Food insecurity, but not HIV-infection status, is associated with adverse changes in body composition during lactation in Ugandan women of mixed HIV status

Suboptimal gestational weight gain and neonatal outcomes in low and middle income countries: individual participant data meta-analysis

OBJECTIVE

To estimate the associations between gestational weight gain (GWG) during pregnancy and neonatal outcomes in low and middle income countries.

DESIGN

Individual participant data meta-analysis.

SETTING

Prospective pregnancy studies from 24 low and middle income countries.

MAIN OUTCOME MEASURES

Nine neonatal outcomes related to timing (preterm birth) and anthropometry (weight, length, and head circumference) at birth, stillbirths, and neonatal death.

ANALYSIS METHODS

A systematic search was conducted in PubMed, Embase, and Web of Science which identified 53 prospective pregnancy studies published after the year 2000 with data on GWG, timing and anthropometry at birth, and neonatal mortality. GWG adequacy was defined as the ratio of the observed maternal weight gain over the recommended weight gain based on the Institute of Medicine body mass index specific guidelines, which are derived from data in high income settings, and the INTERGROWTH-21st GWG standards. Study specific estimates, adjusted for confounders, were generated and then pooled using random effects meta-analysis models. Maternal age and body mass index before pregnancy were examined as potential modifiers of the associations between GWG adequacy and neonatal outcomes.

RESULTS

Overall, 55% of participants had severely inadequate (<70%) or moderately inadequate (70% to <90%) GWG, 22% had adequate GWG (90-125%), and 23% had excessive GWG (≥125%). Severely inadequate GWG was associated with a higher risk of low birthweight (adjusted relative risk 1.62, 95% confidence interval 1.51 to 1.72; 48 studies, 93 337 participants; τ2=0.006), small for gestational age (1.44, 1.36 to 1.54; 51 studies, 93 191 participants; τ2=0.016), short for gestational age (1.47, 1.29 to 1.69; 40 studies, 83 827 participants; τ2=0.074), and microcephaly (1.57, 1.31 to 1.88; 31 studies, 80 046 participants; τ2=0.145) compared with adequate GWG. Excessive GWG was associated with a higher risk of preterm birth (1.22, 1.13 to 1.31; 48 studies, 103 762 participants; τ2=0.008), large for gestational age (1.44, 1.33 to 1.57; 47 studies, 90 044 participants; τ2=0.009), and macrosomia (1.52, 1.33 to 1.73; 29 studies, 68 138 participants; τ2=0) compared with adequate GWG. The direction and magnitude of the associations between GWG adequacy and several neonatal outcomes were modified by maternal age and body mass index before pregnancy.

CONCLUSIONS

Inadequate and excessive GWG are associated with a higher risk of adverse neonatal outcomes across settings. Interventions to promote optimal GWG during pregnancy are likely to reduce the burden of adverse neonatal outcomes, however further research is needed to assess optimal ranges of GWG based on data from low and middle income countries.

Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis

BACKGROUND

Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs.

METHODS AND FINDINGS

We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study's methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies.

CONCLUSIONS

Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.

Body Composition Trajectories During the First 23 Months of Life Differ by HIV Exposure Among Infants in Western Kenya: A Prospective Study

BACKGROUND

Infants who are HIV-exposed and uninfected have suboptimal growth patterns compared to those who are HIV-unexposed and uninfected. However, little is known about how these patterns persist beyond 1 year of life.

OBJECTIVES

This study aimed to examine whether infant body composition and growth trajectories differed by HIV exposure during the first 2 years of life among Kenyan infants using advanced growth modeling.

METHODS

Repeated infant body composition and growth measurements (mean: 6; range: 2-7) were obtained from 6 weeks to 23 months in the Pith Moromo cohort in Western Kenya (n = 295, 50% HIV-exposed and uninfected, 50% male). Body composition trajectory groups were fitted using latent class mixed modeling (LCMM) and associations between HIV exposure and growth trajectories were examined using logistic regression analysis.

