Ci a ion: Mena-Tudela, D.;
So iano-Vidal, F.J.; Vila-Candel, R.;
Quesada, J.A.; Ma ínez-Po ca , C.;
Ma in-Mo eno, J.M. Is Ea ly
Ini ia ion o Ma e nal Lac a ion a
Signi ican De e minan o
Con inuing Exclusi e B eas eeding
up o 6 Mon hs?. In . J. En i on. Res.
Public Heal h 2023,20, 3184.
h ps://doi.o g/10.3390/
ije ph20043184
Academic Edi o : Melissa Thoene
Recei ed: 17 Decembe 2022
Re ised: 9 Feb ua y 2023
Accep ed: 10 Feb ua y 2023
Published: 11 Feb ua y 2023
Copy igh : © 2023 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Is Ea ly Ini ia ion o Ma e nal Lac a ion a Signi ican
De e minan o Con inuing Exclusi e B eas eeding up o
6 Mon hs?
Desi ée Mena-Tudela 1, F ancisco Ja ie So iano-Vidal 2,3 , Ra ael Vila-Candel 2,4,* , José
An onio Quesada 5,6 , C is ina Ma ínez-Po ca 4and Jose M. Ma in-Mo eno 7,8
1Depa men o Nu sing, Uni e si a Jaume I, 12071 Cas ellón de la Plana, Spain
2Depa men o Nu sing, Uni e si a de València, 46007 Valencia, Spain
3Depa men o Obs e ics and Gynaecology, Xà i a-Oninyen Heal h Depa men , 46800 Xà i a, Spain
4Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, 46600 Alzi a, Spain
5Depa men o Clinical Medicine, Uni e sidad Miguel He nández, 03202 Elche, Spain
6
Ne wo k o Resea ch on Ch onici y, P ima y Ca e, and Heal h P omo ion (RICAPPS), 03550 Alican e, Spain
7Depa men o P e en i e Medicine and Public Heal h, Uni e si a de València, 46010 Valencia, Spain
8Biomedical Resea ch Ins i u e INCLIVA, Clinic Uni e si y Hospi al, 46010 Valencia, Spain
*Co espondence: [email p o ec ed]
Abs ac :
Backg ound: The Wo ld Heal h O ganiza ion (WHO) ecommends ea ly ini ia ion o
b eas eeding (EIBF) wi hin he i s hou a e bi h. Howe e , ce ain pe ina al ac o s, namely
caesa ean sec ion, may p e en his goal om being achie ed. The aim o ou s udy was o examine
he ela ionship be ween EIBF (ma e nal lac a ion in he i s hou s and deg ee o la ching be o e
hospi al discha ge) and he main enance o exclusi e b eas eeding (MBF) up o he ecommended
6 mon hs o age (as ad oca ed by he WHO). Me hods: This obse a ional, e ospec i e coho
s udy included a andom sample o all bi hs be ween 2018 and 2019, cha ac e ising he momen
o b eas eeding ini ia ion a e bi h and he in an ’s le el o b eas la ch (measu ed by LATCH
assessmen ool) p io o hospi al discha ge. Da a we e collec ed om elec onic medical eco ds and
om ollow-up heal h checks o in an s up o 6 mon hs pos pa um. Resul s: We included 342 women
and hei newbo ns. EIBF occu ed mos o en a e aginal (p< 0.001) and spon aneous bi hs
wi h spon aneous amnio hexis (p= 0.002). LATCH sco e <9 poin s was associa ed wi h a 1.4- old
ela i e isk o abandoning MBF (95%CI: 1.2–1.7) compa ed wi h a sco e o 9–10 poin s. Conclusions:
Al hough we we e unable o ind a signi ican associa ion be ween EIBF in he i s 2 h a e bi h and
MBF a 6 mon hs pos pa um, low LATCH sco es p io o discha ge we e associa ed wi h low MBF,
indica ing he impo ance o ein o cing he educa ion and p epa a ion e o s o mo he s in he i s
days a e deli e y, p io o he es ablishmen o an in an eeding ou ine upon e u ning home.
Keywo ds:
exclusi e b eas eeding; skin- o-skin con ac ; aginal bi h; caesa ean sec ion; ea ly
ini ia ion o b eas eeding
1. In oduc ion
The Wo ld Heal h O ganiza ion (WHO), in addi ion o o he in e na ional o gani-
sa ions, ecommends ea ly ini ia ion o b eas eeding (EIBF) du ing he i s hou o li e,
main aining exclusi e b eas eeding (MBF) un il 6 mon hs pos pa um, and con inuing
b eas eeding (BF) a e his pe iod in addi ion o sui able heal hy oods o in an s un il
he age o 2 yea s o olde [
1
,
2
]. This o m o eeding is conside ed e ec i e in ensu ing
newbo n in an s’ heal h and su i al wo ldwide [2].
