Ci a ion: Vale o-Chille ón, M.J.;
Mena-Tudela, D.; Ce e a-Gasch, Á.;
González-Cho dá, V.M.;
So iano-Vidal, F.J.; Quesada, J.A.;
Cas o-Sánchez, E.; Vila-Candel, R.
In luence o Heal h Li e acy on
Main enance o Exclusi e
B eas eeding a 6 Mon hs
Pos pa um: A Mul icen e S udy. In .
J. En i on. Res. Public Heal h 2022,19,
5411. h ps://doi.o g/10.3390/
ije ph19095411
Academic Edi o : Felix Akpojene
Ogbo
Recei ed: 29 Ma ch 2022
Accep ed: 27 Ap il 2022
Published: 29 Ap il 2022
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Copy igh : © 2022 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
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dis ibu ed unde he e ms and
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A ibu ion (CC BY) license (h ps://
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In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
In luence o Heal h Li e acy on Main enance o Exclusi e
B eas eeding a 6 Mon hs Pos pa um: A Mul icen e S udy
Ma ía Jesús Vale o-Chille ón1, Desi ée Mena-Tudela 1,* , Águeda Ce e a-Gasch 1,
Víc o Manuel González-Cho dá1, F ancisco Ja ie So iano-Vidal 2,3,4,5 , JoséAn onio Quesada 6,
En ique Cas o-Sánchez 7,8 and Ra ael Vila-Candel 2,5,9
1Depa men o Nu sing, Uni e si a Jaume I, A . de Vicen Sos Bayna , 12071 Cas elló, Spain;
[email p o ec ed] (M.J.V.-C.); [email p o ec ed] (Á.C.-G.); cho [email p o ec ed] (V.M.G.-C.)
2Depa men o Nu sing, Uni e si a de València, 46010 Valencia, Spain; ancisco.j.so iano@u .es (F.J.S.-V.);
a ael. ila@u .es (R.V.-C.)
3Depa men o Nu sing, Uni e si y o Alican e, 03080 Alican e, Spain
4Depa men o Obs e ics and Gynaecology, Hospi al Luis Alcanyis, 46819 Xà i a, Spain
5Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO-SP),
46020 Valencia, Spain
6Depa men o Clinical Medicine, Uni e sidad Miguel He nández, 03202 Elche, Spain; [email p o ec ed]
7
Heal h P o ec ion Resea ch Uni in Heal hca e-Associa ed In ec ion and An imic obial Resis ance a Impe ial
College London, London W12 0NN, UK; [email p o ec ed]
8College o Nu sing, Midwi e y and Heal hca e, Uni e si y o Wes London, B en o d TW8 9GA, UK
9Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, 46600 Valencia, Spain
*Co espondence: [email p o ec ed]
Abs ac :
Backg ound: In e na ional o ganiza ions ecommend ini ia ing b eas eeding wi hin he
i s hou o li e and main aining exclusi e b eas eeding o he i s 6 mon hs. Howe e , wo ldwide
a es o exclusi e b eas eeding o 6-mon h-old in an s is a om mee ing he goal p oposed by
he Wo ld Heal h O ganiza ion, which is o each a minimum o 50% o in an s. Educa ion is one
o he ac o s a ec ing he ini ia ion and con inua ion o b eas eeding, and inciden ally, i is also
ela ed o lowe heal h li e acy. This s udy explo ed he in luence o heal h li e acy on main enance
o exclusi e b eas eeding a 6 mon hs pos pa um. Me hods: A longi udinal mul icen e s udy
wi h 343 women we e ec ui ed be ween Janua y 2019 and Janua y 2020. The i s ques ionnai e
was held du ing he pue pe ium (24–48 h) wi h mo he s p ac icing exclusi e b eas eeding, wi h
whom 6-mon h pos pa um b eas eeding ollow-up was pe o med. Socio-demog aphic, clinical
and obs e ic a iables we e collec ed. B eas eeding e iciency was assessed using he LATCH
b eas eeding assessmen ool. The heal h li e acy le el was e alua ed by he Newes Vi al Sign
sc eening ool. A mul i a ia e logis ic eg ession model was used o de ec p o ec i e ac o s o ea ly
exclusi e b eas eeding cessa ion. Resul s: One hi d o he women con inued exclusi e b eas eeding
a 6 mon hs pos pa um. App oxima ely hal he pa icipan s had a low o inadequa e heal h
li e acy le el. An adequa e heal h li e acy le el, a high LATCH b eas eeding assessmen ool sco e
(
>9 poin s
) and being ma ied we e he p o ec i e ac o s agains exclusi e b eas eeding cessa ion a
6 mon hs pos pa um. Conclusion: Heal h li e acy le els a e closely ela ed o main aining exclusi e
b eas eeding and ac as a p o ec i e ac o agains ea ly cessa ion. A speci ic ins umen is needed
o measu e he lack o “li e acy in b eas eeding”, in o de o e i y he ela ionship be ween heal h
li e acy and main enance o exclusi e b eas eeding.
