J Ad Nu s. 2021;77:703–714. wileyonlinelib a y.com/jou nal/jan
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703© 2020 John Wiley & Sons L d
Recei ed: 16 July 2020
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Re ised: 23 Sep embe 2020
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Accep ed: 27 Oc obe 2020
DOI: 10.1111/jan.14625
ORIGINAL RESEARCH:
EMPIRICAL RESEARCH – QUANTITATIVE
Heal h li e acy o p egnan women and du a ion o
b eas eeding main enance: A easibili y s udy
Ra a Vila-Candel1,2 | F ancisco Ja ie So iano-Vidal2,3,4,5 | Desi ée Mena-Tudela6 |
José An onio Quesada7 | En ique Cas o-Sánchez8,9
1Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, Valencia, Spain
2Depa men o Nu sing, Uni e si a de València, Valencia, Spain
3Depa men o Nu sing, Uni e si y o Alican e, Alican e, Spain
4Depa men o Obs e ics and Gynaecology, Hospi al Luis Alcanyis, Xà i a, Spain
5Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO), Valencia, Spain
6Depa men o Nu sing, Uni e si a Jaume I. A de Vicen Sos Bayna , Cas elló, Spain
7Depa men o Clinical Medicine, Uni e sidad Miguel He nández, Elche, Alican e, Spain
8Na ional Ins i u e o Heal h Resea ch Heal h P o ec ion Resea ch Uni (NIHR HPRU), Heal hca e Associa ed In ec ion and An imic obial Resis ance a
Impe ial College London, London, UK
9School o Heal h Sciences, Ci y, Uni e si y o London, London, UK
Co espondence
Desi ée Mena-Tudela, Depa men o
Nu sing, Uni e si y Jaume I. A da, Sos I
Bayna s/n 12071, Cas ellón de la Plana,
Spain.
Email: [email p o ec ed]
Funding in o ma ion
This p ojec has been unded by he
Conselle ia de Educación, In es igación,
Cul u a y Depo e o he Gene ali a
Valenciana in i s call o g an s o he
conduc ion o R&D&I p ojec s de eloped
by eme ging esea ch g oups in 2018
(Re e ence GV/2018/036). ECS is a ilia ed
wi h he Na ional Ins i u e o Heal h
Resea ch Heal h P o ec ion Resea ch
Uni (NIHR HPRU) [g an numbe HPRU-
2012–10047] in Heal hca e Associa ed
In ec ions and An imic obial Resis ance a
Impe ial College London in pa ne ship wi h
Public Heal h England (PHE), he is an NIHR
Senio Nu se and Midwi e Resea ch Leade ,
and acknowledges he suppo o he NIHR
Biomedical Resea ch Cen e. The iews
exp essed a e hose o he au ho (s) and
no necessa ily hose o he NHS, he NIHR,
he Depa men o Heal h o Public Heal h
England.
Abs ac
Aims: Resea ch he associa ion be ween heal h li e acy (HL) and exclusi e b eas -
eeding a 4-mon hs pos pa um.
Backg ound: Despi e he bene i s o b eas eeding (BF), i s a es a e low wo ldwide.
Among he easons o abandonmen is he le el o ma e nal educa ion. Ma e nal
educa ion has been associa ed wi h HL, bu e idence be ween HL and BF main e-
nance is limi ed.
Design: A c oss-sec ional s udy.
Me hods: The sample comp omised 229 nu sing mo he s ec ui ed om Janua y
2018 o he end o Decembe 2018 a Spain by sys ema ic sampling me hod. Women
we e in e iewed pos pa um on pa ame e s associa ed wi h he s a and con inu-
a ion o BF up o 4 mon hs pos pa um. Mul i a ia e logis ic eg ession models o
explain exposu e a iables and exclusi e BF cessa ion a 4 mon hs.
Resul s: App oxima ely 10% o he pa icipan s had inadequa e HL. Fac o s asso-
cia ed wi h ea ly cessa ion o exclusi e BF a 4 mon hs in he mul i a ia e model
adjus ed using a s epwise a iable selec ion p ocess based on a likelihood a io es
we e ci il s a us, isk o p egnancy, ype o deli e y, limi ed o inadequa e le el o HL,
and LATCH sco e a discha ge, wi h an 85.6% a ea unde he ROC cu e.
Conclusions: Ou s udy o e s p elimina y e idence ega ding he hi he o incon-
sis en ela ion be ween HL and ea ly cessa ion exclusi e BF a 4 mon hs, suppo -
ing he conduc o u he s udies wi h la ge sample sizes and g ea e s a is ical
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1 | INTRODUCTION
B eas eeding (BF) has long- e m clinical bene i s, i lowe s he isk
o in ec ions and sudden in an dea h synd ome, childhood leukae-
mia, o obesi y (Chan e al., 2016). In u n, ma e nal bene i s comp ise
imp o ed bonding wi h he newbo n in an , body weigh s abiliza-
ion, lessened isk o pos pa um dep ession, and a lowe incidence
o b eas o o a ian malignancies (Abou-Dakn, 2018; Chowdhu y
e al., 2015). Las ly, BF a o ds bo h sho - and long- e m economic
and en i onmen al socie al ad an ages (Rollins e al., 2016).
