Jou nal o Human Lac a ion
2018, Vol. 34(2) 304 –312
© The Au ho (s) 2017
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DOI: 10.1177/0890334416676469
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O iginal Resea ch
Backg ound
B eas eeding has ex ensi e physical and psychological ben-
e i s o he mo he and he newbo n. Fo he in an , b eas -
eeding o e s passi e immuniza ion agains in ec ious
diseases, ansla ing o a educ ion o dia heal episodes, bac-
e emia, pneumonia, and meningi is du ing he i s yea o
li e. B eas eeding has also been linked o a educed isk o
sudden in an dea h synd ome, alle gies, as hma, and child-
hood leukemia and o a u he e ec on he incidence o
adul obesi y and diabe es (B i on, McCo mick, Ren ew,
Wade, & King, 2009). Simila ly, ma e nal bene i s include
an imp o ed bond wi h he newbo n, weigh s abiliza ion,
and educed isk o dep ession du ing he pos pa um pe iod,
as well as a lowe li e ime incidence o b eas o o a ian
cance (Commi ee on Heal hca e o Unde se ed Women,
2013; Rollins e al., 2016). B eas eeding p o ides sho - and
long- e m heal h, economic, and en i onmen al ad an ages
o child en, women, and socie y (Rollins e al., 2016).
Di e en s udies ha e shown posi i e, s a is ically signi i-
can e ec s o bo h ooming-in and ea ly mo he –in an skin-
o-skin con ac immedia ely a e bi h on inc easing exclusi e
b eas eeding (EBF) du ing he hospi al s ay (B amson e al.,
2010) and con inua ion o b eas eeding om 1 o 4 mon hs
a e bi h (Aghdas, Tala , & Sepideh, 2014; Moo e, Ande son,
Be gman, & Dowswell, 2012; Righa d & Alade, 1990).
Se e al s udies highligh how a es and du a ion o EBF in
high-income coun ies emain low and p esen a wide in e -
coun y a iabili y (Vic o a e al., 2016), despi e in e na ional
676469JHLXXX10.1177/0890334416676469Jou nal o Human Lac a ionVila-Candel e al.
esea ch-a icle2017
A ec o Ea ly Skin- o-Skin Mo he –In an
Con ac in he Main enance o Exclusi e
B eas eeding: Expe ience in a Heal h
Depa men in Spain
Ra ael Vila-Candel, PhD, MSc, RM1,2, Ki i Duke, RN2,
F. Ja ie So iano-Vidal, BSc, RM2,3,4, and
En ique Cas o-Sánchez, PhD, MPH, RN5
Abs ac
Backg ound: B eas eeding has been shown o esul in ex ensi e physical and psychological bene i s o bo h he mo he and
he newbo n. Howe e , he a e and du a ion o exclusi e b eas eeding (EBF) emains low wo ldwide. Mo he –in an skin- o-
skin con ac (SSC) immedia ely a e bi h has demons a ed esul s ha suppo he a gumen o b eas eeding con inua ion.
Resea ch aim: This s udy aimed o in es iga e he p e alence o EBF 3 mon hs pos pa um and he e ec o ea ly SSC in
main aining op imal EBF p ac ices o mo he s and hei heal hy newbo ns.
Me hods: We conduc ed an obse a ional, e ospec i e s udy in Spain om 2013 o 2015. P egnan women we e
in e iewed immedia ely pos pa um and again a 3 mon hs pos pa um ega ding a iables associa ed wi h b eas eeding
ini ia ion and con inua ion.
Resul s: The e we e 1,071 women ec ui ed. Ea ly SSC was pe o med in 92% o aginal bi hs bu only 57% o u gen
cesa ean bi hs. O women b eas eeding a discha ge, 69.5% pe o med SSC wi h hei newbo n. We ound ha 68.6%
o women we e exclusi ely b eas eeding by discha ge and 46.7% by 3 mon hs pos pa um. Type o eeding a discha ge,
coun y o o igin, and pa i y we e ound o be associa ed wi h each o he (p = .003, p = .001, espec i ely). Ea ly SSC was
also signi ican ly associa ed wi h ype o eeding a discha ge, 1 mon h, 2 mon hs, and 3 mon hs pos pa um (p < .001).
Hypogalac ia (19.8%) was he mos equen ly epo ed ac o o b eas eeding discon inua ion.
Conclusion: B eas eeding p omo ion in e en ions a e likely o imp o e b eas eeding a es a 3 mon hs pos pa um.
Social and economic ac o s should be aken in o accoun when such p og ams a e planned o be implemen ed.
Keywo ds
b eas eeding, b eas eeding a es, ea ly skin- o-skin con ac , ea ly weaning, isk ac o s
Vila-Candel e al. 305
Key Messages
•• Nume ous in e e ing e en s du ing he ma e -
ni y hospi al s ay can cause p oblems o mo h-
e s who in end o b eas eed.
•• Ea ly skin- o-skin con ac may diminish such
in e e ences and p omo e exclusi e b eas eed-
ing up o 3 mon hs pos pa um, ega dless o
ype o deli e y.
