Importance Assigned to Breastfeeding by Spanish Pregnant Women and Associated Factors: A Survey-Based Multivariate Linear Correlation Study

Ci a ion: A nedillo-Sánchez, S.; Su o-Abouza, J.A.; Ca mona-Rod íguez, M.Á.; Mo illa-Rome o-de-la-Osa, R.; A nedillo-Sánchez, I. Impo ance Assigned o B eas eeding by Spanish P egnan Women and Associa ed Fac o s: A Su ey-Based Mul i a ia e Linea Co ela ion S udy. Nu ien s 2024,16, 2116. h ps://doi.o g/ 10.3390/nu16132116 Academic Edi o : Kingsley E. Agho Recei ed: 6 June 2024 Re ised: 28 June 2024 Accep ed: 30 June 2024 Published: 2 July 2024 Copy igh : © 2024 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/). nu ien s A icle Impo ance Assigned o B eas eeding by Spanish P egnan Women and Associa ed Fac o s: A Su ey-Based Mul i a ia e Linea Co ela ion S udy Soco o A nedillo-Sánchez 1,2,3 , Jose An onio Su o-Abouza 1, Miguel Ángel Ca mona-Rod íguez 1, Rubén Mo illa-Rome o-de-la-Osa 1,3,4,* and Inmaculada A nedillo-Sánchez 5 1Depa men o Nu sing, Facul y o Nu sing, Physio he apy and Podia y, Uni e sidad de Se illa, 41009 Se ille, Spain; [email p o ec ed] (S.A.-S.); [email p o ec ed] (J.A.S.-A.); migca [email p o ec ed] (M.Á.C.-R.) 2Midwi e y T aining Uni , Depa men o Ma e no-Fe al Medicine, Gene ics and Rep oduc ion, Hospi al Uni e si a io Vi gen del Rocio, 41013 Se ille, Spain 3Ins i u e o Biomedicine o Se ille, Hospi al Uni e si a io Vi gen del Rocío/Consejo Supe io de In es igaciones Cien í icas/Uni e sidad de Se illa, 41013 Se ille, Spain 4Cen o de In es igación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Mad id, Spain 5School o Compu e Science & S a is ics, O’Reilly Ins i u e, T ini y College Dublin, College G een 2, D02 PN40 Dublin, I eland; [email p o ec ed] *Co espondence: [email p o ec ed] Abs ac : B eas eeding educa ion, ac oss all disciplines, is o en inconsis en and lacking in ex- pe ise and con idence. Howe e , ecommenda ions om heal h p o essionals, he sociocul u al en i onmen , and p e ious knowledge and expe iences signi ican ly in luence women’s decision o b eas eed. This s udy aimed o iden i y ac o s ha p omo e he assignmen o g ea e impo ance o b eas eeding and associa ed p ac ical bene i s. This e ospec i e c oss-sec ional s udy included 276 pa icipan s who comple ed a sel -adminis e ed ques ionnai e. Desc ip i e and bi a ia e analyses we e pe o med, and mul i a ia e linea models we e applied o iden i y ac o s in luencing he impo ance assigned o b eas eeding. Mos pa icipan s we e ma ied o in a ela ionship, we e na i e Spania ds, had seconda y o highe educa ion, and had an a e age age o 32.6 yea s. Se en y pe cen me he physical ac i i y ecommenda ions, and 91% el com o able wi h hei body image du ing p egnancy. The impo ance assigned o b eas eeding was high ac oss a ious aspec s, excep o pos pa um weigh loss and body image. G oup p ena al ca e was only signi ican ly associa ed wi h he impo ance assigned o he b eas eeding echnique (how o b eas eed). The obesogenic en i onmen and he impo ance assigned o nu i ional aspec s and physical ac i i y also u ned ou o be p edic o s, al hough no o all models. In ou egion, he educa ional s a egy o an ena al ca e g oups could con ain gaps ega ding he mo he ’s heal h, which should be add essed in he u u e o imp o e esul s ega ding he ini ia ion and con inua ion o b eas eeding. Keywo ds: b eas eeding; an ena al ca e; heal h educa ion; ma e nal heal h; obse a ional s udy 1. In oduc ion P egnancy is a key oppo uni y o each women wi h essen ial se ices o hei own heal h and ha o hei unbo n child [ 1 ]. An ena al ca e (ANC) is a ca e ul, sys ema ic assessmen and ollow-up o a p egnan women ha includes educa ion, counselling, sc eening, and ea men o assu e he bes possible heal h o he mo he and he child [ 2 ]. An ena al ca e (ANC) is c ucial o p o ec ing he heal h o mo he s and child en [3]. Educa ion cons i u es a i al aspec o p ena al ca e, especially o p imig a id women. P egnan