https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Association of Belief and Experience of Insufficient Breast Milk Supply with Mothers’ Knowledge Regarding Breast Feeding ABSTRACT Background and objectives: Belief and experience of insufficient milk supply (IBMS) are important and modifiable factors for optimal breastfeeding. However, very few people know about maternal belief, experience about breast milk supply, and how it impacts breastfeeding practice. The aim of the study is to identify the prevalence and association between mothers’ belief and experience of insufficient breast milk supply with mother’s knowledge regarding breast feeding. Methods: This descriptive cross-sectional study was conducted on (1,000) participants who took six months postpartum in the primary health care centers (PHCC) and Raparin Teaching Hospital for children (RTHC) in Erbil city /Iraq. Data were collected via direct in- terview. The question used in the interview were developed after a review of the relevant literature. Frequency, percentage, and Chi-square were used for the purpose of data analysis. Results: In general, the study showed the prevalence of mothers' belief regarding insuffi- cient breast milk supply was 59.8%. Also, the prevalence of a mother’s experience was 78.6%. Mothers who had a poor level of knowledge regarding breastfeeding got the high- est percentage, 62.2%. However, it showed the highly significant association between mothers’ knowledge and mode of the last delivery with mothers’ belief of insufficient breast milk supply. Moreover, there was a highly significant association between mother’s experience with socio economic status. Conclusion: The majority of the mothers had belief and experience of insufficient breast milk supply (IBMS). The current study showed a significant association between mothers’ belief with mother’s knowledge regarding the benefits of breastfeeding. Keyword: Belief; Experience; Insufficient breast milk supply; Breastfeeding; Knowledge. Nazeera Tahseen Kareem; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq (Correspondence: nazeera.tahsen@gmail.com) Hamdia Merkhan Ahmad; Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq. 135 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 05/07/2022 Accepted: 09/09/2022 Published: 30/11/2023 mailto:Nazeera.tahsen@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Breast milk is a primary source of nutrition for infants during the first year of life. In the first month, breast milk serves as the newborn's main source of sustenance. In- fants mostly get their nutrition from breast milk, especially during the first six months of life. It has a nutritional composition that closely resembles what a baby needs for growth, immune system health, and brain development. Although human milk has a variety of nutritional compositions, its main components are water, lipids, carbohy- drates, and proteins, each of which plays a significant role in the growth and develop- ment of the infant [1, 2].The American Academy of Pediatrics (AAP) and major or- ganizations like the United Nations Chil- dren's Fund (UNICEF) and World Health Organization (WHO) advise that infants should only be fed breast milk for the first six months. And this should be continued for the second half of the first year or long- er with an overview of complementary foods, as this is what both the infant and mother prefer from the age of six months to the age of two years [3, 4].One of the significant causes of newborn formula sup- plementation and early breastfeeding ter- mination is insufficient breast milk supply [5].The term "insufficient milk supply (IBMS)” refers to a mother's perception that the amount of breast milk she produc- es is insufficient for her child's require- ments. Instead of counting the baby's wet diapers and feces, mothers frequently use certain inaccurate signals, including infant satiety cues or newborn screaming, as the main indicator of inadequate milk supply. After birth, mothers who believe their breast milk supply is insufficient have a tendency to put off starting to breastfeed until they feel it is sufficient. They may also start adding needless formula supplemen- tation early [6,7,8,9].The main cause of low breast milk production is aberrant hormo- nal lactation that takes place during the final week of pregnancy and after the birth of the baby, which leads to insufficient milk production. This can happen if aber- rant hormone levels disturb breastfeed- ing's endocrine balance [9].Several as- pects, such as stress, anxiety, depression, alcohol, smoking, obesity, and heredity, can lead to hormonal imbalances. Un- known factors like, nipple or breast mas- sages that stimulate the oxytocin hormone may also alter how much breast milk a woman produces. However, autocrine con- trol may interfere with milk production [5]. Mothers with a low milk production might think it is impossible to continue breastfeeding [10].The mother may prem- aturely stop nursing for a number of rea- sons, including: demographic, physical, so- cial, psychological, and biological variables that influence mothers' adherence to