•• Ma e nal hough s and belie s can nega i ely
in luence leng h o b eas eeding.
•• Policy make s should discuss, p io o imple-
men a ion, how new measu es may in e e e
wi h p o en echniques ha p o ec ma e nal and
in an heal h.
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 sidad Ca ólica de Valencia San Vicen e Má i , Valencia, Spain
3Depa men o Obs e ics and Gynaecology, Hospi al Lluis Alcanyís de Xa i a, Valencia, Spain
4Depa men o Nu sing, Uni e si y o Alican e, C a. San Vicen e del Raspeig s/n, 03690 San Vicen e del Raspeig, Alican e, Spain
5Na ional Ins i u e o Heal h Resea ch Heal h P o ec ion Resea ch Uni in Heal hca e Associa ed In ec ions and An imic obial Resis ance a Impe ial
College London, London, UK
Da e submi ed: July 5, 2016; Da e accep ed: Oc obe 3, 2016.
Co esponding Au ho :
Ra ael Vila-Candel, PhD, MSc, RM, Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, C a. Co be a km 1, 46.600 Valencia,
Spain.
Email: [email p o ec ed]
ecommenda ions p omo ing EBF. The highes p e alence
a es a 3 mon hs pos pa um we e obse ed in Scandina ian
coun ies, Japan, and New Zealand ( anging om 71% o
81%). In con as , he p e alence a es epo ed in coun ies
such as he Uni ed Kingdom, he Uni ed S a es, I eland,
F ance, Spain, and Canada we e lowe and a ied om 15%
o 51% (Haiek, Gau hie , B osseau, & Rocheleau, 2007;
K ame & Kakuma, 2012; O ibe e al., 2015; Rius e al.,
2014).
In he Valencia egion (Spain), compliance wi h hese
ecommenda ions a 3 and 6 mon hs in 2012 was limi ed
(45.8% and 27.9% espec i ely), acco ding o he la es da a
p o ided by he Obse a o y o Child en’s and Pe ina al
Heal h (Gene ali a Valenciana & Obse a o io de Salud
In an il y Pe ina al, 2012). A ecen s udy (Rius e al., 2014)
in ou egion epo ed a 39% EBF p e alence a e a 3
mon hs.
Ou s udy aimed o de e mine he p e alence o EBF a 3
mon hs pos pa um and he e ec o ea ly SSC on he abili y
o mo he s and hei heal hy newbo n in an s o main ain
op imal EBF p ac ices.
Me hods
S udy Design
We conduc ed an obse a ional, e ospec i e s udy o he
popula ion seen a he La Ribe a Heal h Depa men (Valencia,
Spain) ollowing implemen a ion o a SSC s a egy. The
ca chmen a ea o he depa men includes 249,000 inhabi -
an s, wi h app oxima ely 2,000 bi hs pe yea . The da a we e
collec ed om Janua y 2013 o Decembe 2015.
Sample Size
Be o e ob aining he inal sample, we selec ed women o be
in e iewed h ough simple andomized sampling. The
selec ed mo he s all esided wi hin he ca chmen a ea o
he Heal h Depa men . Mo he s we e asked abou easons
o EBF cessa ion and du a ion a di e en imes (a dis-
cha ge and 1, 2, and 3 mon hs). The in e iews we e con-
duc ed by he midwi e o each pa icipa ing heal h cen e in
he pos pa um pe iod (be ween 4 and 10 days) a heal h
cen e clinics and o e he elephone a 3 mon hs a e bi h.
The in o ma ion abou he ype o eeding a 1 and 2 mon hs
a e labo was ob ained om he elec onic medical eco ds
a he heal h cen e s.
We es ima ed he p e alence o mo he s discon inuing
EBF be o e 3 mon hs o be 50%, in acco dance wi h p e ious
s udies in ou con ex (Rius e al., 2014). We assumed a pop-
ula ion o 6,000 women (2,000 pe yea ), wi h a Type I e o
(alpha isk) o 0.05, an accu acy o 5%, and a d opou a e o
30%. We he e o e calcula ed a sample size o 516 women
o ou s udy.
Women who declined o pa icipa e in he elephone in e -
iew o we e un aceable a e h ee a emp s o con ac by
elephone we e excluded om he s udy. We also excluded
win, mul iple, and p ema u e bi hs o acili a e he compa i-
son wi h p e iously published s udies (Rius e al., 2014).
Measu es and Da a Collec ion
Va iables iden i ied in he li e a u e as associa ed wi h b eas -
eeding ini ia ion we e also e alua ed o hei po en ial con-
ounding e ec s. Re ospec i e da a collec ion was ca ied
ou om Feb ua y o Ap il 2016. In o ma ion a bi h was
e ie ed om elec onic heal h eco ds, whe eas da a a 3
mon hs pos pa um and consen o pa icipa e we e ob ained
h ough phone in e iews. The a iables collec ed comp ised
he ollowing:
306 Jou nal o Human Lac a ion 34(2)
Sociodemog aphic cha ac e is ics. Sociodemog aphic cha ac-
e is ics included we e ma e nal age (in comple ed yea s
un il he due da e) and coun y o o igin.