2 | BACKGROUND
The Wo ld Heal h O ganiza ion (WHO) ecommend BF as he op imal
eeding o all in an s and exclusi e b eas eeding (EBF) o he i s
6 mon hs o li e; howe e , he a e o EBF in 4 mon hs a e deli e y
globally is s ill low (Vic o a e al., 2016). Despi e hese appa en ben-
e i s only abou 36% o all in an s a e exclusi ely b eas ed wo ld-
wide un il app oxima ely he age o 6 mon hs (Vic o a e al., 2016;
Vila-Candel e al., 2019). Many egions ha e di e en ends in he
pe cen age o in an s age 0–5 mon hs exclusi ely b eas ed, Eas e n
and Sou he n A ica 56%, Sou h Asia 57%, No h Ame ica 35%, and
Eas e n Eu ope and Cen al Asia 42% (UNICEF, 2019).
Se e al easons o his ea ly cessa ion ha e been iden i ied,
including hypogalac ia, newbo n weigh gain below he ecommen-
da ions, lowe ma e nal age, low socioeconomic s a us, le el o ma-
e nal educa ion, BF knowledge, in en ion, and sel -e icacy BF, an
unsuppo i e wo king en i onmen , and nega i e ma e nal expec-
a ions o expe ience wi h BF (O ibe e al., 2015; Rami o González
e al., 2018; Vila-Candel e al., 2019).
The in luence o heal h li e acy (HL) on BF p ac ices a e ye o
be explo ed by esea che s (Tsai e al., 2015). The WHO de ines HL
as “ he cogni i e and social skills which de e mine he mo i a ion
and abili y o indi iduals o gain access o, unde s and and use in-
o ma ion in ways which p omo e and main ain good heal h” (Wo ld
Heal h O ganiza ion, 1998). A ange o HL measu emen ools a e
a ailable (Sø ensen e al., 2012). Howe e , mos ools do no e-
lec he mul idimensional na u e o HL, as hey a e p edominan ly
ocused on eading comp ehension, p onuncia ion, and nume acy
(Haun e al., 2014). Low o inadequa e HL is linked o poo heal h
and clinical ou comes, including inc eased hospi alisa ions, eme -
gency depa men use, poo o e all heal h s a us, and highe le els
o mo ali y (Ba e ham e al., 2016). Gi en he signi ican bu den
o low HL on ci izens and use s o he heal h and social ca e sys-
em (Cas o-Sanchez e al., 2018), on iden i ying and add essing his
modi iable isk ac o has been emphasised o imp o e heal h ou -
comes (Kil oyle e al., 2016). A ac o ha condi ions beha iou s ha
a o d posi i e bene i s owa ds BF is HL (Ba e ham e al., 2016;
Cas o-Sánchez e al., 2016).
Le el o educa ion has been associa ed wi h HL (Ga cia-Codina
e al., 2019; Sø ensen e al., 2015), wi h clea e idence o he close
and di ec associa ion be ween educa ion le el and heal h ou comes
(Cas o-Sanchez e al., 2018; Van De Heide e al., 2013). Howe e ,
low le els o HL we e closely ela ed o poo e heal h s a us, e en in
popula ions wi h high le els o educa ion. E en hough HL and i s e-
la ionship wi h educa ional le els ha e no been cla i ied in p e ious
li e a u e (Van De Heide e al., 2016), ha e s ongly ecommended
ha HL should be pa o he equa ion o e alua e he manne in
which heal h in o ma ion is o be handled in he a ge popula ion.
In iew o he impo ance o ma e nal HL and BF, he de ini ion o
p edic o s and isk ac o s could make an essen ial con ibu ion o
imp o ed ma e nal and in an heal h (Kho asani e al., 2017).
A limi ed numbe o s udies ha e e alua ed he ela ionship be-
ween ma e nal HL and BF beha iou s. Few s udies ha e explo ed
he ela ionship be ween ma e nal HL and BF beha iou s, sugges -
ing a posi i e associa ion be ween he HL o he mo he and he
du a ion o BF (Ba nes e al., 2018; Kau man e al., 2001).
3 | THE STUDY
3.1 | Aims
The p esen s udy was designed o in es iga e he associa ion
be ween HL and exclusi e BF a 4-mon hs pos pa um. The a e
o exclusi e BF a 6 mon hs in Spain is e y low, making i di i-
cul o ob ain a su icien numbe o mo he s o a obus analysis
powe . Such s udies a e wa an ed be o e endo sing HL-based in e en ions aim-
ing o mi iga e ea ly cessa ion exclusi e BF.
Impac : Low o inadequa e HL is linked o mul iple poo heal h and clinical ou comes.
We in es iga ed he p e alence o exclusi e BF a 4 mon hs pos pa um, and he
impac o HL in main aining op imal exclusi e BF p ac ices. Limi ed o inadequa e HL
was one o he ac o s associa ed wi h ea ly cessa ion o exclusi e BF in he mul i-
a ia e eg ession model, al hough u he esea ch is needed.
KEYWORDS
b eas eeding, b eas eeding abandonmen , b eas eeding du a ion, ea ly cessa ion, exclusi e
b eas eeding, heal h li e acy, nu sing, women
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VILA-CANDEL E AL.