women should be o e ed in o ma ion based on he cu en a ailable e idence, oge he wi h suppo o enable hem o make in o med decisions abou hei ca e [ 4 ]. ANC o e s an essen ial se ing o dialogue be ween p egnan women and heal hca e Nu ien s 2024,16, 2116. h ps://doi.o g/10.3390/nu16132116 h ps://www.mdpi.com/jou nal/nu ien s Nu ien s 2024,16, 2116 2 o 13 p o ide s (HCP) conce ning heal h beha io s. HCP should o e in o ma ion on pos pa um and newbo n ca e, b eas eeding p ac ices, signs o ala m, and he app op ia e cou se o ac ion [ 5 ]. This educa ion impa ed du ing he an ena al pe iod a ies ex ensi ely in e ms o deli e y me hods and con en . I may enclose s uc u ed an ena al classes conduc ed in g oup o indi idual se ings [6]. An essen ial pa o ANC educa ion is b eas eeding (BF) educa ion. BF is widely acknowledged as he op imal nu i ional sou ce o in an s [ 7 ]. I has been associa ed wi h enhanced child heal h, ma e nal heal h, and mo he –in an bonding [ 8 ]. WHO and UNICEF ecommend ha BF be ini ia ed wi hin he i s hou a e bi h and con inued exclusi ely o he i s six mon hs o li e and wi h sa e and adequa e complemen a y oods o up o 2 yea s o beyond [ 9 ]. The Ame ican College o Obs e icians and Gynecologis s suppo s b eas eeding due o i s bene i s o he heal h o he mo he and child, conside ing i a public heal h asse due o he heal h bene i s i b ings o he mo he and child, wi h minimal con aindica ions o his p ac ice [10]. An ena al BF educa ion is cha ac e ized by he p o ision o in o ma ion du ing p eg- nancy. This may occu on an indi idual o g oup basis, including home isi ing p og ams, pee educa ion ini ia i es, and clinic appoin men s, and i may o may no in ol e pa ne s. BF educa ion ypically en ails a s uc u ed, de ined, desc ip i e, and goal-o ien ed p og am designed o a speci ic pu pose and audience [11]. I is impo an o acknowledge ha HCP’s BF educa ion, in all disciplines, is o en inconsis en , lacking in expe ise and con idence [ 12 – 16 ]. This can educe he e ec i eness o his ype o educa ional in e en ion, and he e o e, suppo ools a e de eloped o p o ide s who ha e shown s a is ically signi ican imp o emen s in he in en ion and du a ion o b eas eeding [ 15 ]. Hospi al counselling on b eas eeding showed a posi i e associa ion wi h he ini ia ion o his p ac ice (aOR = 2.7, 95% CI = 1.60–3.96) ha was signi ican ac oss all aces/e hnici ies, which is a su ey-based s udy conduc ed in Los Angeles [17]. Howe e , he ecommenda ions o HCP in luence p egnan women’s decision o b eas eed [ 18 ]. Scien i ic e idence has been epo ed o he e ec i eness o counselling in he ini ia ion o b eas eeding depending on he ype o p o ide . Thus, ad ice om midwi es and obs e icians is mo e e ec i e han ha om o he specialis s. Addi ionally, women ca ed o by midwi es we e 68% less likely o ne e b eas eed han hose ca ed o by an obs e ician [19]. BF in en ion, a i ude, and knowledge ha e been shown o be s ong p edic o s o ini i- a ion [ 20 – 22 ]. In Saudi A abia, sociodemog aphic ac o s ha e been iden i ied as p edic o s; housewi es we e ou imes mo e likely o ha e a high EBF in en ion compa ed o wo king mo he s [aOR = 4.216 (1.906–9.326), p< 0.001]. Simila esul s o housewi es we e epo ed in a longi udinal s udy ca ied ou wi h women o m Lebanon and Qa a [ 21 ]. Ha ing adequa e knowledge and a posi i e a i ude owa ds b eas eeding we e also posi i e p edic o s ([aOR = 1.193 (1.183–1.421), p= 0.009] and [aOR = 1.282 (1.205–1.365), p= 0.000], espec i ely) [ 20 ]. Women who we e encou aged o b eas eed ha e mo e chances o BF compa ed o hose who did no ecei e his suppo [ 11 ]. As pe he conclusions d awn om a Coch ane e iew, p o ide encou agemen led o an inc ease in exclusi e BF a 3 mon hs and a p olonged BF du a ion up o 4 mon hs [23]. Despi e he many ad an ages and ex ensi e p omo ion o BF, he end owa ds BF in many coun ies has been slowly inc easing. Globally, he p e alence o exclusi e BF du ing he ini