Obs e ic-neona al cha ac e is ics. Obs e ic-neona al cha -
ac e is ics included we e pa i y, ges a ional age a deli e y,
beginning o deli e y, ype o analgesia, ype o deli e y,
gende o he newbo n, bi h weigh , Apga sco e a bo h 1
and 5 minu es, umbilical a e y pH, ea ly SSC, ype o eed-
ing (a discha ge, 1 mon h, 2 mon hs, and 3 mon hs pos pa -
um), easons o b eas eeding cessa ion, and EBF du a ion
in days.
Ea ly SSC was de ined as he p one placing o he naked
in an on he mo he ’s ba e ches a bi h, in he i s minu e
a e bi h, o e y soon a e wa d. The in an is suc ioned
while es ing on he mo he ’s abdomen o ches , i medically
indica ed; ho oughly d ied, and co e ed wi h a p ewa med
blanke . To p e en hea loss, he in an ’s head may be co -
e ed wi h a d y cap, which is eplaced i i becomes damp.
As pa o ou ine p ac ice, all o he in e en ions a e
delayed un il a leas he end o he i s 2 hou s o li e in he
deli e y oom.
The SSC p ocess in mo he s who deli e by cesa ean
bi h ollows his p o ocol: a e he umbilical co d is
clamped and cu a gene al assessmen o he newbo n, in
combina ion wi h he Apga es , is comple ed. Then, as
pe local p o ocol, he in an is d ied, co e ed in a owel,
and handed o he mo he o a b ie con ac while su ge y
is comple ed. Nex , he in an is e u ned o he labo oom
and placed on he bi h pa ne ’s ba e ches . A e su ge y,
he mo he is ans e ed o he labo oom o eco e y
and he newbo n placed on he mo he ’s ba e ches o a
leas 2 unin e up ed hou s.
Al hough he eco ding o ea ly SSC did no include he
exac ime om bi h o echnique implemen a ion o he
exac du a ion, he local p o ocol desc ibed abo e was p e-
cisely ollowed. In ou s udy, when ully in o med mo he s
decided no o p oceed wi h SSC, o i mo he s we e ad ised
o medical (i.e., ma e nal o neona al complica ions) o
o ganiza ional (i.e., p essu e on side ooms) easons o delay
SSC, we conside ed he SSC p ocess “no implemen ed.”
Feeding ype was classi ied as one o he ollowing:
exclusi e b eas eeding, including exp essed milk o milk
om a dono , and allowing he in an o ecei e d ops o sy -
ups ( i amins, medicines, o mine als), as pe Wo ld Heal h
O ganiza ion de ini ion (Ma io , Whi e, Hadden, Da ies, &
Walling o d, 2012; O ibe e al., 2015; Wink is e al., 2015);
o o mula eed only o mixed, i he eeding combined
b eas eeding and eeding o o mula.
Cause o discon inua ion. I b eas eeding was discon inued,
he eason o b eas eeding discon inua ion was speci ied.
Ea ly discon inua ion was classi ied as p io o 3 mon hs
pos pa um (Rius e al., 2014); o al du a ion was exp essed
in whole days. Exclusi e b eas eeding days we e calcula ed
om he day o deli e y.
Da a Analysis
S a is ical analysis was unde aken using SPSS ( e sion 22;
SPSS, Inc., Chicago, Illinois, USA). Desc ip i e s a is ics da a
a e p esen ed as means and s anda d de ia ion o con inuous
a iables (age, ges a ional age, bi h weigh , Apga sco e,
umbilical a e y pH, and du a ion o b eas eeding), o median
and in e qua ile ange o non-no mally dis ibu ed and ca e-
go ical a iables p o ided as ange and pe cen age. A bi a ia e
analysis was pe o med whe e he co ela ions be ween he
dependen ( ype o eed a 3 mon hs) and independen a i-
ables collec ed we e s udied using ei he he chi-squa e es
(χ2) be ween wo ca ego ical a iables o one-way analysis o
a iance o de e mine he ela ionship be ween he ype o
eeding and he numbe o days spen eeding. Bi a ia e analy-
sis ini ially assessed con ounding by adding each po en ial
con ounde a iable o a model ha included ea ly (i.e., p io
o 3 mon hs pos pa um) cessa ion o b eas eeding alone
using odds a io (OR). The mul i a ia e model included in e -
ac ion e ms be ween ea ly cessa ion o b eas eeding (cessa-
ion be o e 3 mon hs) and o he co a ia es s udied. Con idence
in e als (CIs) we e calcula ed o a con idence le el o 95%.
A p < .05 was conside ed s a is ically signi ican .
E hical Conside a ions
The s udy was conduc ed acco ding o he p inciples included
in he Helsinki Decla a ion. The s udy was app o ed by he
Commi ee on Resea ch–E hics Commi ee o he Hospi al
Uni e si a io de la Ribe a in Janua y 2016. All pa icipan s
we e p o ided ull in o ma ion o conside he na u e o he
s udy, olun a y pa icipa ion, and con iden iali y. The
a ending midwi es ec ui ed he women a he clinic and
ob ained hei in o med consen o pa icipa e in he s udy.
