Factors Influencing Duration of Breastfeeding: Insights from a Prospective Study of Maternal Health Literacy and Obstetric Practices

Numerous factors concerning early breastfeeding abandonment have been described, including health literacy (HL). This study's objective was to analyze factors related to early breastfeeding abandonment (<6 months). This prospective multicentric study examined the duration of breastfeeding at 6 months postpartum and was conducted in four different regions of Spain from January 2021 to January 2023. A total of 275 women participated in this study, which focused on maternal HL and obstetric practices. A decrease in the breastfeeding rate was observed from hospital discharge (n = 224, 81.5%) to the sixth month postpartum (n = 117, 42.5%). A Cox regression analysis revealed that inadequate HL levels, lack of mobilization during labour, and induced labour were significantly associated with early breastfeeding cessation (p = 0.022, p = 0.019, and p = 0.010, respectively). The results highlight that women with adequate HL had a 32% lower risk of early breastfeeding abandonment. In comparison, mobilization during labour and induction of labour were linked to a 32.4% reduction and a 53.8% increase in this risk, respectively. These findings emphasize the importance of considering obstetric and HL factors when addressing the breastfeeding duration, indicating opportunities for educational and perinatal care interventions.

Effects of a mobile application on breastfeeding maintenance in the first 6 months after birth: Randomised controlled trial (COMLACT study)

PROBLEM

It is necessary to continue promoting breastfeeding rates.

BACKGROUND

Information and communication technologies have significantly impacted healthcare services and are transforming the sector. There is little evidence of the usefulness of mobile applications to support breastfeeding and increase its duration.

AIM

To assess whether mobile application-LactApp® (Barcelona, Spain)-usage compared with standard care increases the 6-month postpartum breastfeeding rate.

METHODS

A multicentre, randomised, controlled clinical trial of parallel groups was conducted. The study was conducted in four public hospitals in Spain from January 2022 to January 2023. 270 Women were randomly assigned to each parallel group. The women in the intervention group received free access to the mobile application LactApp®, which provides personalised and convenient support to women about BF. Women in the control group received standard care, which included individual counselling about the benefits of maintaining BF for the first 6 months of the baby's life.

FINDINGS

The rate of breastfeeding abandonment at 15 days was 6.4 % in the control group vs 0.0 % in the intervention group (p = 0.105). LactApp® usage did not increase the 6-month postpartum breastfeeding rate compared with standard care (CG = 41.6% vs. IG = 43.6 %; p = 0.826).

DISCUSSION

Further studies must explore how technologies can help improve long-term breastfeeding maintenance. The mobile app seems to reduce early weaning in the first 15 days slightly.

CONCLUSION

Mobile application usage did not increase the breastfeeding rate compared with standard practice but may reduce breastfeeding abandonment in the first 2 weeks postpartum.

Predictors of childbirth experience: Prospective observational study in eastern Spain

BACKGROUND

In recent years, birth experience has been highlighted by national and international organisations as a relevant value in measuring maternal health care quality. According to a standardised tool, we aimed to assess which clinical indicators had the most significant influence on the birth experience.

METHODS

This prospective observational study was carried out in fourteen hospitals in eastern Spain. 749 women consented to the collection of birth variables at discharge, and subsequently, at 1-4 months, data were collected on the birth experience as measured by the Spanish version of the Childbirth Experience Questionnaire. Next, a linear regression analysis was performed to determine which clinical birth indicators greatly influence the birth experience measure.

RESULT

The study sample (n = 749) was predominantly Spanish and primipara, with 19.5% vaginal births. The predictors that emerged in the linear regression model were to have a birth companion (B = 0.250, p = 0.028), drink fluids during labour (B = 0.249, p < 0.001), have early skin-to-skin contact (B = 0.213, p < 0.001) and being transferred to a specialised room for the second stage of labour (B = 0.098, p = 0.016). The episiotomy (B = -0.100, p < 0.015) and having an operative birth (B = -0.128, p < 0.008) showed a negative influence.

CONCLUSION

Our study supports that intrapartum interventions recommended according to clinical practice guidelines positively influence the mother's birth experience. Episiotomy and operative birth should not be used routinely as they negatively influence the birth experience.

Effect of Mobile-Based Counselling on Breastfeeding in Spain: A Randomized Controlled Trial Protocol (COMLACT Study)

PURPOSE

The primary aim of this study is to determine the influence of an intervention in women based on a free mobile application (LactApp^®, Barcelona, Spain) in maintaining breastfeeding (BF) up to 6 months postpartum. The secondary aim is to assess the effect of health literacy (HL) on breastfeeding duration.

