Next Article in Journal
Short-Term Consumption of Hydrogen-Rich Water Enhances Power Performance and Heart Rate Recovery in Dragon Boat Athletes: Evidence from a Pilot Study
Next Article in Special Issue
Feeding Practices, Maternal and Neonatal Outcomes in Vaginal Birth after Cesarean and Elective Repeat Cesarean Delivery
Previous Article in Journal
The Effects of Horticultural Therapy on Sense of Coherence among Residents of Long-Term Care Facilities: A Quasi Experimental Design
Previous Article in Special Issue
Awareness, Perceptions, Gaps, and Uptake of Maternity Protection among Formally Employed Women in Vietnam
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

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

Department of Nursing, Universitat Jaume I, Av. de Vicent Sos Baynat, 12071 Castelló, Spain
Department of Nursing, Universitat de València, 46010 Valencia, Spain
Department of Nursing, University of Alicante, 03080 Alicante, Spain
Department of Obstetrics and Gynaecology, Hospital Luis Alcanyis, 46819 Xàtiva, Spain
Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO-SP), 46020 Valencia, Spain
Department of Clinical Medicine, Universidad Miguel Hernández, 03202 Elche, Spain
Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance at Imperial College London, London W12 0NN, UK
College of Nursing, Midwifery and Healthcare, University of West London, Brentford TW8 9GA, UK
Department of Obstetrics and Gynaecology, Hospital Universitario de la Ribera, 46600 Valencia, Spain
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(9), 5411;
Received: 29 March 2022 / Revised: 23 April 2022 / Accepted: 27 April 2022 / Published: 29 April 2022


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.

1. Introduction

Breastfeeding (BF) offers many health benefits to the mother and the BF infant, both in the short and long term [1]. For example, BF would reduce maternal and infant mortality [2] by 823,000 infants and 20,000 mothers worldwide if exclusive breastfeeding (EBF) up to 6 months was maintained [3]; BF would improve nutritional factors, lower related infant food costs [4,5], and contribute to family and social economic savings by lowering the prevalence of diseases in breastfed newborns (NB) [5,6]. BF also fosters the mother–child bond by encouraging a safe attachment [7] and a better mother–infant relationship [4].
The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) recommend initiating breastfeeding within the first hour of life and maintaining EBF for the first 6 months. EBF rates at 6 months are low, despite efforts by international organizations [8] to protect and promote this practice [9]. According to the Global Health Observatory data repository [10], only 25% of infants in Europe are breastfed exclusively for the first 6 months [11]. In Spain, EBF prevalence at 6 months is around 16.8%, considerably less than the ~75% EBF rate reported at hospital discharge [12,13].
There are multiple factors for the premature abandonment of breastfeeding. Among these factors, we can find the low weight of the infant, the feeling of lack of milk, smoking, the mother’s lack of knowledge about breastfeeding or the incorporation to work [14,15]. Education is other of the factors affecting the initiation and continuation of breastfeeding (BF) [9,16,17], and incidentally it is also related to health literacy (HL) [18,19]. The concept of HL emerged in the 1970s and has been continuously refined since then [20,21]. Health literacy is currently defined as “an individual’s ability to obtain and translate knowledge and information in order to maintain and improve health in ways that are appropriate to the individual and community context” [22]. A low HL level has been linked to difficulties understanding healthcare information and to poor therapeutic concordance, which in turn increases costs and leads to an inefficient use of healthcare resources [22,23].
Likewise, women’s HL levels can also have an effect on their children’s health during pregnancy and after birth [24,25]. As for the decision to breastfeed, the percentage of mothers who decide to BF rises with their HL level [26]. In one small study, health literacy was found to be a protective factor for breastfeeding [27]. Consistent with these results, the aim of this study was to explore the influence between the level of health literacy and the maintenance of exclusive breastfeeding at six months postpartum.

2. Materials and Methods

2.1. Design and Setting

A longitudinal multicenter study was carried out at three hospitals in the Valencian Community (Spain): The General University Hospital of Castellón (Department of Health, Castellón); the University La Ribera Hospital (Department of Health, La Ribera); the Lluís Alcanyís Hospital of Xátiva (Department of Health, Xátiva-Ontinyent). These hospitals were either reference centers for their province (General University Hospital of Castellón and University La Ribera Hospital) or were in a rural area with large catchment populations (Lluís Alcanyís Hospital). Overall, the participating hospitals served 600,000 people.

2.2. Sample

The target population comprised women registered with the Departments of Health of Castellón, La Ribera and Xátiva-Ontinyent, whose birth was at one of the participating hospitals, and who had opted for EBF on discharge.
Systematic sampling of women admitted to hospital during clinical puerperium was conducted by randomly selecting one in every three puerperal women on the maternity ward every Monday. All women who wished to participate in the study were recruited, and they were asked to sign informed written consent. Mothers who were older than 18 years and had no health problems associated and/or puerperal complications at discharge were included in the study.
Some situations may make it difficult to initiate lactation. For this reason, twin pregnancies, and multiple and/or premature pregnancies, and/or congenital anomalies detected in the first 24 h, and/or newborns admitted in neonatal intensive care unit were excluded [16,17]. We excluded women with cognitive impairments, language barriers, or illiteracy (not able to read). Illiterate women were excluded from the study as they would be unable to complete the self-administered health literacy screening tools [25]. Finally, we also excluded mothers who we were unreachable by telephone after three attempts at 6 months postpartum.
We assumed that if the proportion of women with limited HL at baseline were 45%, the EBF cessation rate in the adequate HL group was 40% and, to detect a difference between groups of 15% on EBF cessation, as well as a 0.05 confidence level and 80% statistical power, 350 women were required [27]. Considering a 10% attrition rate, the final sample size was estimated at 385 women. The sample size calculation was performed by EPIDAT v.3.1, Santiago de Compostela, Spain.