Resul s
A o al o 1,071 women ga e bi h be ween 2013 and 2015.
Reasons o exclusion included p e e m bi h (32), win o
mul iple bi hs (14), e usal o pa icipa e (12), o no answe -
ing he elephone (34).
In e ms o sociodemog aphic a iables, he mean (SD)
age was 31.1 (5.6) yea s. Table 1 de ails he dis ibu ion
acco ding o he ype o eeding a discha ge and sociode-
mog aphic and neona al-obs e ic cha ac e is ics obse ed
in he popula ion.
Rega ding he obs e ic a iables, 638 (59.6%) women
we e p imipa ous. The mean (SD) ges a ional age a labo
was 39.2 (1.4) weeks. We obse ed 31 (2.9%) newbo ns
pos e m (> 42 weeks). O he deli e ies, 662 (58.1%) had a
spon aneous onse and 234 (21.8%) we e induced. The
majo i y o bi hs we e comple ed aginally, he a e o non-
elec i e cesa ean sec ion was 12.8% (137/1,071), and 17.8%
(191/1,071) o bi hs we e ins umen ed. Epidu al analgesia
was used in 760 (71%) o he cases s udied.
Vila-Candel e al. 307
O aginal bi hs, 92% (650/705) included ea ly SSC,
whe eas his a e was 86% (165/191) in ins umen ed deli -
e ies, 81% (31/38) o elec i e cesa ean sec ion deli e ies,
and 57% (78/137) o u gen cesa ean bi hs. O women who
we e b eas eeding a discha ge, 69.5% (642/927) had SSC
wi h hei newbo n.
The a e age (SD) bi h weigh was 3,289 (463) g, wi h 28
(2.8%) conside ed o be low weigh o hei ges a ional age
(less han he 10 h pe cen ile), and 175 (17.4%) we e g ea e
han he 90 h pe cen ile. The mean (SD) Apga sco e a 1
minu e was 9.4 (0.8) and a 5 minu es was 9.8 (0.9). The
a e age (SD) umbilical a e y pH was 7.25 (0.1).
Table 1. Cha ac e is ics o he Sample Acco ding o he Type o Feeding a Discha ge.
To al ow EBF Fo mula eeding Mixed eeding
Cha ac e is ic n n (%)n (%)n (%)χ2, d p
Yea 7.85, 4 .097
2013 200 141 (70.5) 59 (29.5) 0 (0.0)
2014 290 190 (65.5) 98 (33.8) 2 (0.7)
2015 581 404 (69.5) 166 (28.6) 11 (1.9)
Coun y o o igina32.73, 14 .003
No h A ica 33 30 (90.9) 3 (9.1) 0 (0.0)
Spain 919 605 (65.8) 302 (32.9) 12 (1.3)
EU coun ies 51 43 (84.3) 8 (15.7) 0 (0.0)
Non-EU coun ies 18 16 (88.9) 2 (11.1) 0 (0.0)
No h Ame ica 2 2 (100.0) 0 (0.0) 0 (0.0)
Sou h Ame ica 23 21 (91.3) 2 (8.7) 0 (0.0)
Res o A ica 9 8 (88.9) 1 (11.1) 0 (0.0)
Asia 16 9 (56.3) 6 (37.5) 1 (6.3)
Pa i ya18.99, 4 < .001
1 Child 638 467 (73.2) 162 (25.4) 9 (1.4)
2 Child en 373 228 (61.1) 142 (38.1) 3 (0.8)
≥ 3 Child en 60 38 (63.3) 21 (35.0) 1 (1.7)
Beginning o deli e y 4.25, 6 .642
Spon aneous 622 424 (68.2) 189 (30.4) 9 (1.4)
S imula ed 165 120 (72.7) 43 (26.1) 2 (1.2)
Induced 234 158 (67.5) 75 (32.1) 1 (0.4)
Elec i e c-sec ion 50 31 (62.0) 18 (36.0) 1 (2.0)
Type o deli e y 5.56, 6 .479
Spon aneous 705 480 (68.1) 214 (30.4) 11 (1.6)
Ins umen ed 191 127 (66.5) 63 (33.0) 1 (0.5)
Elec i e c-sec ion 38 24 (63.2) 14 (36.8) 0 (0.0)
U gen c-sec ion 137 102 (74.5) 34 (24.8) 1 (0.7)
Ea ly SSC a e bi ha26.46, 2 < .001
Pe o med 924 642 (69.5) 277 (30.0) 5 (0.5)
No pe o med 147 91 (61.9) 48 (32.7) 8 (5.4)
Ea ly SSC a e bi h by ype o deli e ya,b 12.48, 6 < .001
Eu ocic 650 452 (69.5) 193 (29.7) 5 (0.8)
Ins umen ed 165 106 (64.2) 59 (35.8) 0 (0.0)
Elec i e c-sec ion 31 19 (61.3) 12 (38.7) 0 (0.0)
U gen c-sec ion 78 65 (83.3) 13 (16.7) 0 (0.0)
Pe cen ile o bi h weigh 9.98, 10 .442
< 10 h 28 19 (67.9) 9 (32.1) 0 (0.0)
10 h–25 h 73 49 (67.1) 24 (32.9) 0 (0.0)
25 h–50 h 205 134 (65.4) 68 (33.2) 3 (1.5)
50 h–75 h 308 221 (71.8) 84 (27.3) 3 (1.0)
75 h–90 h 216 136 (63.0) 77 (35.6) 3 (1.4)
> 90 h 175 129 (73.7) 43 (24.6) 3 (1.7)
Missing da a 66
No e. N = 1,071. c-sec ion = cesa ean sec ion; EBF = exclusi e b eas eeding; EU = Eu opean Union; SSC = skin- o-skin con ac .