METHODS

A multicenter, randomized controlled clinical trial of parallel groups will be carried out. Women will be randomly assigned to each of the parallel groups. In the control group, usual clinical practice will be followed from the third trimester of pregnancy to promote BF. In the intervention group, and in addition to usual clinical practice, the women will use a free mobile application (LactApp^®) from the third trimester to 6 months postpartum. The type of BF at birth, at 15 days and at 3 and 6 months postpartum and the causes of cessation of BF in both groups will be monitored. The hypothesis will be tested using inferential analysis, considering an alpha of 5%. The study protocol was approved by the Clinical Research Ethics Committee of Hospital de la Ribera (Alzira, Valencia, Spain) in February 2021. A per protocol analysis and an intention-to-treat analysis will be performed.

DISCUSSION

This study will identify the influence of a mobile application on improving BF rates. If the application proves effective, we will have a tool with free information available to any user at any time of day, which may be complemented by normal clinical practice and be integrated into our health care system.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05432700.

Development and Validation of the Breastfeeding Literacy Assessment Instrument (BLAI) for Obstetric Women

BACKGROUND

Despite international efforts to protect and promote exclusive breastfeeding (EBF) for infants up to six months of age, global rates of EBF continue to fall short of the targets proposed by the WHO for 2025. Previous studies have shown a relationship between the level of health literacy and the duration of EBF, although this relationship was not determinant, probably due to the use of a generic health literacy questionnaire. Therefore, this study aims to design and validate the first specific breastfeeding literacy instrument.

METHODS

A Breastfeeding Literacy instrument was developed. Content validation was carried out by a group of 10 experts in health literacy, breastfeeding or instrument validation, obtaining a Content Validity index in Scale (S-CVI/Ave) of 0.912. A multicentre cross-sectional study was carried out in three Spanish hospitals to determine the psychometric properties (construct validity and internal consistency). The questionnaire was administered to 204 women during the clinical puerperium.

RESULTS

The Kaiser-Meier-Oklin Test (KMO = 0.924) and Bartlett's Test of Sphericity (X² = 3119.861; p ≤ 0.001) confirmed the feasibility of the Exploratory Factor Analysis, which explained 60.54% of the variance with four factors.

CONCLUSIONS

The Breastfeeding Literacy Assessment Instrument (BLAI) consisting of 26 items was validated.

Is Early Initiation of Maternal Lactation a Significant Determinant for Continuing Exclusive Breastfeeding up to 6 Months?

BACKGROUND

The World Health Organization (WHO) recommends early initiation of breastfeeding (EIBF) within the first hour after birth. However, certain perinatal factors, namely caesarean section, may prevent this goal from being achieved. The aim of our study was to examine the relationship between EIBF (maternal lactation in the first hours and degree of latching before hospital discharge) and the maintenance of exclusive breastfeeding (MBF) up to the recommended 6 months of age (as advocated by the WHO).

METHODS

This observational, retrospective cohort study included a random sample of all births between 2018 and 2019, characterising the moment of breastfeeding initiation after birth and the infant's level of breast latch (measured by LATCH assessment tool) prior to hospital discharge. Data were collected from electronic medical records and from follow-up health checks of infants up to 6 months postpartum.

RESULTS

We included 342 women and their newborns. EIBF occurred most often after vaginal (p < 0.001) and spontaneous births with spontaneous amniorrhexis (p = 0.002). LATCH score <9 points was associated with a 1.4-fold relative risk of abandoning MBF (95%CI: 1.2-1.7) compared with a score of 9-10 points.

CONCLUSIONS

Although we were unable to find a significant association between EIBF in the first 2 h after birth and MBF at 6 months postpartum, low LATCH scores prior to discharge were associated with low MBF, indicating the importance of reinforcing the education and preparation efforts of mothers in the first days after delivery, prior to the establishment of an infant feeding routine upon returning home.

Obstetric-Neonatal Care during Birth and Postpartum in Symptomatic and Asymptomatic Women Infected with SARS-CoV-2: A Retrospective Multicenter Study

This study analyses the obstetric−neonatal outcomes of women in labour with symptomatic and asymptomatic COVID-19. A retrospective, multicenter, observational study was carried out between 1 March 2020 and 28 February 2021 in eight public hospitals in the Valencian community (Spain). The chi-squared test compared the obstetric−neonatal outcomes and general care for symptomatic and asymptomatic women. In total, 11,883 births were assisted in participating centers, with 10.9 per 1000 maternities (n = 130) infected with SARS-CoV-2. The 20.8% were symptomatic and had more complications both upon admission (p = 0.042) and during puerperium (p = 0.042), as well as transfer to the intensive care unit (ICU). The percentage of admission to the Neonatal Intensive Care Unit (NICU) was greater among offspring of symptomatic women compared to infants born of asymptomatic women (p < 0.001). Compared with asymptomatic women, those with symptoms underwent less labour companionship (p = 0.028), less early skin-to-skin contact (p = 0.029) and greater mother−infant separation (p = 0.005). The overall maternal mortality rate was 0.8%. No vertical transmission was recorded. In conclusion, symptomatic infected women are at increased risk of lack of labour companionship, mother−infant separation, and admission to the ICU, as well as to have preterm births and for NICU admissions.

