Nu sing Open. 2021;00:1–9.
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1wileyonlinelib a y.com/jou nal/nop2
1 | INTRODUCTION
The Wo ld Heal h O ganiza ion, he Eu opean Commission and sci-
en i ic socie ies like he Spanish Pedia ics Associa ion ecommend,
exclusi e b eas eeding (EBF) du ing he i s 6 mon hs o in an s’
li es (Asociación Española de Pedia ía [AEP], 2012; Eu opean
Commission, 2007; Wo ld Heal h O ganiza ion [WHO], 2018).
The Ins i u e o Medicine (IOM) desc ibes heal h li e acy (HL) as
he deg ee o which indi iduals ha e he capaci y o ob ain, p ocess
and unde s and he basic heal h in o ma ion and se ices needed
o make app op ia e heal h decisions (So ensen e al., 2013). Low o
limi ed HL is ela ed o less knowledge abou socio- heal h se ices
and inc eased mo bi- mo ali y upon hospi al discha ge (Be kman
e al., 2011; O ice o Disease P e en ion & Heal h P omo ion, 2010).
2 | BACKGROUND
The bene i s o b eas eeding (BF) o mo he include educing he
isk o pos - pa um dep ession and su e ing b eas and o a ian can-
ce h oughou li e, among o he s, and educing he isk o sudden
dea h, alle gies, as hma o leukaemia, among o he s, o newbo ns
(O ibe e al., 2015; Van Dellen e al., 2019). In cen al and sou h-
e n Eu ope, EBF p e alence in coun ies like Spain a ies be ween
Recei ed: 22 Decembe 2020
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Re ised: 26 Feb ua y 2021
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Accep ed: 15 Ma ch 2021
DOI: 10.1002/nop2.885
RESEARCH ARTICLE
Heal h li e acy and i s ela ion o con inuing wi h b eas eeding
a six mon hs pos - pa um in a sample o Spanish women
Ma ía Jesús Vale o- Chille ón1 | Vic o M. González- Cho dà1 | Águeda Ce e a- Gasch1 |
Ra ael Vila- Candel2,3,4 | F ancisco Ja ie So iano- Vidal2,4,5 | Desi ée Mena- Tudela1
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion- NonComme cial License, which pe mi s use, dis ibu ion and ep oduc ion
in any medium, p o ided he o iginal wo k is p ope ly ci ed and is no used o comme cial pu poses.
© 2021 The Au ho s. Nu sing Open published by John Wiley & Sons L d.
1Nu sing Depa men , Uni esi a Jaume I,
Cas ellón, Spain
2Depa men o Nu sing, Facul y o Nu sing
and Podia y, Uni e si a de València,
València, Spain
3Depa men o Obs e ics and
Gynaecology, Hospi al Uni e si a io de la
Ribe a, Alci a, Spain
4Founda ion o he P omo ion o Heal h
and Biomedical Resea ch in he Valencian
Region (FISABIO), Valencia, Spain
5Depa men o Obs e ics and
Gynaecology, Hospi al Lluis Alcanyís, Xa i a,
Spain
Co espondence
Vic o M. González-Cho dà, Depa amen o
de En e me ía (O ice: MD0209DD),
Facul ad de Ciencias de la Salud, Uni e si a
Jaume I, A da Sos Banya , SN.12071,
Cas ellón, Spain.
Email: cho [email protected]
Abs ac
Aim: To explo e he ela ion be ween heal h li e acy (HL) and con inuing b eas eed-
ing (BF) a 6 mon hs pos - pa um.
Design: Obse a ional, longi udinal and p ospec i e s udy be ween Decembe
2018– May 2019. The STROBE checklis was used.
Me hods: 114 mo he /baby pai ings om a Spanish Hospi al we e included. Mo he s’
heal h li e acy was s udied wi h he Newes Vi al Sign and Sho Assessmen o
Heal h Li e acy o Spanish Adul s 50 (SAHLSA- 50). Be o e hospi al discha ge, BF
e iciency was s udied using he LATCH BF sco e and BF con inui y was ollowed o
6 mon hs. Su i al analysis and Cox eg ession we e done.
Resul s: Heal h li e acy le els and BF e ec i eness we e adequa e be o e hospi-
al discha ge. A 6 mon hs pos - pa um, less han hal he sample s ill exclusi ely
b eas ed. The main eason o ea ly exclusi e BF cessa ion was lowe han he ec-
ommended newbo n weigh gain. The HL le el ac ed as a p o ec i e ac o agains
abandonmen o BF.