a Va iable di e s signi ican ly be ween ype o eeding a discha ge a p < .05. b Only 924 pe o med ea ly mo he –in an SSC.
308 Jou nal o Human Lac a ion 34(2)
The esul s o he chi-squa e analyses demons a ed s a-
is ically signi ican di e ences in ype o eeding a dis-
cha ge ela ed o he coun y o o igin and pa i y a iables
(p = .003 and p < .001, espec i ely). Achie ing ea ly SSC
independen ly, and wi h he associa ed ype o deli e y,
showed s a is ically signi ican di e ences in he ype o
eeding a discha ge, 1 mon h, 2 mon hs, and 3 mon hs (p <
.001, espec i ely).
The e olu ion o EBF du ing he ollow-up pe iod is p e-
sen ed in Figu e 1. The p e alence o EBF a hospi al dis-
cha ge was 68.6%, 95% CI [66.9, 70.3]; be o e 30 days
pos pa um was 69.2%, 95% CI [65.5, 72.9]; a 1 mon h
was 55.0%, 95% CI [52.9, 57.0]; a 2 mon hs was 51.3%,
95% CI [48.9, 53.2]; and a 3 mon hs was 46.7%, 95% CI
[46.6, 50.9].
I is no ewo hy ha nea ly a hi d (29.1%, 312) o pue -
pe ae in ended o use o mula eeding igh a e deli e y and
as he con inued sole eeding me hod.
We no ed signi ican di e ences in he ype o eeding a
3 mon hs as a esul o he p esence o an e ec i e ea ly SSC
a e bi h (p < .001), p esen ed in Figu e 2. O hose women
who did SSC, 490 (76%) we e s ill b eas eeding a 3 mon hs,
142 (22%) we e using o mula eeding, and 13 (2%) we e
using mixed eeding.
To al (SD) du a ion o EBF was 68.7 (32.7) days, 95% CI
[66.3, 71.1], and he mean (SD) combined b eas eeding
du a ion (i.e., including bo h EBF and mixed) was 39.3
(21.4) days, 95% CI [33.4, 45.3]. The a e age (SD) EBF
du a ion in women who ceased o b eas eed du ing he i s
mon h was 12.2 (8.5) days, 95% CI [10.9, 13.6].
The mean (SD) du a ion o EBF a e ea ly SSC was 72.6
(31.9), 95% CI [70.2, 75.1], compa ed wi h 42.3 (25.5), 95%
CI [37.1, 47.4], wi hou SSC. S a is ically signi ican di e -
ences on mean alues we e ob ained (p < .001).
The di e en causes o EBF discon inua ion iden i ied by
mo he s du ing he elephone su ey and he a e age EBF
days a e p esen ed in Table 2. The a iables ela i e o hei
esponse and g ade appea in o de o inc easing alue. Da a
ela ed o women who we e exclusi ely b eas eeding a 3
mon hs o hose who decided o p o ide o mula eeding
be o e deli e y a e no shown.
The mos equen ly ci ed eason o EBF discon inua ion
was sel - epo ed hypogalac ia (19.8%), ollowed by lowe -
han- ecommended inc ease in newbo n weigh gain
(15.9%). Those ac o s ela ed o he b eas (in e ed nipple,
mas i is, and so e/c acked nipple) o he newbo n (neona al
pa hology, jaundice, hospi al admission, o low weigh ) led
o an EBF pe iod o less han 30 days. On he o he hand, he
ac o s di ec ly ela ed o he mo he ( e u n o paid employ-
men and epo ed i edness) we e mo e equen ly ci ed
wi hin he i s 2 mon hs.
The mul i a ia e model included in e ac ion e ms be ween
ea ly cessa ion o b eas eeding be o e 3 mon hs and o he
co a ia es s udied, all o which a e p esen ed in Table 3.
Spanish mo he s had wice he isk o discon inuing
b eas eeding when compa ed wi h o eign-bo n mo he s
(OR = 2.5, p < .001). On he o he hand, ac o s associa ed
wi h b eas eeding we e being olde han 32 yea s (OR = 0.7,
p < .05), being mul ipa ous (OR = 0.6, p < .001), gi ing bi h
a e 39 weeks (OR = 0.7, p < .05), and ul illing ea ly SSC
a e bi h (OR = 0.1, p < .001). The e we e no s a is ically
signi ican di e ences o he emaining a iables, which a e
p esen ed in Table 3.