Keywo ds:
b eas eeding; b eas eeding cessa ion; ea ly weaning; exclusi e b eas eeding; heal h
li e acy; nu sing; women
1. In oduc ion
B eas eeding (BF) o e s many heal h bene i s o he mo he and he BF in an , bo h in
he sho and long e m [
1
]. Fo example, BF would educe ma e nal and in an mo ali y [
2
]
In . J. En i on. Res. Public Heal h 2022,19, 5411. h ps://doi.o g/10.3390/ije ph19095411 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2022,19, 5411 2 o 13
by 823,000 in an s and 20,000 mo he s wo ldwide i exclusi e b eas eeding (EBF) up o
6 mon hs was main ained [
3
]; BF would imp o e nu i ional ac o s, lowe ela ed in an
ood cos s [
4
,
5
], and con ibu e o amily and social economic sa ings by lowe ing he
p e alence o diseases in b eas ed newbo ns (NB) [
5
,
6
]. BF also os e s he mo he –child
bond by encou aging a sa e a achmen [7] and a be e mo he –in an ela ionship [4].
The Wo ld Heal h O ganiza ion (WHO) and he Uni ed Na ions In e na ional Chil-
d en’s Eme gency Fund (UNICEF) ecommend ini ia ing b eas eeding wi hin he i s
hou o li e and main aining EBF o he i s 6 mon hs. EBF a es a 6 mon hs a e low,
despi e e o s by in e na ional o ganiza ions [
8
] o p o ec and p omo e his p ac ice [
9
].
Acco ding o he Global Heal h Obse a o y da a eposi o y [
10
], only 25% o in an s in
Eu ope a e b eas ed exclusi ely o he i s 6 mon hs [
11
]. In Spain, EBF p e alence a
6 mon hs is a ound 16.8%, conside ably less han he ~75% EBF a e epo ed a hospi al
discha ge [12,13].
The e a e mul iple ac o s o he p ema u e abandonmen o b eas eeding. Among
hese ac o s, we can ind he low weigh o he in an , he eeling o lack o milk, smoking,
he mo he ’s lack o knowledge abou b eas eeding o he inco po a ion o wo k [
14
,
15
].
Educa ion is o he o he ac o s a ec ing he ini ia ion and con inua ion o b eas eeding
(BF) [
9
,
16
,
17
], and inciden ally i is also ela ed o heal h li e acy (HL) [
18
,
19
]. The concep
o HL eme ged in he 1970s and has been con inuously e ined since hen [
20
,
21
]. Heal h
li e acy is cu en ly de ined as “an indi idual’s abili y o ob ain and ansla e knowledge
and in o ma ion in o de o main ain and imp o e heal h in ways ha a e app op ia e o
he indi idual and communi y con ex ” [
22
]. A low HL le el has been linked o di icul ies
unde s anding heal hca e in o ma ion and o poo he apeu ic conco dance, which in u n
inc eases cos s and leads o an ine icien use o heal hca e esou ces [22,23].
Likewise, women’s HL le els can also ha e an e ec on hei child en’s heal h du ing
p egnancy and a e bi h [
24
,
25
]. As o he decision o b eas eed, he pe cen age o
mo he s who decide o BF ises wi h hei HL le el [
26
]. In one small s udy, heal h li e acy
was ound o be a p o ec i e ac o o b eas eeding [
27
]. Consis en wi h hese esul s, he
aim o his s udy was o explo e he in luence be ween he le el o heal h li e acy and he
main enance o exclusi e b eas eeding a six mon hs pos pa um.
2. Ma e ials and Me hods
2.1. Design and Se ing
A longi udinal mul icen e s udy was ca ied ou a h ee hospi als in he Valencian
Communi y (Spain): The Gene al Uni e si y Hospi al o Cas ellón (Depa men o Heal h,
Cas ellón); he Uni e si y La Ribe a Hospi al (Depa men o Heal h, La Ribe a); he Lluís
Alcanyís Hospi al o Xá i a (Depa men o Heal h, Xá i a-On inyen ). These hospi als
we e ei he e e ence cen e s o hei p o ince (Gene al Uni e si y Hospi al o Cas ellón
and Uni e si y La Ribe a Hospi al) o we e in a u al a ea wi h la ge ca chmen popula ions
(Lluís Alcanyís Hospi al). O e all, he pa icipa ing hospi als se ed 600,000 people.
2.2. Sample
The a ge popula ion comp ised women egis e ed wi h he Depa men s o Heal h
o Cas ellón, La Ribe a and Xá i a-On inyen , whose bi h was a one o he pa icipa ing
hospi als, and who had op ed o EBF on discha ge.
Sys ema ic sampling o women admi ed o hospi al du ing clinical pue pe ium was
conduc ed by andomly selec ing one in e e y h ee pue pe al women on he ma e ni y
wa d e e y Monday. All women who wished o pa icipa e in he s udy we e ec ui ed, and
hey we e asked o sign in o med w i en consen . Mo he s who we e olde han 18 yea s
and had no heal h p oblems associa ed and/o pue pe al complica ions a discha ge we e
included in he s udy.