KEYWORDS
childbi h, heal h li e acy, midwi e y, nu sing, pos - pa um
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VALERO- CHILLERÓN E AL.
15%– 51% (O ibe e al., 2015; Rius e al., 2014), and lowe s o 16% a
6 mon hs (Cabedo e al., 2019).
Women's HL may also ha e e ec s on hei o sp ing's heal h
du ing p egnancy and la e (Co a ino, 2013). Di e en s udies sug-
ges ha mo he s wi h high HL le els a e mo e likely o ini ia e and
con inue BF (Co a ino, 2013; Kohan e al., 2007).
The e o e, HL le els can be used by midwi es and nu ses o iden-
i y women a isk o abandonmen o BF hanks o hei p o essional
compe ences and close con ac s when a ending o p egnan and
pue pe al women in Spain and elsewhe e (WHO, 2016). Howe e ,
no s udies we e ound in Spain ha ha e ela ed he HL le el and
con inuing BF a 6 mon hs pos - pa um. The objec i e o his s udy
was o explo e he ela ion be ween he HL o a sample o Spanish
mo he s and con inuing BF a 6 mon hs pos - pa um.
3 | METHODS
3.1 | S udy design and pa icipan s
This obse a ional, longi udinal and p ospec i e s udy was con-
duc ed o de e mine he ela ion be ween HL le els and con inuing
BF a 6 mon hs pos - pa um in a sample o Spanish mo he s. The
Guidelines o epo ing obse a ional s udies (STROBE) was used
(see Supplemen a y File 1).
The s udy popula ion comp ised women who ga e bi h a he
Gene al Uni e si y Hospi al o Cas ellón (Spain).
A sample o 114 women was es ima ed by in ini e popula ion sam-
pling, wi h a 0.05 alpha isk and a 0.2 be a isk wi h bila e al con as ,
a common 1- poin s anda d de ia ion o he Sho Assessmen o
Heal h Li e acy o Spanish Adul s (SALSHA_50) ins umen and 10%
losses. Sample selec ion was done by consecu i e non- p obabili y
sampling o hose pue pe al women who con inued EBF a e 36 h
pos - pa um. All he women we e 18 yea s o olde , and hey olun-
a ily pa icipa ed. Twin p egnancies, p e- e m newbo ns and in an s
admi ed o neona al in ensi e ca e uni s we e excluded.
3.2 | Measu emen
Socio- demog aphic a iables we e selec ed, such as ma e nal age,
coun y o o igin, le el o educa ion (illi e a e, p ima y/seconda y
educa ion, oca ional aining, uni e si y s udies), p egnan wom-
en's occupa ional s a us (wo k, do no wo k, s uden ). Obs e ic
a iables we e also collec ed, such as pa i y (nullipa ous, mul ipa-
ous), isk p egnancy (low isk, ges a ional diabe es, hypo hy oidism,
p egnancy- ela ed hype ension, assis ed ep oduc i e ea men ,
mo e han one isk p egnancy), ges a ional week a bi h (a - e m,
pos - e m), mode o bi h ( aginal, induced, caesa ean), ea ly skin- o-
skin con ac (wi h he mo he , wi h he a he , no pe o med) and
skin- o- skin du a ion.
Mo he s’ HL le els we e e alua ed be o e being discha ged
om hospi al wi h wo alida ed ins umen s. Each one e alua es
di e en HL- ela ed aspec s; on he one hand, he Newes Vi al Sign
(NVS) e alua es eading comp ehension and nume ical skills wi h an-
swe s o six ques ions abou he label o he nu i ional composi ion
o ice c eam (Wa sh e al., 2014). This ins umen classi ies HL as
“inadequa e” (0– 1 poin s), “limi ed” (2– 3 poin s) o “adequa e” (4– 6
poin s). I s in e nal consis ency in Spanish was accep able (α = 0.69)
(Weiss e al., 2005). On he o he hand, he SAHLSA_50 su ey, wi h
50 i ems, e alua es ecognizing wo ds and eading comp ehension
(α = 0.92; es – e es eliabili y = .86) (Lee e al., 2010). The in-
s umen 's o e all sco e classi ies HL as inadequa e (<37 poin s) o
adequa e (≥37 poin s).