(Cabedo-Fe ei o e al., 2019). Fu he mo e, o assess he p e a-
lence o EBF a 4 mon hs pos pa um and iden i y he a iables as-
socia ed wi h low and high HL.
3.2 | Design
This s udy used a desc ip i e, c oss-sec ional, ques ionnai e-based
design.
3.3 | Pa icipan s
The ca chmen a ea o he Heal h Depa men comp ises o 251,000
inhabi an s, wi h abou 1,700 bi hs pe yea . La Ribe a Uni e si y
Hospi al is a s a e- unded e ia y hospi al wi h 300 beds. The po -
olio o heal h se ices o e ed o ci izens in Spain depends on each
o he 17 Au onomous Regions, and hei abili y o independen ly
ailo heal h esou ces o he needs o he local popula ion.
The popula ion was de ined as women in hei pos pa um
pe iod (24–48 h a e deli e y) who we e ollowed-up un il hei
in an s eached 4 mon hs o age. We selec ed women in hei pos -
pa um pe iod using a p obabili y sampling wi h sys ema ic moni o -
ing. The esea ch eam selec ed o in e iew wo women a andom
pe week om hose who we e inpa ien . Con enience sampling was
pe o med, wi h he ollowing inclusion c i e ia: (a) nu sing mo he s
in hei immedia e pos pa um pe iod, (b) women wi hou cogni i e
p oblems, language di icul ies o hose who we e illi e a e, and (c)
single bi hs a e m o acili a e compa ison wi h p e ious s udies
(Vila-Candel e al., 2017). Women could no be con ac ed in he
elephone in e iew a e h ee a emp s we e excluded du ing ol-
low-up isi s om he s udy.
Du ing he i s in e iew a he hospi al, consen o ms and pe -
sonal con ac in o ma ion o u he ollow-up appoin men s we e
ob ained om candida es who we e willing o pa icipa e.
The sample size was es ima ed by EPIDAT 3.1 wi h he ollowing
se ings: assuming a isk o a i ion o EBF in he g oup o pa ien s
wi h adequa e HL o 40% (Rius e al., 2014), e sus 60% among pa-
ien s wi h inadequa e HL, wi h equally sized g oups, a powe o 85%
and a 95% le el o con idence. The calcula ed sample size equi ed
was 222 pa icipan s.
3.4 | Da a collec ion
Da a we e collec ed om pa icipan s using a pape ques ionnai e.
The esea che s ec ui ed con enience samples o women om
hospi al om Janua y 2018 o he end o Decembe 2018. The
HL sc eening ool was sel -adminis a ed and ook app oxima ely
10 min o comple e.
Feeding ype was classi ied in o exclusi e BF including exp essed
milk o milk om a dono (O ibe e al., 2015; Wink is e al., 2015)
o o mula eed, ei he alone o mixed (i eeding combined BF and
o mula eed). B eas eeding s a us was eco ded a he ime o hos-
pi al discha ge (48–72 h ), and a 1, 2, and 4 mon hs pos pa um.
Ea ly cessa ion o EBF was classi ied as cessa ion be o e 4 mon hs
pos pa um (yes/no).
Subsequen ly, he communi y midwi e a he heal hca e cen e,
who al eady had wo es ablished pos pa um con ol appoin men s
wi h he mo he s (a 1 & 2 mon hs pos pa um), ga he ed in o ma-
ion ega ding hei BF s a us. A 4 mon hs pos pa um, a elephone
in e iew was conduc ed, chosen o minimize he isk o missing
da a and maximize da a accu acy, as his was he pe iod whe e
women scheduled an appoin men wi h hei paedia ician and he
paedia ic nu se esponsible o he ca e o he newbo n o ou ine
immuniza ion.
3.5 | E hical conside a ions
The s udy adhe ed wi h he ecommenda ions o he Decla a ion
o Helsinki and was app o ed by he Clinical Resea ch E hics
Commi ee o La Ribe a Uni e si y Hospi al in No embe 2017
(HULR_11/2017/#43). All pa icipan s we e ully in o med abou he
s udy, he olun a y na u e o pa icipa ion, and con iden iali y. The
esea ch eam ec ui ed he women a he hospi al and w i en in-
o med consen was ob ained in all cases, and gua an eed anonym-
i y and con iden iali y.
3.6 | Da a analysis
Desc ip i e s a is ics we e epo ed as means and s anda d de ia-
ions o con inuous a iables (age, age a i s p egnancy, ges a-
ional age, bi h weigh , LATCH sco e, du a ion o BF), and as anges
and pe cen ages o ca ego ical a iables.
The exposu e a iable o he li e acy le el measu ed by NVS was
analysed ca ego ically. The ca ego ies ‘Inadequa e’ and ‘Limi ed’
we e collapsed in o a single ca ego y. Rega ding BF s a us om hos-
pi al discha ge, he esponse a iable “EBF cessa ion a 4 mon hs”
was di ided in o wo ca ego ies: “EBF a 4 mon hs” and “gi es up
BF a 4 mon hs”, which included ei he o mula eeding o mixed
eeding.
We analysed he le el o HL wi h he NVS sc eening ools and
he cha ac e is ics o he women who ga e up BF a 4 mon hs ia
2 × 2 ables and he chi-squa ed es (χ2) o quali a i e a iables.