Some si ua ions may make i di icul o ini ia e lac a ion. Fo his eason, win
p egnancies, and mul iple and/o p ema u e p egnancies, and/o congeni al anomalies
de ec ed in he i s 24 h, and/o newbo ns admi ed in neona al in ensi e ca e uni we e
In . J. En i on. Res. Public Heal h 2022,19, 5411 3 o 13
excluded [
16
,
17
]. We excluded women wi h cogni i e impai men s, language ba ie s, o
illi e acy (no able o ead). Illi e a e women we e excluded om he s udy as hey would
be unable o comple e he sel -adminis e ed heal h li e acy sc eening ools [
25
]. Finally,
we also excluded mo he s who we we e un eachable by elephone a e h ee a emp s a
6 mon hs pos pa um.
We assumed ha i he p opo ion o women wi h limi ed HL a baseline we e 45%, he
EBF cessa ion a e in he adequa e HL g oup was 40% and, o de ec a di e ence be ween
g oups o 15% on EBF cessa ion, as well as a 0.05 con idence le el and 80% s a is ical powe ,
350 women we e equi ed [
27
]. Conside ing a 10% a i ion a e, he inal sample size was
es ima ed a 385 women. The sample size calcula ion was pe o med by EPIDAT .3.1,
San iago de Compos ela, Spain.
2.3. Da a Collec ion, Main Va iables and HL Measu e
The pa icipa ing hospi als a end an a e age o 1600 bi hs pe yea in Cas ellón,
1400 bi hs in La Ribe a, and 700 bi hs in Xà i a-On inyen . The e o e, he numbe o
pa icipan s in each depa men has been in luenced by he numbe o bi hs a ended in
each hospi al.
P in ed ques ionnai es we e used o collec da a. Pa icipan s we e ec ui ed be ween
Janua y 2019 and Janua y 2020 du ing clinical pue pe ium (24–48 h a e gi ing bi h).
One esea che pe pa icipa ing cen e o e saw he i s da a collec ion, excep o he
HL sc eening ool, which women sel -adminis e ed be o e discha ge om hospi al. The
BF ollow-up a 1, 2 and 4 pos pa um mon hs was pe o med by he same esea che by
consul ing each pa icipan s’ elec onic heal h eco ds. Finally, when b eas ed in an s we e
6 mon hs old, mo he s we e elephoned o documen hei eeding ype.
BF e icacy was e alua ed using he LATCH b eas eeding assessmen ool. This
ques ionnai e has been alida ed in Spanish [
28
] and con ains i e i ems (“La ch”, “Audible
swallowing”, “Type o nipple”, “Com o ” and “Hold–posi ioning”). Each i em is sco ed
nume ically (0–2), whe e 0 is he wo s possible and 2 he bes possible si ua ion. A
sco e o 8–10 e lec s e ec i e b eas eeding. Du ing ieldwo k, BF e icacy was e alua ed
wi h his ins umen by he esea che in cha ge a each pa icipa ing hospi al be o e
hospi al discha ge.
While con ac ing mo he s, hey we e asked whe he hey con inued EBF. I hei
answe was nega i e, hey we e asked abou he eeding ype hey p o ided and how long
hey had p ac iced EBF. The ques ions we e: 1. A e you s ill exclusi ely b eas eeding you
baby? 2. I no , o how long did you exclusi ely BF you baby? Finally, eeding ype
in o ma ion and du a ion we e eco ded in hei elec onic medical eco ds. The esea che s
a emp ed a maximum o h ee calls pe pa icipan and ollowed a p e-es ablished sc ip
o educe da a loss as much as possible and maximize da a quali y. Feeding ype was
classi ied as [
16
,
29
]: 1. EBF means ha in an ecei es only b eas milk o exp essed milk;
2. Fo mula milk; 3. Mixed BF (combina ion o b eas milk and o mula milk). BF s a us
was eco ded a hospi al discha ge (48–72 h), and a 1, 2, 4 and 6 mon hs a e gi ing bi h.
Ea ly EBF cessa ion was conside ed i i occu ed be o e 6 mon hs pos pa um (yes/no), as
se ou by he Wo ld Heal h O ganiza ion among i s 2025 a ge s [30].
The HL was explo ed h ough an in e iew a discha ge and was measu ed by he
Newes Vi al Sign (NVS) ques ionnai e alida ed in Spanish, wi h accep able in e nal con-
sis ency (
α
= 0.69) [
31
]. This sel -adminis e ed ques ionnai e con ains six ques ions abou a
nu i ional ice c eam label. One poin is sco ed pe co ec answe [
32
]. Ques ions a e eely
answe ed and do no lead pa icipan s o any expec ed esponse ype. I classi ies he HL
le el acco ding o he o e all sco e as “adequa e” (4–6 poin s) o “limi ed” (<4 poin s).