RESULTS

All infants exhibited poor growth. However, HIV-exposed infants generally grew suboptimally than unexposed infants. Across all body composition models except for the sum of skinfolds, HIV-exposed infants had a higher likelihood of belonging to the suboptimal growth groups identified by LCMM than the HIV-unexposed infants. Notably, HIV-exposed infants were 3.3 times more likely (95% CI: 1.5-7.4) to belong to the length-for-age z-score growth class that remained at a z-score of < -2, indicating stunted growth. HIV-exposed infants were also 2.6 times more likely (95% CI: 1.2-5.4) to belong to the weight-for-length-for-age z-score growth class that remained between 0 and -1, and were 4.2 times more likely (95% CI: 1.9-9.3) to belong to the weight-for-age z-score growth class that indicated poor weight gain besides stunted linear growth.

CONCLUSIONS

In a cohort of Kenyan infants, HIV-exposed infants grew suboptimally compared to HIV-unexposed infants beyond 1 year of age. These growth patterns and longer-term effects should be further investigated to support the ongoing efforts to reduce early-life HIV exposure-related health disparities.

Pathways linking social support, self-efficacy, and exclusive breastfeeding among women in northern Uganda

Despite improvements in infant feeding practices over the past two decades, the prevalence of exclusive breastfeeding (EBF) is below global targets. Social support can create an enabling environment for recommended infant feeding practices such as EBF, but the types of social support most important for sustained EBF and their potential mechanisms of action have not been thoroughly characterized. We therefore aimed to assess the relationship between EBF-specific social support, EBF self-efficacy, and EBF at 1 and 3 months among postpartum women in northern Uganda. Women (n = 238, 36.2% living with HIV) were recruited during pregnancy. EBF, social support, and EBF self-efficacy were assessed at 1 and 3 months postpartum. Path analysis was used to assess relationships between these factors. Most mothers exclusively breastfed to 1 (80.8%) and 3 months postpartum (62.9%). EBF-specific, but not general, social support differed by EBF status. EBF-specific social support was associated with higher odds of EBF, which was almost fully mediated by EBF self-efficacy. That is, there was evidence that social support primarily influences EBF through its association with self-efficacy. In sum, EBF-specific social support and self-efficacy likely promote EBF and are modifiable factors that can be intervened upon.

Factors Associated With Postpartum Weight Retention in African Women: A Systematic Review

Background and Objective:

The obesity epidemic among women in Africa is a health problem, and many studies attribute it to childbearing. However, most studies of postpartum weight retention (PPWR) occur in high-income countries. Therefore, this review sought to identify the potential factors affecting PPWR among African women.

Methods:

Four databases were searched from January 2000 to December 2020: Medline/PubMed, Google scholar, Ajol research, FreeFullPDF. The quality of included studies was assessed using the Newcastle Ottawa Scale.

Results:

Fifteen studies (5 from west, 4 from south, 3 from east, 2 from central, and 1 from north) were included: 8 cohort and 7 prospective cohort studies. Two studies examined the effect of obesity and weight gain during pregnancy on PPWR, 3 studies assessed the effect of childbirth, 4 examined the effect of breastfeeding, 4 assessed the impact of morbidities such as HIV, and 2 looked at food insecurity. Five studies demonstrated that postpartum weight is due to residual pregnancy weight gain and childbirth weight gain and is accentuated as parity increases (n = 2). Breastfeeding has a controversial effect, while morbidity (n = 4) and food insecurity (n = 4) contributed to weight loss. The variation in weight was also influenced by cultural practices (n = 1), prepregnancy weight (n = 1), and socioeconomic status (n = 1). On all domains, only 3 included studies were of good quality.

Conclusions:

Pregnancy weight gain, childbirth, breastfeeding, morbidity, and food insecurity were associated with PPWR. However, preexisting factors must be considered when developing PPWR modification strategies. In addition, due to the limited number of studies included, robust conclusions cannot be drawn.

Beyond the BMI: Validity and Practicality of Postpartum Body Composition Assessment Methods during Lactation: A Scoping Review

The assessment of body composition during lactation is an important indicator of maternal nutritional status, which is central to the overall health of the mother and child. The lactating woman's nutritional status potentially impacts on breastmilk composition and the process of lactation itself. The purpose of this scoping review was to synthesize comparative studies that sought to validate various body composition assessment techniques for use in lactating women in the postpartum period. Using the PRISMA-ScR guidelines, a comprehensive, systematic literature search was conducted using Scopus, Web of Science, and PubMed. Eight comparative studies were included in the review, with data from 320 postpartum women. The design methodologies varied substantially across studies, and included a range of simple techniques to advanced multi-compartment models for assessing body composition. The validity and reliability of measurement tools must be considered alongside issues of safety, practicality, and appropriateness to guide the research design when applied to lactating women.