BF e iciency was analysed upon hospi al discha ge by he
LATCH BF sco e, which is a sys ema ic e alua ion sys em alida ed
in Spanish by Báez León and e al. (2008). This ool assigns a nume -
ical alue o 0, 1 o 2 o i e o he e alua ed componen s wi h a
maximum o 10 poin s (“La ch,” “Audible swallowing,” “Type o nip-
ple,” “Com o ” o mo he s in ela ion o b eas /nipple, and “Hold
– posi ioning” ela ed o need o assis ance). This scale o e s good
con e gen alidi y wi h o he widely used BF assessmen ins u-
men s (Al un as e al., 2014).
Feeding ype (EBF, mixed o o mula) was e alua ed upon hos-
pi al discha ge. Only one esea che pe o med he ollow- up by
elephone wi h he mo he s a i s , second, ou h and six h mon h
pos - pa um. Follow- up included asking abou eeding ype when
making he elephone call, in he e en o changes in i since he
las ime da a we e collec ed, and abou he pos - pa um week when
EBF was changed o mixed o o mula eeding. I mo he s indica ed
mixed o o mula eeding, hey we e asked he eason o ea ly EBF
cessa ion o abandonmen o BF espec i ely (no/li le milk, inc ease
ligh baby weigh han ha ecommended, b eas p oblems, e u n
o wo k, o he , unknown).
Due o a lack o consensus in he li e a u e o de ine he e ms o
BF cessa ion, in he p esen s udy we ha e di e en ia ed be ween
ea ly EBF cessa ion ( he baby is ed by o mula eeding and BF), and
abandonmen o BF ( he baby is ed by only o mula eeding).
3.3 | Da a collec ion
The ieldwo k was ca ied ou , be ween Decembe 2018– May 2019,
by he nu sing p o essionals o he Ma e ni y Uni a he Gene al
Uni e si y Hospi al o Cas ellón, a app oxima ely 36 h pos - pa um
a e ob aining women's o al consen .
Fo ms we e locked and s o ed, and only p ocessed by a single
eam membe , who des oyed hem a e comple ing ieldwo k.
3.4 | S a is ical analysis
A desc ip i e analysis was done o he s udy a iables acco ding o
hei ype. In he su i al analysis condi ioned o con inue BF, he
Kaplan– Meie non- pa ame ic me hod was used o s udy he possi-
ble ela ions be ween BF du a ion and HL. The compa ison be ween
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VALERO- CHILLERÓN E AL.
wo su i al cu es was done by log- ank es ing. Cox eg ession
was pe o med o p edic BF su i al acco ding o he isk ha o he
a iables con e ed. This analysis was done wi h EBF cases and was
epea ed o include EBF and mixed BF cases. Finally, he Cox p opo -
ional haza d model was used o iden i y he o e all di e ences ad-
jus ed o he haza d a io wi h ime. No analysis o missing da a was
necessa y. Da a we e p ocessed and codi ied wi h he R so wa e,
3.5.1. S a is ical signi icance was se a p < .05.
3.5 | E hical conside a ions
This s udy was app o ed by he Clinical Resea ch Commi ee o he
Gene al Uni e si y Hospi al o Cas ellón (Spain) on 6 No embe
2018 (PIC- 2018– 18). The pa icipan s ecei ed enough use ul in-
o ma ion abou he s udy's objec i es and me hodology and ga e
hei o al consen . This s udy me he legisla ion cu en ly in o ce
in Spain abou pe sonal da a p o ec ion (O ganic Law 15/1999, o
13 Decembe on Pe sonal Da a P o ec ion; O ganic Law 3/2018, 5
Decembe , on Pe sonal Da a P o ec ion and Gua an eeing Digi al
Righ s). The Decla a ion o Helsinki p inciples we e espec ed.
4 | RESULTS
The sample was o med by 120 mo he /baby pai ings. Two mo h-
e s e used o pa icipa e in he s udy and ou we e los du ing
ollow- up. The mean age o he inal sample (N = 114) was 32 yea s
(SD = 5.363; Min = 20; Max = 43; IQR = 7), o whom 66.66% (N = 76)
we e Spanish, had comple ed Seconda y o Highe Educa ion
(61.40%; N = 70) and wo ked (75.43%; N = 86).
Rega ding he obs e ic a iables, 51.75% (N = 59) we e p imip-
a ous and 80.70% (N = 92) had a low- isk p egnancy. Ges a ional di-
abe es was he mos epo ed isk (7.02%; N = 8). Bi h modes we e
50.88% (N = 58) spon aneous and aginal, 27.19% (N = 31) we e
induced and 21.93% (N = 25) we e caesa ean. O all he newbo ns,
86.84% (N = 99) unde wen ea ly skin- o- skin con ac wi h hei
mo he o 2 h o mo e (58.77%; N = 67). Table 1 shows he e o-
lu ion o eeding ypes du ing he 6- mon h pos - pa um ollow- up.