2.4. Da a Analysis
A desc ip i e analysis was pe o med using absolu e and ela i e equencies o qual-
i a i e a iables (socio-demog aphic and obs e ic a iables), and he mean and s anda d
de ia ion (
±
SD) o quan i a i e a iables. The HL- ela ed ac o s and hose associa ed
In . J. En i on. Res. Public Heal h 2022,19, 5411 4 o 13
wi h EBF cessa ion a 6 mon hs we e analyzed using 2
×
2 ables, he chi-squa ed es (
χ2
)
o quali a i e a iables and by compa ing he means o quan i a i e a iables ia he
one- ac o analysis o a iance (ANOVA) o he S uden ’s - es , espec i ely.
The magni udes o he associa ions wi h EBF cessa ion a 6 mon hs we e deal wi h
by he i o he mul i a ia e logis ic models. The odds a io (OR) was es ima ed along
wi h hei 95% con idence in e als (95% CIs). A s epwise p ocedu e based on AIC’s
c i e ion (Akaike In o ma ion C i e ion) was ollowed o selec a iables. 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, Vienna, Aus ia). As
he analysis included wo a iables, NVS and EBF cessa ion, he le el o signi icance was
adjus ed by he Bon e oni me hod o p< 0.025.
3. Resul s
O 391 pa icipan s ini ially ec ui ed, 48 (12.3%) we e la e excluded: 42 (87.5%) due
o ollow-up loss and six (12.5%) because hey did no wish o con inue in he s udy du ing
ollow-up. The homogenei y be ween hose who we e included and hose who we e
excluded o los om pa icipa ion was analyzed. 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, heal h li e acy le el by NVS o
coun y o o igin be ween he g oup ha was included and he g oup ha was excluded in
his s udy.
The inal sample size was 343 women who epo ed EBF when discha ged om hospi-
al, and who we e included in he BF ollow-up un il b eas ed in an s we e 6 mon hs old.
3.1. Socio-Demog aphic Cha ac e is ics
The pa icipan s’ mean age was 32.5 yea s (
±
5.3). The mean ges a ional age a bi h
was 39 + 3 weeks (
±
1.1), and he mean bi h weigh was 3301.2 g (
±
464.5). Table 1shows
he o he socio-demog aphic a iables included in his s udy.
Table 1. Cha ac e is ics o he included emales (n = 343).
n %
EBF 6 mon hs Yes 117 34.1%
No 226 65.9%
NVS Adequa e HL le el 179 52.2%
Limi ed HL le el 164 47.8%
Depa men o Heal h
La Ribe a 216 63.0%
Xá i a-On inyen 24 7.0%
Cas ellón 103 30.0%
Ci il s a us Ma ied 216 63.0%
Single, sepa a ed,
di o ced 127 37.0%
Le el o educa ion
P ima y o lowe 97 28.3%
1s cycle, Seconda y 58 16.9%
2nd cycle, Seconda y 86 25.1%
Uni e si y diploma 40 11.7%
G adua e 62 18.1%
P egnan women’s occupa ion
Businesswoman/P o essional
35 10.2%
Employee 203 59.2%
Unemployed 84 24.5%
No looking o a job 21 6.1%
Coun y o o igin Spain 278 81.0%
Fo eign 65 19.0%
In . J. En i on. Res. Public Heal h 2022,19, 5411 5 o 13
Table 1. Con .
n %
Pa ne ’s occupa ion Employee 273 79.6%
Businesspe son/P o essional
31 9.0%
O he s 39 11.4%
Pa i y One 176 51.3%
Two o mo e 167 48.7%
Skin- o-skin con ac a bi h No 38 11.1%
Yes 305 88.9%
Bi h ype
Spon aneous 202 58.9%
Ins umen ed 62 18.1%
STC 79 23.0%
Risk p egnancy Low isk 236 68.8%
High isk * 107 31.2%
n Mean (SD)
Mo he ’s age (yea s) 343 32.5 (5.2)
Age wi h i s p egnancy (yea s) 343 29.8 (5.7)
Ges a ional week a bi h (weeks) 343 39.3 (1.1)
LATCH sco e (0 o 10) 343 8.8 (0.9)
Bi h weigh (g ams) 343 3301.2 (464.5)
EBF: exclusi e b eas eeding; NVS: Newes Vi al Sign; STC: segmen ans e se caesa ean; LATCH: La ch audible
ype com o hold. * High isk p egnancy = P eeclampsia, Ges a ional diabe es, Obesi y, Low body mass index,
Mo he age > 35 yea s, Assis ed Rep oduc i e T ea men , Thy oid pa hology, Small o ges a ional age, la ge o
ges a ional age, e al g ow h es ic ion, Au oimmune diseases, P e ious cesa ean sec ion, P e ious p e e m bi h
and Hepa i is Vi us in ec ion.
3.2. BF-Rela ed Va iables
The mean LATCH b eas eeding assessmen ool sco e o BF e iciency was 8.8 ou o
10 poin s (
±
0.9). The 6-mon h EBF a e was 34.1% (117/343), wi h 65.9% (226/343) o EBF
cessa ion be o e 6 mon hs (Figu e 1).