Influence of Health Literacy on Maintenance of Exclusive Breastfeeding at 6 Months Postpartum: A Multicentre Study

Background: International organizations recommend initiating breastfeeding within the first hour of life and maintaining exclusive breastfeeding for the first 6 months. However, worldwide rates of exclusive breastfeeding for 6-month-old infants is far from meeting the goal proposed by the World Health Organization, which is to reach a minimum of 50% of infants. Education is one of the factors affecting the initiation and continuation of breastfeeding, and incidentally, it is also related to lower health literacy. This study explored the influence of health literacy on maintenance of exclusive breastfeeding at 6 months postpartum. Methods: A longitudinal multicenter study with 343 women were recruited between January 2019 and January 2020. The first questionnaire was held during the puerperium (24−48 h) with mothers practicing exclusive breastfeeding, with whom 6-month postpartum breastfeeding follow-up was performed. Socio-demographic, clinical and obstetric variables were collected. Breastfeeding efficiency was assessed using the LATCH breastfeeding assessment tool. The health literacy level was evaluated by the Newest Vital Sign screening tool. A multivariate logistic regression model was used to detect protective factors for early exclusive breastfeeding cessation. Results: One third of the women continued exclusive breastfeeding at 6 months postpartum. Approximately half the participants had a low or inadequate health literacy level. An adequate health literacy level, a high LATCH breastfeeding assessment tool score (>9 points) and being married were the protective factors against exclusive breastfeeding cessation at 6 months postpartum. Conclusion: Health literacy levels are closely related to maintaining exclusive breastfeeding and act as a protective factor against early cessation. A specific instrument is needed to measure the lack of “literacy in breastfeeding”, in order to verify the relationship between health literacy and maintenance of exclusive breastfeeding.

Health literacy and its relation to continuing with breastfeeding at six months post-partum in a sample of Spanish women

AIM

To explore the relation between health literacy (HL) and continuing breastfeeding (BF) at 6 months post-partum.

DESIGN

Observational, longitudinal and prospective study between December 2018-May 2019. The STROBE checklist was used.

METHODS

114 mother/baby pairings from a Spanish Hospital were included. Mothers' health literacy was studied with the Newest Vital Sign and Short Assessment of Health Literacy for Spanish Adults 50 (SAHLSA-50). Before hospital discharge, BF efficiency was studied using the LATCH BF score and BF continuity was followed for 6 months. Survival analysis and Cox regression were done.

RESULTS

Health literacy levels and BF effectiveness were adequate before hospital discharge. At 6 months post-partum, less than half the sample still exclusively breastfed. The main reason for early exclusive BF cessation was lower than the recommended newborn weight gain. The HL level acted as a protective factor against abandonment of BF.

Health literacy of pregnant women and duration of breastfeeding maintenance: A feasibility study

AIMS

Research the association between health literacy (HL) and exclusive breastfeeding at 4-months postpartum.

BACKGROUND

Despite the benefits of breastfeeding (BF), its rates are low worldwide. Among the reasons for abandonment is the level of maternal education. Maternal education has been associated with HL, but evidence between HL and BF maintenance is limited.

DESIGN

A cross-sectional study.

METHODS

The sample compromised 229 nursing mothers recruited from January 2018 to the end of December 2018 at Spain by systematic sampling method. Women were interviewed postpartum on parameters associated with the start and continuation of BF up to 4 months postpartum. Multivariate logistic regression models to explain exposure variables and exclusive BF cessation at 4 months.

RESULTS

Approximately 10% of the participants had inadequate HL. Factors associated with early cessation of exclusive BF at 4 months in the multivariate model adjusted using a stepwise variable selection process based on a likelihood ratio test were civil status, risk of pregnancy, type of delivery, limited or inadequate level of HL, and LATCH score at discharge, with an 85.6% area under the ROC curve.