2.3. Data Collection, Main Variables and HL Measure

The participating hospitals attend an average of 1600 births per year in Castellón, 1400 births in La Ribera, and 700 births in Xàtiva-Ontinyent. Therefore, the number of participants in each department has been influenced by the number of births attended in each hospital.
Printed questionnaires were used to collect data. Participants were recruited between January 2019 and January 2020 during clinical puerperium (24–48 h after giving birth). One researcher per participating center oversaw the first data collection, except for the HL screening tool, which women self-administered before discharge from hospital. The BF follow-up at 1, 2 and 4 postpartum months was performed by the same researcher by consulting each participants’ electronic health records. Finally, when breastfed infants were 6 months old, mothers were telephoned to document their feeding type.
BF efficacy was evaluated using the LATCH breastfeeding assessment tool. This questionnaire has been validated in Spanish [28] and contains five items (“Latch”, “Audible swallowing”, “Type of nipple”, “Comfort” and “Hold–positioning”). Each item is scored numerically (0–2), where 0 is the worst possible and 2 the best possible situation. A score of 8–10 reflects effective breastfeeding. During fieldwork, BF efficacy was evaluated with this instrument by the researcher in charge at each participating hospital before hospital discharge.
While contacting mothers, they were asked whether they continued EBF. If their answer was negative, they were asked about the feeding type they provided and how long they had practiced EBF. The questions were: 1. Are you still exclusively breastfeeding your baby? 2. If not, for how long did you exclusively BF your baby? Finally, feeding type information and duration were recorded in their electronic medical records. The researchers attempted a maximum of three calls per participant and followed a pre-established script to reduce data loss as much as possible and maximize data quality. Feeding type was classified as [16,29]: 1. EBF means that infant receives only breast milk or expressed milk; 2. Formula milk; 3. Mixed BF (combination of breast milk and formula milk). BF status was recorded at hospital discharge (48–72 h), and at 1, 2, 4 and 6 months after giving birth. Early EBF cessation was considered if it occurred before 6 months postpartum (yes/no), as set out by the World Health Organization among its 2025 targets [30].
The HL was explored through an interview at discharge and was measured by the Newest Vital Sign (NVS) questionnaire validated in Spanish, with acceptable internal consistency (α = 0.69) [31]. This self-administered questionnaire contains six questions about a nutritional ice cream label. One point is scored per correct answer [32]. Questions are freely answered and do not lead participants to any expected response type. It classifies the HL level according to the overall score as “adequate” (4–6 points) or “limited” (<4 points).

2.4. Data Analysis

A descriptive analysis was performed using absolute and relative frequencies for qualitative variables (socio-demographic and obstetric variables), and the mean and standard deviation (±SD) for quantitative variables. The HL-related factors and those associated with EBF cessation at 6 months were analyzed using 2 × 2 tables, the chi-squared test ( χ 2) for qualitative variables and by comparing the means for quantitative variables via the one-factor analysis of variance (ANOVA) or the Student’s t-test, respectively.
The magnitudes of the associations with EBF cessation at 6 months were dealt with by the fit of the multivariate logistic models. The odds ratio (OR) was estimated along with their 95% confidence intervals (95% CIs). A stepwise procedure based on AIC’s criterion (Akaike Information Criterion) was followed to select variables. Data analysis was performed on SPSS v.25.0 statistical package (IBM Corp. Released 2018. IBM SPSS Statistics for Windows, Armonk, NY, USA) and R (R project 2019, Version 3.5.1, Vienna, Austria). As the analysis included two variables, NVS and EBF cessation, the level of significance was adjusted by the Bonferroni method to p < 0.025.

3. Results

Of 391 participants initially recruited, 48 (12.3%) were later excluded: 42 (87.5%) due to follow-up loss and six (12.5%) because they did not wish to continue in the study during follow-up. The homogeneity between those who were included and those who were excluded or lost from participation was analyzed. There were no significant differences in age, age at first pregnancy, gestational age at delivery, health literacy level by NVS or country of origin between the group that was included and the group that was excluded in this study.
The final sample size was 343 women who reported EBF when discharged from hospital, and who were included in the BF follow-up until breastfed infants were 6 months old.

3.1. Socio-Demographic Characteristics

The participants’ mean age was 32.5 years (±5.3). The mean gestational age at birth was 39 + 3 weeks (±1.1), and the mean birth weight was 3301.2 g (±464.5). Table 1 shows the other socio-demographic variables included in this study.

3.2. BF-Related Variables

The mean LATCH breastfeeding assessment tool score for BF efficiency was 8.8 out of 10 points (±0.9). The 6-month EBF rate was 34.1% (117/343), with 65.9% (226/343) for EBF cessation before 6 months (Figure 1).

3.3. HL Level

Of all participants, 47.8% (164/343) had a limited HL level. The factors associated with a limited HL level were, a lower level of education (p < 0.001), being unemployed or not looking for a job (p = 0.003), and not born in Spain (p < 0.001). However, the mother’s older age (p < 0.001) was associated with a higher HL level (Table 2). Figure 2 indicates the distribution of HL levels in relation to EBF at 6 months.
Table 3 shows the relationship between the collected variables and their association with EBF cessation at 6 months. The variables associated with early EBF cessation were a limited HL level (p < 0.001), being a single, separated, divorced mother (p < 0.001), having a lower level of education (p = 0.022), and obtaining a lower LATCH breastfeeding assessment tool score (p < 0.001). Conversely, a mean score of 9.19 (±0.85) for BF efficiency at hospital discharge, as measured by the LATCH breastfeeding assessment tool, presented a statistically significant association (p < 0.001) with continuing with EBF until infants were 6 months old.

3.4. Variables Related to Early EBF Cessation

The multivariate regression model shown in Table 4 for EBF cessation before 6 months suggests that a limited HL level is associated with more than twice the probability of EBF cessation before 6 months compared to an adequate HL level adjusted by mother’s age, level education, civil status and the LATCH breastfeeding assessment tool. Both being married and obtaining a higher LATCH breastfeeding assessment tool score were also protective factors against EBF cessation before infants were 6 months old.