The prevalence of overweight/obesity and its association with household food insecurity among women living with HIV in rural Eswatini

BACKGROUND

Eswatini is currently afflicted by an extremely high prevalence of HIV (27%) and malnutrition (both under-and over-nutrition). While rates of overweight/obesity in the general adult population have been documented, data on overweight/obesity and associated risk factors among women living with HIV (WLHIV) in Eswatini is limited. This study examines the prevalence of overweight/obesity and associated risk factors, with an emphasis on clarifying the association between household food insecurity and overweight/obesity for WLHIV in rural Eswatini.

METHODS

This cross-sectional study was conducted among WLHIV (n = 166) in rural communities of Eswatini. Data were collected using an interviewer-administered survey questionnaire between October and November, 2017. Body Mass Index (BMI) was calculated to determine overweight and obesity among study participants. Women with BMI values of 25 kg/m² or greater were classified as being overweight/obese. Multivariable log-binomial regression models were used to examine associations between household food insecurity and overweight/obesity in our study.

RESULTS

Nearly a third (32.5%) of the women in our study were overweight and almost a quarter were obese (22.9%). We found significant associations between household food insecurity and overweight/obesity, with women who experienced household food insecurity the most being 0.38 times less likely to be overweight/obese compared to those who experienced household food insecurity the least (ARR: 0.38, 95% CI: 0.2-0.71). In our study sample, women who perceived themselves as being in poor health were less likely to be overweight/obese compared to those who perceived themselves as being in good health (ARR: 0.58, 95% CI: 0.39-0.86). We found significant associations between overweight/obesity and alcohol use, with the risk of overweight/obesity nearly 1.5 times higher among women who consumed alcohol compared to those who did not (ARR: 1.49, 95% CI: 1.07-2.05).

CONCLUSIONS

The high prevalence of overweight/obesity among food insecure women in poverty stricken communities may pose significant challenges for nutritional health and HIV management. With an increasing prevalence of overweight/obesity in food insecure households, there is a need to re-evaluate current strategies and develop multi-level targeted interventions that include prevention of excessive weight gain among women, particularly those living with HIV in rural Eswatini. HIV programs could include screening to identify individuals at risk for overweight/obesity in this population, and provide nutrition education for weight management for those individuals.

HIV-Exposed, Uninfected Infants in Uganda Experience Poorer Growth and Body Composition Trajectories than HIV-Unexposed Infants

BACKGROUND

HIV-uninfected infants of HIV-positive women may experience worse growth and health outcomes than infants of HIV-negative women, but this has not been thoroughly investigated under the World Health Organization's most recent recommendations to reduce vertical transmission.

OBJECTIVE

To determine whether HIV-exposed and -uninfected (HEU) infants whose mothers received Option B+ have higher odds of experiencing suboptimal growth trajectories than HIV-unexposed, -uninfected infants, and if this relationship is affected by food insecurity.

DESIGN

Repeated anthropometric measures were taken on 238 infants (HEU = 86) at 1 week and 1, 3, 6, 9, and 12 months after delivery in Gulu, Uganda. Latent class growth mixture modeling was used to develop trajectories for length-for-age z-scores, weight-for-length z-scores, mid-upper arm circumference, sum of skinfolds, and arm fat area. Multinomial logistic models were also built to predict odds of trajectory class membership, controlling for socioeconomic factors.

RESULTS

HEU infants had greater odds of being in the shortest 2 length-for-age z-scores trajectory classes [odds ratio (OR) = 3.80 (1.22-11.82), OR = 8.72 (1.80-42.09)] and higher odds of being in smallest sum of skinfolds trajectory class [OR = 3.85 (1.39-10.59)] vs. unexposed infants. Among HEU infants, increasing food insecurity was associated with lower odds of being in the lowest sum of skinfolds class [OR = 0.86 (0.76-0.98)].