CONCLUSIONS

Our study offers preliminary evidence regarding the hitherto inconsistent relation between HL and early cessation exclusive BF at 4 months, supporting the conduct of further studies with larger sample sizes and greater statistical power. Such studies are warranted before endorsing HL-based interventions aiming to mitigate early cessation exclusive BF.

IMPACT

Low or inadequate HL is linked to multiple poor health and clinical outcomes. We investigated the prevalence of exclusive BF at 4 months postpartum, and the impact of HL in maintaining optimal exclusive BF practices. Limited or inadequate HL was one of the factors associated with early cessation of exclusive BF in the multivariate regression model, although further research is needed.

THIRD TRIMESTER ULTRASOUND SCAN COMBINED WITH A CLINICAL METHOD FOR ACCURATE BIRTHWEIGHT PREDICTION AT TERM: A COHORT STUDY IN SPAIN

OBJECTIVE

To develop and assess an equation based on maternal clinical parameters and third trimester ultrasound biometry (combined method), and compare it with ultrasound-estimated foetal weight (EFW) calculated using the Hadlock 2 formula.

METHODS

Cohort study. A total of 1,224 women with singleton pregnancies who had undergone foetal ultrasound scanning (USS) at 34 weeks were recruited. The study was conducted at a reference center in Valencia (Spain) between January and December 2016. A gestation-adjusted projection (GAP) method was applied to estimated foetal-weight-for-gestational-age by foetal gender at delivery (EFWa). A multivariate regression was created to estimate foetal weight at term (EFWmr) using anthropometric, demographic, ultrasonographic and obstetric-neonatal variables. EFWa and EFWmr were calculated and compared with actual birthweight.

RESULTS

The proportion for EFWmr within <10% of actual birthweight was greater than EFWa (82% vs. 65%, p<0.001). The mean relative error in foetal-weight predictions by using EFWmr was reduced from 6.7% to 0.9% (difference 5.7% 95% CI: 5.4 to 6.0) paired t-test p<0.001, significantly improving the accuracy attainable with USS. The EFWmr outperformed the GAP method in predicting birthweight, within 1% relative error. For new- borns <2,500 g, the proportion of estimates within <10% of the actual birthweight for the EFWmr was greater than that of the EFWa (20.4 vs. 16.3%, p=0.005). For babies with normal birthweight (2,500-3,999 g), EFWmr was a better predictor of birthweight than EFWa (84.5 vs. 65.7%, p<0.001).

CONCLUSIONS

Mathematical modelling to predict birthweight improves third trimester routine ultrasound measurement to estimate neonatal weight at term.

Analysis of Caesarean Section Rates Using the Robson Classification System at a University Hospital in Spain

Background: The WHO recommends the use of the Robson ten-group classification system (RTGCS) as an effective monitoring and analysis tool to assess the use of caesarean sections (CS). The present study aimed to conduct an analysis of births using the RTGCS in La Ribera University Hospital over nine years and to assess the levels and trends of CS births. Methods: Retrospective study between January 1, 2010, and December 31, 2018. All eligible women were allocated in RTGCS to determine the absolute and relative contribution made by each group to the overall CS rate; linear regression and weighted least squares regression analysis were used to analyze trends over time. The risk of CS of women with induced versus spontaneous onset of labor was calculated with an odds ratio (OR) with a 95% CI. Results: 16,506 women gave birth during the study period, 19% of them by CS. Overall, 20.4% of women were in group 1 (nulliparous, singleton cephalic, term, spontaneous labor), 29.4% in group 2 (nulliparous, singleton cephalic, term, induced labor or caesarean before labor), and 12.8% in group 4 (multiparous, singleton cephalic, term, induced or caesarean delivery before labor) made the most significant contributions to the overall rate of CS; Conclusions: In our study, Robson Groups 1, 2, and 4, were identified as the main contributors to the hospital’s overall CS rate. The RTGCS provides an easy way of collecting information about the CS rate, is a valuable clinical method that allows standardized comparison of data, and time point, and identifies the groups driving changes in CS rates.

Changes in health sciences students' perception of obstetric violence after an educational intervention

BACKGROUND

Obstetric violence is a type of gender-based violence that is presented structurally. This type of violence has physical and psychological consequences for both the women who experience it and health professionals. The World Health Organization adds that health professionals need training to ensure that pregnant women are treated with compassion and dignity.

OBJECTIVES

The objective of the study was to evaluate health sciences students' perception of obstetric violence and to identify possible changes after an educational intervention.

DESIGN

A pre-post quasi-experimental study was carried out between January and June 2019.

SETTINGS AND PARTICIPANTS

Students of medicine and nursing from Jaume I University (Universitat Jaume I) (Spain).