In . J. En i on. Res. Public Heal h 2022, 19, x 6 o 14
Figu e 1. Feeding ype du ing he s udy pe iod.
3.3. HL Le el
O all pa icipan s, 47.8% (164/343) had a limi ed HL le el. The ac o s associa ed wi h
a limi ed HL le el we e, a lowe le el o educa ion (p < 0.001), being unemployed o no
looking o a job (p = 0.003), and no bo n in Spain (p < 0.001). Howe e , he mo he ’s olde
age (p < 0.001) was associa ed wi h a highe HL le el (Table 2). Figu e 2 indica es he dis-
ibu ion o HL le els in ela ion o EBF a 6 mon hs.
Table 2. Rela ion be ween HL le els (NVS) and he s udied a iables.
Adequa e HL Le el Limi ed HL Le el
n % n % p-Value 1
Depa men o Heal h
La Ribe a 107 49.5 109 50.5 0.424
Xá i a-On inyen 13 54.2 11 45.8
Cas ellón 59 57.3 44 42.7
Ci il s a us Ma ied 114 52.8 102 47.2 0.775
Single, sepa a ed, di o ced 65 51.2 62 48.8
Le el o educa ion
P ima y o lowe 35 36.1 62 63.9 <0.001
1s cycle, Seconda y 19 32.8 39 67.2
2nd cycle, Seconda y 44 51.2 42 48.8
Uni e si y diploma 32 80.0 8 20.0
G adua e 49 79.0 13 21.0
P egnan women’s
occupa ion
Businesswoman 23 65.7 12 34.3 0.003
Employee 113 55.7 90 44.3
Unemployed 39 46.4 45 53.6
No looking o a job 4 19.0 17 81.0
Coun y o o igin Spain 164 59.0 114 41.0 <0.001
Fo eign 15 23.1 50 76.9
Pa ne ’s occupa ion
Employee 148 54.2 125 45.8 0.183
Businesspe son 16 51.6 15 48.4
O he s 15 38.5 24 61.5
Pa i y One 99 56.3 77 43.8 0.122
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A discha ge 1 mon h 2 mon hs 4 mon hs 6 mon hs
Fo mula Mixed EBF
Figu e 1. Feeding ype du ing he s udy pe iod.
In . J. En i on. Res. Public Heal h 2022,19, 5411 6 o 13
3.3. HL Le el
O all pa icipan s, 47.8% (164/343) had a limi ed HL le el. The ac o s associa ed
wi h a limi ed HL le el we e, a lowe le el o educa ion (p< 0.001), being unemployed o
no looking o a job (p= 0.003), and no bo n in Spain (p< 0.001). Howe e , he mo he ’s
olde age (p< 0.001) was associa ed wi h a highe HL le el (Table 2). Figu e 2indica es he
dis ibu ion o HL le els in ela ion o EBF a 6 mon hs.
Table 2. Rela ion be ween HL le els (NVS) and he s udied a iables.
Adequa e HL Le el Limi ed HL Le el
n % n % p-Value 1
Depa men o Heal h
La Ribe a 107 49.5 109 50.5 0.424
Xá i a-On inyen 13 54.2 11 45.8
Cas ellón 59 57.3 44 42.7
Ci il s a us Ma ied 114 52.8 102 47.2 0.775
Single, sepa a ed,
di o ced 65 51.2 62 48.8
Le el o educa ion
P ima y o lowe 35 36.1 62 63.9 <0.001
1s cycle, Seconda y 19 32.8 39 67.2
2nd cycle, Seconda y 44 51.2 42 48.8
Uni e si y diploma 32 80.0 8 20.0
G adua e 49 79.0 13 21.0
P egnan women’s
occupa ion
Businesswoman 23 65.7 12 34.3 0.003
Employee 113 55.7 90 44.3
Unemployed 39 46.4 45 53.6
No looking o a job 4 19.0 17 81.0
Coun y o o igin Spain 164 59.0 114 41.0 <0.001
Fo eign 15 23.1 50 76.9
Pa ne ’s occupa ion Employee 148 54.2 125 45.8 0.183
Businesspe son 16 51.6 15 48.4
O he s 15 38.5 24 61.5
Pa i y One 99 56.3 77 43.8 0.122
Two o mo e 80 47.9 87 52.1
Skin- o-skin con ac a bi h No 19 50.0 19 50.0 0.775
Yes 160 52.5 145 47.5
Bi h ype
Spon aneous 95 47.0 107 53.0 0.068
Ins umen ed 38 61.3 24 38.7
STC 46 58.2 33 41.8
Risk p egnancy Low isk 115 48.7 121 51.3 0.057
High isk 64 59.8 43 40.2
n Mean (SD) n Mean (SD) p- alue 2
Mo he ’s age (yea s) 179 33.5 (4.8) 164 31.4 (5.5) 0.001
Ges a ional week a bi h (weeks) 179 39.3 (1.1) 164 39.4 (1.1) 0.765
LATCH sco e (0 o 10) 179 8.9 (0.9) 164 8.7 (0.9) 0.037
Bi h weigh (g ams) 179 3281 (476.6) 164 3311 (452.2) 0.684
EBF: exclusi e b eas eeding; NVS: Newes Vi al Sign; STC: segmen ans e se caesa ean; LATCH: La ch audible
ype com o hold: 1Chi-squa e es ; 2S uden ’s - es .