A e con olling o o he co a ia es included, he mul-
i a ia e model showed Spanish o igin (OR = 2.1, p < .001)
as an independen ac o associa ed wi h ea ly cessa ion o
b eas eeding, and in e sely, being mul ipa ous (OR = 0.6,
Figu e 1. E olu ion o ype o eeding om hospi al discha ge o
3 mon hs pos pa um (N = 1,071). Figu e 2. Applica ion o ea ly skin- o-skin con ac a e bi h
and ype o eeding a 3 mon hs pos pa um (N = 1,071).
Vila-Candel e al. 309
p < .001), ha ing gi en bi h a e 39 weeks (OR = 0.6, p <
.001), and ha ing pe o med ea ly SSC a e aginal bi h
o cesa ean bi h (OR = 0.1, p < .001) we e acili a ing ac-
o s, p esen ed in Table 3 as adjus ed OR. In e ac ion e ms
be ween ea ly cessa ion o b eas eeding and o he co a i-
a es we e no signi ican in ou mul i a iable analysis.
Discussion
This was one o he mos comp ehensi e andomized s udies
ca ied ou in Spain. I had a la ge sample size and a da a col-
lec ion pe iod o 3 consecu i e yea s. I ocused on he e ec
o ea ly mo he –in an SSC du ing he i s 2 hou s a e
deli e y, one o he ac o s a o ing he ini ia ion o b eas -
eeding (Moo e e al., 2012).
The p e alence o b eas eeding a hospi al discha ge
(68.6%) in ou s udy was lowe han wha had been ob ained by
o he g oups in Spain (Ba iuso Lap esa, 2007; Gomis-Ceb ián
e al., 2009; Oli e -Roig e al., 2008; O ibe e al., 2015; Ri illa
Ma ugán e al., 2003), anging om 70% o 84%.
The a e o EBF a discha ge in ou Heal h Depa men
(Gene ali a Valenciana & Obse a o io de Salud In an il y
Pe ina al, 2012) inc eased by 8% om 2011 o 2015.
Pa ien -cen e ed policies a bi h such as hose desc ibed
(Aghdas e al., 2014; Moo e e al., 2012; Righa d & Alade,
1990) could be esponsible o he imp o emen seen in
b eas eeding igu es.
The p e alence o EBF a 3 mon hs in ou popula ion
(46.7%) was sligh ly highe han wha o he au ho s ha e
ecen ly desc ibed (Ba iuso Lap esa, 2007; O ega Ga cía
e al., 2008; Rius e al., 2014), al hough i is lowe han o he
coho s in no he n Spain (62.5%) (O ibe e al., 2015). As pe
o he s udies in Spain, a educ ion in b eas eeding a es
anging om 22% o 42% a e hospi al discha ge was
obse ed. In ou da a, he discon inua ion o b eas eeding
was ela ed o ini ial b eas eeding pe cen age. The pa e n
Table 2. Causes o B eas eeding Cessa ion Wi h A e age
Exclusi e B eas eeding Du a ion.
Du a ion in days
Cause n (%)M (SD) Median (IQR)
In e ed nipple 1 (0.4) 3.0 (0.0)
Pa hology o he
newbo n
2 (0.9) 7.0 (4.2)
Jaundice 3 (1.3) 3.3 (2.0)
Mas i is 3 (1.3) 19.0 (11.5)
Admission o in ensi e
neona al ca e
2 (2.6) 7 (0-7)
Di icul a achmen 8 (3.4) 6.5 (4.5)
Low weigh 10 (4.3) 3.6 (3.6)
Ma e nal pa hology 10 (4.3) 3 (0-30)
Excessi e weigh loss 11 (4.7) 6 (3-26)
So e/c acked nipple 13 (5.6) 12.6 (8.0)
Wo k/s udies
inco po a ion
14 (6.0) 42.3 (21.1)
Ma e nal s ess 18 (7.8) 25.3 (18.3)
Ti edness 19 (8.2) 60 (60-60)
Nega i e expec a ions/
ma e nal decision
31 (13.4) 10 (3-30)
Weigh gain lowe han
ecommended
37 (15.9) 15 (10-35)
Hypogalac ia 46 (19.8) 20 (6-56)
No e. n = 234. IQR = in e qua ile ange.
Table 3. Odds Ra ios and 95% Con idence In e als F om
Bi a ia e Analysis and Mul i a ia e Logis ic Analysis o Fac o s
Rela ed o Exclusi e B eas eeding Cessa ion a 3 Mon hs.