To achie e EIBF wi hin he newbo n’s i s hou o li e and o es ablish adequa e BF,
immedia e skin- o-skin con ac (SSC) be ween he mo he and newbo n has been iden i ied
as an e ec i e heal hca e in e en ion [3–5].
In . J. En i on. Res. Public Heal h 2023,20, 3184. h ps://doi.o g/10.3390/ije ph20043184 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2023,20, 3184 2 o 11
Al hough immedia e SSC is widely accep ed, he e a e socio-economic and pe ina al
ac o s, especially caesa ean sec ion, which make i di icul o achie e his goal, despi e
knowledge ha ea ly SSC is possible a e caesa ean sec ion, and pe o ming i as ea ly
as possible is ecommended [
6
,
7
]. Di e en au ho s ha e epo ed he many bene i s o
SSC and ha e obse ed ha women wish o pe o m his p ac ice [
8
,
9
]; howe e , i is
un o una ely no widesp ead. Mo eo e , a h ee old inc eased isk has been epo ed o
delaying BF ini ia ion in in an s bo n by caesa ean sec ion compa ed wi h in an s bo n by
aginal bi h [
10
,
11
]. In addi ion o bi h ype, di e en pe ina al and socio-economic ac o s
ela ed o delayed EIBF ha e been iden i ied, such as in apa um complica ions, labou
du a ion, ges a ional age a bi h [
11
,
12
], use o anaes he ics and opia es [
13
], newbo n’s
sex, bi h weigh , APGAR sco e, and being admi ed o a neona al in ensi e ca e uni
(NICU) [5,14].
Di e en s udies ha e s essed he impo ance o analysing he ela ionship be ween
he pe ina al ac o s ha migh in luence EIFB and he in an ’s le el o b eas la ch; howe e ,
ew s udies ha e obse ed i s ela ionship wi h mid- e m (<6 mon hs) MBF. Fo his eason,
i emains necessa y o e i y he ela ionship be ween EIBF, e ec i e la ching, and MBF
un il 6 mon hs pos pa um. The seconda y objec i es o his s udy a e o de e mine he
ac o s in luencing EIBF, e ec i e la ching, and MBF un il 6 mon hs pos pa um.
2. Ma e ials and Me hods
2.1. S udy Design
An obse a ional, e ospec i e coho s udy was pe o med. This s udy was con-
duc ed a he Uni e si y La Ribe a Hospi al (HULR) in Valencia (Spain), which se es a
popula ion o app oxima ely 250,000 inhabi an s and sees a mean 1400 bi hs/yea .
The inclusion c i e ia we e women aged 18 yea s o olde and all na u al bi hs and
caesa ean sec ions ha ook place a he HULR be ween 2018 and 2019 in which EIBF
occu ed inside a deli e y oom a e ‘ e y ea ly SSC’. In line wi h Moo e e al.’s [
3
]
de ini ion, e y ea ly SSC was de ined as con ac beginning app oxima ely 30–40 min
pos pa um, whe ein he naked in an , wi h o wi hou a cap, is placed p one on he
mo he ’s ba e ches and a blanke is placed ac oss he in an ’s back.
Twin and mul iple bi hs, p e e m in an s, newbo ns admi ed o a NICU, in an s wi h
no eco d o EIBF wi hin he i s 120 min a e bi h inside a deli e y oom, and in an s
wi h BF- ype eco ds los du ing he 6-mon h pos pa um ollow-up we e excluded.
2.2. Da a Collec ion
Da a collec ion was based on he elec onic medical eco ds. All child en bo n in
he hospi al wi h in an eeding eco ds we e included. The s udy sample was selec ed
by simple andom sampling. The esponse a iable was in an eeding. Feeding ype
upon hospi al discha ge was classi ied and g ouped as BF, a i icial, o mixed. In an s
who abandoned exclusi e BF we e assigned o he a i icial o mixed g oup. Milk eeding
was measu ed a 1, 2, 4, and 6 mon hs pos pa um. Exclusi e MBF was de ined as in an s
who we e ed exclusi ely d awn/dono b eas milk om he mo he . In addi ion, MBF
newbo ns only ecei ed i amin d ops o sy ups, medica ions, o mine als [
15
]. A i icial
eeding was de ined when he b eas ed in an was ed only wi h a i icial milk, and mixed
eeding was de ined when an in an ’s eeding combined BF and a i icial milk.