ial six mon hs o li e has isen by 10% o e he las decade, eaching 48% in 2023 and nea ing he Wo ld Heal h Assembly’s objec i e o 50% by 2025 [24]. I has been shown ha analyzing he impo ance ha women gi e o b eas eeding based on hei knowledge and p e ious expe iences, bo h o i s ini ia ion and con inua ion, should be an objec o s udy a he egional le el due o possible sociocul u al in luences and hose speci ic o he heal hca e sys ems. Howe e , hese aspec s emain unclea in ou egion. Nu ien s 2024,16, 2116 3 o 13 The aim o his s udy was o de e mine how he sociodemog aphic, die a y, and physical ac i i y p o iles o p egnan women, in ou demog aphic con ex , may in luence he impo ance hey assign o di e en aspec s o BF. Addi ionally, a e he pa icipa ion in g oup ANC, he e icacy o he disclosed messages ega ding BF was e alua ed by he signi icance women assigned o hem. These included pos pa um weigh managemen , he p e en ion o childhood obesi y, he in an ’s o e all heal h, as well as he ac o s in luencing hei p io i iza ion. Th ough his analysis, ou aim was o enhance he unde s anding o he in luence o BFE in g oup ANC on p egnan women’s impo ance assigned o BF, wi h he po en ial o de ec s eng hs and gaps in he con en o BF educa ion in ou con ex . 2. Ma e ials and Me hods 2.1. Resea ch Design and Pa icipan s This was an obse a ional, e ospec i e, c oss-sec ional s udy. The s udy was con- duc ed acco ding o he la es Consolida ed S anda ds o Repo ing Obse a ional S udies (STROBE) 2008 guidelines o epo ing obse a ional s udies [25]. The s udy was conduc ed in a Spanish hi d-le el hospi al ha ca es o 5196 bi hs annually [ 26 ]. Woman o all ages and socioeconomic backg ound a end he hospi al, which o e s high complex se ices as well as basic obs e ic ca e. Women ecei e ANC h ough he Public Heal h Sys em, which encompasses bo h p ima y ca e (midwi e and Gene al P ac i ione ) and obs e ic assis ance. BF educa ion is in eg a ed in o ANC, whe e he in en ion owa ds BF is documen ed in heal h eco ds om he i s indi idual isi . BF educa ion p ima ily occu s wi hin g oup ANC in he hi d imes e . This session co e s aspec s including he ana omy, he bene i s o BF, BF echniques, BF posi ions, b eas milk exp ession, my hs su ounding BF, con acep ion, as well as he disad an ages o o mula eeding [ 27 ]. Despi e ecommenda ions by heal h au ho i ies, midwi es can a ange hei BF educa ion acco ding o hei own p e e ences. The hospi al is in he hi d phase o he Mo he Baby F iendly Hospi al acc edi a ion. A admission o deli e y, all women a e asked abou plans o in an eeding. Skin- o-skin con ac and BF is ini ia ed immedia ely a e aginal deli e y. When he clinical condi ion o he mo he is s able a e a caesa ean sec ion, BF is ini ia ed wi hin 120–180 min o deli e y. In addi ion, all women who gi e bi h in he hospi al a e gi en p ac ical BF aining by midwi es, nu ses, and pedia icians, BF is obse ed, and suppo and BF counselling se ices a e p o ided. A consecu i e sampling p ocedu e was employed o selec pa icipan s. To de e mine he minimum sample size equi ed o his s udy, Gpowe so wa e 3.1 ( - e e sion) was used. The ollowing pa ame e s we e selec ed: amily es (F-Tes ), s a is ical es : Linea mul iple eg ession: ixed model, R 2 de ia ion om ze o. The ype o analysis was as ollows: he equi ed sample size-gi en alpha (0.05), powe (0.95), and e ec size (0.1) we e compu ed. No simila s udies we e ound o de e mine a heo e ical e ec size, so a minimum e ec size was employed o maximize he sample size. The minimum numbe o pa icipan s o include in he s udy was 204. The s udy ´ s inclusion c i e ia we e adul ( ≥ 18 yea s old) single on p egnan women a ≥ 37 ges a ional weeks who accep ed and signed he in o med consen o m. The exclusion c i e ia we e p egnan women wi h men al ins abili y and/o communica ion di icul ies due o language ba ie s o who we e no willing o pa icipa e. 2.2. Da a Collec ion Me hods and Su ey Pe iod Women