4. Discussion

The present study focuses on continuation of EBF until infants are 6 months old and explores influential factors, namely HL levels.
One of the WHO’s goals for 2025 is to reach EBF rates of at least 50% until infants are 6 months old [30]. Worldwide EBF rates at 6 months fall short of this recommendation [33]. Between 2006 and 2012 in Europe, it was estimated that only 25% of breastfed infants received EBF for the first 6 months of life [11]. According to the European Health Information Gateway [34], EBF rates at 6 months were 58.3% in Italy (2011), 53.9% in Portugal (2013) and 58.4% in Spain (2017). However, more recent studies carried out in Spain report considerably lower EBF infants until the age of 6 months, ranging from 16.8% [12], 21.6% [35], or 31.4% [36], to 43% [37].
Different studies have reported an association between mothers’ level of education and continuing with EBF and showing that the higher the level of education, the longer that EBF lasts [35,36,37], in line with our results. Other authors have established an association between level of education and HL levels [18,19]. Although it may seem that a low educational level could be associated with a low HL, this relationship does not always have to be observed [38]. A relation was also recently found between HL levels and continuing EBF in a pilot study; however, the follow-up period only covered 4 months [25]. Therefore, the present study verifies a statistically significant association between limited HL level and EBF cessation before 6 months in line with previous studies [27], and observed that the probability of EBF cessation was more than two-fold compared to the mothers with an adequate HL level.
Previous studies have related found an association with mothers’ age and early EBF cessation [9,35,37]. In agreement with results hitherto reported [39], we noted a statistically significant association between being older and EBF rates at 6 months postpartum. This association might be due to ongoing family support, better socio-economic status or a higher level of knowledge about BF benefits, as other research has shown [40,41,42,43]. There are also reports indicating that those families with single, separated, or divorced mothers, the probability of EBF cessation before 6 months postpartum more than doubles. For continuing EBF, several studies have verified that family support [44] and having a partner are key factors [45,46]. Other authors have reported how the probability of EBF cessation before 6 months postpartum more than doubles in families with single, separated, or divorced mothers [47,48]. Women’s immediate environment (family, friends and neighbours) is the most influential social support network in shaping pregnant women’s expectations and decisions about pregnancy, labour and nursing [49]. However, the NVS tool does not incorporate those social aspects, unlike other tools such as the Health Literacy Questionnaire [50], so their influence on the HL of breastfeeding women remains to be clarified [51]. It is noteworthy that being older with a first pregnancy also showed a statistically significant association with an adequate HL level. It was not surprising that the two variables contributing to continuing EBF, namely an adequate HL level and older maternal age, were also closely interrelated, as seen in a recent study in Spain [43]. Nevertheless, future studies are needed to corroborate the relationship between being older with first pregnancy and continuing EBF and a higher HL level, and the factors that could influence the relationship between both these variables must also be explored.
The average LATCH score was high with a small standard deviation, which suggests that the majority of the study population was breastfeeding effectively or nearly effectively. It is worth stressing the predictive capacity of the LATCH breastfeeding assessment tool. Different studies have measured BF efficacy both postpartum and before hospital discharge. These studies showed that BF efficacy can be effectively evaluated using LATCH [52], and its predictive performance is high at 6 weeks postpartum [53,54,55]. The present study revealed that high LATCH breastfeeding assessment tool scores were significantly associated with a lower probability—almost half—of EBF cessation before breastfed infants were 6 months. As the LATCH breastfeeding assessment tool seems to be useful, future studies should take advantage of these findings to relate the LATCH scores with continuation of EBF in the longer term. However, the LATCH could be further refined to incorporate elements such as mother/infant interaction [56]. This tool has major flaws, including the inability of the user to assign different scores per breast (e.g., if one nipple is flat and the other is everted), the lack of representation of infant’s oral anatomy and functionality.
Moreover, women often seek support beyond their home if it is not available there. However, more studies need to be conducted to corroborate the association between family support and continuing EBF to 6 months.
Despite the need for more robust studies to determine the association between level of health literacy and maintenance of exclusive breastfeeding at 6 months postpartum, this study shows a profile of women that should not go unnoticed by health professionals caring for women during the perinatal period. According to the results of this study, the profile of women who are more likely to early EBF cessation would be those who are younger, single, separated or divorced, who have a limited level of LH as measured by the NVS instrument, as well as those who have a LATCH score below 9. Different interventions in low HL women have been designed to improve the outcomes and experiences in relation to breastfeeding promotion. Interventions based on education alone are inadequate to improve low HL, and multidimensional and multidisciplinary methodologies are needed to identify the best strategy. In addition, more research is needed in order to improve this knowledge, due to the low quality of the evidence of the studies [57]. Therefore, the development of interventions to improve LH in relation to BF seems to be an interesting future line of research.


One limitation of this study is the information bias related to the reasons for BF cessation. This information could not be collected because the reason for breastfeeding cessation is not always reflected on electronic health records. Several studies have widely reported on reasons explaining why BF cessation is poorly registered [13,58]. Although this information is relevant, it is beyond the scope of our study. The three health departments use the same electronic medical record that is also common to the Valencian community (ABUCASIS II), so the information bias was controlled because the quality of the records was uniform between the three hospitals. In addition, marital status was taken into account, but other consensual unions were disregarded. Future research should take this into account.
The percentage of the women excluded by criteria or lost were similar in the three health departments. We obtained a heterogeneous sample between the three health departments, explained by the number of annual deliveries, and the availability of the researcher responsible for the hospital to recruit the sample, being lower in Xàtiva health department than the others. Although the analysed sample could be larger than that obtained, the decision that a single researcher for each centre would carry out the evaluations in the clinical puerperium, and later take charge of the follow-up, analysing the medical records and making the telephone calls at six months, we believe that the information bias is reduced, avoiding recording and interpretation errors.
The strengths of this study include the characteristics of the sample, as it was randomised and representative.
This study identified that a limited HL level was a statistically significant risk factor for EBF cessation before breastfed infants were 6 months old. It should be noted that NVS is designed to measure HL in the general population; perhaps the use of a specific tool designed for perinatal women would provide different results. The screening tool herein employed was the Newest Vital Sign (NVS), whose validated Spanish version presents acceptable internal consistency (Cronbach’s α = 0.69) [31]. This instrument has been previously employed to assess the association between HL levels and continuing EBF until breastfed infants were 4 months old [25]. Nonetheless, it is worth indicating that continuing BF might be more closely related to HL while breastfeeding compared to general HL level.