Figu e 1 shows he BF e olu ion du ing he 6- mon h ollow- up.
Ve ically, he di e en sec ions in which BF moni o ing was ca -
ied ou a e shown. Ho izon ally, he di e en eeding ypes a e
indica ed ( o mula eeding in g ey and ound- poin ed; EBF in pink
and a solid line; mixed eeding in o ange and a double line; censo ed
pa ien s in b own and a dashed line). I should be no ed ha cen-
so ed pa ien s e e o hose losses ha occu ed du ing ollow- up,
bu o whom BF s a us was a ailable a an ea lie cu - o poin . A
each cu - o poin , he numbe o in an s ecei ing each eeding
ype is displayed (squa e wi h a line and colou co esponding o
eeding ype). Be ween wo cu - o poin s, he changes ha ook
place among he di e en eeding ypes (shaded squa e wi h whi e
ex ) we e classi ied acco ding o easons o ea ly EBF cessa ion
o abandonmen o BF (speci ied in b acke s and de ailed in he
igu e legend). Simila ly, a each cu - o poin , he p obabili y o an
in an being ed EBF (p 1), mixed eeding (p 2) o o mula eeding
(p 3) is shown. The igu e legend indica es how hese p obabili ies
we e calcula ed.
I was no ewo hy ha he p obabili y o con inuing BF a
6 mon hs was p 1 = 0.412. The p obabili y o ea ly EBF cessa ion
(p 2) o abandonmen o BF (p 3) ose wi h each passing mon h since
bi h. Indeed, om ollow- up ou h mon h, he highe p obabili y o
abandonmen o BF (p 3 = 0.255) e sus ha o con inuing mixed BF
(p 2 = 0.19) is s essed.
The main eason o ea ly EBF cessa ion du ing he 6- mon h ol-
low- up inc eased wi h lowe baby weigh han ha ecommended
in 31.34% (N = 21) o cases. O hese, 80.95% (N = 17) changed o
mixed BF and he es o o mula eeding. The main eason o aban-
donmen o BF was pe cei ing hypogalac ia in 41.46% (N = 17) o
cases. O hese, 88.24% (N = 15) o cases had a emp ed o con inue
wi h mixed BF.
Acco ding o he NVS scale, 53.51% (N = 61) o ou pa icipan s
had an adequa e HL le el, 28.95% (N = 33) had a limi ed le el and
17.54% (N = 20) had an inadequa e HL le el. None heless, acco ding
o SAHLSA- 50, 83.33% (N = 95) had an adequa e HL le el, while
he le el o he emaining mo he s was inadequa e (16.67%: N = 19).
Wi h he LATCH BF sco e, he mean BF e iciency sco e o he im-
media e pue pe al pe iod was 8.313 poin s (SD = 1.408; p50 = 8;
IQR = 1).
4.1 | EBF su i al analysis
Table 2 and Figu e 2 o e he compa ison o con inuing EBF acco d-
ing o he HL le el measu ed by he NVS ins umen and he co e-
sponding su i al analysis, and a non- s a is ically signi ican ela ion
be ween he numbe o ea ly EBF cessa ion cases and he HL le el
Mon h
Exclusi e
B eas eeding Mixed eeding Fo mula eeding
Censo ed
pa ien s
N%N%N%N%
Fi s 101 88.60 97.89 43.51 – –
Second 84 73.68 18 15.79 11 9.65 10.88
Fou h 67 58.77 16 14.04 26 22.81 54.39
Six h 47 41.23 21 18.42 38 33.33 87.02
TABLE 1 E olu ion o he ypes
o eeding h oughou he 6 mon hs
pos - pa um
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VALERO- CHILLERÓN E AL.
was shown (p = .2). Simila esul s we e ob ained o SAHLSA- 50
(p = .6) (Table 2; Figu e 3).
4.2 | BF su i al analysis
A su i al analysis was un o o e all BF (including EBF and mixed
BF) compa ed o he HL le el. Table 3 and Figu e 4 show how he
mo he s wi h an adequa e HL le el, as measu ed by he NVS ins u-
men , ob ained a lowe pe cen age o abandonmen o BF cases, as
well as a s a is ically signi ican ela ion be ween HL and con inuing
BF (p = .05). Howe e , no signi ican di e ences we e ound o he
pe cen age o abandonmen o BF cases a 6 mon hs when HL was
e alua ed by SAHLSA- 50 (p = .9) (Table 3; Figu e 5).