we e ec ui ed du ing a p ena al isi o he hospi al. The s udy’s objec i es and aims we e explained by a midwi e esea che . A sel -adminis e ed ques ionnai e was designed ollowing a li e a u e e iew. I consis ed o h ee main sec ions: he socio- demog aphic and obs e ic p o ile, li es yle habi s, and he impo ance assigned o di e en aspec s o BF. Sociodemog aphic and obs e ic da a included age, place o bi h, educa ion, ci il s a us, obesogenic en i onmen , pa i y, a endance o g oup ANC, and smoking. Nu ien s 2024,16, 2116 4 o 13 Li es yle habi s included ea ing habi s du ing p egnancy, physical ac i i y, and adhe - ence o a Medi e anean die (MD). App op ia e Physical ac i i y was conside ed ollowing WHO ecommenda ions (a leas 150 min o mode a e-in ensi y ae obic physical ac i i y h oughou he week) [ 28 ]. Adhe ence o MD was accessed h ough he MEDAS scale [ 29 ]. I consis s o 14 i ems, whe e pa icipan s epo hei habi ual equency o amoun con- sumed o 12 main componen s o MD, along wi h wo ood habi s ela ed o MD. Each o he i ems sco ed ei he 1 o 0 based on pa icipan s’ adhe ence. The esul ing MD sco e de i ed om MEDAS anges om 0 o 14 [30]. The pa icipan s we e asked o indica e he impo ance hey assigned o di e en aspec s o BF h ough a Like scale, wi h i e-poin esponse op ions anging om No a all impo an (1) o Ve y impo an (5). These aspec s included he BF echnique, BF and pos pa um weigh loss, BF and baby’s heal h, and BF and childhood obesi y. The su ey was pilo - es ed o cla i y by 50 esponden s. The da a collec ion ook place be ween Ma ch and Decembe 2019. P egnan women comple ed he ques ionnai e du ing a p ena al isi , and an h opome ic da a we e e ie ed om he P egnan Women ´ s Heal h documen . 2.3. Da a Analysis S a is ical analyses we e pe o med using SPSS so wa e ( e sion 23; IBM Co po a ion, A monk, NY, USA). Desc ip i e analyses we e pe o med wi h he use o equencies and measu es o cen al endency and dispe sion o cha ac e ize he s udy sample and he esul s o he ques ionnai e. To iden i y ac o s associa ed wi h he impo ance assigned o BF, bi a ia e analyses we e pe o med by chi-squa e analysis and Fishe ’s exac es o quali a i e a iables, whe e app op ia e, and pa ame ic o non-pa ame ic es s o mean compa ison acco ding o no mali y and homoscedas ici y c i e ia [ 31 ]. To e alua e he po- en ial con ounde e ec s o he a iables ha eached s a is ical signi icance, mul i a ia e linea models we e pe o med o es ima e wha ac o s in luence he impo ance women assigned o di e en aspec s o BF. We ollowed a ule o humb commonly used in s a is ics and eg ession modeling ha sugges s ha , a a minimum, you should ha e 10 e en s pe a iable o adequa ely es ima e he model pa ame e s. In he con ex o mul i a ia e linea eg ession, his would ansla e in o ha ing a leas 10 subjec s o each co a ia e in you model. This allowed, acco ding o ou sample size, o include 26 co a ia es in ini ial models, and he Backwa d Elimina ion echnique was applied ( he co a ia es a e i e a i ely elimina ed one by one, s a ing wi h he one wi h he highes p alue, ha is, he leas signi ican s a is ically). In bo h bi a ia e and mul i a ia e analyses, s a is ical signi icance was se a 5%. 2.4. E hical Aspec s E hics commi ee app o al was ob ained om he E hics Commi ee (P o ocol C.P. MSA-FP-2019-01-C.I.). W i en and e bal in o med consen was ob ained om he pa - icipan s. The pa icipan s signed an in o med consen o m decla ing hei olun a y pa icipa ion once hey unde s ood he objec i es and dynamics o he s udy. They we e awa e o he possibili y o abandoning he s udy a any ime and ha he p ocessing o hei in o ma ion would be anonymous and unde he p ecep s o cu en legisla ion on he p ocessing o pe sonal da a. 3. Resul s Two hund ed and se en y-six (276) pa icipan s esponded o he ques ionnai e; how- e e , no all women answe ed all ques ions. Tables 1and 2show missing da a o each i em. The p o ile o women was mainly na i e Spania ds who we