Table 3shows he ela ionship be ween he collec ed a iables and hei associa ion
wi h EBF cessa ion a 6 mon hs. The a iables associa ed wi h ea ly EBF cessa ion we e
a limi ed HL le el (p< 0.001), being a single, sepa a ed, di o ced mo he (p< 0.001),
ha ing a lowe le el o educa ion (p= 0.022), and ob aining a lowe LATCH b eas eeding
assessmen ool sco e (p< 0.001). Con e sely, a mean sco e o 9.19 (
±
0.85) o BF e iciency
a hospi al discha ge, as measu ed by he LATCH b eas eeding assessmen ool, p esen ed
In . J. En i on. Res. Public Heal h 2022,19, 5411 7 o 13
a s a is ically signi ican associa ion (p< 0.001) wi h con inuing wi h EBF un il in an s we e
6 mon hs old.
In . J. En i on. Res. Public Heal h 2022, 19, x 7 o 14
Two o mo e 80 47.9 87 52.1
Skin- o-skin con ac a
bi h
No 19 50.0 19 50.0 0.775
Yes 160 52.5 145 47.5
Bi h ype
Spon aneous 95 47.0 107 53.0 0.068
Ins umen ed 38 61.3 24 38.7
STC 46 58.2 33 41.8
Risk p egnancy Low isk 115 48.7 121 51.3 0.057
High isk 64 59.8 43 40.2
n Mean (SD) n Mean (SD) p- alue 2
Mo he ’s age (yea s) 179 33.5 (4.8) 164 31.4 (5.5) 0.001
Ges a ional week a bi h (weeks) 179 39.3 (1.1) 164 39.4 (1.1) 0.765
LATCH sco e (0 o 10) 179 8.9 (0.9) 164 8.7 (0.9) 0.037
Bi h weigh (g ams) 179 3281 (476.6) 164 3311 (452.2) 0.684
EBF: exclusi e b eas eeding; NVS: Newes Vi al Sign; STC: segmen ans e se caesa ean; LATCH:
La ch audible ype com o hold: 1 Chi-squa e es ; 2 S uden ’s - es .
Figu e 2. Dis ibu ion o HL le els in ela ion o EBF a 6 mon hs (N = 343).
Table 3 shows he ela ionship be ween he collec ed a iables and hei associa ion
wi h EBF cessa ion a 6 mon hs. The a iables associa ed wi h ea ly EBF cessa ion we e a
limi ed HL le el (p < 0.001), being a single, sepa a ed, di o ced mo he (p < 0.001), ha ing
a lowe le el o educa ion (p = 0.022), and ob aining a lowe LATCH b eas eeding assess-
men ool sco e (p < 0.001). Con e sely, a mean sco e o 9.19 (±0.85) o BF e iciency a
hospi al discha ge, as measu ed by he LATCH b eas eeding assessmen ool, p esen ed
a s a is ically signi ican associa ion (p < 0.001) wi h con inuing wi h EBF un il in an s
we e 6 mon hs old.
Table 3. Fac o s ela ed o EBF cessa ion be o e 6 mon hs.
EBF 6 Mon hs: Yes EBF 6 Mon hs: No
n % n % p-Value 1
NVS Adequa e HL le el 79 44.1 100 55.9 <0.001
Limi ed HL le el 38 23.2 126 76.8
Depa men o Heal h
La Ribe a 65 30.1 151 69.9 0.105
Xá i a-On inyen 11 45.8 13 54.2
Cas ellón 41 39.8 62 60.2
0%
10%
20%
30%
40%
50%
60%
70%
80%
Limi ed HL le el Adequa e HL le el
PERCENTAGE
HL LEVEL
NO EBF a 6 mon hs EBF a 6 mon hs
Figu e 2. Dis ibu ion o HL le els in ela ion o EBF a 6 mon hs (N = 343).
Table 3. Fac o s ela ed o EBF cessa ion be o e 6 mon hs.