5. Conclusions

The present study demonstrates how adequate HL levels can influence the maintenance of EBF, acting as a protective factor against early cessation. Therefore, one recommendation is to include HL level as a relevant risk factor when adopting preventive strategies to increase the EBF rate at 6 months postpartum in order to move towards international recommendations. Further exploration of the components of HL and its relationship to factors influencing cessation of EBF will be important.

Author Contributions

R.V.-C., D.M.-T. and F.J.S.-V. contributed to conception and design of the study. J.A.Q. contributed to acquisition and analysis. M.J.V.-C., D.M.-T. and Á.C.-G. contributed to interpretation and drafted the manuscript. V.M.G.-C. and E.C.-S. critically revised the manuscript. All authors have read and agreed to the published version of the manuscript.


This project has been funded by Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO) for the conduction of II Grant on Nursing I&D&I 2020 (UGP-20-250). E.C.-S is affiliated with the Health Protection Research Unit in Healthcare-Associated Infection and Antimicrobial Resistance at Imperial College London.

Institutional Review Board Statement

This study was approved by the participating hospitals’ Clinical Research Committees (Castellón: PIC-2018-18; La Ribera: HULR_#17_2018; Xátiva: HLLA04/2018). All written informed consents of participants who willingly and anonymously took part were previously collected. This study was designed in accordance with the legislation in place in Spain on personal data protection (Law 3/2018, 5 December, on Personal Data Protection and Guaranteeing Digital Rights). The Declaration of Helsinki principles were respected.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Please note that the database is in an open repository. You can access the data through this link: (accessed on 20 February 2022).


The authors wish to acknowledge all the midwives and health professionals implicated in this study. We also need to thank the women for their support and participation.

Conflicts of Interest

The authors declare no conflict of interest.