e ma ied o in a ela- ionship, wi h seconda y o high educa ion and an a e age age o 32.6 (SD 5.8), anging be ween 18 and 47 yea s old. Rega ding physical ac i i y, 70% o he sample me WHO physical ac i i y ecommenda ions o p egnan women. Only 9% el uncom o able wi h Nu ien s 2024,16, 2116 5 o 13 hei body image du ing p egnancy. Table 1shows da a o sociodemog aphic obs e ic cha ac e is ics and physical ac i i y (Table 1). Table 1. Sociodemog aphic and obs e ic cha ac e is ics and physical ac i i y. Va iables To al Women % (IC 95) N n Na ionali y 263 Spanish 247 93.9 (90.4–96.2) Eas e n Eu ope 5 1.9 (0.8–4.4) Hispa-Ame ican 10 3.8 (2.1–6.7) O he s 1 0.4 (0.1–2.1) Educa ional le el 275 Highe Educa ion 109 39.6 (34.0–45.5) P ima y School 42 15.3 (11.5–20.0) Seconda y School 116 42.2 (36.5–48.1) None 8 2.9 (1.5–5.6) Ci il S a us 274 Ma iage/couple 261 95.2 (92.1–97.2) Single 5 1.8 (0.8–4.29) O he s 8 3 (1.5–5.7) Nullipa a 276 174 63 (57.2–68.5) Smokes in p egnancy 275 31 11.3 (8.1–15.6) Obesogenic En i on. 274 40 14.6 (11.0–19.3) G oup An ena al Ca e 273 193 70.7 (65.0–75.8) Pg Physical Ac i i y 272 160 59 (53.0–65.0) In o Physical Ac i i y 271 213 78.6 (73.3–83.1) Belie es PA nega i e 269 28 10.4 (7.3–14.6) Changes in PA 255 149 58.4 (52.3–64.3) Mee s WHO PA ecom. 215 151 70.2 (63.8–76.0) APP PA 243 44 18.1 (13.8–23.4) P egnancy body Image 275 P e y 133 48.4 (42.5–54.3) Nei he p e y no ugly 115 41.8 (36.1–47.7) Uncom o able 27 9.8 (6.8–13.9) No e: En i on, en i onmen ; Pg, p e-ges a ional; PA, Physical Ac i i y; WHO, Wo ld Heal h O ganiza ion; ecom, ecommenda ion; APP, applica ion. Almos hal o he women had a heal hy p eges a ional BMI, mos did no ha e a ges a ional weigh gain (GWG) a ge , and GWG was e enly dis ibu ed among i s h ee ca ego ies, inadequa e, heal hy, and excessi e. O e hal o he sample changed hei ea ing habi s, main aining he same appe i e and ood amoun . Hal p esen ed c a ing and 60% p esen ed nauseas. Only 18% o he sample had a low adhe ence o MD (Table 2). Table 3shows he impo ance assigned o di e en aspec s h ough a Like scale, wi h highe punc ua ions o mo e impo ance assigned. The a e age punc ua ion o all a iables was o e ou ou o i e poin s, excep he impo ance assigned o BF o pos pa um weigh loss and body image be o e and du ing p egnancy (nea ou poin s). Mo e han hal o he pa icipan s had a good adhe ence o MD, wi h a median sco e 9.3 o e 14 poin s. Nu ien s 2024,16, 2116 6 o 13 Table 2. An h opome ics and ea ing habi s. Va iables To al Women % (IC 95) N n pgBMI 275 Unde weigh 7 2.6 (1.2–5.2) No mal 127 46.2 (40.4–52.1) O e weigh 84 30.5 (25.4–36.2) Obesi y 57 20.7 (16.4–26.0) Ges a ional Weigh Gain 275 Inadequa e 87 31.6 (26.4–37.4) Heal hy 91 33.1 (27.8–38.9) Excessi e 97 35.3 (29.9–41.1) GWG Ta ge 267 Inc ease 11 4.2 (2.4–7.4) Main ain 63 24 (19.4–29.7) Lose 2 0.8 (0.2–2.8) None 185 71 (65.1–76.1) Ea ing Habi s Change 264 142 53.8 Ea o wo 267 No 253 94.8 (91.4–96.9) Appe i e 139 Inc eased 17 12.2 (0.8–1.9) Same 73 52.5 (4.4–6.1) Dec eased 49 35.3 (2.8–4.3) Change in Quan i y 273 Mo e 85 31.1 (2.6–3.7) Same 139 51.0 (4.5–5.8) Less 49 17.9 (1.4–2.3) Snacking 270 162 60 (54.1–65.7) S ess/anxie y 267 Ea mo e 119 44.6 (3.9–5.1) Ea he same 97 36.3 (3.1–4.2) Ea less 51 19.1 (1.5–2.4) C a ing 270 132 49 (43.0–55.0) Nausea 270 169 62.6 (56.5–68.2) Adhe ence o MD 216 155 71.8 (65.4–77.3) No e: pgBMI, P e-ges a ional Body Mass; GWG, Ges a ional Weigh Gain; MD, Medi e anean Die . Table 3. Impo ance assigned o aspec s o B eas eeding and Desc ip i e Quan i a i e Va iables. Va iable Media SD Minimum 25% 50% 75% Maximum nNA ADH_MD.9 9.3 2.1 1.0 8.0 10.0 11.0 14.0 216 60 Age 32.6 5.8 16.0 29.0 33.0 37.0 47.0 276 0 Image Be o e 3.7 1.0 1.0 3.0 4.0 4.0 5.0 272 4 Image P egnancy 3.5 1.1 1.0 3.0 4.0 4.0 5.0 271 5 pgBMI 26.1 5.7 17.3 22.1 25.0 28.3 46.0 275 1 Impo ance PA 4.1 1.1 1.0 3.0 4.0 5.0 5.0 250 26 Impo ance Nu 4.3 1.1 1.0 4.0 5.0 5.0 5.0 253 23 Impo ance BF How 4.6 