The s udy a iables we e: (1) socio-demog aphic (ma e nal age and coun y o o igin)
and (2) obs e ic (ges a ional age, pa i y, p egnancy isk (based on he Spanish Socie y o
Gynaecology and Obs e ics, classi ica ion as low, medium, high/ e y high de e mined by
heal hca e p o ide . Di e en ac o s, such as ma e nal age, p e ious medical condi ions,
p e ious o ac ual obs e ic his o y, and li es yle ac o s, may a ec he mo he
´
s heal h
and/o he de eloping oe us [
15
]), bi h ini ia ion, amnio hexis ype, analgesia, and
end o bi h); ollowing he ecommenda ions o De ane e al. [
16
], (3) pe ina al a iables
(newbo n’s sex, bi h weigh , bi h leng h, cephalic pe ime e , umbilical a e y pH), and
(4) eeding (LATCH b eas eeding assessmen ool [
17
], EIBF ime and eeding ype) we e
In . J. En i on. Res. Public Heal h 2023,20, 3184 3 o 11
included. The ime un il EIBF was eco ded by he midwi e who assis ed he bi h as ou-
ine da a in he elec onic medical eco d and was ca ego ised in o wo pe iods,
≤
60 min
o >60 min, wi h a maximum ime o 120 min. The LATCH sco e was measu ed and
eco ded on he da e o discha ge om he hospi al. This LATCH scale measu es BF e i-
ciency using i e i ems. Each i em is gi en a maximum sco e o 2 poin s and a minimum
sco e o 0, wi h a maximum 10-poin sco e ( he ac onym LATCH co esponds o: L ‘how
well in an la ches on o he b eas ’, A ‘audible swallowing’, T ‘ ype o nipple’, C ‘com-
o ’, and H ‘hold-posi ioning’). To op imise he LATCH analysis, LATCH sco es we e
ca ego ised in o wo ca ego ies: <9 poin s and 9–10 poin s. As epo ed by o he au ho s, a
LATCH sco e
≥
8 a 48 h o discha ge had a sensi i i y o 93.5% and speci ici y o 92.1%,
wi h hese mo he s being 9.28 imes mo e likely o BF a 6 weeks pos pa um [17].
Sample size was calcula ed by assuming a 50% MBF p e alence a 6 mon hs pos pa -
um wi h 5% p ecision, a 95% con idence in e al (95%CI), and an expec ed 10% p opo ion
o losses. The sample equi ed 335 women. Finally, andomisa ion o medical eco d num-
be s was pe o med o he bi hs ha occu ed du ing he s udy pe iod, assigning e e y
indi idual a numbe by using a andom numbe gene a o and hen andomly picking a
subse o he es ima ed popula ion.
2.3. Da a Analysis
Desc ip i e analysis was pe o med wi h all he a iables by calcula ing equencies
o he quali a i e a iables, minimums, maximums, and mean
±
s anda d de ia ion (SD)
o he quan i a i e a iables.
To analyse how abandoning BF e ol ed be ween 1 and 6 mon hs, a simple linea
eg ession line was adjus ed o he p opo ion o abandonmen s pe mon h. The R
2
associa ion was calcula ed. The ac o s associa ed wi h he p esence o an a - isk LATCH
(<9 poin s) [
17
], EIBF a e >1 h, and abandoning MBF a 6 mon hs pos pa um we e
analysed using con ingency ables and by applying he Chi-squa ed es o he quali a i e
a iables. The mean alues o he quan i a i e a iables we e compa ed using S uden ’s
- es .
To es ima e he magni ude o he associa ions wi h abandoning MBF a 6 mon hs, ela-
i e isks (RRs) we e es ima ed using Poisson eg ession models wi h obus a iance [
18
]
in addi ion o hei 95% CIs. A s epwise p ocedu e was ollowed o selec he a iables
based on he Akaike In o ma ion C i e ion. Da a analysis was pe o med using SPSS .26.0
o Windows (IBM Co p. 2018, A monk, NY, USA) and R (R p ojec 2019, e sion 4.0.2). As
he analysis included wo a iables (EIBF and abandoning MBF), he le el o signi icance
was adjus ed by he Bon e oni me hod o p< 0.025.
2.4. E hical Conside a ions
This s udy ecei ed a a ou able opinion om he Resea ch E hics Commi ee and he
Resea ch Commi ee (CEI-CI) o HULR (HULR2020_34). The bioe hical p inciples o he
Decla a ion o Helsinki we e applied.