METHODS

An ad hoc scale comprising 33 items was designed to measure the students' perceptions. In addition, sociodemographic and control variables were collected. Descriptive analyses of the sample and the scale were carried out, and a bivariate analysis was performed.

RESULTS

Of the students surveyed, 89.7% were women, and the majority was nursing students. Of the 33 items, 28 (84.84%) showed statistically significant changes in the pre-post-intervention measurement. Twenty-five of the 33 items (75.75%) showed a relationship with the sociodemographic variables of gender, field, course and ever having been pregnant.

CONCLUSION

This study shows the change in health sciences students' perceptions of obstetric violence after an educational intervention. In addition, the normalization of this type of violence was observed with the progression of training and with personal obstetric experience.

Determinants of seasonal influenza vaccination in pregnant women in Valencia, Spain

BACKGROUND

In most countries the coverage of seasonal influenza vaccination in pregnant women is low. We investigated the acceptance, reasons for rejection and professional involvement related to vaccine information in pregnant women in Valencia, Spain.

METHODS

Observational retrospective study in 200 pregnant women, 100 vaccinated and 100 unvaccinated, were interviewed during the 2014/2015 vaccination campaign. Electronic medical records, immunization registry and telephone interviews were used to determine reasons for vaccination and immunization rejection.

RESULTS

40.5% of pregnant women in the health department were vaccinated. The midwife was identified as source of information for 89% of women. The vaccine was rejected due to low perceptions of risk of influenza infection (23%), lack of information (19%), considering the vaccine as superfluous (16%), close proximity of delivery date (13%) and fear of side effects (12%).

CONCLUSION

Pregnant women in Spain declined to be vaccinated due to under-estimation of the risk of contracting or being harmed by influenza, and lack of information. Interventions aiming to optimize vaccination coverage should include information addressing the safety and effectiveness of the current vaccine together with improved professional training and motivation.

[Relationship between maternal body mass index, gestational weight gain and birth weight; prospective study in a health department]

OBJECTIVES

To ascertain the relationship between maternal weight gain and birth weight, in every pre-gestational body mass index (BMI) category.

MATERIAL AND METHODS

A two-stage sampling observational and descriptive study was carried out in the health department of La Ribera (Valencia, Spain). The sample was divided into four groups according to pre-gestational BMI.

FINDINGS

140 pregnant women were studied. We observed rising pre-gestational weight gain (PWG) and trimestral gradients. There was a higher increase from the first to the second trimester than from the second to the third trimester in every pre-gestational BMI category. According to the international recommendations of Institute of Medicine, 16.4% of women had an inferior gestational weight gain (GWG), 38.6% were within the recommendations and 45% were above them. The pre-gestational BMI, categorized by the WHO, is related to the birth weight, showing a statistical significance (F=6.636 and and p<0.001). Obese mothers with a higher weight gain than the recommended have newborns with higher birth weight (4,353 ± 821.924 g) and, underweight mothers with a lower weight gain than the recommended, have newborns with lower birth weights (2,900 ± 381.83 g) than the rest of the groups.

CONCLUSIONS

The absolute gestational weight gain did not show a statistical significance compared to the birthweight in any of the pre-gestational BMI categories and, as an isolated indicator, is not an added value to the prenatal quality control.

Can we improve the birth weight prediction? The effect of normal BMI using a multivariate model

OBJECTIVE

The construction of a predictive model that improves the estimation of the fetal weight (EFW).

STUDY DESIGN

a comparative, descriptive study. One hundred forty pregnant women were recruited at two-stage sample in health department in Spain. They were classified in four groups depending on the pre-gestational BMI. Fetal weight at term was estimated by ultrasound at 33-35 weeks (EFW40w) by one gynecologist. A regression model was created with the variables that reacted to the newborn's weight, symphysis-fundal height (SFH), EFW40w, gestational age (GA), ferritin level and cigarettes smoked.

RESULTS

A multivariate model was created for the NW group to estimate the fetal weight (EFWme), resulting in R2=0.727 (p<0.001). The differences of the averages obtained between EFW40w and EFWme, with the newborn's weight were significant (p<0.001). EFWme underestimates birth weight by 0.07 g (mean error 0.53%), and EFW40w overestimates it by 300.89 g (mean error 10.12%). In order to evaluate the predictive model and verify the predictions we used the Bland-Altman analysis. The average error in estimating the birth weight with EFWme was 1.94% underestimating the result, whereas the ultrasound error overestimated the result 10.93%.

CONCLUSION

The multivariate model created for the NW group improves the accuracy of the ultrasound.