0.8 0.0 5.0 5.0 5.0 5.0 273 3 Impo ance BF PCO 4.1 1.2 2.0 3.0 5.0 5.0 5.0 246 30 Impo ance BF PWL 3.7 1.3 2.0 3.0 4.0 5.0 5.0 246 30 Impo ance BF BH 4.7 0.8 0.0 5.0 5.0 5.0 5.0 273 3 No e: SD, s anda d de ia ion; NA, no a ailable; ADH_MD, Adhe ence o Medi e anean Die ; BMI, Body Mass Index; PA, Physical Ac i i y; Nu , Nu i ion; BF, B eas Feeding; PCO, P e en Child Obesi y; PWL, Pos pa um Weigh Loss; BH, Baby´s Heal h. Nu ien s 2024,16, 2116 7 o 13 Fou mul i a ia e linea eg ession models we e e alua ed, in which hose a iables ela ed o BF and di e en aspec s such as he BF echnique and impo ance as a p o ec i e ac o agains childhood/ma e nal obesi y and as a gua an o o he baby’s (gene al) heal h we e included as dependen a iables (Table 4). Table 4. Lineal models. Model 1: Dependen Va iable: IA o How o BF Independen Va iables Es ima e p-Value Models’ Pa ame e s In e cep (be a 0) 0.40 0.067 Adjus ed R2: 0.62 F-s a is ic: 98.03 on 4 and 239 DF, p- alue: <0.001 Obesogenic En i onmen 0.24 0.006 Impo ance Nu 0.14 <0.001 Impo ance BF BH 0.74 <0.001 G oup An ena al Ca e 0.20 0.003 Model 2: Dependen Va iable: IA o BF as a Tool o Losing Pos -Pa um Weigh Independen Va iables Es ima e p-Value Models’ Pa ame e s In e cep (be a 0) 0.73 0.024 Adjus ed R2: 0.48 F-s a is ic: 46.02 on 4 and 227 DF, p- alue: <0.001 No p egnancy smoking −0.31 0.021 Obesogenic En i onmen 0.33 0.057 Image P egnancy 0.14 0.036 Impo ance BF PCO 0.65 <0.001 Model 3: Dependen Va iable: IA o BF as a P e en i e Fac o o Childhood Obesi y Independen Va iables Es ima e p-Value Models’ Pa ame e s In e cep (be a 0) −0.06 0.87 Adjus ed R2: 0.47 F-s a is ic: 65.8 on 3 and 219 DF, p- alue: <0.001 Impo ance PA 0.19 0.004 Impo ance BF How 0.31 <0.001 IA o BF as a means o losing pp-weigh 0.52 <0.001 Model 4: Dependen Va iable: IA o BF o Main ain Baby’s Heal h Independen Va iables Es ima e p-Value Models’ Pa ame e s In e cep (be a 0) 1.14 <0.001 Adjus ed R2: 0.62 F-s a is ic: 64.02 on 6 and 227 DF, p- alue: <0.001 Obesogenic en i onmen −0.20 0.022 Impo ance BF How 0.76 <0.001 Impo ance BF PCO 0.05 0.065 You heal h—baby’s [baby´s] −0.39 0.042 You heal h—baby’s [main] −0.78 0.029 You heal h—baby’s [none] −0.18 0.051 No e: IA, Impo ance assigned; BF, b eas eeding; pp, pos -pa um. The i s aimed a seeing wha ac o s in luenced he impo ance assigned by mo he s o he BF echnique. I showed ha he p esence o obese subjec s in he amily en i onmen , he impo ance assigned o nu i ion du ing BF, BF as a gua an o o he baby ´ s heal h, as well as a endance o g oup ANC we e a o able ac o s, al hough hey had li le impac . Howe e , he model o e all ob ained a coe icien o de e mina ion o 0.62, esul ing in a signi ican model. Fo he model ha e alua ed he impo ance assigned o BF as a ool o losing weigh in he pos pa um, obesi y in he amily en i onmen , conce n abou BI be o e p egnancy, and pa icipan s ha assigned a high impo ance o BF as a ool o p e en ing childhood obesi y we e obse ed as ac o s wi h a di ec ela ionship. Howe e , a s a is ically sig- ni ican associa ion was obse ed, indica ing an in e se ela ionship wi h non-smoking beha io s (nei he p io o no du ing p egnancy). The hi d model in es iga ed he impo ance assigned o BF as a p o ec i e ac o agains childhood obesi y. In i , he impo ance assigned o physical ac i i y du ing Nu ien s 2024,16, 2116 8 o 13 p egnancy, he BF echnique, and BF as a ool o losing weigh in he pos pa um pe iod appea ed as p omo ing ac o s. Finally, he las model assessed he impo ance assigned o BF as a means o main ain- ing he baby’s heal h. A signi ican di ec ela ionship was obse ed wi h he impo ance assigned o he BF echnique and o BF as a ool o p e en ing childhood obesi y. Howe e , i was in e sely ela ed o he p esence o an obesogenic en i onmen . Nega i e coe icien s also esul ed o conside ing physical ac i i y du ing p egnancy as nega i e o he baby’s heal h, one’s heal h, o nei he , using he heal h o bo h (mo he and