS pre-test, it was determined that there was no statistically significant difference between the groups (p>0.05). It was determined that the total mean scores for the BSES sub-dimensions and the MAS intermediate and posttest of the mothers in the experimental group were higher compared to the mothers in the control group, and the difference was statistically significant (p<0.05).

Discussion

dimenIn the study, it was found that the total BSES mean scores of the mothers in the experimental group increased after postpartum yoga intervention. Yoga is basically a mental and spiritual practice involving physical movements (asana), special breathing techniques (pranayama) and deep concentration (meditation) [11,12]. In the study carried out by Trakroo et al. (2013) [13], it was reported that pranayama practices calmed people down by providing deep relaxation. In the literature review, no study on the effects of pranayama practices on breastfeeding was found. We think that pranayama studies, that are included in postpartum yoga practices, calm mothers down and direct them to their infants, which allowed them to breastfeed their infants more frequently.

Asana included in yoga practice means physical posture and is a form of exercise since requires active and/or passive participation of muscle groups [11,12]. Fatigue and exhaustion in the postpartum period can be reduced by systematic body movements [14]. In their study, Karbandi, et al. (2017) [15] determined that relaxation exercises increased breastfeeding self-efficacy in postpartum women. In their study, Bender, Williams & Dufour (2017) [16] determined that the relaxation exsions ercises performed in the postpartum period encouraged women to breastfeed. Meditation, which is the last stage of yoga practice in the postpartum period, helps person to feel good and move away from negative thoughts [17]. In the study carried out by Kawanishi et al. (2015) [18], on pregnant women, it was indicated that meditation in yoga practice led to the elimination of the person’s pressure and tension, the development of the self, and increased feelings of love and compassion. Blosco, et al. (2013) [19] determined that 8-week meditation practice increased breastfeeding self-efficacy and decreased stress and depression. Yoga performed during the postpartum period will help the woman to cope with the stressors during this period, will relax her and increase the success of breastfeeding [12].

In our study, it was determined that the mean MAS scores of the mothers in the experimental group after the application were significantly higher than that of the mothers in the control group. In the literature review; It has been determined that yoga is psychologically good for mothers and contributes positively to mother attachment by increasing communication between mother and baby [20-24]. The results of our study are similar to the literature. In our study, it was determined that the mean MAS scores of both groups after the practice were higher than their mean MAS scores before the practice (p<0.05). Maternal attachment is a special and meaningful relationship which develops between the infant and mother over time. In their study, Barone et al. determined that maternal attachment increased with gestational age as prenatal attachment increased. We think that the increase in the mean maternal attachment scores of the mothers in the control group in our study was due to the increase in the infant’s age.

Conclusion

Breastfeeding self-efficacy and maternal attachment of the mothers in the experimental group further increased compared to the mothers in the control group. In accordance with the results obtained from the study; healthcare professionals serving in the postpartum period are recommended to take into account the factors that would affect breastfeeding and maternal attachment of mothers and to take steps to improve their physical and psychological health.

Acknowledgment

We thank the institutions that contributed to our research. This work was supported by a university scientific research projects grant (TDK-2017/852).