3. Resul s
O he 1104 cases wi h ea ly SSC, an EIBF eco d, and mo he s wishing o unde ake
pos pa um BF, 497 women we e andomly included. Due o loss h ough ollow-up a he
di e en cu -o poin s, 155 cases we e omi ed (Figu e 1). We we e in e es ed in analysing
he missing cases o de e mine whe he he e we e s a is ically signi ican di e ences
be ween hem, especially ega ding he ype o BF a discha ge. The e we e no signi ican
di e ences be ween he g oup o women los o ollow-up and ype o BF a discha ge
ega ding age, ges a ional age a deli e y, newbo n
´
s sex, p egnancy isk, coun y o
o igin, analgesia, o bi h s a ed. In con as , he e we e signi ican educ ions among he
pa icipan s wi h lowe LATCH sco es (p < 0.01), ype o amnio hexis (p < 0.01), and end
o bi h (p < 0.01). In addi ion, he e was a signi ican di e ence be ween his g oup and
he ype o BF a discha ge, whe e women who had EIBF (
≤
60 min) wi h exclusi e MBF a
In . J. En i on. Res. Public Heal h 2023,20, 3184 4 o 11
discha ge (EIBF
≤
60 min wi h MBF [n= 106], wi h abandonmen o exclusi e BF [n= 15];
EIBF >60 min wi h MBF [n= 20] and wi h abandonmen o exclusi e BF [n= 14]; p< 0.001).
In . J. En i on. Res. Public Heal h 2023, 20, 3184 4 o 11
he di e en cu -o poin s, 155 cases we e omi ed (Figu e 1). We we e in e es ed in
analysing he missing cases o de e mine whe he he e we e s a is ically signi ican
di e ences be ween hem, especially ega ding he ype o BF a discha ge. The e we e no
signi ican di e ences be ween he g oup o women los o ollow-up and ype o BF a
discha ge ega ding age, ges a ional age a deli e y, newbo n´s sex, p egnancy isk,
coun y o o igin, analgesia, o bi h s a ed. In con as , he e we e signi ican educ ions
among he pa icipan s wi h lowe LATCH sco es (p < 0.01), ype o amnio hexis (p < 0.01),
and end o bi h (p < 0.01). In addi ion, he e was a signi ican di e ence be ween his g oup
and he ype o BF a discha ge, whe e women who had EIBF (≤60 min) wi h exclusi e MBF
a discha ge (EIBF ≤60 min wi h MBF [n = 106], wi h abandonmen o exclusi e BF [n = 15];
EIBF >60 min wi h MBF [n = 20] and wi h abandonmen o exclusi e BF [n = 14]; p < 0.001).
Figu e 1. Flow cha o he s udy. MBF: exclusi e b eas eeding.
The inal analysed sample con ained 342 women (Table 1) wi h a mean age o 32.9 ± 5.4
yea s, o whom 87.7% (300/342) we e Spanish. The mean ges a ional age a bi h was 39+4 ±
1.2 weeks, and 38.9% (133/342) had a caesa ean sec ion, 55.8% (191/342) we e p imipa ous,
and 29.5% (101/342) had a high- isk o e y high- isk p egnancy.
O all he newbo ns, 51.2% (175/342) we e boys, and he mean bi h weigh was 3,351 ±
485 g. The eco ded alid EIBF a e was 11.9% (342/2879), wi h 87.7% (300/342) o mo he s
pe o ming EIBF du ing he i s hou o li e. Mo eo e , 20.2% (69/342) ob ained a high- isk
LATCH sco e (<9 poin s). Abandoning MBF inc eased wi h newbo n’s age o 26.0% (89/253),
34.5% (118/224), 43.9% (150/192), and 61.4% (210/132) a 1, 2, 4, and 6 mon hs pos pa um,
espec i ely. A linea end was obse ed o abandoning MBF up o 6 mon hs pos pa um,
wi h a 6.79% mean p opo ion o abandonmen pe mon h (linea R
2
= 0.984).
Figu e 1. Flow cha o he s udy. MBF: exclusi e b eas eeding.
The inal analysed sample con ained 342 women (Table 1) wi h a mean age o
32.9
±
5.4 yea s, o whom 87.7% (300/342) we e Spanish. The mean ges a ional age a bi h
was 39+4
±
1.2 weeks, and 38.9% (133/342) had a caesa ean sec ion, 55.8% (191/342) we e
p imipa ous, and 29.5% (101/342) had a high- isk o e y high- isk p egnancy.
Table 1. The s udied sample’s cha ac e is ics (n= 342).
n%
Abandoning MBF a1 Mon h No 253 74.0%
Yes 89 26.0%
Abandoning MBF a2 mon hs No 224 65.5%
Yes 118 34.5%
Abandoning MBF a4 mon hs No 192 56.1%
Yes 150 43.9%
Abandoning MBF a6 mon hs No 132 38.6%
Yes 210 61.4%
LATCH b9–10 No mal 273 79.8%
< 9 Risk 69 20.2%
In . J. En i on. Res. Public Heal h 2023,20, 3184 5 o 11
Table 1. Con .