inad- equate breast milk production. The degree of breastfeeding success, sleep, nutrition, family support, family income, and a moth- er's ability and self-efficacy can all contrib- ute to her decision to continue exclusively nursing [11].The prevalence of insufficient breast milk supply in the USA over the first year of life was between 43% and 55% [12], 54% in Iran [14], 56% in Poland [15], 58% in Australia [16], 47% in New Zealand [5], and 36% in Madrid [13].Many studies result on mothers' notion and attitudes toward breast feeding, but few discuss IBMS beliefs and experiences. But there was not any specific study in regard to the belief in insufficient breast milk supply in Kurdistan. The objectives of the study were to:1) Determine the prevalence of belief and experience insufficient breast milk supply. 2) Find associations between IBMS with knowledge of the mother regarding breast feeding, parity, mode of last deliv- ery, and socio-economic status. 136 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article or more. For measuring family income, the socio-economic status scale (SES) was used, which was composed of the follow- ing variables. It was determined by the mother's age, education level, and occupa- tion, as well as her husband's occupation and possession of a car and a house [35]. Part ‘two’obestrical history of women in- cludes: parity ( 1- primiparous, 2-4 multip- arous, ≥ 5 grand multiporous ), abortion, mode of last delivery ,vagianal and cesere- an delivery. Part ‘three’ includes the moth- er's belief and seven items about the rea- sons and factors that affected insufficient breast milk supply.Part ‘four’ includes the mother’s experiance of IBMS with 6 itimes. Part ‘five’ of the questionnaire( the questionnaire was via direct interview ) was regarding the mothers' knowledge to- ward breast feeding (BF) consisted of 16 items that were divided into two sections. Items were scored as one when answered correctly or zero when answered incorrect- ly. The total score for the scale ranged from zero to 16 points, with a higher score indicating a higher degree of maternal BF knowledge. The first section had eight question items relating to the benefits of breastfeeding for the infant. The second section consisted of eight question items about the benefits of BF for the mother. The level of knowledge regarding breastfeeding was categorized into three levels as follows: 1) Poor level of knowledge (0–5); 2) Fair level of knowledge (6–10); and 3) Good level of knowledge (11–16). The data were entered and analyzed via using the Statistics Pack- age for Social Science (SPSS, version 26), to find out the descriptive statistics (frequency and percentage) and Chi- square test. A descriptive cross-sectional study was conducted from September 1st 2020 to September 1st 2022, with data collected during the postpartum period in eight pri- mary health care centers (PHCC) and Raparin Teaching Hospital (RTH) in Erbil city from October 1, 2021 to May 25, 2022. The PHCC was chosen randomly from the following geographical areas: Nazdar Bamarny and Zhiyan (North), Azadi and Rasty (South), Nawras and Maham- mad Bajalan (West), and Kurdistan and Mala Fandi (East). The approval was ob- tained from the Ethical and Scientific Com- mittee of the College of Nursing at Hawler Medical University (N.103, on October 7th ,2021). The formal agreement was re- served from Directorate of Health and PHCC and RTH. Verbal consent was ob- tained from all participants before starting interview.Data were gathered directly from 1,000 mothers who participated in the study during the postpartum period through a questionnaire. and the calculat- ed net had been used to estimate the sample size of the study, according to the following values: The confidence interval was 95%, the margin of error showed 1%, and the population proportion was 50%. In terms of inclusion criteria (prime and multiparous women, women with a healthy newborn baby capable of breast milk sucking, and mothers at 6 months postpartum), and in regard to exclusion criteria: mothers who refused to partici- pate in the study; mothers who have breast diseases such as breast cancer, breasts mass, or breast surgery. The ques- tionnaire consisted of five parts: part one: Socio-demographic information, including age, education level, employment, and residence location; types of family, and body mass index: Underweight: under 18.5, Normal weight: 18.5-24.99, Over weight, 25-29.99, and Obese, had got 30 137 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Table 1- focuses on the sociodemographic characteristics of the study sample, which were estimated based on participants age, level of education, occupation status, and their residential location, economic status, family type, and BMI. The highest percent- age (51.8%) of the study sample was be- tween 21-30 years old, while the lowest percentage (3.1%) was between ≥ 40 years old. According to the mother's level of ed- ucation, it shows that intermediate levels had the highest percentage 27.6% while MSc holders had got 1.4% that was the lowest percentage. In terms of occupation, mothers who had