CONCLUSIONS

There continues to be differences in growth patterns by HIV-exposure under the new set of World Health Organization guidelines for the prevention of mother-to-child transmission of HIV and the feeding of HEU infants in low-resource settings that are not readily identified through traditional mixed-effects modeling. Food insecurity was not associated with class membership, but differentially affected adiposity by HIV-exposure status.

Postpartum obesity and weight gain among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women in South Africa

In South Africa, up to 40% of pregnant women are living with human immunodeficiency virus (HIV), and 30-45% are obese. However, little is known about the dual burden of HIV and obesity in the postpartum period. In a cohort of HIV-uninfected and HIV-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa, we examined maternal anthropometry (weight and body mass index [BMI]) from 6 weeks through 12 months postpartum. Using multinomial logistic regression, we estimated associations between baseline sociodemographic, clinical, behavioural, and HIV factors and being overweight-obese I (BMI 25 to <35), or obese II-III (BMI >35), compared with being underweight or normal weight (BMI <25), at 12 months postpartum. Among 877 women, we estimated that 43% of HIV-infected women and 51% of HIV-uninfected women were obese I-III at enrollment into antenatal care, and 51% of women were obese I-III by 12 months postpartum. On average, both HIV-infected and HIV-uninfected women gained, rather than lost, weight between 6 weeks and 12 months postpartum, but HIV-uninfected women gained more weight (3.3 kg vs. 1.7 kg). Women who were obese I-III pre-pregnancy were more likely to gain weight postpartum. In multivariable analyses, HIV-infection status, being married/cohabitating, higher gravidity, and high blood pressure were independently associated with being obese II-III at 12 months postpartum. Obesity during pregnancy is a growing public health concern in low- and middle-income countries, including South Africa. Additional research to understand how obesity and HIV infection affect maternal and child health outcomes is urgently needed.

Household energy insecurity: dimensions and consequences for women, infants and children in low- and middle-income countries

Energy insecurity, the lack of access to adequate, affordable, reliable, acceptable, and clean sources of energy for a healthy and sustainable livelihood, poses a challenge to several households. However, the conceptualization of its dimensions and role in the health outcomes of women, infants, and children in most sub-Saharan African countries have rarely been investigated systematically. We assessed the dimensions and adverse consequences of household energy insecurity (HEINS) in a sample of 347 Ghanaians and 420 Nigerians, with over 80% participation of women. The majority of respondents from Ghana (57%) and Nigeria (80%) had experienced of energy insecurity, at least once in the last four weeks. Following the energy insecurity framework, the experiences of participants were classified into physical, behavioral, and economic dimensions of energy insecurity. The consequences of energy insecurity grouped into psychosocial, nutritional, and disease domains. The development of a national as well as a cross-culturally validated scale that embodies these dimensions and domains will facilitate the assessment of the prevalence, causes, and consequences of HEINS. This will eventually enable the development of interventions and policies to mitigate energy insecurity and unearth modifiable factors that influence deleterious maternal, infant and child health outcomes in low-and middle-income countries.

Quality of Caregiving is Positively Associated With Neurodevelopment During the First Year of Life Among HIV-Exposed Uninfected Children in Uganda

OBJECTIVE

We sought to evaluate whether maternal characteristics and infant developmental milieu were predictive of early cognitive development in HIV-exposed uninfected (HEU) and HIV-unexposed uninfected (HU) infants in Uganda.

DESIGN

Longitudinal pregnancy study.

METHODS

Ugandan women (n = 228) were enrolled into the Postnatal Nutrition and Psychosocial Health Outcomes study with a 2:1 HIV-uninfected: infected ratio. Maternal sociodemographic, perceived social support, and depressive symptomatology were assessed. Infant growth and neurocognitive development were assessed at 6 and 12 months of age using Mullen Scales of Early Learning (MSEL). Caldwell Home Observation for Home Environment was used to gauge caregiving quality. Linear mixed-effects models were built to examine the relationships between maternal and infant characteristics with infant MSEL scores by HIV exposure.

RESULTS

Two MSEL measures were available for 215 mother-child dyads: 140 infants (65%) were HIV-uninfected (HU), 57 (27%) were HIV-exposed uninfected (HEU) with mothers reporting antiretroviral therapy, and 18 (8%) were HEU with mothers not reporting antiretroviral therapy. HEU had lower MSEL Composite (β = -3.94, P = 0.03) and Gross Motor scores (β = -3.41, P = 0.01) than HU. Home Observation for Home Environment total score was positively associated with MSEL Composite (β = 0.81, P = 0.01), Receptive Language (β = 0.59, P = 0.001), and Expressive Language (β = 0.64, P = 0.01) scores.