Mo eo e , he compa ison o a e ages was made wi h he applica-
ion o he S uden - es o quan i a i e a iables. Likewise, ol-
low-up d opou s we e analysed o e he 4 mon hs o de e mine any
di e ences be ween g oups.
To analyse he magni ude o he associa ion be ween a iables,
we gene a ed mul i a ia e logis ic eg ession models o explain
exposu e a iables and EBF cessa ion a 4 mon hs. These models
we e adjus ed using a s epwise a iable selec ion p ocess based on
a likelihood a io (LR) es . The esul s p esen adjus ed odds a ios
(OR), con idence in e als (CIs) calcula ed o a con idence le el
706
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VILA-CANDEL E AL.
o 95%, and associa ed p- alues. Da a analysis was pe o med on
SPSS .25.0 s a is ical package (IBM Co p. Released 2018. IBM SPSS
S a is ics o Windows, A monk, NY, USA) and R (R p ojec 2019,
Ve sion 3.5.1). S a is ical signi icance was conside ed o p < 0.05.
3.7 | Validi y, eliabili y, and igou
Da a collec ion included demog aphic cha ac e is ics and, HL e alu-
a ion ools. LATCH and, o he gynaecological da a we e ob ained
om elec onic medical eco ds.
3.7.1 | Ea ly cessa ion o exclusi e b eas eeding
In all ou ine isi s, he mo he s we e asked abou he ea ly cessa-
ion o EBF and du a ion o EBF since hei discha ge om hospi al
(1. A e you BF you baby wi hou he help o any o mula eeding? 2.
I no , o how long ha e you been exclusi ely BF you baby?). Finally,
he in o ma ion ela ed o he ype o eeding and du a ion was eg-
is e ed in he pe sonal elec onic medical heal h eco d.
3.7.2 | B eas eeding LATCH sco e
The BF LATCH sco e se es o p edic EBF success up o 6 weeks
pos pa um (Sowjanya & Venugopalan, 2018) and p o ides a sys-
ema ic me hod o ga he in o ma ion abou indi idual BF ses-
sions. LATCH sco e assigns a nume ical sco e o 0, 1, o 2 o i e
key componen s o BF o a possible o al sco e o 10 poin s: “L”
is o how well he in an la ches on o he b eas , “A” is o he
amoun o audible swallowing no ed, “T” is o he mo he 's nip-
ple ype/condi ion, “C” is o he mo he 's le el o com o , and
“H” is o he amoun o help he mo he needs o hold he in an
o he b eas (Jensen e al., 1994). LATCH sco e showed ha co -
ela ions we e s ong and posi i e o each i em and o al LATCH
sco e. The Spea man co ela ion coe icien s anged om 0.65–
0.91 (Al un as e al., 2014). We assessed he LATCH sco e in he
ma e ni y uni daily du ing admission and included i in ou da a
upon discha ge (To nese e al., 2012).
3.7.3 | Heal h li e acy sc eening ool
The HL was explo ed h ough an in e iew a discha ge using he
Newes Vi al Sign (NVS) (Weiss e al., 2005). This ool explo es
eading and nume acy using a se o six ques ions based on an ice-
c eam's nu i ional in o ma ion label o he esponden . Pa icipan s
we e no b ie ed abou he ype o answe expec ed no was ex a
ime p o ided. The o al sco e (0–6 poin s) ca ego izes indi iduals
as ha ing a s ong p obabili y o limi ed li e acy (sco e: 0–1 poin s),
possible limi ed li e acy (sco e: 2–3 poin s) o adequa e li e acy
(sco e: 4–6 poin s) as pe au ho s ins uc ions. NVS scale has also
been alida ed o he Spanish speaking popula ion, wi h mode a e
eliabili y (C onbach α = 0.69).
4 | RESULTS
4.1 | Demog aphic cha ac e is ics
Rega ding he sociodemog aphic cha ac e is ics o he pa icipan s,
he mean (SD) age was 32.5 (5.2) yea s. A Table 1 can be ound de-
ails o he dis ibu ion acco ding o he HL sc eening ool used. The
mean (SD) LATCH sco e on he day o discha ge in women wi h EBF
and mixed BF was 8.95 (0.95). A hi d (38.8%, N = 89) o he women
planned o use o mula eeding immedia ely a e deli e y, as he
only con inued ype o eeding.
A o al o 278 women we e ini ially selec ed h ough he inclu-
sion c i e ia o he s udy. Two hund ed and wen y-nine mo he s
comple ed he in e iews a discha ge (82.3%) and 187 mo he s a
in an age 4 mon hs (65.1%), as p esen ed in Figu e 1. We analysed
he homogenei y among hose who ag eed, and hose who declined
o pa icipa e. The e we e no signi ican di e ences in age, age
a i s p egnancy, ges a ional age a deli e y, o coun y o o igin
be ween he g oup ha accep ed and he g oup ha declined o
pa icipa e.
Rega ding he women los o ollow-up, s a is ically signi ican
educ ions in he sample popula ion we e eco ded a one, wo,
and 4 mon hs among he pa icipan s wi h lowe educa ional s a us
(p = 0.011; p = 0.017; p = 0.019, espec i ely) and lowe HL le els as
measu ed by he NVS (p = 0.019; p = 0.035; p = 0.016, espec i ely),
p esen ed in Figu e 2.