4.3 | Cox eg ession
The p edic i e model o EBF du a ion acco ding o he socio-
demog aphic and obs e ic a iables, and hose ela ed o HL
( 2 = 0.432; p < .001), showed ha ma e nal age be ween 30–
35 yea s (HR = 0.2; p = .007), and being bo n in a No h A ican
coun y (HR = 0.062; p < .01), we e p o ec i e a iables agains
ea ly EBF cessa ion, while induced bi h (HR = 4.385; p < .01), no
pe o ming ea ly skin- o- skin con ac du ing he i s hou s a e
bi h (HR = 13.51; p = .031) o assis ed ep oduc i e ea men s
(HR = 16.03; p < .01) inc eased he isk o ea ly EBF cessa ion be-
o e 6 mon hs pos - pa um. The Cox p opo ional haza ds model
con i med lack o o e all di e ences adjus ed o he haza d a io
du ing ollow- up (p = .074).
The Cox eg ession p edic i e model was used wi h BF du a ion
(bo h EBF and mixed eeding) acco ding o he socio- demog aphic
and obs e ic a iables, and hose ela ed o HL ( 2 = 0.393; p < .001).
I e ealed ha ma e nal age be ween 30– 35 yea s (HR = 0.176;
p = .024), an adequa e HL le el (NVS ins umen ) (HR = 0.076;
p = .014), being bo n in a No h A ican coun y (HR = 0.057;
p = .006) and no being p imipa ous (HR = 0.251; p < .01) we e p o-
ec i e a iables, while assis ed ep oduc i e ea men s inc eased
he isk o abandonmen o BF (HR = 21.36; p = .002). The Cox p o-
po ional haza ds model con i med lack o o e all di e ences ad-
jus ed o he haza d a io du ing ollow- up (p = .328).
5 | DISCUSSION
In ou s udy, baby weigh gains lowe han ecommended was he
main eason o ea ly EBF cessa ion, ollowed by b eas p oblems
and pe cei ing lack o milk, which ag ee wi h he esul s epo ed
by O ibe, e al. (2015), and Vila- Candel, So iano- Vidal, e al. (2018).
Acco ding o he esul s epo ed by O ibe and e al. (2015), wi h
minimum baby weigh gains, ea ly EBF cessa ion was he main ea-
son a e ob aining p o essional ad ice (70.8%), whe eas wi h hy-
pogalac ia and BF p oblems, ea ly cessa ion was he main decision
ha mo he s o amily ela i es ga e in 65.1% and 84.2% o cases,
espec i ely, wi h no p e ious diagnosis made by a heal hca e p o-
essional (O ibe e al., 2015).
FIGURE 1 E olu ion o eeding du ing he 6 mon hs pos - pa um, easons and p obabili y o ea ly EBF cessa ion o abandonmen o BF.
BF, b eas eeding; EBF, exclusi e b eas eeding
Censo ed
Paen s
Mixed
Feeding
EBF
Fo mula
Feeding
n=114n=47n=67n=101n=84
n=9n=18
n=16
p 2=
0·19
n=21
p 2=
0·313
n=4
p 3=
0·035
n=11
p 3=
0·1
n=26
p 3=
0·255
n=38
p 3=
0·458
n=5n=8
EBF Fo mula Feeding
MixedFeeding Censo ed paen s
p 1:p /EBFpos pa um
p 2:p Mixed F. /EBF p e ious
p 3:p Fo mulaF./(EBF +Mixed F.)p e ious
(1)Lack o milk
(2)Less han ecommended weigh gain
(3) B eas p oblems
(4)Back o wo k
(5)O he s
(6)Unknown
(2) n=1
(3) n=3
(1) n=3
(2) n=6
(1)n=2
(2) n=7
(6) n=4
(2) n=1
(3) n=2
(1) n=4
n=5
(1) n=2
(2) n=2
(3) n=1
(6) n=1
(1) n=1
(2) n=2
(4) n=1
(5) n=1
(6) n=2
(1)n=6
(6) n=3
(1) n=2
(2) n=2
(4) n=2
(5) n=11
(1) n=5
(4) n=3
(5) n=1
(6) n=2
(4) n=1
n=9n=4
n=4n=2
n=1
Pos -
pa um Fi s Second Fou h Six h
n=47
p 1=
0·412
n=67
p 1=
0·588
n=101
p 1=
0·886
n=84
p 1=
0·737
n=9
p 2=
0·079
n=18
p 2=
0·178
n=1
n=1
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VALERO- CHILLERÓN E AL.