n%
EIBF c≤60 min 300 87.7%
> 60 min 42 12.3%
Newbo n’s sex
Male 175 51.2%
Female 167 48.8%
Coun y o o igin O he s 42 12.3%
Spain 300 87.7%
Pa i y
One 191 55.8%
Two 119 34.8%
Th ee o mo e 32 9.4%
P egnancy isk
Low 199 58.2%
Medium 42 12.3%
High/Ve y high 101 29.5%
Analgesia Epidu al 240 70.2%
O he s 102 29.8%
Bi h s a ed by
S imula ed 42 12.3%
Induced 77 22.5%
Caesa ean 42 12.3%
Spon aneous 181 52.9%
End o bi h
Vaginal 209 61.1%
Caesa ean 133 38.9%
Amnio hexis
A i icial 211 61.7%
Spon aneous 131 38.3%
nMinimum Maximum Mean SD d
Ma e nal age 342 18.0 51.0 32.9 5.4
Ges a ional age (weeks) 342 37.0 42.0 39.4 1.2
Bi h weigh (g) 342 2195.0 5730.0 3351.5 485.0
Bi h leng h (cm) 342 43.0 55.5 50.0 1.9
Cephalic pe ime e (cm) 342 31.0 48.0 34.5 1.7
Umbilical a e y pH 306 7.08 7.43 7.3 0.1
a
MBF: exclusi e b eas eeding;
b
LATCH: b eas eeding assessmen ool sco e;
c
EIBF: ea ly ini ia ion o b eas -
eeding; dSD: s anda d de ia ion.
O all he newbo ns, 51.2% (175/342) we e boys, and he mean bi h weigh was
3351
±
485 g. The eco ded alid EIBF a e was 11.9% (342/2879), wi h 87.7% (300/342) o
mo he s pe o ming EIBF du ing he i s hou o li e. Mo eo e , 20.2% (69/342) ob ained
a high- isk LATCH sco e (<9 poin s). Abandoning MBF inc eased wi h newbo n’s age
o 26.0% (89/253), 34.5% (118/224), 43.9% (150/192), and 61.4% (210/132) a 1, 2, 4, and
6 mon hs pos pa um, espec i ely. A linea end was obse ed o abandoning MBF up o
6 mon hs pos pa um, wi h a 6.79% mean p opo ion o abandonmen pe mon h (linea
R2= 0.984).
Table 2shows he esul s o analysing he p o iles o mo he s wi h EIBF acco ding o
EIBF ime (
≤
60 min o >60 min). EIBF wi hin 1 h o li e occu ed mos o en wi h aginal
(p< 0.001) bi hs and spon aneous bi hs wi h spon aneous amnio hexis (p= 0.002).
Mo eo e , he e was an associa ion be ween EIBF and LATCH sco e (p= 0.023), whe e 89.7%
(245/342) o newbo ns wi h sco es o 9–10 ecei ed EIBF be o e 60 min. The p e alence o
In . J. En i on. Res. Public Heal h 2023,20, 3184 6 o 11
MBF a 1, 2, 4, and 6 mon hs was 74.0% (253/342), 65.5% (224/342), 56.1% (192/342), and
38.6% (132/342), espec i ely. No signi ican di e ences we e ound be ween MBF a 1, 2,
4, and 6 mon hs and he quan i a i e a iables.
Table 2. Rela ion be ween ea ly la ching and he o he a iables (n= 342).
EIBF a≤60 min EIBF a> 60 min
n%n%p-Value b
Newbo n’s sex
Male 158 90.3% 17 9.7% 0.139
Female 142 85.0% 25 15.0%
Coun y o o igin O he s 41 97.6% 1 2.4% 0.037
Spain 259 86.3% 41 13.7%
Pa i y
One 160 83.8% 31 16.2%
0.043
Two 110 92.4% 9 7.6%
Th ee o mo e 30 93.8% 2 6.3%
P egnancy isk
Low 174 87.4% 25 12.6%
0.983
Medium 37 88.1% 5 11.9%
High/ e y high
89 88.1% 12 11.9%
Analgesia Epidu al 211 87.9% 29 12.1% 0.865
O he s 89 87.3% 13 12.7%
Bi h s a ed by
Caesa ean 35 83.3% 7 16.7%
0.155
Spon aneous 165 91.2% 16 8.8%
S imula ed 37 88.1% 5 11.9%
Induced 63 81.8% 14 18.2%
End o bi h
Vaginal 197 94.3% 12 5.7% <0.001
Caesa ean 103 77.4% 30 22.6%
Type o amnio hexis A i icial 176 83.4% 35 16.6% 0.002
Spon aneous 124 94.7% 7 5.3%
LATCH 9–10 No mal 245 89.7% 28 10.3% 0.023
<9 Risk 55 79.7% 14 20.3%
MBF 1 mon h
Yes 219 86.6% 34 13.4% 0.271
No 81 91.0% 8 9.0%
MBF 2 mon hs
Yes 195 87.1% 29 12.9% 0.605
No 105 88.9% 13 11.1%
MBF 4 mon hs
Yes 165 85.9% 27 14.1% 0.256
No 135 90.0% 15 10.0%
MBF 6 mon hs
Yes 115 87.1% 17 12.9% 0.789
No 185 88.1% 25 11.9%
aEIBF: ea ly ini ia ion o b eas eeding; bChi-squa ed es .