  1. Chowdhury, R.; Sinha, B.; Sankar, M.J.; Taneja, S.; Bhandari, N.; Rollins, N.; Bahl, R.; Martines, J. Breastfeeding and Maternal Health Outcomes: A Systematic Review and Meta-Analysis. Acta Paediatr. Int. J. Paediatr. 2015, 104, 96–113. [Google Scholar] [CrossRef][Green Version]
  2. Kim, S.K.; Park, S.; Oh, J.; Kim, J.; Ahn, S. Interventions Promoting Exclusive Breastfeeding up to Six Months after Birth: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int. J. Nurs. Stud. 2018, 80, 94–105. [Google Scholar] [CrossRef]
  3. Victora, C.G.; Bahl, R.; Barros, A.J.D.; França, G.V.; Horton, S.; Krasevec, J.; Murch, S.; Sankar, M.J.; Walker, N.; Rollins, N.C. Breastfeeding in the 21st Century: Epidemiology, Mechanisms, and Lifelong Effect. Lancet 2016, 387, 475–490. [Google Scholar] [CrossRef][Green Version]
  4. Peñacoba, C.; Catala, P. Associations between Breastfeeding and Mother-Infant Relationships: A Systematic Review. Breastfeed. Med. 2019, 14, 616–629. [Google Scholar] [CrossRef] [PubMed]
  5. Hansen, K. Breastfeeding: A Smart Investment in People and in Economies. Lancet 2016, 387, 416. [Google Scholar] [CrossRef]
  6. Quesada, J.A.; Méndez, I.; Martín-Gil, R. The Economic Benefits of Increasing Breastfeeding Rates in Spain. Int. Breastfeed. J. 2020, 15, 34. [Google Scholar] [CrossRef]
  7. Linde, K.; Lehnig, F.; Nagl, M.; Kersting, A. The Association between Breastfeeding and Attachment: A Systematic Review. Midwifery 2020, 81, 102592. [Google Scholar] [CrossRef]
  8. United Nations International Children’s Emergency Fund Breastfeeding. A Mother’s Gift, for Every Child. Available online: (accessed on 2 February 2022).
  9. Ramiro González, M.D.; Ortiz Marrón, H.; Arana Cañedo-Argüelles, C.; Esparza Olcina, M.J.; Cortés Rico, O.; Terol Claramonte, M.; Ordobás Gavín, M. Prevalence of Breastfeeding and Factors Associated with the Start and Duration of Exclusive Breastfeeding in the Community of Madrid among Participants in the ELOIN. An. Pediatr. 2018, 89, 32–43. [Google Scholar] [CrossRef]
  10. Global Health Observatory Infants Exclusively Breastfed for the First Six Months of Life. Available online: (accessed on 3 January 2022).
  11. Bagci Bosi, A.T.; Eriksen, K.G.; Sobko, T.; Wijnhoven, T.M.A.; Breda, J. Breastfeeding Practices and Policies in WHO European Region Member States. Public Health Nutr. 2016, 19, 753–764. [Google Scholar] [CrossRef][Green Version]
  12. Cabedo, R.; Manresa, J.M.; Cambredó, M.V.; Montero, L.; Reyes, A.; Gol, R.; Falguera, G. Types of Breastfeeding and Reasons That Influence to Stop It before 6 Months. Lactem Study. Matronas Prof. 2019, 20, 54–61. [Google Scholar]
  13. Vila-Candel, R.; Soriano-Vidal, F.J.; Murillo-Llorente, M.; Pérez-Bermejo, M.; Castro-Sánchez, E. Maintenance of Exclusive Breastfeeding after Three Months Postpartum: An Experience in a Health Department of a Valencian Community. Aten. Primaria 2019, 51, 91–98. [Google Scholar] [CrossRef]
  14. Dutheil, F.; Méchin, G.; Vorilhon, P.; Benson, A.C.; Bottet, A.; Clinchamps, M.; Barasinski, C.; Navel, V. Breastfeeding after Returning to Work: A Systematic Review and Meta-Analysis. Int. J. Environ. Res. Public Health 2021, 18, 8631. [Google Scholar] [CrossRef]
  15. Patil, D.S.; Pundir, P.; Dhyani, V.S.; Krishnan, J.B.; Parsekar, S.S.; D’Souza, S.M.; Ravishankar, N.; Renjith, V. A Mixed-Methods Systematic Review on Barriers to Exclusive Breastfeeding. Nutr. Health 2020, 26, 323–346. [Google Scholar] [CrossRef] [PubMed]
  16. Oribe, M.; Lertxundi, A.; Basterrechea, M.; Begiristain, H.; Santa Marina, L.; Villar, M.; Dorronsoro, M.; Amiano, P.; Ibarluzea, J. Prevalence of Factors Associated with the Duration of Exclusive Breastfeeding during the First 6 Months of Life in the INMA Birth Cohort in Gipuzkoa. Gac. Sanit. 2015, 29, 4–9. [Google Scholar] [CrossRef] [PubMed][Green Version]
  17. Rius, J.M.; Ortuño, J.; Rivas, C.; Maravall, M.; Calzado, M.A.; López, A.; Aguar, M.; Vento, M. Factors Associated with Early Weaning in a Spanish Region. An. Pediatría 2014, 80, 6–15. [Google Scholar] [CrossRef]
  18. Yamashita, T.; Kunkel, S.R. An International Comparison of the Association among Literacy, Education, and Health across the United States, Canada, Switzerland, Italy, Norway, and Bermuda: Implications for Health Disparities. J. Health Commun. 2015, 20, 406–415. [Google Scholar] [CrossRef]
  19. Van Der Heide, I.; Wang, J.; Droomers, M.; Spreeuwenberg, P.; Rademakers, J.; Uiters, E. The Relationship between Health, Education, and Health Literacy: Results from the Dutch Adult Literacy and Life Skills Survey. J. Health Commun. 2013, 18, 172–184. [Google Scholar] [CrossRef] [PubMed][Green Version]
  20. Sorensen, K.; Van den Broucke, S.; Pelikan, J.M.; Fullam, J.; Doyle, G.; Slonska, Z.; Kondilis, B.; Stoffels, V.; Osborne, R.H.; Brand, H.; et al. Measuring Health Literacy in Populations: Illuminating the Design and Development Process of the European Health Literacy Survey Questionnair (HLS-EU-Q). BMC Public Health 2013, 13, 948. [Google Scholar] [CrossRef][Green Version]
  21. Haun, J.N.; Valerio, M.A.; McCormack, L.A.; Sørensen, K.; Paasche-Orlow, M.K. Health Literacy Measurement: An Inventory and Descriptive Summary of 51 Instruments. J. Health Commun. 2014, 19, 302–333. [Google Scholar] [CrossRef]
