Factors Associated with Exclusive Breastfeeding during Admission to a BFHI Hospital A Cross‐ Sectional Study in Spain

1. Introduction

The World Health Organization (WHO) recognizes breastfeeding (BF) as the optimal nourishment for infants and recommends that children commence breastfeeding within the first hour of birth and be exclusively breastfed for the initial 6 months of life. Subsequently, they should begin consuming safe and suitable complementary foods while continuing breastfeeding for up to two years or beyond [1]. BF not only provides nutritional benefits but also confers psychological and emotional advantages to both the newborn (NB) and the mother [2,3,4,5,6]. Additionally, it contributes to the economic and social well-being of families by promoting better infant health outcomes [7,8].

According to the latest National Health Survey in Spain from 2017, breastfeeding was the most prevalent feeding method for babies during the first 6 weeks (73.9%), but it decreased to 63.9% by 3 months. By 6 months, 41.6% of babies were being fed with formula milk, thereby relegating breastfeeding to a secondary position (39%) [9]. This trend is associated with various sociodemographic, clinical, and psychological factors, including maternal insecurity and doubts during the breastfeeding process, as well as the absence of a supportive environment [10,11]. The sociolaboral and cultural shifts of recent decades have negatively impacted breastfeeding rates, with maternal return to work being a primary cause of breastfeeding cessation [12,13,14]. Insufficient maternal knowledge about breastfeeding is also a contributing factor to early breastfeeding discontinuation [15,16]. This may partly stem from the lack of or inadequate dissemination of information by nursing staff, which in turn can lead to premature breastfeeding cessation [17,18,19]. Furthermore, nursing staff providing care to women in the early postpartum days may also have insufficient knowledge about breastfeeding [20].

Currently, healthcare services are beginning to establish breastfeeding support groups and programs [21,22]. The Initiative for the Humanization of Birth and Breastfeeding Care (BFHI) launched by the WHO and UNICEF, aims to encourage hospitals, health services, and particularly maternity wards, to adopt practices that protect, promote, and support exclusive breastfeeding from birth [23,24,25]. One of the standards for continuous improvement in these hospitals is that at least 75% of mothers should practice exclusive breastfeeding during hospitalization [26]. Our hospital has been part of the IHAN network since 2015, in phase 2D since 2020. Hospitals in phase 2D are required to conduct self-assessments to identify areas for improvement in factors that may influence exclusive breastfeeding [27]. Our objective was to determine which factors related to mothers could influence the degree of exclusive breastfeeding during hospitalization, as well as to assess breastfeeding mothers’ attitudes towards breastfeeding.

2. Materials and Methods

Study Design

The study was conducted from June 2023 to February 2024 in Galicia, a region in northwest Spain with a population of 2.7 million inhabitants, where breastfeeding abandonment stands at 58.8% within the first year of infant life [28]. To address the study objectives, a multicenter cross-sectional study was undertaken in the healthcare area of Santiago de Compostela, covering a population of 450,000. In 2023, there were 1948 births in this healthcare area. Five Primary Health Centers (PHCs) were selected for the study through intentional sampling. These comprised 2 urban PHCs (Concepción Arenal PHC and Vite PHC) and 3 rural PHCs (Boqueixón PHC, O Pino PHC, and Touro PHC).

Sample Selection and Procedure

To achieve the study objectives, women aged 18 or older, mothers of infants under 12 months who had chosen breastfeeding or started but switched to formula feeding before 6 months, and who gave birth at the clinical hospital of Santiago de Compostela, were randomly selected from the participating HCs. Participation was offered during contact with the pediatric nurse. Mothers of children older than 12 months or those opting for formula feeding were excluded.

Data were collected using a specific data collection notebook comprising sections on sociodemographic variables of women, variables related to children, and variables related to breastfeeding, including type of breastfeeding during admission and discharge, support and information on breastfeeding during admission and follow-up in the HC, and family support for breastfeeding.

Additionally, the Iowa Infant Feeding Attitude Scale (IIFAS) was employed to gauge maternal attitudes toward feeding their baby, validated for the Spanish population [29]. The IIFAS-s scale, containing 9 items, was administered either on paper or online via a QR code, voluntarily and anonymously, through the nurse or midwife.

Ethical and Legal Considerations

The study was approved by the Territorial Committee of Ethics in Research of Santiago-Lugo (registration code: 2023/199), ensuring informed consent from participants.

Variables and Statistical Analysis

Sociodemographic variables (mother’s age, child’s age, educational level, economic status, type of delivery, social and family support, return to work) and hospitalization-related variables (previous breastfeeding experience, skin-to-skin contact, child’s admission, information received about breastfeeding, type of breastfeeding during admission) were collected.

Qualitative variables were presented as numbers and percentages, and quantitative variables as mean and standard deviation or median and interquartile range.

Bivariate analyses explored the relationship between maternal characteristics or hospitalization-related variables and those measured through the IIFAS-s. Logistic regression models calculated crude and adjusted odds ratios (ORs), with confounding variables included based on significance in the bivariate analysis (p<0.1). All analyses adhered to a 95% confidence level and significance at p<0.05.

3. Results

Sample Description

A total of 64 women were studied, with a participation rate of 100%. All women offered participation in the study accepted. The mean age of the mothers was 36.6 ± 4.1 years, with 45 (70.3%) being ≥ 35 years old. The mean age of the children was 6.3 ± 3.6 months.

Nine (14.1%) newborns were admitted to the hospital’s neonatology unit at the time of birth. Further characteristics of the participating women can be seen in Table 1.