baby) oge he as a e e ence ca ego y. 4. Discussion The esul o his s udy sugges s he e ec i eness o in o ma ion ancho ing ega ding he BF echnique ob ained du ing g oup ANC, iden i ying his momen as a key ime o include addi ional in o ma ion ega ding BF ha could media e in women ´ s decisions ega ding BF, ini ia ion, and main enance a es. I highligh s some ac o s ha p omo e he impo ance women assign o BF in ela ion o bene i s o bo h mo he s and babies. Addi ionally, i is a desc ip i e s udy on sociodemog aphic, die a y, and physical ac i i y du ing p egnancy in women om ou en i onmen . These ac o s we e explo ed as possible p omo e s o he impo ance assigned o he discussed issues, wi h no signi ican esul s. BFE places much emphasis on he BF echnique, which is c ucial o BF ini ia ion and main enance [ 32 ]. The indings o his s udy sugges ha ce ain aspec s conce ning BF, like i s in luence on ma e nal heal h, a e being inadequa ely add essed, po en ially hinde ing p egnan women om ecognizing hei signi icance. This is e iden in he models ob ained, as a endance o g oup ANC only eme ged as a p omo ing ac o o he impo ance assigned o he BF echnique. Al hough women a ibu e medium o high impo ance alues (abo e h ee) o he es o he issues (Table 2), a endance o g oup ANC did no appea as a p omo ing ac o in he espec i e models. Conside ing he posi i e e ec ha g oup ANC had on he BF echnique message, i would be clinically in e es ing o include and p omo e o he aspec s. Gi en he impo ance ha pos pa um weigh e en ion has on he obesi y epidemic, [ 33 , 34 ], as well as he nega i e consequences o childhood obesi y [35], hese aspec s should be emphasized. Al hough ou indings indica e p egnan women a e conce ned abou BF echniques, a quali a i e s udy among p ima y ca e Spanish midwi es e ealed ha many women a ending g oup ANC end o p io i ize discussions on deli e y and associa ed pain, o en elega ing BF o a seconda y conce n [ 36 ]. This aligns wi h a ecen s udy in i s - ime mo he s in England, who indica ed ha ob aining us wo hy in o ma ion h ough di ec in e ac ions wi h expe s was essen ial o mee ing hei needs and boos ing hei con idence. Howe e , when ques ioned abou he ype o in o ma ion ha would se e his pu pose, hei a en ion was only di ec ed owa d childbi h [ 37 ]. Paz-Pascual no ed ha Spanish women o en exp essed a p e e ence o exclusi e BF o be add essed p e e ably in pos na al classes, alongside opics like newbo n ca e and mo he hood, which we belie e would be oo la e. They also mani es ed he need o g ea e accompanimen in he pue pe ium and less p essu e conce ning BF [ 38 ]. In his line, women iden i ied hemsel es and socie y (HCP, media, and pa ne s) [ 39 ] as he main sou ces o p essu e o BF. This p essu e was nega i ely associa ed wi h he BF expe ience ( = − 0.34, p< 0.01) and sel - e icacy ( = − 0.39, p< 0.01) [ 40 ], as well as wi h men al heal h symp oms [ 39 ]. This leads us o conside ha al hough BF suppo is essen ial in he pue pe ium, i could be in e es ing o seek a mo e sui able ime du ing p egnancy o add ess BF. We sugges ha du ing he second imes e , women a e less ocused on childbi h and could he e o e be mo e ecep i e o BFE. Suppo ing his p oposi ion, some au ho s ha e desc ibed ha ma e nal conce ns and p egnancy- ela ed anxie y a e mo e in ense in ea ly and la e p egnancy [ 41 , 42 ]. We also belie e ha i is necessa y o implemen educa ional s a egies ha , while p omo ing BF as he op imal way o eed babies, elie es women om he p essu e hey eel. Nu ien s 2024,16, 2116 9 o 13 The BF a es among pa icipan s in g oup ANC, when compa ed o indi idual ca e, sugges ha g oup ANC shows signi ican ly highe a es o BF ini ia ion and exclusi e BF a hospi al discha ge [ 43 , 44 ]. G ay (2024) epo ed ha i inc eases BF a 6 mon hs (odds a io = 2.66; p= 0.045) and leads o highe BF in en ion, compe ence, and au onomous mo i a ion ini ia ion [ 45 ]. The Andalusia Bi h and Pa en ing P epa a ion