  22. Liu, C.; Wang, D.; Liu, C.; Jiang, J.; Wang, X.; Chen, H.; Ju, X.; Zhang, X. What Is the Meaning of Health Literacy? A Systematic Review and Qualitative Synthesis. Fam. Med. Community Health 2020, 8, e000351. [Google Scholar] [CrossRef]
  23. Castro-Sánchez, E.; Chang, P.W.S.; Vila-Candel, R.; Escobedo, A.A.; Holmes, A.H. Health Literacy and Infectious Diseases: Why Does It Matter? Int. J. Infect. Dis. 2016, 43, 103–110. [Google Scholar] [CrossRef] [PubMed][Green Version]
  24. Khorasani, E.C.; Peyman, N.; Esmaily, H. Relations between Breastfeeding Self-Efficacy and Maternal Health Literacy among Pregnant Women. Evid. Based Care J. 2017, 6, 18–25. [Google Scholar] [CrossRef]
  25. Vila-Candel, R.; Soriano-Vidal, F.J.; Mena-Tudela, D.; Quesada, J.A.; Castro-Sánchez, E. Health Literacy of Pregnant Women and Duration of Breastfeeding Maintenance: A Feasibility Study. J. Adv. Nurs. 2021, 77, 703–714. [Google Scholar] [CrossRef] [PubMed]
  26. Corrarino, J.E. Health Literacy and Women’s Health: Challenges and Opportunities. J. Midwifery Women’s Health 2013, 58, 257–264. [Google Scholar] [CrossRef]
  27. Valero-Chilleron, M.J.; González-Chordá, V.M.; Cervera-Gasch, Á.; Vila-Candel, R.; Soriano-Vidal, F.J.; Mena-Tudela, D. Health Literacy and Its Relation to Continuing with Breastfeeding at Six Months Postpartum in a Sample of Spanish Women. Nurs. Open 2021, 8, 3394–3402. [Google Scholar] [CrossRef] [PubMed]
  28. Báez León, C.; Blasco Contreras, R.; Martín Sequeros, E.; del Pozo Ayuso, M.L.; Sánchez Conde, A.I.; Vargas Hormigos, C. Validación Al Castellano de Una Escala de Evaluación de La Lactancia Materna: El LATCH. Análisis de Fiabilidad. Index Enferm. 2008, 17, 205–209. [Google Scholar] [CrossRef]
  29. Winkvist, A.; Brantsaeter, A.L.; Brandhagen, M.; Haugen, M.; Meltzer, H.M.; Lissner, L. Maternal Prepregnant Body Mass Index and Gestational Weight Gain Are Associated with Initiation and Duration of Breastfeeding among Norwegian Mothers. J. Nutr. 2015, 145, 1263–1270. [Google Scholar] [CrossRef]
  30. World Health Organization. Global Targets 2025. To Improve Maternal, Infant and Young Child Nutrition. Nutrition. Available online: (accessed on 3 March 2022).
  31. Weiss, B.D.; Mays, M.Z.; Martz, W.; Castro, K.M.; DeWalt, D.A.; Pignone, M.P.; Mockbee, J.; Hale, F.A. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Ann. Fam. Med. 2005, 3, 514–522. [Google Scholar] [CrossRef][Green Version]
  32. Warsh, J.; Chari, R.; Badaczewski, A.; Hossain, J.; Sharif, I. Can the Newest Vital Sign Be Used to Assess Health Literacy in Children and Adolescents? Clin. Pediatrics 2014, 53, 141–144. [Google Scholar] [CrossRef]
  33. Sarki, M.; Parlesak, A.; Robertson, A. Comparison of National Cross-Sectional Breast-Feeding Surveys by Maternal Education in Europe (2006–2016). Public Health Nutr. 2019, 22, 848–861. [Google Scholar] [CrossRef][Green Version]
  34. World Health Organitzation. Proportion of Infants Breastfed at Age 6 Months. European Health Information Gateway. Available online: (accessed on 21 January 2022).
  35. López de Aberasturi Ibáñez de Garayo, A.; Santos Ibáñez, N.; Ramos Castro, Y.; García Franco, M.; Artola Gutiérrez, C.; Arara Vidal, I. Prevalence and Determinants of Breastfeeding: The Zorrotzaurre Study. Nutr. Hosp. 2021, 38, 50–59. [Google Scholar] [CrossRef] [PubMed]
  36. Fernández-Cañadas Morillo, A.; Durán Duque, M.; Hernández López, A.B.; Muriel Miguel, C.; Martínez Rodríguez, B.; Oscoz Prim, A.; Pérez Riveiro, P.; Salcedo Mariña, A.; Royuela Vicente, A.; Casillas Santana, M.L.; et al. A Comparison of Factors Associated with Cessation of Exclusive Breastfeeding at 3 and 6 Months. Breastfeed. Med. 2017, 12, 430–435. [Google Scholar] [CrossRef] [PubMed]
  37. Lechosa-Muñiz, C.; Paz-Zulueta, M.; Sáez de Adana Herrero, M.; Cornejo del Rio, E.; Mateo Sota, S.; Llorca, J.; Cabero-Perez, M.J. Health Care Costs Associated to Type of Feeding in the First Year of Life. Int. J. Environ. Res. Public Health 2020, 17, 4719. [Google Scholar] [CrossRef] [PubMed]
  38. Parnell, T.A.; Stichler, J.F.; Barton, A.J.; Loan, L.A.; Boyle, D.K.; Allen, P.E. A Concept Analysis of Health Literacy. Nurs. Forum 2019, 54, 315–327. [Google Scholar] [CrossRef]
  39. Al-Sahab, B.; Lanes, A.; Feldman, M.; Tamim, H. Prevalence and Predictors of 6-Month Exclusive Breastfeeding among Canadian Women: A National Survey. BMC Pediatrics 2010, 10, 20. [Google Scholar] [CrossRef][Green Version]
  40. Rempel, L.A.; Rempel, J.K.; Moore, K.C.J. Relationships between Types of Father Breastfeeding Support and Breastfeeding Outcomes. Matern. Child Nutr. 2017, 13, e12337. [Google Scholar] [CrossRef]
  41. Bjorset, V.K.; Helle, C.; Hillesund, E.R.; Overby, N.C. Socio-Economic Status and Maternal BMI Are Associated with Duration of Breast-Feeding of Norwegian Infants. Public Health Nutr. 2018, 21, 1465–1473. [Google Scholar] [CrossRef][Green Version]
  42. Chen, C.; Cheng, G.; Pan, J. Socioeconomic Status and Breastfeeding in China: An Analysis of Data from a Longitudinal Nationwide Household Survey. BMC Pediatrics 2019, 19, 167. [Google Scholar] [CrossRef]