EBF 6 Mon hs: Yes EBF 6 Mon hs: No
n % n % p-Value 1
NVS Adequa e HL le el 79 44.1 100 55.9 <0.001
Limi ed HL le el 38 23.2 126 76.8
Depa men o Heal h
La Ribe a 65 30.1 151 69.9 0.105
Xá i a-On inyen 11 45.8 13 54.2
Cas ellón 41 39.8 62 60.2
Ci il s a us Ma ied 89 41.2 127 58.8 <0.001
Single, sepa a ed,
di o ced 28 22.0 99 78.0
Le el o educa ion
P ima y o lowe 25 25.8 72 74.2 0.022
1s cycle, Seconda y 22 37.9 36 62.1
2nd cycle, Seconda y 29 33.7 57 66.3
Uni e si y diploma 22 55.0 18 45.0
G adua e 19 30.6 43 69.4
P egnan women’s
occupa ion
Businesswoman 11 31.4 24 68.6 0.850
Employee 73 36.0 130 64.0
Unemployed 26 31.0 58 69.0
No looking o a job 7 33.3 14 66.7
Coun y o o igin Spain 100 36.0 178 64.0 0.133
Fo eign 17 26.2 48 73.8
Pa ne ’s occupa ion Employee 95 34.8 178 65.2 0.330
Businesspe son 7 22.6 24 77.4
O he s 15 38.5 24 61.5
Pa i y One 58 33.0 118 67.0 0.643
Two o mo e 59 35.3 108 64.7
Skin- o-skin con ac a bi h No 9 23.7 29 76.3 0.151
Yes 108 35.4 197 64.6
In . J. En i on. Res. Public Heal h 2022,19, 5411 8 o 13
Table 3. Con .
EBF 6 Mon hs: Yes EBF 6 Mon hs: No
n % n % p-Value 1
Bi h ype
Spon aneous 62 30.7 140 69.3 0.255
Ins umen ed 23 37.1 39 62.9
STC 32 40.5 47 59.5
Risk p egnancy Low isk 76 32.2 160 67.8 0.268
High isk 41 38.3 66 61.7
n Mean (SD) n Mean (SD) p- alue 2
Mo he ’s age (yea s) 117 33.2 (4.5) 226 32.1 (5.6) 0.049
Ges a ional week a bi h (weeks) 117 39.3 (1.0) 226 39.4 (1.1) 0.498
LATCH sco e (0 o 10) 117 9.2 (0.8) 226 8.7 (0.9) <0.001
Bi h weigh (g ams) 117 3328 (474.7) 226 3286 (459.6) 0.637
EBF: exclusi e b eas eeding; NVS: Newes Vi al Sign; STC: segmen ans e se caesa ean; LATCH: La ch audible
ype com o hold: 1Chi-squa e es ; 2Mann–Whi ney es .
3.4. Va iables Rela ed o Ea ly EBF Cessa ion
The mul i a ia e eg ession model shown in Table 4 o EBF cessa ion be o e 6 mon hs
sugges s ha a limi ed HL le el is associa ed wi h mo e han wice he p obabili y o EBF
cessa ion be o e 6 mon hs compa ed o an adequa e HL le el adjus ed by mo he ’s age,
le el educa ion, ci il s a us and he LATCH b eas eeding assessmen ool. Bo h being
ma ied and ob aining a highe LATCH b eas eeding assessmen ool sco e we e also
p o ec i e ac o s agains EBF cessa ion be o e in an s we e 6 mon hs old.
Table 4. Mul i a ia e logis ic model o EBF cessa ion be o e 6 mon hs.
OR 95% CI p-Value
NVS Adequa e HL le el 1
Limi ed HL le el 2.52 (1.45–4.36) 0.001
Ci il s a us Ma ied 1
Single, sepa a ed,
di o ced, widowed 2.32 (1.34–4.01) 0.003
Le el o educa ion P ima y o lowe 1
1s cycle, Seconda y 0.62 (0.30–1.31) 0.210
2nd cycle, Seconda y 0.86 (0.43–1.73) 0.664
Uni e si y diploma 0.51 (0.22–1.20) 0.124
G adua e 1.11 (0.50–2.50) 0.799
Mo he ’s age (yea s) 0.99 (0.94–1.04) 0.569
LATCH sco e ( ange 6 o 10) 0.53 (0.40–0.71) <0.001
n model = 343; n EBF cessa ion = 226; ROC a ea = 0.7401, 95% CI: 0.6868–0.7933; Likelihood Ra io Tes = 58.0
(p< 0.001). NVS: Newes Vi al Sign; OR: Odds Ra io; 95% CI: 95% con idence in e al.
4. Discussion
The p esen s udy ocuses on con inua ion o EBF un il in an s a e 6 mon hs old and
explo es in luen ial ac o s, namely HL le els.
One o he WHO’s goals o 2025 is o each EBF a es o a leas 50% un il in an s a e
6 mon hs old [
30
]. Wo ldwide EBF a es a 6 mon hs all sho o his ecommenda ion [
33
].
Be ween 2006 and 2012 in Eu ope, i was es ima ed ha only 25% o b eas ed in an s e-
cei ed EBF o he i s 6 mon hs o li e [
11
]. Acco ding o he Eu opean Heal h In o ma ion
Ga eway [
34
], EBF a es a 6 mon hs we e 58.3% in I aly (2011), 53.9% in Po ugal (2013)
and 58.4% in Spain (2017). Howe e , mo e ecen s udies ca ied ou in Spain epo con-
side ably lowe EBF in an s un il he age o 6 mon hs, anging om 16.8% [
12
], 21.6% [
35
],
o 31.4% [36], o 43% [37].