4.2 | P e alence o exclusi e b eas eeding
The ime cou se o EBF o e ollow-up is p esen ed in Figu e 3. The
p e alence o EBF a he ime o hospi al discha ge was 55.0%, 95%
CI (48.5–61.4) e sus 46.0%, 95% CI (26.5–38.6) a 1 mon h, 39.0%,
95% CI (20.8–32.2) a 2 mon hs, and 25.6%, 95% CI (16.1–26.6) a
4 mon hs. In u n, 48.3%, 95% CI (14.1–24.2) o he women showed
ea ly cessa ion o EBF.
4.3 | Va iables ela ed o heal h li e acy
The NVS sc eening ool yielded sco es be ween 0–6. These sco es
we e ca ego ized as indica i e o inadequa e (9.6%, N = 22), limi ed
(45.4%, N = 104), and adequa e HL (45%, N = 103). Table 1 p e-
sen s he esul s ob ained wi h he HL le els analysed in ela ion
o he NVS ool (Adequa e/Inadequa e o Limi ed). We iden i ied
s a is ically signi ican di e ences in e ms o he le el o educa ion
(p < 0.001) and ma e nal employmen (p < 0.001). The mul i a i-
a e logis ic eg ession model o inadequa e o limi ed HL sugges ed
ha le el o educa ion and ma e nal employmen we e associa ed
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VILA-CANDEL E AL.
TABLE 1 Cha ac e is ics o he s udy sample acco ding o he heal h li e acy sc eening ool (NVS) (N = 229)
Cha ac e is ics
NVS
To al ow Adequa e Limi ed o inadequa e
χ2, d a p- alueN N (%) N (%)
Ci il s a us (N = 228)
Wi h pa ne /sepa a ed/
di o ced
74 32 (43.2) 42 (56.8) 2.9, 1 0.087
Ma ied 154 89 (57.8) 65 (42.2)
Le el o educa ion
P ima y school 84 19 (22.6) 65 (77.4) 41.4, 2 < 0.001
Seconda y school 90 41 (45.6) 49 (54.4)
Uni e si y 55 43 (78.2) 12 (21.8)
Employmen s a us
Sel -employmen /Highe
p o essional/Manage ial
employmen
22 13 (59.1) 9 (40.9) 22.5, 2 <0.001
Employee 132 73 (55.3) 59 (44.7)
S uden /Unemployed 75 17 (22.7) 58 (77.3)
Coun y o o igin
Spain 211 98 (46.4) 113 (53.6) 2.3, 1 0.126
Fo eign 18 5 (27.8) 13 (72.2)
Pa ne employmen s a us
Sel -employmen /Highe
p o essional/Manage ial
employmen
32 17 (53.1) 15 (46.9) 2.4, 2 0.301
Employee 175 79 (45.1) 96 (54.9)
S uden /Unemployed 22 7 (31.8) 15 (68.2)
Pa i y
Nullipa ous 124 58 (46.8) 66 (53.2) 0.3, 1 0.553
Mul ipa ous 105 45 (42.9) 60 (57.1)
Medical isk ac o s du ing p egnancy
None/Low isk 181 87 (48.1) 94 (51.9) 5.1, 2 0.075
P e-ges a ional/
ges a ional diabe es/
P e-eclampsia
22 5 (22.7) 17 (77.3)
Thy oid pa hology/ARTb 26 11 (42.3) 15 (57.7)
Type o deli e y (N = 168)
Eu ocic 91 44 (48.4) 47 (51.6) 2.3, 2 0.310
Ins umen ed 37 23 (62.2) 14 (37.8)
U gen cesa ean sec ion 40 23 (57.5) 17 (42.5)
Type o b eas eeding a discha ge (N = 229)
EBFc 126 62 (49.2) 64 (50.8) 2.7, 2 0.259
Fo mula eeding 89 34 (38.2) 55 (61.8)
Mixed eeding 14 7 (50.0) 7 (50.0)
Type o b eas eeding a 1 mon h (N = 198)d
EBFc 74 47 (63.5) 27 (36.5) 10.7, 2 0.005
Fo mula eeding 100 39 (39.0) 61 (61.0)
Mixed eeding 24 10 (41.7) 14 (58.3)
(Con inues)
708
|
VILA-CANDEL E AL.
wi h limi ed o inadequa e HL. In addi ion, ma e nal age was iden i-
ied as a con ounding a iable. Women who we e unemployed o
cu en ly s udying we e mo e likely o ha e inadequa e HL as com-
pa ed wi h sel -employed/highe p o essional/manage ial employed
women, all p esen ed in Table 2.