semiskilled manual occu- pations got 50.8%, which was the highest percentage, and highly skilled professional mothers scored the lowest percentage, which is 1.2% The study shows residential place, urban mothers had got the highest percentage 69.5% while ‘rural’ had got the lowest percentage 2.9%. The study, also, shows that the majority of the participants, 76%, had their own car, and the minority, 24%, didn't have it. furthermore, it shows the percentage of having house, the high- est percentage 53.4% didn't have it and the lowest percentage 46.6% had it. In addi- tion, it shows the percentage of the moth- er’s body mass index. mothers who were overweight got the highest percentage 46.8% and underweight mothers the low- est percentage 0.3%. According to their family types, mothers who had unclear family type were the majority with the highest percentage (73.3%), and extended family mothers were the minority with the lowest percentage (26.7%). The results also indicate the socioeconomic levels of moth- ers; it shows that middle socioeconomic level mothers had the highest percentage (52.2%), while mothers who had a high so- cioeconomic level had the lowest percent- age (only 3.6%).Table 2 - indicates the ob- stetrical data of the study samples, in . terms of parity, the highest percentage 65.5% of the study sample were multipa- rous, while the lowest percentage 9.3% of them were grant mute parous. The highest percentage, 65.5%, of the study samples had no abortions, while the lowest per- centage, 1.0% of them had more than three abortions. The high percentage, 89.7%, had no neonatal deaths, while the lowest percentage, 0.4%, had >3 neonatal deaths. Regarding mode of last delivery, the highest percentage, 63.2%, was a ce- sarean section, while vaginal delivery gave the lower percentage, 36.8%.The preva- lence of belief was 59.8% regarding insuffi- cient breast milk supply. And the mothers experience was 78.6% regarding insuffi- cient breast milk supply. Table 3 highlights, the mothers’ knowledge towards all items of breastfeeding and the benefits for in- fants and the mothers were showed. Re- garding the benefits of breastfeeding for the baby, protects against infection and illnesses had the highest percentage (54.9%). Also, it showed that breastfeeding leads to uterine involution had the highest percentage (37.8%), regarding the benefits of breastfeeding for the mother. The over- all level of perceptions among participants showed that 62.2% of the mothers had poor level of knowledge. Table 4 shows that there was a highly significant associa- tion between mode of the last delivery and mothers' knowledge with belief because of their p- value rates (0.01). It shows that there is not a significant association be- tween parity and socioeconomic status with belief because of their P- value rates (0.869) and (0.986).Table 5 shows that there was a highly significant association between socioeconomic status with moth- er’s experience because of its P-value rate (0.01), also mother’s knowledge is nearby significant, it shows that there's not any significant association between experience and the other factors 138 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 139 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Socio-demographic characteristic of the study sample (n=1000). Variables F (%) Age groups (years) ≤20 21-30 31-40 >40 52 518 399 31 (5.2) (51.8) (39.9) (3.1) Mother education Illiterate Primary (or read and write) Intermediate High school or vocational Institute (2years) College (Bachelor degree) College (MSc degree) 144 112 276 146 131 177 14 (14.4) (11.2) (27.6) (14.6) (13.1) (17.7) (1.4) Occupation status Unskilled Manual Semi-skilled manual Skilled manual and manual Associated professional Skilled professional or senior managerial Highly skilled professional Residential place Urban Sub urban Rural Possession of car 91 508 239 108 42 12 695 276 29 (9.1) (50.8) (23.9) (10.8) (4.2) (1.2) (69.5) (27.6) (2.9) Yes No Possession of house Yes No Socio economic status Low economic level Middle economic level High economic level Type of family Nuclear Extended BMI Under weight Normal weight Over weight Obese 760 240 466 534 442 522 36 733 267 3 314 469 215 (76) (24) (46.6) (53.4) (44.2) (52.2) (3.6) (73.3) (26.7) (0.3) (31.4) (46.9) (21.5) Economic status: It was depending on the mother’s age, level of education, mother’s occupation, also Husbands occupation, car, house [35]. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 140 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Mothers obstetrical history sample size (n=1000) Variable F (%) Parity Primiparous Multiparous Grant multiparous 252 655 93 (25.2) (65.5) (9.3) Abortion None 1-3 >3 655 335 10 (65.5) (33.5) (1) Neonatal death None 897 (89.7 1-3 >3 Mode of last delivery 109 4 (10.9) (0.4) Vaginal delivery Cesarean delivery Mothers believed of insufficient breast milk supply Yes No Mothers experienced of insufficient breast milk supply Yes No 368 632 598 402 786 214 (36.8) (63.2) (59.8) (40.2) (78.6) (21.4) Table 3: Mother’s Knowledge Regarding Breast feeding Benefits of breast feeding Correct (%) Incorrect (%) Benefit of breast feeding for infant 1- Protects against infection and illnesses 2- Promotes bonding between mother and child 3- Baby is rarely constipate 4- Strengthen child’s bones 5- Enhances development 6- Enhances intelligent 7- Is at the right temperature 8- It is always clean Benefit of Breastfeeding for Mother 549 (54.9) 152 (15.2) 154 (15.4) 350 (35) 494 (49.4) 490 (49) 198 (19.8) 167 (16.7) 451 (45.1) 848 (84.8) 855 (85.5) 650 (65) 506 (50.6) 510 (51) 802 (80.2) 833 (83.3) 1-Leads to uterine involution 378 (37.8) 622 (62.2) 2-Decrease incidence of breast disease 365(36.5) 635(63.5) 3-Decrease incidence ovarian cancer 363 (36.3) 637 (63.7) 4- Helps mother's body to return to normal 239 (23.9) 761 (76.1) 5- Provides emotional satisfaction to the mother 153 (15.3) 847 (84.7) 6- Save money 159 (15.9) 841 (84.1) 7- Lose weight faster after birth 247 (24.7) 753 (75.3) 8- Spacing birth. 101 (10.1) 899 (89.9) Overall Mother’s Knowledge F (%) Poor knowledge 622 (62.2) Fair knowledge 368 (36.8) High knowledge 10 (1) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 141 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: Associated factors with belief of insufficient breast milk supply Factors Believed Not believed P -value F (%) F ( %) Parity Primiparous 150 (59.5) 102 (40.5) 0.869NS Multiparous 390 (59.5) 265 (40.5) Grant multiparous 58 (62.4) 35 (37.6) Mode of last delivery Vaginal delivery 79 (21.5) 289 (78.5) 0.017HS Cesarean delivery 98 (15.5) 534 (84.5) Mothers’ knowledge Poor knowledge 369 (59.3) 253 (40.7) 0.015*HS Fair knowledge 223 (60.6) 145 (39.4) Good knowledge 6 (60) 4 (40) Socio-economic status Low socioeconomic level 266 (60.2) 176 (39.8) 0.986NS Middle socio-economic level 310 (59.4) 212 (40.6) High socio-economic level 22 (61.1) 14 (38.9) *Fisher’s exacted test was applied. NS: Non significant HS: Highly significant Table 5: Associated factors with mother’s experience about insufficient breast milk supply Factors Experienced Not experience P -value F (%) F ( %) Parity Primiparous Multiparous 525 (80.2) 130 (19.8) 0.064 NS Grant multiparous 76 (81.7) 17 (18.3) Mode of last delivery Vaginal delivery 299(81.3) 69 (18.8) 0.119 NS Cesarean- Section 487(77.1) 145(22.9) Mothers’ knowledge Poor knowledge 474 (76.2) 148 (23.8) 0.051*NS Fair knowledge 303 (82.3) 65 (17.7) Good knowledge 9 (90) 1 (10.0) Socio-economic status Low economic level 329 (74.4) 113 (25.6) 0.014S Middle economic level 426 (81.6) 96 (18.4) High economic level 31 (86.1) 5 (13.9) NS: Non significant S: Significant. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article DISCUSSION 142 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Promoting positive beliefs about breast milk in women during postpartum is an important precursor to future breastfeed- ing. The study showed that knowledge about the benefits of breastfeeding and perceived social influences were important for individuals with positive breastfeeding belief. The study included 1,000 healthy women who were six months postpartum, and the results revealed that the majority of the participants were between the ages of 21-30 years old. This finding is con- sistent with the findings of Sultania et al. (2019), who conducted a cross-sectional study of 1000 healthy women in India [18], and discovered that the majority of them were between the ages of 20 and 30. and Topothai, (2021) conducted a cross- sectional study on 676 mothers, of whom a high percentage were 17-35 years old, in Bangkok [19].The current study found that, the majority of residential places were in urban areas; this finding is similar to that of Huang (2022), who conducted a longitu- dinal cohort study in China; 628 of the 1520 mothers recruited into the study were from urban areas [20]. The result of the present study indicates that over- weight mothers had the highest percent- age of 46.9% in regard to BMI; this result agrees with the result of two studies Preusting's (2017) descriptive cohort study, which included 216 women, showed that the majority of participants had become overweight [21]. Nommsen et al. (2010) also conducted a cohort study with 431 postpartum women. showed the high per- centage of overweight people (44.8% in California) [22].The current study found that intermediate level education received the highest percentage of 27.6% in terms of mother's education, which agrees with the findings of Abdallah (2018), who con- ducted a cross-sectional study with 384 women and found that intermediate level education received the highest percent- age of 58.6%, which is higher than the current study in Zagazig [23]. But in an- other study in India by Sultania et al. (2019), it showed that the illiterate had the highest percentage [18].Regarding types of families, the result showed that the highest percentage was the nuclear type (73.3%). This is consistent with a study by Menekse, (2021) a descriptive a cross-sectional study that included 429 mothers in Turkey, where the highest percentage, 83.4%, were living in a nucle- ar family [24].In the present study, the highest percentage in SES (socioeconomic status) (52.2%) was middle economic lev- el. This result is