I was s iking ha he main eason o ea ly EBF cessa ion
du ing he 6- mon h ollow- up was inc easing lowe baby weigh
han ha ecommended, whe eas he main eason o abandonmen
o BF was pe cei ing hypogalac ia. In o he wo ds, mo he s o en
supplemen BF wi h o mula eeding because o hei baby's mini-
mum weigh gains, which makes BF du ing ea ly and la e pue pe al
pe iods di icul (Cabedo e al., 2019). I is wo h men ioning ha
ue hypogalac ia is p esen in only 16.3% o cases because he e-
maining cases a e due o a alse pe cep ion o lacking milk, which
leads o ea ly EBF cessa ion (Go oni e al., 2019; Vila- Candel, Duke,
e al., 2018). None heless, o he causes can make mo he s pe cei e
hypogalac ia, such as sho BF imes due o he newbo n's be e
sucking e iciency (O ibe e al., 2015).
Se e al au ho s ha e poin ed ou ha hose mo he s who e-
cei e educa ion abou BF a e mo e likely o ini ia e and con inue EBF
(Cohen e al., 2018). O he wo ks ha e indica ed ha a change in BF
cul u e is necessa y. The e o e, his aining mus s a om ea ly
p eschool ages by means o sui able ac i i ies o each age o b ing
abou a social adap ion in he u u e adul popula ion as ea ly as pos-
sible (Ča ipo ić e al., 2018).
TABLE 2 Kaplan– Meie es ima ed su i al unc ion. E en : ea ly
EBF cessa ion, compa ison acco ding o he HL le el measu ed by
NVS and SAHLSA- 50 (N = 114)
04 (1)a 9 (2) 17 (4) 26 (6) p alueb
Newes i al sign
Adequa e heal h li e acy
ni 61 55 45 41 30
di – 3 – 1 –
S( ) 10.852 0.738 0.686 0.515
CP – – 2 – –
Limi ed Heal h Li e acy
ni 33 29 20 13 10
di – 1 2 1 – .200
S( ) 10.848 0.573 0.404 0.368
CP – – 2 1 –
Inadequa e heal h li e acy
ni 20 17 15 12 7
di – 1 1 – –
S( ) 10.800 0.747 0.640 0.407
CP – – 1 2 –
Sho assessmen o heal h li e acy o Spanish adul s
Adequa e heal h li e acy
ni 95 83 65 54 41
di – 4 3 2 –
S( ) 10.832 0.672 0.592 0.476
CP – – 5 1 –
Inadequa e heal h li e acy .600
ni 19 18 15 12 6
di – 1 – – –
S( ) 10.895 0.789 0.632 0.344
CP – – – 2 –
Abb e ia ions: CP, censo ed pa ien s; di, Numbe o ea ly cessa ion
o EBF p oduced; ni, pa ien s a isk; S( ), Su i al unc ion S( ) = s( )
(p e ious) × (ni−di)/ni.
aWeeks (mon hs).; bp- alue: chi- squa ed.
FIGURE 2 Kaplan– Meie es ima ed su i al unc ion. E en :
ea ly EBF cessa ion, compa ison acco ding o he HL le el
measu ed by NVS. EBF, exclusi e b eas eeding; HL, heal h li e acy;
NVS, Newes Vi al Sign
0510 15 20 25
0.00.2 0.40.6 0.81.0
Weeks un il ea ly cessa ion o exclusi e b eas eeding
P og ession− ee su i al
Newes Vi al Sign
Adequa e Heal h Li e acy
Inadequa e Heal h Li e acy
Limi ed Heal h Li e acy
FIGURE 3 Kaplan– Meie es ima ed su i al unc ion. E en :
ea ly EBF cessa ion, compa ison acco ding o he HL le el
measu ed by SAHLSA- 50. EBF, exclusi e b eas eeding; HL, heal h
li e acy; SAHLSA- 50, Sho Assessmen o Heal h Li e acy o
Spanish Adul s 50
0510 15 20 25
0.00.2 0.40.6 0.81.0
Weeks un il ea ly exclusi e b eas eeding cessa ion
P og ession− ee su i al
Sho Assessmen o Heal h Li e acy o Spanish Adul s
Adequa e Heal h Li e acy
Inadequa e Heal h Li e acy
6
|
VALERO- CHILLERÓN E AL.