  43. Gómez-Acebo, I.; Dierssen-Sotos, T.; Palazuelos, C.; Castanõ-Vinyals, G.; Pérez-Gómez, B.; Amiano, P.; Fernández-Villa, T.; Ardanaz, E.; Suarez-Calleja, C.; Alguacil, J.; et al. Changes in Individual and Contextual Socio-Economic Level Influence on Reproductive Behavior in Spanish Women in the MCC-Spain Study. BMC Women’s Health 2020, 20, 72. [Google Scholar] [CrossRef][Green Version]
  44. Tchaconas, A.; Keim, S.A.; Heffern, D.; Adesman, A. Pediatric Care Providers, Family, and Friends as Sources of Breastfeeding Support beyond Infancy. Breastfeed. Med. 2018, 13, 116–122. [Google Scholar] [CrossRef]
  45. Fox, R.; McMullen, S.; Newburn, M. UK Women’s Experiences of Breastfeeding and Additional Breastfeeding Support: A Qualitative Study of Baby Café Services. BMC Pregnancy Childbirth 2015, 15, 147. [Google Scholar] [CrossRef] [PubMed][Green Version]
  46. Pemo, K.; Phillips, D.; Hutchinson, A.M. Midwives’ Perceptions of Barriers to Exclusive Breastfeeding in Bhutan: A Qualitative Study. Women Birth 2020, 33, e377–e384. [Google Scholar] [CrossRef] [PubMed]
  47. Dagher, R.K.; McGovern, P.M.; Schold, J.D.; Randall, X.J. Determinants of Breastfeeding Initiation and Cessation among Employed Mothers: A Prospective Cohort Study. BMC Pregnancy Childbirth 2016, 16, 194. [Google Scholar] [CrossRef] [PubMed][Green Version]
  48. Li, J.; Kendall, G.E.; Henderson, S.; Downie, J.; Landsborough, L.; Oddy, W.H. Maternal Psychosocial Well-Being in Pregnancy and Breastfeeding Duration. Acta Paediatr. Int. J. Paediatr. 2008, 97, 221–225. [Google Scholar] [CrossRef][Green Version]
  49. Camacho-Morell, F.; Esparcia, J. Influence and Use of Information Sources about Childbearing among Spanish Pregnant Women. Women Birth 2020, 33, 367–376. [Google Scholar] [CrossRef]
  50. Osborne, R.H.; Batterham, R.W.; Elsworth, G.R.; Hawkins, M.; Buchbinder, R. The Grounded Psychometric Development and Initial Validation of the Health Literacy Questionnaire (HLQ). BMC Public Health 2013, 13, 658. [Google Scholar] [CrossRef][Green Version]
  51. Cabellos-García, A.C.; Castro-Sánchez, E.; Martínez-Sabater, A.; Díaz-Herrera, M.Á.; Ocaña-Ortiz, A.; Juárez-Vela, R.; Gea-Caballero, V. Relationship between Determinants of Health, Equity, and Dimensions of Health Literacy in Patients with Cardiovascular Disease. Int. J. Environ. Res. Public Health 2020, 17, 2082. [Google Scholar] [CrossRef][Green Version]
  52. Altuntas, N.; Turkyilmaz, C.; Yildiz, H.; Kulali, F.; Hirfanoglu, I.; Onal, E.; Ergenekon, E.; Koç, E.; Atalay, Y. Validity and Reliability of the Infant Breastfeeding Assessment Tool, the Mother Baby Assessment Tool, and the LATCH Scoring System. Breastfeed. Med. 2014, 9, 191–195. [Google Scholar] [CrossRef]
  53. Shah, M.H.; Roshan, R.; Parikh, T.; Sathe, S.; Vaidya, U.; Pandit, A. LATCH Score at Discharge: A Predictor of Weight Gain and Exclusive Breastfeeding at 6 Weeks in Term Healthy Babies. J. Pediatr. Gastroenterol. Nutr. 2021, 72, e48–e52. [Google Scholar] [CrossRef]
  54. Sowjanya, S.V.N.S.; Venugopalan, L. LATCH Score as a Predictor of Exclusive Breastfeeding at 6 Weeks Postpartum: A Prospective Cohort Study. Breastfeed. Med. 2018, 13, 444–449. [Google Scholar] [CrossRef]
  55. Kumar, A.S.; Koppad, R.; Ashok, N.C.; Madhu, B.; Kumar, D.S.; Dhar, M.; Chandrashekar, S.V. Mothers Literacy Status and Its Association with Feeding Practices and PEM among 1-5 Year Aged Children in Southern Part of India, Mysore. Asian Pac. J. Trop. Dis. 2012, 2, S624–S628. [Google Scholar] [CrossRef]
  56. Chapman, D.J.; Kuhnly, J.E. Lactation Assessment Tools: A Qualitative Analysis of Registered Nurses’ Perceptions of Tool Limitations and Suggested Improvements. J. Hum. Lact. 2018, 34, 682–690. [Google Scholar] [CrossRef] [PubMed]
  57. Vila-Candel, R.; Martínez-Arnau, F.M.; de la Cámara-de Las Heras, J.M.; Castro-Sánchez, E.; Pérez-Ros, P. Interventions to Improve Health among Reproductive-Age Women of Low Health Literacy: A Systematic Review. Int. J. Environ. Res. Public Health 2020, 17, 7405. [Google Scholar] [CrossRef] [PubMed]
  58. Vila-Candel, R.; Duke, K.; Soriano-Vidal, F.J.; Castro-Sánchez, E. Affect of Early Skin-to-Skin Mother–Infant Contact in the Maintenance of Exclusive Breastfeeding: Experience in a Health Department in Spain. J. Hum. Lact. 2018, 34, 304–312. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Feeding type during the study period.
Figure 1. Feeding type during the study period.
Ijerph 19 05411 g001
Figure 2. Distribution of HL levels in relation to EBF at 6 months (N = 343).
Figure 2. Distribution of HL levels in relation to EBF at 6 months (N = 343).
Ijerph 19 05411 g002
Table 1. Characteristics of the included females (n = 343).
Table 1. Characteristics of the included females (n = 343).
EBF 6 monthsYes11734.1%
NVSAdequate HL level 17952.2%
Limited HL level16447.8%
Department of HealthLa Ribera21663.0%
Civil status Married21663.0%
Single, separated, divorced12737.0%
Level of educationPrimary or lower9728.3%
1st cycle, Secondary5816.9%
2nd cycle, Secondary8625.1%
University diploma4011.7%
Pregnant women’s occupationBusinesswoman/Professional3510.2%
Not looking for a job216.1%
Country of originSpain27881.0%
Partner’s occupationEmployee27379.6%
Two or more16748.7%
Skin-to-skin contact at birthNo3811.1%