Fac o OR [95% CI] p
Adjus ed OR
[95% CI] p
Ma e nal age
(yea s)
< .05 ns
< 32 1.0
≥ 32 0.7 [0.6, 0.9]
Coun y o o igin < .001 < .001
Fo eign 1.0 1.0
Spain 2.5 [1.7, 3.6] 2.1 [1.1, 3.0]
Deli e y analgesia ns ns
No 1.0
Yes 1.2 [0.9, 1.7]
Onse o labo ns ns
Spon aneous 1.0
Induced 0.9 [0.7, 1.2]
Type o deli e y ns ns
Eu ocic 1.0
Dys ocic 0.9 [0.7, 1.1]
Ea ly SSC a e
bi ha
< .05 < .001
No pe o med 1.0 1.0
Pe o med 0.1 [0.0, 0.1] 0.1 [0.0, 0.1]
Pa i y < .001 < .001
P imipa ous 1.0 1.0
Mul ipa ous 0.6 [0.5, 0.8] 0.6 [0.4, 0.8]
Pe cen ile bi h
weigh
ns ns
≥ 10 h 1.0
< 10 h 1.2 [0.5, 2.5]
Newbo n gende ns ns
Male 1.0
Female 1.1 [0.8, 1.4]
Ges a ional age
(weeks)
< .05 < .001
< 39 1.0 1.0
≥ 39 0.7 [0.6, 0.9] 0.6 [0.5, 0.8]
No e. N = 1,071. CI = con idence in e al; ns = nonsigni ican alue
> .05; OR = odds a io; SSC = skin- o-skin con ac . C ude OR was
calcula ed using he isk o he con ingency ables (2 × 2) be ween he
ea ly cessa ion o b eas eeding and he s udied a iables. Adjus ed
OR was ob ained by mul i a ia e logis ic eg ession be ween ea ly
cessa ion o b eas eeding and co a ia es wi h s a is ical signi icance
in c ude OR (ma e nal age, coun y o o igin, ea ly SSC, pa i y, and
ges a ional age).
310 Jou nal o Human Lac a ion 34(2)
seems o epea o e 3 mon hs, ega dless o b eas eeding
p e alence eached a discha ge om hospi al. Gi en ha
social and employmen policies in Spain a e homogeneous,
we sugges ha heal h ca e-le el coo dina ion and awa eness
o he mo he abou EBF may play a ele an ole in hese
obse ed di e ences be ween di e en Spanish egions,
al hough such analysis is ou side he scope o ou cu en
esea ch.
In ou popula ion, he combined du a ion o b eas eeding
s ood a 39 days, highe han obse ed in o he s udies in Spain
(Oli e -Roig e al., 2008; O ega Ga cía e al., 2008). Any
in e en ions aiming o imp o e his indica o would bene i
om iden i ying he pe iod du ing which mos b eas eeding
d opou s occu . In ou popula ion, he c i ical pe iod s ood a
12 days, in ag eemen wi h o he au ho s (Oli e -Roig e al.,
2008). The e o e, suppo o b eas eeding mo he s and hei
en i onmen du ing his ansi ional pe iod would be c ucial o
ensu e main enance o EBF (Beake, Pellowe, Dykes, Schmied,
& Bick, 2012). We clea ly iden i ied wo speci ic pe iods du -
ing which he g ea es b eas eeding cessa ion occu ed in ou
se ing, as seen in Table 2. The i s pe iod is om hospi al
discha ge o he i s mon h o li e o he newbo n, du ing
which p oblems ela ed o he b eas and he newbo n appea .
These p oblems in u n coincide wi h he loss o b eas eeding
s a e wel a e suppo and un il bo h he mo he and child a e
assessed in p ima y ca e. The second pe iod is a e 2 mon hs
o li e and may be associa ed wi h ac o s ela ed o he mo h-
e ’s in e es o abili y o con inue b eas eeding in conjunc ion
wi h a e u n o paid employmen (O ibe e al., 2015; Rius
e al., 2014). P o iding pee suppo ha includes one-on-one
o g oup counseling has been shown o inc ease b eas eeding
ini ia ion and/o du a ion (Ha oon, Das, Salam, Imdad, &
Bhu a, 2013; Ing am, 2013). Se ices include b eas eeding
educa ion classes, p ena al classes, and clinical e e als.
Popula ions ha may bene i he mos om pee counseling
include disad an aged and low-income women (Ke in,
Kemp, & Pul e , 2010).
Se e al s udies (Ba iuso Lap esa, Sánchez-Val e de
Visus, Rome o Iba a, & Vi o ia Come zana, 2000; Jo ani
Roda e al., 2002; Ri illa Ma ugán e al., 2003) poin o
hypogalac ia as he main cause o EBF discon inua ion, ol-
lowed by in an ailu e o gain weigh and/o in an weigh
loss. The la e was he eason mos equen ly ci ed by
mo he s o combining b eas eeding wi h o mula eeding.
A ending o hese cases, we can see ha hey a e in e ela ed
and can conclude ha pe haps ac ing on he hypogalac ia
would co ec he lack o in an weigh gain. A he same
ime, i is impo an o conside ha mos o he condi ions
e e ed o by mo he s as hypogalac ia a e in ac subjec i e
pe cep ions. In eali y, only 5% o cases would ma ch a clini-
cal desc ip ion (Oli e -Roig e al., 2008; O ibe e al., 2015).
The subjec i e hypogalac ia may be a ec ed by a a ie y o
ex e nal ac o s, including p o essional ad ice ha may no
ela e o he mo he ’s abili y and desi e o b eas eed (Oli e -
Roig e al., 2008).