The esul s ob ained wi h he su i al analysis and Cox eg es-
sion demons a ed ha , despi e he ob ained models o e ing a
modes p edic i e capaci y (EBF model 2 = 0.432; o al BF model
2 = 0.393), he HL measu ed by NVS was s a is ically signi ican
o con inuing o al BF (Adequa e Heal h Li e acy HR = 7.621e-
02, p = .015), and came close o he s a is ical signi icance o EBF
(Limi ed Heal h Li e acy HR = 2.979e- 01, p = .083; Adequa e Heal h
Li e acy HR = 2.545e- 01, p = .063). I was a p o ec i e ac o in bo h
models agains bo h ea ly EBF cessa ion and agains abandonmen
o BF.
In any case, i is wo h e lec ing on he sui abili y o he ins u-
men s employed o e alua e HL. These ins umen s we e chosen
because hey ha e been alida ed in Spanish and we we e unable
o ind ei he a alida ed ins umen in he Spanish popula ion o
a speci ic ins umen o BF li e acy, and s udying BF li e acy as a
p edic i e a iable o EBF du a ion was po en ially mo e ele an .
The LATCH BF sco e has been p o en o be s a is ically signi -
ican as a p edic o o EBF a 6 weeks pos - pa um (Sowjanya &
Venugopalan, 2018). Howe e , i was no possible o obse e his
ela ion in he p esen s udy.
5.1 | Limi a ions
Al hough ou s udy sample su iced, i was limi ed, and he s udy was
conduc ed in only one cen e. I s longi udinal design educed he
isk o pue pe al mo he s’ memo y bias as in o he s udies (Rami o
González e al., 2018). Howe e , i is impo an o e alua e he sui -
abili y o including o he po en ially ele an a iables o BF du a-
ion, such as smoking habi , socio- economic le el, p e ious nega i e
BF expe iences, p ena al a i ude owa ds eeding a newbo n and
pe cei ed ecei ed suppo by heal hca e p o essionals du ing he
pe ina al pe iod (Cohen e al., 2018; Rami o González e al., 2018).
I would be impo an o also conside o he a iables such as he
labou wo ld, BF- ela ed wo king condi ions o pos - pa um emo-
ional symp oms such as anhedonia, insomnia, a igue, i i abili y o
04 (1)a 9 (2) 17 (4) 26 (6) pb
Newes i al sign
Adequa e heal h li e acy .05
ni 68 58 56 48 43
Di – – 4 4 –
S( ) 10.951 0.868 0.764 0.746
CP – – 2 – –
Limi ed heal h li e acy
Ni 32 31 26 21 14
di – – – 3 1
S( ) 10.969 0.813 0.609 0.466
CP – – 2 1 –
Inadequa e heal h li e acy
ni 21 20 17 14 13
di – – – 1 –
S( ) 10.905 0.854 0.653 0.653
CP – – 1 2 –
Sho assessmen o heal h li e acy o spanish adul s
Adequa e heal h li e acy .9
ni 95 90 81 70 57
di – – 4 8 1
S( ) 10.947 0.840 0.704 0.646
CP – – 5 1 –
Inadequa e heal h li e acy
ni 19 19 17 13 13
di – – – – –
S( ) 1 1 0.895 0.684 0.684
CP – – – 2 –
Abb e ia ions: CP, censo ed pa ien s; di, numbe o abandonmen s o BF p oduced; ni, pa ien s a
isk; S( ), su i al unc ion S( ) = s( )(p e ious) × (ni−di)/ni.
aWeeks (mon hs).; bp- alue: chi- squa ed.
TABLE 3 Kaplan– Meie es ima ed
su i al unc ion. E en : abandonmen
o BF, compa ison acco ding o he HL
le el measu ed by NVS and SAHLSA- 50
(N = 114)
|
7
VALERO- CHILLERÓN E AL.
no being able o concen a e (O ibe e al., 2015). P e ious s udies
ha e epo ed ha one o he easons o ea ly EBF cessa ion (be-
o e 4 mon hs pos - pa um) migh be due o lack o ei he BF sup-
po o BF ollow- up wi h pa icipan s wi h a low le el o educa ion
(O ibe e al., 2015; Rami o González e al., 2018). I would be in e -
es ing o di e en ia e be ween he eason o ea ly cessa ion and
he main pe son who led his decision o be made. Tha is, one same
eason, such as hypogalac ia, may be p omo ed by he mo he who
pe cei es she does no p oduce enough milk, o by he heal hca e
p o essional who uly diagnoses hypogalac ia.
6 | CONCLUSION
HL le el ac s as a p o ec i e ac o agains ea ly EBF cessa ion.