Table 3shows how signi ican ly mo e mo he s who abandoned MBF a 6 mon hs
pos pa um ob ained LATCH sco es <9 poin s (81.2%) han sco es o 9–10 poin s (56.4%)
(p< 0.001). No di e ences we e obse ed be ween bi h ypes ega ding abandoning MBF
a 6 mon hs pos pa um; 61.3% (82/133) o mo he s abandoned MBF a e aginal bi h,
and 61.6% (128/209) abandoned MBF a e caesa ean sec ion (p= 0.939). No signi ican
di e ences we e ound o any quan i a i e a iable.
In . J. En i on. Res. Public Heal h 2023,20, 3184 7 o 11
Table 3. Abandoning exclusi e b eas eeding a 6 mon hs pos pa um (n= 342).
No Abandoned MBF a6 Mon hs Abandoned MBF a6 Mon hs
n%n%p-Value b
LATCH c9–10 No mal 119 43.6% 154 56.4% < 0.001
<9 isk 13 18.8% 56 81.2%
EIBF d≤60 min 115 38.3% 185 61.7% 0.789
>60 min 17 40.5% 25 59.5%
Newbo n’s sex
Male 67 38.3% 108 61.7% 0.904
Female 65 38.9% 102 61.1%
Coun y o o igin O he s 15 35.7% 27 64.3% 0.682
Spain 117 39.0% 183 61.0%
Pa i y
One 71 37.2% 120 62.8%
0.580
Two 46 38.7% 73 61.3%
Th ee o mo e 15 46.9% 17 53.1%
P egnancy isk
Low 76 38.2% 123 61.8%
0.422
Medium 13 31.0% 29 69.0%
High/ e y high
43 42.6% 58 57.4%
Analgesia while
gi ing bi h
Epidu al 94 39.2% 146 60.8% 0.740
O he s 38 37.3% 64 62.7%
Bi h s a ed by
Caesa ean 15 35.7% 27 64.3%
0.616
Spon aneous 72 39.8% 109 60.2%
S imula ed 19 45.2% 23 54.8%
Induced 26 33.8% 51 66.2%
End o bi h
Vaginal 81 38.8% 128 61.2% 0.939
Caesa ean 51 38.3% 82 61.7%
Type o amnio hexis A i icial 78 37.0% 133 63.0% 0.432
Spon aneous 54 41.2% 77 58.8%
a
MBF: exclusi e b eas eeding;
b
Chi-squa ed es ;
c
LATCH: b eas eeding assessmen ool sco e;
d
EIBF: ea ly
ini ia ion o b eas eeding.
Table 4shows he mul i a ia e analysis used o calcula e he RR o abandoning MBF
a 6 mon hs pos pa um. We ound no op imum model o explain MBF abandonmen a
6 mon hs pos pa um because no ac o s we e associa ed wi h his phenomenon. Only a
LATCH sco e <9 poin s was associa ed wi h a 1.4- old (1.2–1.7) inc eased RR o abandoning
MBF compa ed wi h a sco e be ween 9–10 poin s adjus ed o EIBF ime. EIBF did no unc-
ion as ei he a con ounde o a modi ying a iable in his associa ion; he e o e, he LATCH
sco e was independen ly ela ed o he main enance o abandonmen o exclusi e MBF.
Table 4. Mul i a ia e analysis o abandoning exclusi e b eas eeding a 6 mon hs pos pa um.
Simple Adjus men Mul i a ia e Adjus men
RR a95%CI bp-Value cRR a95%CI bp-Value c
LATCH d≥9 No mal 1 1
<9 Risk 1.44 (1.23–1.67) <0.001 1.45 (1.24–1.70) <0.001
EIBF e≤60 min 1 1
>60 min 0.97 (0.74–1.26) 0.794 0.91 (0.71–1.17) 0.458
a
RR: ela i e isk;
b
CI: con idence in e al;
c
Poisson mul iple eg ession model;
d
LATCH: b eas eeding
assessmen ool; eEIBF: ea ly ini ia ion o b eas eeding.