In ou popula ion, o all women o mula eeding a 3
mon hs (47%), 29% had al eady made up hei minds o eed
by o mula on he deli e y day. The e o e, we could in e
ha 18% had op ed o o mula eeding as a consequence o
EBF ailu e. Whe eas mos mo he s (71%) do no ini ially
ejec b eas eeding and ha e a posi i e iew o i , abou hal
o women a 3 mon hs ha e no had hei expec a ions me .
Such unme expec a ions we e e lec ed in ou s udy as he
hi d cause o EBF discon inua ion, which could be a oided
by employing p o essional suppo and con inuous moni o -
ing (O ibe e al., 2015; Ren ew, McCo mick, Wade, Quinn,
& Dowswell, 2012).
As o he ela ionship be ween pa i y and du a ion o
EBF a 3 mon hs, we obse ed s a is ically signi ican esul s
showing a g ea e endency o sus ain EBF in mul ipa ous
women, coinciding consis en ly wi h p e ious s udies
(Ba iuso Lap esa e al., 2000; O ibe e al., 2015).
Al hough ecen esea ch (Pé ez-Ríos, Ramos-Valencia,
& O iz, 2008) concluded ha labo by cesa ean sec ion neg-
a i ely con ibu ed o ini ia ing and main aining EBF, ou
indings did no suppo such a p emise. We hink ha hospi-
al p o ocols and ou ines ha we ha e de eloped since 2012,
such as SSC ollowing deli e y including cesa ean sec ion,
ha e bene i ed ou pa ien s in his a ea, in ag eemen wi h
o he s udies (B amson e al., 2010; S e ens, Schmied,
Bu ns, & Dahlen, 2014; Yuksel e al., 2015).
The e o e, we belie e ha coo dina ion be ween p ima y
and specialized ca e is essen ial o achie e EBF o be e
quali y and du a ion. Heal h ca e p o ide s mus ac i ely
wo k o es ablish b eas eeding as he s anda d o in an
eeding (Beake e al., 2012). Such a scena io can be encou -
aged by he implemen a ion o measu es suppo i e o EBF,
such as he Baby-F iendly Hospi al Ini ia i e (Ma ens,
2012), and he elen less p omo ion o EBF in p ima y ca e
(Ca aneo e al., 2010).
Ou esul s on EBF, al hough a om excellen , do
imp o e on wha has been published in simila s udies
(Ba iuso Lap esa, 2007; Gomis-Ceb ián e al., 2009; Rius
e al., 2014; Ri illa Ma ugán e al., 2003). Howe e , ou
s udy has some limi a ions. Fi s , he da a collec ed in he
elephone su ey explo ing he causes o discon inua ion o
b eas eeding may su e om ecall o social desi abili y
biases, as well as being conside ed coe ci e. Second, he
exac ime o each o he SSC sessions was no con olled. As
a gene al ule, women and newbo ns we e able o spend 120
unin e up ed minu es oge he ; howe e , se ice p essu es
some imes o ced us o clea he busy deli e y oom, he e-
o e p e en ing us om gua an eeing ha he bond had been
made in ull. In ha case, SSC was eco ded as “no pe -
o med.” In ou s udy, al hough he exac elapsed ime om
bi h un il SSC was no eco ded, ou p o ocol es ablished
ha i had o be pe o med wi hin he i s 30 minu es. In
addi ion, e en hough we did no exac ly eco d he o al
du a ion o ime when he echnique was pe o med, we used
da a om he cu en elec onic heal h eco d pla o m,
Vila-Candel e al. 311
which ensu es ha a minimum o 120 minu es is eached by
he midwi e y eam in he deli e y oom. We we e no able
o andomize he pe o mance o ea ly SSC as i is a ac o
conduci e o b eas eeding, and he e o e, alloca ion o a “no
ea ly SSC” ial a m, wi hholding his p ac ice, would ha e
impinged on he bes in e es s o bo h he mo he and he
neona e (B amson e al., 2010; Moo e e al., 2012).
Conclusion
B eas eeding p omo ion in e en ions a e likely o imp o e
b eas eeding a es, as sugges ed by ou s udy. Fu he ou -
come e alua ion o he measu es implemen ed in ou o gani-
za ion o imp o e b eas eeding a es is equi ed.
B eas eeding p omo ion p og ams may bene i om
add essing social and economic de e minan s a ec ing
women who wan o b eas eed.
Acknowledgmen s
The au ho s hank all pa icipan s in he s udy and especially S.
Sebas ián, A. Ma ínez, E. Bell is, E. Planells, C. Ma eu, R. Espuig,
and M. J. Gómez, who collabo a ed on he da a collec ion. They
would like o hank C. Ma ínez o he eedback on his a icle.
Decla a ion o Con lic ing In e es s
The au ho s decla ed no po en ial con lic s o in e es wi h espec
o he esea ch, au ho ship, and/o publica ion o his a icle.
Funding
The au ho s ecei ed no inancial suppo o he esea ch, au ho -
ship, and/o publica ion o his a icle.
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