Howe e , i s p edic i e capaci y is limi ed because a ange o ac-
o s in luences con inuing BF and speci ic ins umen s ha measu e
BF li e acy a e lacking. The ela ion be ween HL, o BF li e acy, and
con inuing BF should be in es iga ed by longi udinal s udies wi h
bigge samples, which should con empla e o he a iables ha in lu-
ence con inuing BF.
7 | RELEVANCE TO CLINICAL PRACTICE
This s udy is he i s in Spain o conside he ela ion be ween BF
o 6 mon hs pos - pa um and HL. In his way, HL p o ed o be a
p o ec i e ac o agains ea ly EBF cessa ion.
In he con ex o he p esen s udy, p egnan women a e habi -
ually in con ac wi h heal h p o essionals such as midwi es while
p egnan and du ing he i s days o hei newbo n's li e and also
wi h nu ses and paedia icians o he i s six pos - pa um mon hs.
These p o essionals’ suppo h oughou he BF p ocess is unda-
men al, especially i any di icul ies a ise. The e o e, a speci ic and
alida ed ins umen o li e acy in BF would allow o iden i y isk
ac o s o a oid ea ly EBF cessa ion.
ACKNOWLEDGEMENTS
Ou mos since e hanks o he heal h p o essionals o he Ma e ni y
Uni o he Gene al Uni e si y Hospi al o Cas ellón (Spain) who
con ibu ed o he conduc o his s udy. As well as all he pa ici-
pan s who made i possible.
CONFLICT OF INTERESTS
None.
AUTHORS CONTRIBUTIONS
Vale o- Chille ón, MJ. Me hodology, Fo mal analysis, In es iga ion,
W i ing— O iginal D a . González- Cho dà, VM. Fo mal analysis,
In es iga ion, W i ing— O iginal D a , Supe ision, P ojec adminis-
a ion. Ce e a- Gasch, A. Fo mal analysis, In es iga ion, W i ing—
O iginal D a . Vila- Candel, R. Concep ualiza ion, Me hodology,
W i ing— Re iew and Edi ing. So iano- Vidal, FJ. Concep ualiza ion,
W i ing— Re iew and Edi ing. Mena- Tudela, D. Concep ualiza ion,
Fo mal analysis, W i ing— O iginal D a , Supe ision, P ojec
adminis a ion.
DATA AVAILABILITY STATEMENT
The da a ha suppo he indings o his s udy a e a ailable om
he co esponding au ho upon easonable eques .
FIGURE 4 Kaplan– Meie es ima ed su i al unc ion. E en :
abandonmen o BF, compa ison acco ding o he HL le el
measu ed by NVS. BF, exclusi e b eas eeding; HL, heal h li e acy;
NVS, Newes Vi al Sign
0510 15 20 25
0.00.2 0.40.6 0.81.0
Weeks un il abandonmen o b eas eeding
P og ession− ee su i al
Newes Vi al Sign
Adequa e Heal h Li e acy
Inadequa e Heal h Li e acy
Limi ed Heal h Li e acy
FIGURE 5 Kaplan– Meie es ima ed su i al unc ion. E en :
abandonmen o BF, compa ison acco ding o he HL le el
measu ed by SAHLSA- 50. BF, b eas eeding; HL, heal h li e acy;
SAHLSA- 50, Sho Assessmen o Heal h Li e acy o Spanish
Adul s 50
0510 15 20 25
0.00.2 0.40.6 0.81.0
Weeks un il abandonmen o b eas eeding
P og ession− ee su i al
Sho Assessmen o Heal h Li e acy o Spanish Adul s
Adequa e Heal h Li e acy
Inadequa e Heal h Li e acy
8
|
VALERO- CHILLERÓN E AL.
ORCID
Vic o M. González- Cho dà h ps://o cid.
o g/0000-0001-7426-6686
Ra ael Vila- Candel h ps://o cid.o g/0000-0002-3734-2480
F ancisco Ja ie So iano- Vidal h ps://o cid.
o g/0000-0002-6210-6471
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SUPPORTING INFORMATION
Addi ional suppo ing in o ma ion may be ound online in he
Suppo ing In o ma ion sec ion.
How o ci e his a icle: Vale o- Chille ón MJ, González-
Cho dà VM, Ce e a- Gasch Á, Vila- Candel R, So iano- Vidal
FJ, Mena- Tudela D. Heal h li e acy and i s ela ion o
con inuing wi h b eas eeding a six mon hs pos -pa um in a
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doi.o g/10.1002/nop2.885