In . J. En i on. Res. Public Heal h 2023,20, 3184 8 o 11
4. Discussion
EIBF a ou s MBF a e hospi al discha ge; howe e , we did no ind a signi ican
associa ion be ween EIBF and MBF a 6 mon hs pos pa um. The lack o a signi ican
ela ionship does no imply ha he ela ionship does no exis . I is possible ha he
abandonmen was caused by social o en i onmen al a iables and/o suppo policies
aimed a main aining BF ha a ec ed he main enance o BF in he long e m o a g ea e
ex en [
13
,
19
]. Howe e , we clea ly and signi ican ly obse ed a co ela ion be ween he
LATCH sco e assessed be o e hospi al discha ge and he main enance o MBF a 6 mon hs,
and his ela ionship was s a is ically independen om whe he o no EIBF had occu ed
in he i s hou o he newbo n’s li e. This inding sugges s ha he LATCH assessmen
should no be conside ed simply a collec ion o in o ma ion, bu a he a p oac i e elemen
in he educa ion and enabling in e en ion o he mo he be o e e u ning home. I he
mo he is able o manage sa is ac o y BF au onomously, i is mo e likely ha exclusi e BF
will con inue un il he six h mon h, he eby achie ing he goal ha is clea ly de ined as
ideal by he scien i ic li e a u e and endo sed by he WHO and UNICEF [20].
Rega ding he ela ionship be ween EIBF and bi h ype, we obse ed how EIBF ook
longe o ini ia e in newbo ns a e caesa ean sec ion han in hose bo n by aginal bi h [
4
].
This inding co obo a es o he s udies ha obse ed ha women wi h immedia e SSC
we e mo e likely o ini ia e ea ly BF in di e en modes o bi h [
11
,
21
–
24
]. A e caesa ean
sec ion a ou hospi al, ea ly SSC is pe o med by he women chosen by he mo he un il
she a i es. Al hough SSC is no usually pe o med la e han 15 min a e bi h, i could
be s a ed ea lie i ea ly SSC was implemen ed in caesa ean sec ion- ype bi hs. A delay in
ini ia ing BF could be explained by cha ac e is ics ela ed o su ge y and could be due o
he mo he s’ ini ial pos -su gical eco e y. A nega i e bi h expe ience, a igue, and anxie y,
especially in he con ex o an u gen caesa ean sec ion, may esul in mo he s needing
o es , which can delay he ini ia ion o BF [
11
]. End o bi h ype ( aginal s. caesa ean
sec ion) did no ha e a signi ican e ec on abandoning MBF ea ly a 6 mon hs, as epo ed
in o he publica ions [
4
,
11
]. Rega ding he ime o ini ia e BF, a sho e ime be ween bi h
and BF ini ia ion was no associa ed wi h inc eased long- e m BF a es, which is in line wi h
he esul s o o he s udies [
5
]. BF is an ins inc i e ac o he heal hy newbo n. The ime
p essu e o he in an ’s i s la ch-on should be ela i ised. In his ega d, i is impo an o
highligh he impo ance o ea ly SSC be ween he mo he and newbo n ega dless o he
ype o childbi h o he ges a ional age and weigh o he baby, as ecommended by he
WHO [
25
]. Heal h p o essionals should ocus on allowing ime and space o his dyad and
obse ing and being a ailable o ma e nal conce ns and hand o .
Rega ding he ela ionship be ween EIBF and numbe o child en, he likelihood o
EIBF inc eased as pa i y inc eased. The mo he ’s expe ience and empowe men may play
a key ole [
26
], whe e empowe men is a ool ha mo i a es women wi h au onomy o
employ esou ces and o o e come s uc u al o social limi a ions [
26
]. In addi ion, heal h
li e acy migh play a ole [
27
]. None heless, u u e s udies should con i m hese hypo heses.
The LATCH assessmen ool is no designed o make long- e m p edic ions; howe e ,
o he s udies ha e indica ed i s possible p edic i e alue as a a iable associa ed wi h he
con inua ion o long- e m MBF [
17
,
28
]. In addi ion, ou s udy obse ed how LATCH sco es
below 9 poin s a ou ed MBF abandonmen a 6 mon hs, which was also associa ed wi h
lowe bi h weigh and cephalic pe ime e alues. This obse a ion opens an in e es ing
line o u u e esea ch in which he LATCH assessmen ool could unc ion as a p edic o
o long- e m BF.
The mul i a ia e model indica ed ha he LATCH ool in e ened in he con inua ion
o long- e m MBF by demons a ing ha EIBF did no a ec his associa ion. Heal hca e
p o essionals’ con inuous pos pa um suppo o ms a undamen al pa o EIBF [
5
,
12
,
13
].