compatible with the find- ing of Nukpezah, (2017), who conducted a study on 393 mothers in Ghana [25], which showed the highest percentage (53.1%) were in the middle economic lev- el, while these results are in contrast with the finding of Sultania et al. (2019), who showed that 49% belonged to the low socio-economic level in India [18]. Habibi (2018) discovered a 44% low economic level in a cross-sectional study of 297 mothers in Casablanca [26]. The current study showed that there was a highly sig- nificant association between socioeco- nomic status with mother’s experience regarding insufficient breast milk supply. But there was not significant between mothers’ belief with socio economic sta- tus. The results of the present study showed that the highest percentage in the study, 65.5%, were multiparous, re- spectively, which is consistent with a pre- vious study done by Topothai (2021) [19]. Sandhi et al. (2020) conducted a cross- sectional study and included 237 partici- pants in Yogyakarta City More than half of the mothers were multiparous [9].However, primiparous was 25.2% that was similar to the previous study Sultania et al (2019) that 25.5% was https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Conclusion 143 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. in Erbil, Iraq. The highest percentage of mother's experiences was 72% in the study by Gewa (2016) [31], which con- ducted a cross-sectional study on 400 mothers, which is in contrast with anoth- er study by Gatti et al. (2018) [17].The study showed that the mothers with poor knowledge were the majority in regards to the benefits of breastfeeding for the baby and the mother; this result is almost similar to the previous studies by Ahmed and Piro (2019) that conducted a cross- sectional study in Erbil, Iraq; Sultania et al. (2019) in India; Cardoso (2017) in Por- tugal; and Qarabi (2017) in Saudi Arabia [32, 18, 33, 34, 35].The study indicated that there was a highly significant associa- tion between the mother's belief and knowledge with insufficient breast milk supply, which was similar to the previous study's result by Menekse (2021) [24]. But in the longitudinal design study that applied to 61 participants in New Zealand by Hintz (2019) [5], there was not a sig- nificant association between a mother's knowledge and the perception of insuffi- cient milk supply. The study shows a near -significant association between mothers' experience with insufficient breast milk supply, which is similar to the previous studies by Gewa (2016) [31] and Hintz (2019). The results of the present study indicate that there is an association between mother's belief of insufficient breast milk supply with mothers’ knowledge about breastfeeding. Also, there is an associa- tion between the mother's belief with mode of last delivery. Besides, there is an association between a mother's experi- ence with socio-economic status regard- ing insufficient breast milk supply. primiparous [18].The current study showed that the most percentage in the mode of the last delivery was cesarean section, that agree with previous studies by Menekse (2021) and Segura (2022) sys- tematic review showed that the majority was caesarean sections [24, 27]. Yet, it dis- agrees with two previous studies that the high percentage in vaginal delivery by Topothai (2021) [19] and Sandhi et al (2020) [9].The present study, also, showed that there was a significant association be- tween the mode of last delivery and be- liefs. Yet, there was not a significant associ- ation between parity, belief, and experi- ence with insufficient breast milk supply. The result of parity is similar in two stud- ies, McCarter-Spaulding and Kearney (2001), which concluded a cross-sectional study of 60 mothers in the northern United States [28]. and previous study, Sandhi et al. (2020) [9].Moreover, the result shows that beliefs and experiences are highly sig- nificant along with mothers’ concepts re- garding insufficient breast milk supply and breast feeding. This finding is consistent with previous studies Camurdan (2008) descriptive cross-sectional study included 1230 mothers in Turkey [29]. Sacco (2006) conducted a qualitative study using semi- structured interviews with 200 mothers in Mexico [30], which found that postpartum mothers who did not practice exclusive breastfeeding had a perception of insuffi- cient milk supply. The current study found the prevalence of mothers' belief about insufficient milk supply to be 59.8%; that was the most prevalent reason for stop- ping breast feeding during the first six months. However, in a study conducted by Sultania et al. (2019) in India, insufficient breast milk supply was cited by 41% of re- spondents as the most common reason for discontinuing breastfeeding [18].The prev- alence of a mother’s experience with in- sufficient breast milk supply was 78.6% https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article REFERENCES 144 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] Gruca MA. Breast milk macronutrient com- position and infant growth in rural west Afri- ca. 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