Regarding the assistance received from professionals during their hospitalization, 41 (64.1%) women consider it good, while 23 (35.9%) consider it improvable. Regarding the information received during hospitalization about breastfeeding, 36 women (56.3%) consider it good, while 28 (43.7%) consider it improvable.

30 (46.9%) of the women had received information about breastfeeding at their HC from the pediatric nurse, 20 (31.3%) considered they didn’t need it, and 14 (21.9%) did not receive any information at their HC. Regarding the level of satisfaction received, 5 (7.8%) women declared being not satisfied at all, 4 (6.3%) declared being somewhat satisfied, 6 (9.4%) fairly satisfied, and 15 (23.4%) very satisfied.

Despite receiving information about breastfeeding in the hospital and HC, 31 (48.4%) had contacted breastfeeding support groups/counseling, and 58 (90.6%) declared having good family support for breastfeeding.

Attitudes Towards Breastfeeding

Table 2 shows women’s attitudes towards breastfeeding through the IIFAS-s. The overall score (mean ± standard deviation) of the test was 36.95 ± 5.17. Items 5 and 6 had the lowest and highest scores, respectively.

Women whose newborns do not use pacifiers show higher scores on the IIFAS-s, indicating a more favorable attitude towards breastfeeding. Conversely, no differences are observed between women’s demographic variables and the mean scores of the IIFAS-s.

Factors Influencing Exclusive Breastfeeding during Hospitalization

The following table (Table 4) shows factors associated with the woman or certain hospitalization characteristics that may influence the implementation of exclusive breastfeeding during hospitalization. It can be observed that having previous children, prior experience with breastfeeding, and the newborn not being admitted to the neonatology unit increase the likelihood of exclusive breastfeeding during admission.

When adjusting the odds ratio (OR) associated with these variables for possible confounding variables, having previous children and prior experience with breastfeeding remain associated with exclusive breastfeeding during hospitalization.

4. Discussion

To our knowledge, this is the first study to evaluate factors associated with exclusive breastfeeding, especially during hospital admission. Our results show that factors such as having previous children or prior experience with breastfeeding increase the likelihood of exclusive breastfeeding during subsequent births. Studies have linked multiparity with a positive association with breastfeeding duration. Additionally, other studies have confirmed that previous breastfeeding experiences, unsuccessful attempts at breastfeeding, and the inability to breastfeed the first child have been associated with lower breastfeeding initiation rates in subsequent children.

The results of our study show a percentage of women exclusively breastfeeding during admission of 73.4%, with 75% being the sentinel indicator for the rate of exclusive breastfeeding at discharge for IHAN accreditation. This study identified that the number of women breastfeeding exclusively post-discharge increased by seven respondents (10% more), possibly explained by the role of the primary care pediatric nurse or the mother’s contact with breastfeeding support groups. Evidence demonstrates that interventions to support breastfeeding in primary care have a positive effect on breastfeeding rates, duration, or exclusive maintenance. A systematic review by Balogun et al. asserts that the rate of breastfeeding initiation improves among women who received breastfeeding education and support led by healthcare professionals compared to those who received standard care.

Skin-to-skin contact, performed by 81.3% of participants, appears to be beneficial for breastfeeding in the short and long term, as shown in a systematic review that observed improvements in both breastfeeding status and duration. Regarding factors influencing exclusive breastfeeding during hospitalization, we observed that if the child is not admitted to the neonatal unit, there is an increased probability of establishing exclusive breastfeeding during admission, as well as having previous experience with exclusive breastfeeding. This is consistent with studies demonstrating that rooming-in mother/child in neonatal units increases the probability of successful exclusive breastfeeding.

The total score of the IIFAS-s scale in our study does not differ from available evidence, where it can be observed that women present positive attitudes towards exclusive breastfeeding, especially during pregnancy and hospital admission. Regarding the results extracted from the IIFAS-s scale, it can be observed that mothers’ attitudes towards breastfeeding through the IIFAS-s scale do not show statistically significant differences by demographic factor. Concerning pacifier use, systematically questioned since numerous studies demonstrate that pacifier use is related to a lower rate of exclusive breastfeeding, although some demonstrate the opposite. Our data reflect that women whose newborns do not use pacifiers show higher scores on the IIFAS-s, indicating a more favorable attitude towards breastfeeding. Additionally, it is noteworthy that only 50% of surveyed mothers report that breastfed babies are healthier than formula-fed babies, when no literature has been found to demonstrate otherwise.

As strengths of this study, we would like to highlight the survey as a cost-effective and efficient tool for obtaining data: its accessibility, ease of use, and availability in both paper and QR code formats have allowed us to reach the target population in a short period. Additionally, the IIFAS-s scale is considered a good predictor of attitudes towards initiating exclusive breastfeeding, although not as a predictor of maintaining exclusive breastfeeding during hospital admission. By using these two methods in this study, we consider that we used the appropriate tool to obtain a representative picture of the attitudes and characteristics of our group.

Regarding the study’s limitations, it is worth mentioning the inherent limitations of a cross-sectional design, although our results serve to generate hypotheses on the topic of work. On the other hand, the achieved sample size may not be sufficient to provide high power to our results. It would be necessary to carry out studies with prospective designs to corroborate our results.

5. Conclusions

There is still a long way to go in promoting breastfeeding and maintaining it. Mothers must be supported by the healthcare personnel who attend to them at all times and all under the same consensus and protocol, avoiding providing contradictory information. Despite this, the fact that the increase in exclusive breastfeeding occurs post-discharge indicates that good work is being done by primary care pediatric nursing staff. It is important to identify the factors that contribute to increasing the probability that mothers choose exclusive breastfeeding. We must guide our training efforts to these factors.