Pe haps, ou e o s mus concen a e on cons an ly p o iding mo he s wi h p o essional
suppo as needed o hem o disco e a com o able and painless BF posi ion a e ei he
aginal bi h o caesa ean sec ion (e.g., placing he newbo n in a c oss-sec ional posi ion
i bo n by caesa ean sec ion o op imise SSC and o imp o e spon aneous la ching). This
In . J. En i on. Res. Public Heal h 2023,20, 3184 9 o 11
could indi ec ly imp o e he LATCH sco e and help mo he s o con inue wi h long- e m
MBF [
11
]. Because ac o s, such as a i icial eeding and bi h by caesa ean sec ion, a e
associa ed wi h he de elopmen o long- e m diseases, such as mul iple scle osis [
29
],
e o s made o imp o e BF as a u u e heal h in e en ion a e he minimum, especially as
i in ol es inexpensi e heal hca e measu es wi h excellen and posi i e ou comes o he
heal h o mo he s and hei babies. None heless, his line o inqui y would bene i om
u u e esea ch.
In iew o ou esul s and in line wi h o he s udies [
30
], i is necessa y o abandon
he idea ha s a ing BF a e caesa ean sec ion is mo e di icul . Wo king wi h a mul i-
disciplina y eam o aise he awa eness o heal hca e p o essionals who a end women
gi ing bi h by caesa ean sec ion would be a ele an a ea o in es iga e. In addi ion, mo e
espec ul heal hca e in line wi h Baby-F iendly Hospi al Ini ia i e (BFHI) ecommenda-
ions would ma k he di e ence wi h he ela ed a iables. I is essen ial o unde line ha
acc edi a ion by he BFHI does no ensu e e icien suppo [
31
]; howe e , i is a s ep in
his di ec ion.
Despi e he indings p esen ed in his s udy, i had se e al limi a ions. The e o e, ou
esul s mus be ca e ully in e p e ed, and we mus conside he impac o ollow-up losses
on he ue p e alence o MBF. Mo e cases we e los han he ini ially es ima ed sample
because ou s udy was e ospec i e, and some elec onic medical eco ds we e missing.
Al hough his limi a ion is common in e ospec i e s udies, ou s udy was able o each
he es ima ed sample size. Mo eo e , he s udy sample’s andomisa ion a oided selec ion
bias, which imp o ed he compa ison be ween EIBF and end o bi h ype ( aginal s.
caesa ean sec ion).
Fu he mo e, we would like o emphasise ha de e mining he causes o abandon-
men o MBF would ha e p oduced in e es ing da a, al hough his could only ha e been
in es iga ed i he s udy had a p ospec i e design; un o una ely, i was no pa o ou
objec i e o analyse he causes o MBF abandonmen . I should be no ed ha he esul s
could ha e been imp o ed i he SSC guidelines had been ollowed, achie ing immedia e
SSC (wi hin 10 min) and a oiding he use o a cap on he newbo n [3].
5. Conclusions
Al hough EIBF as soon as possible is conside ed a p io i y, in his s udy, i was no
associa ed wi h MBF a 6 mon hs pos pa um. Howe e , we ound ha low LATCH
sco es we e associa ed wi h cessa ion a 6 mon hs. Any heal h in e en ion capable o
imp o ing LATCH sco es would imply highe a es o he desi ed MBF a ge , and we
ha e he p o essional and e hical esponsibili y o ein o ce educa ion and empowe men
in e en ions o he mo he be o e she e u ns home and es ablishes he in an eeding
ou ine o acili a e he pa h owa ds achie ing he goal o MBF un il he six h mon h,
which has p o en o be bene icial o bo h he child and he mo he .
Au ho Con ibu ions:
Concep ualisa ion and me hodology, R.V.-C. and J.M.M.-M.; o mal analysis,
J.A.Q.; da a cu a ion, R.V.-C. and F.J.S.-V.; w i ing—o iginal d a p epa a ion, R.V.-C., F.J.S.-V. and
D.M.-T.; w i ing— e iew and edi ing, R.V.-C., F.J.S.-V., D.M.-T., C.M.-P. and J.M.M.-M. All au ho s
ha e ead and ag eed o he published e sion o he manusc ip .
Funding:
This esea ch was unded by Fundación pa a el Fomen o de la In es igación Sani a ia y
Biomédica de la Comuni a Valenciana (FISABIO) g an numbe UGP-20-100 o he De elopmen o
Resea ch P ojec s o Eme ging G oups, 2019.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed in acco ding o he guidelines o
he Decla a ion o Helsinki and app o ed by he Resea ch E hics Commi ee o Hospi al Uni e si a io
La Ribe a (HULR2020_34) and by he co esponding commi ees o he o he pa icipa ing cen es.
In o med Consen S a emen :
Pa ien consen was wai ed because his was a e ospec i e s udy
based on eco ded da a.