In . J. En i on. Res. Public Heal h 2022,19, 5411 9 o 13
Di e en s udies ha e epo ed an associa ion be ween mo he s’ le el o educa ion and
con inuing wi h EBF and showing ha he highe he le el o educa ion, he longe ha EBF
las s [
35
–
37
], in line wi h ou esul s. O he au ho s ha e es ablished an associa ion be ween
le el o educa ion and HL le els [
18
,
19
]. Al hough i may seem ha a low educa ional
le el could be associa ed wi h a low HL, his ela ionship does no always ha e o be
obse ed [
38
]. A ela ion was also ecen ly ound be ween HL le els and con inuing EBF in
a pilo s udy; howe e , he ollow-up pe iod only co e ed 4 mon hs [
25
]. The e o e, he
p esen s udy e i ies a s a is ically signi ican associa ion be ween limi ed HL le el and
EBF cessa ion be o e 6 mon hs in line wi h p e ious s udies [
27
], and obse ed ha he
p obabili y o EBF cessa ion was mo e han wo- old compa ed o he mo he s wi h an
adequa e HL le el.
P e ious s udies ha e ela ed ound an associa ion wi h mo he s’ age and ea ly EBF
cessa ion [
9
,
35
,
37
]. In ag eemen wi h esul s hi he o epo ed [
39
], we no ed a s a is i-
cally signi ican associa ion be ween being olde and EBF a es a 6 mon hs pos pa um.
This associa ion migh be due o ongoing amily suppo , be e socio-economic s a us
o a highe le el o knowledge abou BF bene i s, as o he esea ch has shown [
40
–
43
].
The e a e also epo s indica ing ha hose amilies wi h single, sepa a ed, o di o ced
mo he s, he p obabili y o EBF cessa ion be o e 6 mon hs pos pa um mo e han doubles.
Fo con inuing EBF, se e al s udies ha e e i ied ha amily suppo [
44
] and ha ing a
pa ne a e key ac o s [
45
,
46
]. O he au ho s ha e epo ed how he p obabili y o EBF
cessa ion be o e 6 mon hs pos pa um mo e han doubles in amilies wi h single, sepa-
a ed, o di o ced mo he s [
47
,
48
]. Women’s immedia e en i onmen ( amily, iends and
neighbou s) is he mos in luen ial social suppo ne wo k in shaping p egnan women’s
expec a ions and decisions abou p egnancy, labou and nu sing [
49
]. Howe e , he NVS
ool does no inco po a e hose social aspec s, unlike o he ools such as he Heal h Li e acy
Ques ionnai e [
50
], so hei in luence on he HL o b eas eeding women emains o be
cla i ied [
51
]. I is no ewo hy ha being olde wi h a i s p egnancy also showed a s a is i-
cally signi ican associa ion wi h an adequa e HL le el. I was no su p ising ha he wo
a iables con ibu ing o con inuing EBF, namely an adequa e HL le el and olde ma e nal
age, we e also closely in e ela ed, as seen in a ecen s udy in Spain [
43
]. Ne e heless,
u u e s udies a e needed o co obo a e he ela ionship be ween being olde wi h i s
p egnancy and con inuing EBF and a highe HL le el, and he ac o s ha could in luence
he ela ionship be ween bo h hese a iables mus also be explo ed.
The a e age LATCH sco e was high wi h a small s anda d de ia ion, which sugges s
ha he majo i y o he s udy popula ion was b eas eeding e ec i ely o nea ly e ec i ely.
I is wo h s essing he p edic i e capaci y o he LATCH b eas eeding assessmen ool.
Di e en s udies ha e measu ed BF e icacy bo h pos pa um and be o e hospi al discha ge.
These s udies showed ha BF e icacy can be e ec i ely e alua ed using LATCH [
52
], and i s
p edic i e pe o mance is high a 6 weeks pos pa um [
53
–
55
]. The p esen s udy e ealed
ha high LATCH b eas eeding assessmen ool sco es we e signi ican ly associa ed wi h a
lowe p obabili y—almos hal —o EBF cessa ion be o e b eas ed in an s we e 6 mon hs.
As he LATCH b eas eeding assessmen ool seems o be use ul, u u e s udies should ake
ad an age o hese indings o ela e he LATCH sco es wi h con inua ion o EBF in he
longe e m. Howe e , he LATCH could be u he e ined o inco po a e elemen s such
as mo he /in an in e ac ion [
56
]. This ool has majo laws, including he inabili y o he
use o assign di e en sco es pe b eas (e.g., i one nipple is la and he o he is e e ed),
he lack o ep esen a ion o in an ’s o al ana omy and unc ionali y.
Mo eo e , women o en seek suppo beyond hei home i i is no a ailable he e.
Howe e , mo e s udies need o be conduc ed o co obo a e he associa ion be ween amily
suppo and con inuing EBF o 6 mon hs.
Despi e he need o mo e obus s udies o de e mine he associa ion be ween le el o
heal h li e acy and main enance o exclusi e b eas eeding a 6 mon hs pos pa um, his
s udy shows a p o ile o women ha should no go unno iced by heal h p o essionals ca ing
o women du ing he pe ina al pe iod. Acco ding o he esul s o his s udy, he p o ile