4.4 | Va iables ela ed o ea ly cessa ion o exclusi e
b eas eeding a 4 mon hs
On conside ing he cha ac e is ics o he women and he e e ed ea ly
cessa ion o EBF be o e 4 mon hs, we obse ed s a is ically signi ican
di e ences in he mul i a ia e logis ic eg ession model pe o med
(N = 88). The a ea unde he ROC cu e o ea ly cessa ion o BF was
0.856 (95% CI [0.777–0.935]; p < 0.001). Rega ding he quan i a i e
a iables, only he BF LATCH sco e a discha ge was associa ed o
ea ly cessa ion o EBF (p = 0.002), wi h a highe a e age sco e 9.3, (SD
0.64) e sus 8.7 (SD 1.01) among he women who s opped EBF. Ci il
s a us (p = 0.001), isk o p egnancy (p = 0.002), and ype o deli e y
(p = 0.018) we e associa ed wi h cessa ion. The HL le el as pe he NVS
ool was no s a is ically signi ica i e wi h he ea ly cessa ion o EBF bu
he associa ion was high (OR = 2.6; 95% CI [0.837–8.553]; p = 0.097)
and clinically ele an , as p esen ed in Table 3.
5 | DISCUSSION
This is one o he mos comp ehensi e s udies published o da e in
Spain on BF ini ia ion, main enance, and p edisposing ac o s o
EBF a 4 mon hs pos pa um, and on he o e all in luence o HL
upon hese beha iou s. Based on he esul s o he p esen s udy,
e en hough he e was no signi ican ela ionship be ween he le els
o HL o nu sing mo he s wi h he EBF a 4 mon hs, al hough hei
associa ion could be plausible.
The p e alence o EBF a 4 mon hs was sligh ly highe han wha
was epo ed p e iously in Spain (Rod íguez-Pé ez e al., 2017), al-
hough lowe han in o he coho s in no he n Spain (51.4%–62.5%)
(O ibe e al., 2015; Rami o González e al., 2018). These di e ences
could be a ibu able o he me hodologies used o da a collec ion,
o he scope o BF policies o he di e en o ganiza ions (Díaz-
Gómez e al., 2016). Addi ionally, we need o conside he impac o
ollow-up losses on he ue p e alence o EBF.
In ou s udy, o e one-hal o all he women we e using o mula
eeding a 4 mon hs. I could, he e o e, be in e ed ha a 13.5% o
he women had op ed o o mula eeding due o EBF ailu e, and
his was in line wi h ou p e ious s udy (Vila-Candel e al., 2018).
While BF ini ia ion a e was high, he con inua ion a e declined
subsequen ly. The EBF a e was s ill sub-op imal and do no mee
he global public heal h ecommenda ion se by WHO, and his may
indica e ha addi ional measu es a e needed (De Roza e al., 2019).
Heal h li e acy has been iden i ied as a c i ical and modi iable
ac o o imp o e heal h ou comes and educe heal h dispa i ies
(Ho man e al., 2017). We ound ha while he NVS ool classi ied
45% o he women as ha ing adequa e HL, his igu e was highe
han p e iously epo ed ac oss he boa d (Cheong e al., 2018;
Gazma a ian e al., 2012; Komenaka e al., 2015; Poo man
e al., 2014). Fac o s associa ed wi h HL we e le el o educa ion
and employmen s a us. Since educa ion is a c ucial HL p edic o ,
Cha ac e is ics
NVS
To al ow Adequa e Limi ed o inadequa e
χ2, d a p- alueN N (%) N (%)
Type o b eas eeding a 2 mon hs (N = 191)e
EBFc 60 41 (68.3) 19 (31.7) 13.6, 2 0.001
Fo mula eeding 110 43 (39.1) 67 (60.9)
Mixed eeding 21 9 (42.9) 12 (57.1)
Type o b eas eeding a 4 mon hs (N = 187)
EBFc 48 32 (66.7) 16 (33.3) 9.7, 2 0.007
Fo mula eeding 120 49 (40.8) 71 (59.2)
Mixed eeding 19 11 (57.9) 8 (42.1)
EBFc cessa ion a 4 mon hs
No 46 32 (69.6) 14 (30.4) 3.9, 1 0.046
Yes 43 21 (48.8) 22 (51.2)
aχ2, d : chi-squa e es , deg ees o eedom.
bART: assis ed ep oduc i e echnology.
cEBF: exclusi e b eas eeding.
dLos o ollow-up a 1 mon h = 31.
eLos o ollow-up a 2 mon hs = 38.
Los o ollow-up a 4 mon hs = 42.
TABLE 1 (Con inued)
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709
VILA-CANDEL E AL.
his could explain he ela i ely weak disc imina ing capaci y o he
NVS scale (Delanoë e al., 2016). In gene al, low HL was also co -
ela ed wi h lowe socioeconomic o employmen s a us (Sø ensen
e al., 2013). Acco dingly, mo he s wi h a highe educa ion le el
ended o ini ia e BF mo e o en and we e likely o b eas eed o
a mo e ex ended pe iod o ime, compa ed wi h hei less-educa ed
FIGURE 1 Flowcha o pa ien
selec ion and s udy ollow up 278 women we e ec ui ed
229 women we e included
Women a 1 mon h.
198
Women a 2 mon hs.
191
Women a 4 mon hs.
187
31 women
did no answe o he 1 mon h ollow up call.
7 women
did no answe o he 2 mon hs ollow up call.
4 women
did no answe o he 4 mon hs ollow up call.
