Decision-making process of exclusive breastfeeding at 6 months postpartum based on the COM-B model: a multicenter, cross-sectional study in Southeast China.

BACKGROUND: Exclusive breastfeeding (EBF) for the first 6 months is crucial for public health, yet EBF rates in China remain below the 50% target of "Healthy China 2030." In Southeast China, adequate maternal knowledge and healthcare access do not ensure sustained EBF practices, indicating a clear knowledge-behavior gap. Traditional education models often ignore the interaction between psychological capabilities and environmental opportunities. Grounded in the COM-B (Capability, Opportunity, Motivation-Behavior) model, this multicenter study investigates EBF decision-making among postpartum women in this region. By examining how Capability (knowledge) and Opportunity (social support) interact through Motivation (self-efficacy), this research provides an evidence-based framework for targeted EBF interventions. METHODS: A multicenter, cross-sectional study was conducted. We used convenience sampling to recruit 400 women at 6 months postpartum from two public hospitals in Southeast China. Validated instruments, including the Breastfeeding Knowledge Questionnaire, Breastfeeding Family Support Scale, and Breastfeeding Self-Efficacy Scale (Short Form), were used for data collection. Data analysis involved descriptive statistics, independent t-tests, ANOVA, and Partial Least Squares Structural Equation Modeling (PLS-SEM) to test the hypothesized pathways. RESULTS: The exclusive breastfeeding (EBF) rate at 6 months postpartum was 30.25%. The PLS-SEM model explained 35.7% of the variance in EBF behavior (R 2 = 0.357). Breastfeeding knowledge (Capability)did not directly predict EBF behavior (p = 0.534). However, it showed a significant indirect effect. Specifically, knowledge positively predicted self-efficacy (Motivation) (B = 0.136), which in turn predicted EBF (B = 0.201). Furthermore, family support (Opportunity) had a direct positive effect on EBF (B = 0.097). It also predicted self-efficacy (B = 0.528), demonstrating a significant indirect effect on EBF behavior. CONCLUSION: Based on the COM-B model, this study identifies maternal self-efficacy (Motivation) as a key mediator connecting breastfeeding knowledge (Capability) and family support (Opportunity) to EBF behavior. These findings suggest that knowledge-focused education alone is insufficient. Future public health interventions should adopt a family-centered approach. Clinical programs should integrate family support and prioritize building maternal confidence to effectively improve EBF rates.