CONCLUSIONS

HIV exposure is associated with lower infant cognitive development scores. Increasing maternal quality of caregiving may improve early cognitive development.

Adaptation and psychometric evaluation of the breastfeeding self-efficacy scale to assess exclusive breastfeeding

Background

Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess exclusive breastfeeding self-efficacy, but rather self-efficacy for any breastfeeding. Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy.

Methods

We modified and added items from Dennis’ Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1 (n = 239) and 3 (n = 238) months postpartum (clinicaltrials.gov NCT02925429). We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge.

Results

The modification of the original BSES-SF to target exclusive breastfeeding produced 19 items, which were reduced to 9 based on item correlations and factor loadings. Two dimensions of the adapted scale, the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding BSES-EBF emerged: Cognitive and Functional subscales, with alpha coefficients of 0.85 and 0.79 at 3 months postpartum. Predictive and discriminant validity and known group comparisons assessments supported its validity.

Conclusions

This version of the Breastfeeding Self-Efficacy scale, the BSES-EBF Scale, is valid and reliable for measuring exclusive breastfeeding self-efficacy in northern Uganda, and ready for adaptation and validation for clinical and programmatic use elsewhere.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2217-7) contains supplementary material, which is available to authorized users.

HIV infection and increased food insecurity are associated with adverse body composition changes among pregnant and lactating Kenyan women

BACKGROUND/OBJECTIVES

Body composition changes markedly during reproduction. In sub-Saharan Africa, impacts of HIV infection on body composition across pregnancy and lactation in the context of Option B+ antiretroviral therapy are unknown. Therefore, we sought to evaluate the role of HIV infection on body composition during pregnancy and lactation among Kenyan women.

SUBJECTS/METHODS

A cohort of pregnant women (n = 333; 50.5% HIV+, receiving ART) were enrolled at seven clinics in western Kenya. Two prenatal (mean ± SD: 23.6 ± 4.4 and 33.4 ± 2.0 weeks gestation) and three postpartum (6, 14, and 36 weeks) measurements included: individual-level food insecurity, height, weight, fat mass (FM), and fat-free mass (FFM) by bioimpedance analysis (BIA), mid-upper arm circumference (MUAC), and triceps skinfold (TSF), allowing for AMA (arm muscle area) and AFA (arm fat area) derivation. Multivariable longitudinal regression models were used to relate HIV to body composition changes.

RESULTS

In longitudinal models, HIV-infected women had lower weight (ß = -3.0 kg, p = 0.003), fat mass (ß = -1.5 kg, p = 0.02), fat-free mass (ß = -1.5 kg, p = 0.01), TSF (ß = -2.6 mm, p < 0.001), AFA (ß = -3.9 cm³, p < 0.001), and MUAC (ß = -1.0 cm, p = 0.001), but not AMA (p = 0.34), across all observations. Food insecurity was inversely associated with AMA and MUAC postpartum (AMA ß-range = -0.47 to -0.92 cm³; MUAC ß-range = -0.09 to -0.15 cm, all p < 0.05).

CONCLUSIONS

HIV infection was associated with lower weight, fat mass, fat-free mass, TSF, AFA, and MUAC values during pregnancy and lactation, while food insecurity was intermittently associated with body composition. This suggests that pregnant and lactating women living with HIV and food insecurity could benefit from nutritional support.

Measuring exclusive breastfeeding social support: Scale development and validation in Uganda

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather they assess social support for any breastfeeding. Further, they are tailored towards high-income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low-income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes' Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda, at 1 (n = 238) and 3 (n = 237) months post-partum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items and exploratory factor analysis at 1 month post-partum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months post-partum. We then conducted tests of predictive, convergent, and discriminant validity against EBF, self-efficacy, general social support, and depression. The modification of the Hughes' scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional, and Informational, with alpha coefficients of 0.79, 0.85, and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was supported. The EBFSS scale is valid and reliable for measuring EBFSS in northern Uganda and may be of use in other low-income settings to assess determinants of EBF.