49 women we e excluded:
20 declined o pa icipa e
4 we e absen in he oom
6 decla ed o be busy
3 eel oo unwell
16 decla ed language ba ie
FIGURE 2 Dis ibu ion o d opou s
du ing he ollow-up pe iod o EBF
be ween HL le els acco ding o he NVS
ools (N = 42)
35%
30%
25%
20%
Pe cen age
15%
10%
5%
0%
1 mon h 2 mon hs 4 mon hs
Adequa e HL
Limi ed HL
Inadequa e HL
710
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VILA-CANDEL E AL.
coun e pa s (Rami o González e al., 2018; Whipps, 2017). Thus,
ou indings con i m he exis ence o ela ionships be ween educa-
ional le el and HL, as pe o he s udies (Van De Heide e al., 2013).
Among he women op ing o ea ly cessa ion o EBF, abou hal
had limi ed o inadequa e HL acco ding o he NVS. Some au ho s
ha e epo ed ha 30% o women wi h inadequa e HL ha e ne e
b eas ed, as compa ed wi h 13% o women wi h adequa e HL
(Poo man e al., 2014). O he s udies based on he REALM (Rapid
Es ima e o Adul Li e acy in Medicine) ool ha e concluded ha a
high HL is associa ed wi h EBF a wo mon hs (Kau man e al., 2001),
and wi h a signi ican ly high likelihood o BF con inua ion a pos -
pa um (S a o d e al., 2016). O he au ho s ha e obse ed an
associa ion be ween ma e nal HL and BF sel -e icacy (Kho asani
e al., 2017). Fu he mo e, no signi ican ela ionship be ween HL
le els and BF pa e n has been epo ed as pe o he s udies (Mi jalili
e al., 2018).
In his wo k, single, sepa a ed, di o ced, o widowed women, a
isk in p egnancy, wi h limi ed o inadequa e HL, wi h spon aneous
deli e y and wi h low LATCH alues a discha ge we e associa ed
wi h he ea ly cessa ion o EBF a 4 mon hs. In ou s udy, a s able
ela ionship was associa ed wi h mo e ex ended pe iods o BF and
was a ibu ed o pa ne suppo o BF. This suppo has been p e-
iously associa ed wi h inc eased a es o ini ia ion and du a ion o
BF (Leng e al., 2019; Rempel e al., 2017).
Besides, women a inc eased an ena al obs e ic isk we e less
likely o op o EBF a 4 mon hs. The unde lying easons could be
clinical o psychological, as seen in limi ed EBF and assis ed ep o-
duc ion (Ba e a e al., 2019), o hype ensi e p egnancy diso de
(G oe e al., 2013). Ne e heless, he obse a ion could be ela ed
o inc eased le els o anxie y, esul ing in a sho ened EBF pe iod
(Ys om, 2012).
Se e al s udies ha e con i med ha bi h by caesa ean sec ion
signi ican ly hinde s BF in he i s hou o li e (Hobbs e al., 2016).
Howe e , mo he s who success ully s a BF a e a caesa ean sec-
ion p ocedu e a e as likely o con inue EBF a 6 mon hs, as compa ed
wi h mo he s who gi e bi h ia aginal deli e y (Kiani e al., 2018;
Lau e al., 2015).
Rega ding HL le els, women wi h highe sco es could ha e inc eased
awa eness o he impo ance o BF, ha e be e access o esou ces, o
FIGURE 3 Dis ibu ion o ype o
b eas eeding be ween discha ge o he
ou h mon h (N = 229)
60%
50%
40%
30%
20%
10%
0%
EBF Fo mula eeding
Type o eeding.
Mixed eeding
A discha ge
1 mon h
2 mon hs
4 mon hs
Pe cen age
TABLE 2 Odds a ios and 95% con idence in e als o he
mul i a ia e logis ic eg ession analysis o ac o s ela ed o
inadequa e heal h li e acy (NVS)
Fac o s
NVSa
OR (95% CI) p- alue
Age 1.037 (0.974–1.105) 0.252
Ci il s a us
Wi h pa ne /
sepa a ed/di o ced
–
Ma ied
Le el o educa ion
P ima y school 1
Seconda y schoolb 0.393 (0.194−0.797) 0.01
Uni e si yb 0.085 (0.035−0.207) <0.001
Employmen s a us
Sel -employmen /
Highe p o essional/
Manage ial
employmen /
Employee
1
S uden /Unemployed 3,723 (1.854–7.475) <0.001
Coun y o o igin
Spain –
Fo eignb
No e: Adjus ed odds a io calcula ed using he s epwise selec ion
me hod based on he likelihood a io es .
aA ea unde he ROC cu e o inadequa e heal h li e acy acco ding o
NVS = 0.775, 95% CI (0.715–0.834); χ2 = 58.774; p < 0.001; N = 126.
bVa iable di e s signi ican ly be ween ype o heal h li e acy a
p < 0.05.
|
711
VILA-CANDEL E AL.
be su ounded by o he women who would help hem add ess di icul-
ies (Díaz-Gómez e al., 2016; Vila-Candel e al., 2017). This seems o
suppo ou hypo hesis, as women wi h low HL ha e lowe EBF a e a
4 mon hs pos pa um han women wi h adequa e HL.
We analysed he HL and sociodemog aphic cha ac e is ics o
women who we e los o ollow-up. Women wi h lowe educa ional
and HL le els we e a a highe isk o d opping ou o abandoning he
s udy. Heal hca e p o essionals should hus ailo local esou ces o
suppo hese women. The use o ools including he LATCH sco e a
discha ge o HL sc eening ques ionnai es be o e deli e y (To nese
e al., 2012), could iden i y women who may be mo e hesi an o
access heal h se ices o seek specialized p o essional help (So iano-
Vidal e al., 2018).
5.1 | Limi a ions
Ou esul s ela ed o EBF, while a om excellen , imp o e upon
o he compa able s udies (O ibe e al., 2015; Rius e al., 2014).
Ne e heless, ou s udy has limi a ions. Fi s ly, ega ding he
mul i a ia e model cons uc ed o de e mine he ac o s ha explain
he ea ly cessa ion EBF, only 88 subjec s could be included in he
model. This size o build a model ha iden i ies e ec s be ween a -
iables is sca ce. Secondly, he magni ude o he OR ob ained should
be conside ed in he ligh o he limi ed sample size, co espond-
ing o women wi h low HL and ea ly cessa ion o EBF. This could
ha e led o o e es ima ing he likelihood o EBF cessa ion. Howe e ,
ac o s associa ed wi h cessa ion would no be in luenced by his
limi a ion.
On he o he hand, we p agma ically selec ed and used NVS ool
based on hei soundness and expe ience. While he e a e mo e han
40 ools a ailable, he e is s ill a pauci y o HL esea ch conduc ed in
Spain (Ka noe & Kayse , 2015), wi h no ools alida ed in his coun-
y. The only alida ed ools o da e a e e e ed o Spanish-speaking
Hispanics (Lee e al., 2010; Weiss e al., 2005). In hese cases, some
au ho s ecommended adjus ed linguis ic alida ion p ocedu es.
Un o una ely, such alida ion has been made o Spanish spoken in
Spain, wi h no anscul u al alida ion o adap a ion o he p egnan
women (Acquad o e al., 2008).
6 | CONCLUSION
Mul iple well-known bio-psycho-social and economic ac o s in lu-
ence decisions abou BF, such de e minan s should al eady be con-
side ed by BF suppo and p omo ion p og ams.
Ou s udy o e s p elimina y e idence ega ding he hi he o in-
consis en ela ion be ween HL and ea ly cessa ion EBF a 4 mon hs,
suppo ing he conduc o u he s udies wi h la ge sample sizes
and g ea e s a is ical powe . Such s udies a e wa an ed be o e
endo sing HL-based in e en ions aiming o mi iga e ea ly cessa-
ion EBF. On he o he hand, heal h li e acy would con ibu e o and
p omo e pe son-cen ed ma e ni y heal h ca e and would esul in
mul iple o he bene i s o women and in an s.
ACKNOWLEDGEMENTS
The au ho s acknowledge he suppo o all he nu ses and midwi es
o he Obs e ics Depa men a La Ribe a Uni e si y Hospi al who
helped o sc een sui able pa icipan s o he s udy, and all he pa -
icipan women.
CONFLICT OF INTEREST
No con lic o in e es has been decla ed by he au ho s.
AUTHOR CONTRIBUTIONS
VILA-CANDEL, Ra a and MENA-TUDELA, Desi ée designed he
wo k. VILA-CANDEL, Ra a; SORIANO-VIDAL, F ancisco Ja ie and,
QUESADA, José An onio acqui ed, analysed, and in e p e ed he
da a. VILA-CANDEL, Ra a and MENA-TUDELA, Desi ée w o e a
d a . All au ho s e iewed he con en o he pape wi h signi ican
in ellec ual con ibu ions. All au ho s app o ed he inal e sion o
publica ion.
TABLE 3 Odds a ios and 95% con idence in e als o he
mul i a ia e logis ic eg ession analysis o ac o s ela ed o ea ly
cessa ion o b eas eeding a 4 mon hs (N = 88)
Fac o s OR (95% CI) p- alue
LATCHa sco eb 0.321 (0.155−0.666) 0.002
Ci il s a us
Wi h pa ne /
sepa a ed/di o ced
1
Ma iedb 0.105 (0.028−0.392) 0.001
Medical isk ac o s du ing p egnancy
None/Low isk 1
High iskb 19.017 (3.056–118.342) 0.002
NVS ca ego ies
Adequa e 1
Limi ed o Inadequa e 2.675 (0.837–8.553) 0.097
Type o deli e y
Eu ocic 1
Ins umen ed 0.397 (0.106–1.487) 0.171
U gen cesa ean
sec ion
0.154 (0.033−0.724) 0.018
No e: Adjus ed odds a io calcula ed using he s epwise selec ion
me hod based on he likelihood a io es .
A ea unde he ROc cu e o ea ly cessa ion o b eas eeding = 0.856,
95% CI (0.777–0.935); χ2 = 40.650; p < 0.001; N = 88.
Analysis ca ied ou on 88 pa icipan s wi h in o ma ion on all a iables.
One pa icipan excluded om analysis due o incomple e da a ci il
s a us.
aLATCH: LATCH assessmen ool.
bVa iable di e s signi ican ly be ween ype o eeding a 4 mon hs a
p < 0.05.