Guide [ 27 ] ecommends ha BF be add essed du ing one g oup ANC isi , along wi h indi idual ca e. Howe e , we belie e ha a single isi may no su icien ly aise mo he s’ awa eness abou he impo ance o BF beyond he baby’s heal h. E ec i e BFE equi es mo e a en ion o signi ican ly impac mo he s’ awa eness o i s impo ance. Nasim epo ed a dose- esponse e ec ; mo e ANC isi s had highe a es o BF ini ia ion and du a ions [ 46 ]. S akeholde s should ake no e o hese indings and ensu e ha ANC includes he app op ia e numbe o HCP and isi s. I is wo h no ing ha Spain has one o he lowes a es o midwi es in he Eu opean Union, wi h 17–21 p ac ising midwi es pe 100,000 inhabi an s [ 47 ] and a cu en ly unde s a ed wo k o ce. Midwi e ca e has been associa ed wi h be e heal h esul s o mo he s and child en, including highe BF a es [ 48 – 50 ]. Likewise, insu icien suppo om he heal h sys em educes he p obabili y o BF [13]. In ou s udy, women assigned a lo o impo ance o BF in ela ion o he baby ´ s heal h and BF echnique, while he impo ance ega ding he mo he ´ s heal h and i s in luence on pue pe al weigh loss had he leas impo ance. This highligh s ha p egnan women seem mo e conce ned abou hei babies han hemsel es. We sugges , in line wi h o he au ho s, ha ANC should emb ace new pe spec i es ha app oach holis ic ma e nal heal h issues, no solely ocusing on he child ´ s ca e [ 51 ]. A eo ien a ion owa ds a heal h p omo ion ha is mo he -cen ed is c ucial o mee women ´ s needs and enhance heal h esul s [ 52 ]. G ea e emphasis could be placed on women’s decision o b eas eed and i s sho - and long- e m bene i s o bo h he mo he and newbo n. Despi e he ac ha , as ou esul s con i m, in line wi h o he esea ch [ 53 ], mos women el com o able o epo ed o look beau i ul du ing p egnancy, body dissa is ac ion du ing he pos pa um is common [ 54 ]. Expec a ions o he ideal Wes e n beau y s anda d, media ed by social no ms, p essu e mo he s o quickly e u n o p e-p egnancy weigh soon a e bi h [ 55 ]. This is a goal ha is o en no achie ed. Dissa is ac ion wi h he ma e nal body is linked o se e al nega i e ou comes, including pos pa um dep ession [ 56 , 57 ] and sho e BF du a ions [ 58 ]. In ou model, women who assign mo e poin s o he impo ance o BF as a ool o eco e ing p eges a ional weigh also do so o he impo ance o BF o he p e en ion o childhood obesi y. P omo ing hese posi i e aspec s o he BF expe ience in ANC could se e as a ca alys o encou aging he ea ly ini ia ion and main enance a es o BF and i s associa ed bene i s. Fo example, we s ongly belie e ha BFE should highligh he impo ance o BF as a media o o ma e nal heal h, including nega i e ou comes ela ed o body dissa is ac ion ela ed o pos pa um weigh e en ion. Ou esul s show ha adhe ence o MD in ou sample was high, wi h be e esul s han hose epo ed o I aly o p egnan women [ 59 ]. No associa ion be ween adhe ence o MD and impo ance assigned by p egnan women o di e en heal h- ela ed aspec s was ound. Howe e , he MD pa e n is associa ed wi h bene i s du ing p egnancy and he p e en ion o ce ain diseases, including ca dio ascula diseases [ 60 ]. I s p omo ion among p egnan women could se e as a bene icial public heal h s a egy o p e en ing o e weigh and nu ien de iciencies [ 61 ]. Resea ch also sugges s ha women who choose o BF end o ollow heal hie die s, ha e be e die a y knowledge, and p omo e an o e all heal hie die in hei child en [ 62 ]. B eas eeding o 6 mon hs o longe is associa ed wi h a highe adhe ence o he MD du ing he p eschool yea s [63]. Women who adhe ed o he MD and b eas ed no only achie ed physical bene i s such as a lowe p opo ion o co po al a y issue [ 64 ] bu also achie ed emo ional bene i s such as a lowe isk o dep essi e episodes [ 65 ]. Due o he bene i s ha MD has on mo he s and newbo ns in he long and sho e m, i s p omo ion should be a undamen al aspec in ANC. While mas e ing BF echnique is c ucial o new mo he s o ini ia e and sus ain lac a ion, BFE