Birth typeSpontaneous20258.9%
Risk pregnancyLow risk23668.8%
High risk *10731.2%
nMean (SD)
Mother’s age(years)34332.5 (5.2)
Age with first pregnancy(years)34329.8 (5.7)
Gestational week at birth(weeks)34339.3 (1.1)
LATCH score(0 to 10)3438.8 (0.9)
Birth weight(grams)3433301.2 (464.5)
EBF: exclusive breastfeeding; NVS: Newest Vital Sign; STC: segment transverse caesarean; LATCH: Latch audible type comfort hold. * High risk pregnancy = Preeclampsia, Gestational diabetes, Obesity, Low body mass index, Mother age > 35 years, Assisted Reproductive Treatment, Thyroid pathology, Small for gestational age, large for gestational age, fetal growth restriction, Autoimmune diseases, Previous cesarean section, Previous preterm birth and Hepatitis Virus infection.
Table 2. Relation between HL levels (NVS) and the studied variables.
Table 2. Relation between HL levels (NVS) and the studied variables.
Adequate HL LevelLimited HL Level
n%n%p-Value 1
Department of HealthLa Ribera10749.510950.50.424
Civil statusMarried11452.810247.20.775
Single, separated, divorced6551.26248.8
Level of educationPrimary or lower3536.16263.9<0.001
1st cycle, Secondary1932.83967.2
2nd cycle, Secondary4451.24248.8
University diploma3280.0820.0
Pregnant women’s occupationBusinesswoman2365.71234.30.003
Not looking for a job419.01781.0
Country of originSpain16459.011441.0<0.001
Partner’s occupationEmployee14854.212545.80.183
Two or more8047.98752.1
Skin-to-skin contact at birthNo1950.01950.00.775
Birth typeSpontaneous9547.010753.00.068
Risk pregnancyLow risk11548.712151.30.057
High risk6459.84340.2
nMean (SD)nMean (SD)p-value 2
Mother’s age(years)17933.5 (4.8)16431.4 (5.5)0.001
Gestational week at birth(weeks)17939.3 (1.1)16439.4 (1.1)0.765
LATCH score(0 to 10)1798.9 (0.9)1648.7 (0.9)0.037
Birth weight(grams)1793281 (476.6)1643311 (452.2)0.684
EBF: exclusive breastfeeding; NVS: Newest Vital Sign; STC: segment transverse caesarean; LATCH: Latch audible type comfort hold: 1 Chi-square test; 2 Student’s t-test.
Table 3. Factors related to EBF cessation before 6 months.
Table 3. Factors related to EBF cessation before 6 months.
EBF 6 Months: YesEBF 6 Months: No
n%n%p-Value 1
NVSAdequate HL level7944.110055.9<0.001
Limited HL level3823.212676.8
Department of HealthLa Ribera6530.115169.90.105
Civil status Married8941.212758.8<0.001
Single, separated, divorced2822.09978.0
Level of educationPrimary or lower2525.87274.20.022
1st cycle, Secondary2237.93662.1
2nd cycle, Secondary2933.75766.3
University diploma2255.01845.0
Pregnant women’s occupationBusinesswoman1131.42468.60.850
Not looking for a job733.31466.7
Country of originSpain10036.017864.00.133
Partner’s occupationEmployee9534.817865.20.330
Two or more5935.310864.7
Skin-to-skin contact at birthNo923.72976.30.151
Birth typeSpontaneous6230.714069.30.255
Risk pregnancyLow risk7632.216067.80.268
High risk4138.36661.7
nMean (SD)nMean (SD)p-value 2
Mother’s age(years)11733.2 (4.5)22632.1 (5.6)0.049
Gestational week at birth(weeks)11739.3 (1.0)22639.4 (1.1)0.498
LATCH score(0 to 10)1179.2 (0.8)2268.7 (0.9)<0.001
Birth weight(grams)1173328 (474.7)2263286 (459.6)0.637
EBF: exclusive breastfeeding; NVS: Newest Vital Sign; STC: segment transverse caesarean; LATCH: Latch audible type comfort hold: 1 Chi-square test; 2 Mann–Whitney test.
Table 4. Multivariate logistic model for EBF cessation before 6 months.
Table 4. Multivariate logistic model for EBF cessation before 6 months.
OR95% CIp-Value
NVSAdequate HL level1
Limited HL level2.52(1.45–4.36)0.001
Civil statusMarried1
Single, separated, divorced, widowed2.32(1.34–4.01)0.003
Level of educationPrimary or lower1
1st cycle, Secondary0.62(0.30–1.31)0.210
2nd cycle, Secondary0.86(0.43–1.73)0.664
University diploma0.51(0.22–1.20)0.124
Mother’s age(years)0.99(0.94–1.04)0.569
LATCH score(range 6 to 10)0.53(0.40–0.71)<0.001
n model = 343; n EBF cessation = 226; ROC area = 0.7401, 95% CI: 0.6868–0.7933; Likelihood Ratio Test = 58.0 (p < 0.001). NVS: Newest Vital Sign; OR: Odds Ratio; 95% CI: 95% confidence interval.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Valero-Chillerón, M.J.; Mena-Tudela, D.; Cervera-Gasch, Á.; González-Chordá, V.M.; Soriano-Vidal, F.J.; Quesada, J.A.; Castro-Sánchez, E.; Vila-Candel, R. Influence of Health Literacy on Maintenance of Exclusive Breastfeeding at 6 Months Postpartum: A Multicentre Study. Int. J. Environ. Res. Public Health 2022, 19, 5411.

AMA Style

Valero-Chillerón MJ, Mena-Tudela D, Cervera-Gasch Á, González-Chordá VM, Soriano-Vidal FJ, Quesada JA, Castro-Sánchez E, Vila-Candel R. Influence of Health Literacy on Maintenance of Exclusive Breastfeeding at 6 Months Postpartum: A Multicentre Study. International Journal of Environmental Research and Public Health. 2022; 19(9):5411.

Chicago/Turabian Style

Valero-Chillerón, María Jesús, Desirée Mena-Tudela, Águeda Cervera-Gasch, Víctor Manuel González-Chordá, Francisco Javier Soriano-Vidal, José Antonio Quesada, Enrique Castro-Sánchez, and Rafael Vila-Candel. 2022. "Influence of Health Literacy on Maintenance of Exclusive Breastfeeding at 6 Months Postpartum: A Multicentre Study" International Journal of Environmental Research and Public Health 19, no. 9: 5411.

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop