Advertisement

Early predictors of short duration of exclusive breastfeeding among Havana women

Open AccessPublished:June 22, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101098

      Abstract

      Problem

      In Cuba, only 40.9% of infants under the age of six months are exclusively breastfed with the average duration of exclusivity being only 2.4 months. Evidence to guide the development of breastfeeding interventions among Cuban women to achieve exclusive breastfeeding to six months is limited. The objective was to identify early predictors for discontinuation of exclusive breastfeeding before six months among Cuban women.

      Methods

      In a cohort study, 273 maternal-infant pairs were recruited immediately following childbirth at a public hospital in Havana, Cuba and followed up to six months postpartum. A univariate and multivariate strategy was used to identify early predictors of the discontinuation of exclusive breastfeeding before six months.

      Results

      While all women were exclusively breastfeeding at hospital discharge, only 20.5% continued to six months postpartum. The average duration of exclusive breastfeeding was 3.13 months (SD ± 2.14 months). Factors associated with the early discontinuation of exclusive breastfeeding were: (1) breastfeeding not initiated within the first hour of birth, (2) infant birthweight <3.3 kgs, (3) pacifier use, (4) maternal dissatisfaction with infant growth, (5) maternal mental health problems at one month and (6) low breastfeeding self-efficacy at birth and one month. In the multivariate analysis, only maternal dissatisfaction with infant growth progress at one month and birth weight <3.3 kg predicted the early discontinuation of exclusive breastfeeding.

      Conclusion

      Women who gave birth to an infant with a lower birth weight and were dissatisfied with their infant's growth trajectory were high risk to prematurely discontinue exclusive breastfeeding before six months.

      Keywords

      1. Introduction

      The World Health Organization (WHO) recommends breastfeeding should be initiated within the first hour of birth and continued exclusively to six months postpartum.
      World Health Organization
      Exclusive breastfeeding for six months best for babies everywhere. Statement.
      ,
      UNICEF
      Breastfeeding: A Mother's Gift for Every Child.
      It has been well documented over the past 30 years that breastfeeding has a significant positive effect on child health and development.
      • Horta B.L.
      • Loret De Mola C.
      • Victora C.G.
      Breastfeeding and intelligence: a systematic review and meta-analysis.
      • Yan J.
      • Liu L.
      • Zhu Y.
      • Huang G.
      • Wang P.P.
      The association between breastfeeding and childhood obesity: a meta-analysis.
      • Horta B.L.
      • Loret De Mola C.
      • Victora C.G.
      Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and meta-analysis.
      • Sankar M.J.
      • Sinha B.
      • Chowdhury R.
      • et al.
      Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis.
      Further, there is ever-growing evidence to suggest that an increase in the duration of exclusive breastfeeding may be associated with a reduction in the risk of the child being overweight and developing obesity later in life.
      • Yan J.
      • Liu L.
      • Zhu Y.
      • Huang G.
      • Wang P.P.
      The association between breastfeeding and childhood obesity: a meta-analysis.
      ,
      • Abarin T.
      • Yan Wu Y.
      • Warrington N.
      • Lye S.
      • Pennell C.
      • Briollais L.
      The impact of breastfeeding on FTO-related BMI growth trajectories: an application to the Raine pregnancy cohort study.
      Given that obesity is an important risk factor for cardiovascular disease, diabetes, and mental health, exclusive breastfeeding to six months postpartum may be an important preventative strategy to address the rising rates of non-communicable diseases.
      • Boivin M.
      • Pérusse D.
      • Dionne G.
      • et al.
      The genetic-environmental etiology of parents' perceptions and self-assessed behaviours toward their 5-month-old infants in a large twin and singleton sample.
      ,
      • Yeste D.
      • Carrascosa A.
      [Obesity-related metabolic disorders in childhood and adolescence].
      Breastfeeding is also beneficial for mothers since it may provide protection against postpartum hemorrhage, breast and ovarian cancers, and type 2 diabetes mellitus.
      UNICEF
      Breastfeeding: A Mother's Gift for Every Child.
      The scaling up of breastfeeding to a near-universal level internationally could prevent 823,000 annual deaths in children younger than 5 years and 20,000 annual deaths from breast cancer.
      • Victora C.G.
      • Bahl R.
      • Barros A.J.D.
      • et al.
      Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.
      Despite these important short and long-term benefits, globally only 42% of infants less than six months of age are exclusively breastfed.
      UNICEF. Global Breastfeeding Scorecard
      Tracking progress for breastfeeding policies and programmes. Webpage.
      In Cuba, only 40.9% of infants under the age of six months are exclusively breastfed with the average duration of exclusivity being only 2.4 months.
      Dirección de Registros Médicos y Estadísticas de Salud
      Anuario Estadístico de Salud 2018.
      While the Cuban government has made a significant investment into improving maternal and child health outcomes, breastfeeding exclusivity to six months remains an unattained goal. The Cuban government is aligned with the WHO Nutrition Goals and the Sustainable Development Goals and has set a goal to increase exclusive breastfeeding prevalence rate to 50% by 2025 among infants under six months of age.
      World Health Organization
      Global targets 2025. To improve maternal, infant and young child nutrition. Webpage.
      Evidence to guide the development of breastfeeding interventions among Cuban women to achieve this goal is limited as there is no data to identify potential targetable risk factors to support continued exclusivity. To date, Cuban breastfeeding studies have been primarily descriptive
      • Fernández Brizuela E. de J.
      Estudio bibliométrico sobre lactancia materna en las revistas médicas cubanas durante el período 2009-2013.
      and little is known about modifiable behaviors that influence the duration of exclusive breastfeeding to six months postpartum. The purpose of this study was to identify early predictors of the discontinuation of exclusive breastfeeding before six months among Cuban women. These data will be used to guide the development of culturally appropriate breastfeeding support interventions.

      2. Methods

      2.1 Participants and procedures

      A prospective cohort study was conducted where mother-infant pairs were recruited immediately after birth at Ángel Arturo Aballí Hospital in Havana, Cuba. This hospital is a maternal and Child hospital that holds the status of Mother and Child Friendly Hospital, which implements the ten steps established for successful breastfeeding. In Cuba, almost all (99%) of the deliveries are institutional, and most women are discharged within 48 hours if they do not have any complications.
      Recruitment occurred from January to June 2016 among mothers who resided in the health care areas of the Los Pinos, Capri, Párraga and Grimau polyclinics. For women to be considered eligible, they had to have a live singleton term birth and they were excluded if they had a severe health condition during pregnancy or the postpartum period that could interfere with breastfeeding or an infant who required NICU care. Following informed consent procedures, pediatricians conducted semi-structured interviews with participants in the immediate postpartum period before hospital discharge. Subsequent follow-up interviews were conducted every 4 weeks (±3 days) during the child's well-baby visit at the local health clinics by trained research staff until six-months postpartum. The Ethics Committee of the School of Medical Sciences Julio Trigo López approved the project protocol as did the Ministry of Health of Cuba.

      2.2 Predictor variables

      Exclusive breastfeeding was defined as no other food or drink, not even water, except breast milk (including expressed breast milk) to 6 months postpartum.
      World Health Organization
      Infant and yound child feeding. Webpage.
      The discontinuation of exclusive breastfeeding before six months was considered the dependent variable in this study. The independent variables were classified into four domains: (1) sociodemographic, (2) obstetric and infant health, (3) maternal satisfaction with support and infant growth, and (4) maternal psychological state.
      Sociodemographic variables included: maternal age (<20, 20–35, >35 years); skin color (white, black, mestizo); highest level of education completed (elementary school, high school, university); occupation (housewife, state worker, other); cohabiting with the infant's father (yes, no); maternal smoking status at one month (yes, no); and family functioning using the measure developed by Louro
      • Louro I.
      Familia en el ejercicio de la medicina general integral.
      where scores 70-57 = good family functioning, 56-43 = moderate family functioning, and ≤42 = poor family functioning. Obstetric and infant variables included: parity (primiparous, multiparous), type of delivery (vaginal, cesarean section), initiation of breastfeeding in the first hour of delivery (yes, no), informed about the benefits of exclusive breastfeeding (yes, no), infant sex (male, female), birth weight (≥3.3 kg, which was the sample's mean birth weight, <3.3 kg), and use of a pacifier at one month of age (yes, no). Maternal satisfaction variables included: perceptions of breastfeeding progress (satisfied, unsatisfied), partner breastfeeding support (satisfied, unsatisfied), family and friends breastfeeding support (satisfied, unsatisfied), and infant growth trajectory (very satisfied, satisfied, and unsatisfied).
      Finally, variables assessing maternal psychological state included: anxiety assessed using the State-Trait Anxiety Inventory (STAI) (no presence of anxiety: 40 or presence of anxiety: > 40)
      • Dennis C.L.
      • Falah-Hassani K.
      • Shiri R.
      Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis.
      ,
      • Grigoriadis S.
      • Graves L.
      • Peer M.
      • et al.
      Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: systematic review and meta-analysis.
      and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) (no presence of depression symptoms: 9 or presence of depression symptoms: > 9).
      • Dennis C.L.
      • Falah-Hassani K.
      • Shiri R.
      Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis.
      The presence of comorbid anxiety and depression (STAI >40 and EPDS >9) were also assessed. Maternal breastfeeding self-efficacy was examined in-hospital and at one month postpartum using the Spanish version of the Breastfeeding Self-Efficacy Scale-short form (BSES-SF) developed by Dennis
      • Dennis C.L.
      • Creedy D.
      Psychosocial and psychological interventions for preventing postpartum depression.
      and validated in Spanish by Oliver.
      • Oliver-Roig A.
      • D'Anglade-González M.L.L.
      • García-García B.
      • Silva-Tubio J.R.R.
      • Richart-Martínez M.
      • Dennis C.L.L.
      The Spanish version of the breastfeeding self-efficacy scale-short form: reliability and validity assessment.
      High breastfeeding self-efficacy was a BSES-SF score ≥ than the sample mean.

      2.3 Statistical analysis

      Descriptive statistics were summarized using absolute numbers and percentages, means, and standard deviations. The dependent variable was average duration in months of exclusive breastfeeding. The univariate associations between the independent variables selected and the duration of exclusive breastfeeding were explored by comparing, with the use of t-test and ANOVA, the means of duration of exclusive breastfeeding in months according to categories of above-mentioned variables. The percentages of missing data for the independent variables were less than 10%. To estimate the strength of the association in the cases where this was significant, the Odds Ratio (OR) was calculated using a 95% Confidence Interval (CI). From these results, a multivariate analysis was performed using multiple logistic regression with dichotomous responses to assess which variables contributed to a significant independent risk of short duration of exclusive breastfeeding and only significant variables were included in the final model. The data did not show multicollinearity between the predictor variables. With the information obtained, data was processed using the SPSS Version 22 program.

      3. Results

      During the six months of recruitment, 341 women were eligible to participate in the study and were recruited. Of these, 273 (80.0%) completed the monthly interviews to six months postpartum. Reasons for withdrawal included moving out of the study area (n = 13, 3.8%), refusal to complete a follow up interview (n = 8, 2.3%), and living outside the geographical area despite being cared for during pregnancy within the area (n = 47, 13.8%).
      All participants were exclusively breastfeeding at hospital discharge. The percentage of women exclusive breastfeeding declined steadily to 82.1% at one month, 61.9% at three months and 20.5% at six-months postpartum. About half of the women were mestizo ethnicity (51.6%), had high school education or more (52.0%), and classified themselves as housewives (54.2%). The majority were between 20 and 35 years old (75.8%), lived with the infant's father (86.4%), and were considered living in a functional family (62.3%). Approximately two-thirds of women were primiparous (61%), had a vaginal delivery (61.0%), and breastfed their infant in the first hour after birth (60.8%). A high percentage (82.4%) reported being informed about the benefits of breastfeeding and 83.2% were satisfied with the progress of breastfeeding in-hospital. At one month, 81.9% of women were satisfied with their infant's growth, 75.8% were satisfied with the breastfeeding support from their partner, and 71.8% reported being satisfied with their family support. As for the infants, 50.2% were male, 51.1% had a birth weight ≥3.3 kg, and 24.2% used a pacifier at one month of age.
      The mean score for the breastfeeding-self-efficacy scale did not change significantly from hospital discharge (M: 60.6; SD ± 7.2) to one month postpartum (M: 60.2; SD ± 8.9). In total, 48.0% of mothers in-hospital and 51.4% at one month were classified as having high breastfeeding self-efficacy. Ten percent of women had high anxiety with an STAI score >40 in the immediate postpartum period, increasing slightly to 12.0% at one month. Similarly, 17.6% had depressive symptoms in the immediate postpartum period as demonstrated with an EPDS score >9 decreasing to 11.3% at one month. Comorbid symptoms of both high anxiety and depressive symptoms were reported by 3.1% of women in the immediate postpartum period, increasing to 6.4% at one month.

      3.1 Variables associated with the duration of exclusive breastfeeding

      The mean duration of exclusive breastfeeding was 3.13 months (SD ± 2.14).
      Variables associated with the average monthly duration of exclusive breastfeeding included: not initiating breastfeeding during the first hour after birth (p = .008), infant birthweight <3.3 kg (p = .003), use of a pacifier at one month (p = .003), dissatisfaction with infant growth at one month (p = .001), low breastfeeding self-efficacy in-hospital (p = .041) and at one month (p = .003), high anxiety (p = .050), symptoms of depression (p = .008) or comorbidity (p = .08) at one month (Table 1). Building upon these differences, the following variables significantly predicted a shorter duration of exclusive breastfeeding: did not initiate breastfeeding after the first hour of birth (OR: 1.84, 95% CI: 1.11–3.04), infant birthweight <3.3 kg (OR: 1.88, 95% CI: 1.15–3.08), pacifier use at one month (OR: 1.98, 95% CI: 1.11–3.55), mother dissatisfaction with infant growth at one month (OR: 3.02; CI: 95%: 1.53–5.95), low breastfeeding self-efficacy in-hospital (OR:1.85; IC 95%:1.06–3.22) and at one month (OR: 1.89, 95% CI: 1.13–3.15), maternal anxiety (OR: 2.93, 95% CI: 1.33–6.46), depression (OR: 2.60, 95% CI: 1.17–5.77) or comorbidity (anxiety and depression) (OR: 3.73, 95% CI: 1.27–10.92) at one month (Table 2).
      Table 1Maternal variables and differences in mean duration (in months) of exclusive breastfeeding.
      VARIABLECATEGORIESN(%)Mean duration of breastfeedingaSDbP *
      SOCIO-DEMOGRAPHIC VARIABLES
      RaceWhite10538.52.942.1520.485
      Black279.93.192.298
      Mestizo14151.63.272.074
      Age<204315.83.101.9610.807
      20–3520775.83.172.140
      >35238.42.862.494
      Level of EducationElementary School9936.33.092.1670.059
      High School14252.02.952.074
      University3211.73.942.124
      OccupationHousewife14854.23.132.1950.784
      State worker10137.03.172.059
      Others248.82.832.057
      Family functioning

      Marital status of the parents
      Functional15762.33.322.121.497
      Moderately functional7128.22.962.045
      Dysfunctional249.53.212.413
      Mother living with the infant's fatherYes23686.43.142.153.719
      No3713.63.001.986
      Mother's smoking status 1monthYes2910.62.652.497.174
      No24489.43.252.044
      OBSTETRIC VARIABLES AND RELATED TO THE INFANT
      ParityPrimiparous16761.23.142.036.846
      Multiparous10638.83.082.277
      Delivery typeVaginal16661.03.302.172.086
      Caesarean Section10639.02.842.048
      Breastfeeding initiated within the first hour of birthYes16160.83.412.164.008**
      No10739.22.702.033
      Informed of EB benefitsYes22582.43.032.148.167
      No4817.63.502.032
      Infant's sexMale13750.23.032.054.494
      Female13649.83.212.205
      Birthweight<3.3 kg13348.92.742.095.003**
      ≥3.3 kg13951.13.502.093
      Uses pacifier at 1 monthYes6624.22.562.240.010**
      No20775.83.352.049
      VARIABLES RELATED TO THE PERCEPTIONS OF MOTHERS
      Progress of breastfeeding at hospitalSatisfied22783.23.162.118.477
      Unsatisfied4616.82.912.189
      Satisfied with breastfeeding partner support at 1 monthYes20775.83.292.087.165
      No6624.22.852.227
      Satisfied with breastfeeding family support at 1 monthYes19671.83.272.051.275
      No7728.22.942.235
      Satisfied with the infant's growth at 1 monthVery satisfied19981.93.282.050.001**
      Satisfied3914.82.082.143
      Unsatisfied83.31.502.070
      VARIABLES RELATED TO THE PSYCHOLOGICAL STATUS OF MOTHERS
      Breastfeeding self-efficacy at HospitalHigh12348.03.422.064.041*
      Low13352.02.882.164
      Breastfeeding self-efficacy at 1 monthHigh12751.43.541.975.003**
      Low12048.62.732.241
      Anxiety symptoms (STAI>40) in-hospitalNo23390.03.182.063.620
      Yes2610.02.922.481
      Anxiety symptoms (STAI) 1 monthNo22188.03.222.093.050*
      Yes3012.02.402.444
      Depression symptoms (EPDS>9) in-hospitalNo21682.43.192.086.488
      Yes4617.62.962.231
      Depression symptoms (EPDS>9)1 monthNo22888.73.222.096.008**
      Yes2911.32.102.350
      Comorbidity in-hospitalNo25196.93.182.081.291
      Yes83.12.382.825
      Comorbidity 1 monthNo23593.63.202.102.016*
      Yes166.41.882.500
      a in months; b Standard Deviation (SD).
      *Test t - Student: Dichotomous variables * significant difference at 5%, ** significant difference at 1%.
      ANOVA test: Polychotomous variables * significant difference at 5%; ** significant difference at 1%.
      Table 2Variables associated with a shorter duration of exclusive breastfeeding among Havana women in the univariate analysis.
      VARIABLECrude ORsConfidence interval 95%
      MinMax
      Breastfeeding initiated within the first hour of birth
      Yes (reference)1.0
      No1.841.113.04
      Infant's weight at birth
      <3.3 kg1.881.153.08
      ≥3.3 kg (reference)1.0
      Pacifier's use at 1 month
      Yes1.981.113.55
      No (reference)1.0
      Infant's growth satisfaction at 1 month
      Satisfied (reference)1.0
      Unsatisfied3.021.535.95
      Breastfeeding self-efficacy at Hospital
      High (reference)1.0
      Low1.851.063.22
      Breastfeeding self-efficacy at 1 month
      High (reference)1.0
      Low1.891.133.15
      Maternal anxiety (STAI) 1 month
      Presence2.931.336.46
      No presence (reference)1.0
      Maternal depression (Edinburgh) 1 month
      Presence2.601.175.77
      No presence (reference)1.0
      Comorbidity 1 month
      Presence3.731.2710.92
      No presence (reference)1.0
      In multivariate analysis, the only variables that remained in the final model as independent predictors of short duration of exclusive breastfeeding included: dissatisfaction with infant growth at one month (OR: 3.164; 95% CI: 1.373–7.288) and birth weight <3.3 kg (OR: 1.898; 95% CI: 1.010–3.569, Table 3). The Hosmer Lemeshow test (Chi-square = 0.108; p = .948) showed that there were no significant differences between the observed and expected values of the dependent variable, suggesting that the model obtained fitted the data well (OR:1.85; IC 95%:1.06–3.22).
      Table 3Variables associated with a shorter duration of exclusive breastfeeding among Havana women in the multivariate logistic regression.
      VariableCoefficientE. T.SigOR adjustIC del 95%
      InferiorSuperior
      Unsatisfied with the infant's growth at 1 month1.152.426.0073.1641.3737.288
      Birth weight <3.3 kg.641.322.0471.8981.0103.569
      Constant−1.024.245.000.359

      4. Discussion

      Focusing on the purpose of this study, this is the first study among Cuban women to examine factors predictive of a short duration/discontinuation of exclusive breastfeeding before six months postpartum. Overall, we found a high rates of exclusive breastfeeding at one month (82.1%) at one month which decreased to 61.9% at three months postpartum. However, there was a significant drop in exclusivity to 20.5% at six months postpartum. Among the sociodemographic and other variables examined to identify predictors of a shorter duration of exclusivity only infant birth weight and maternal satisfaction with infant growth at one month postpartum were significant.
      According to UNICEF data, 91.8% of infants are breastfed for the first two days after birth and 40.6% are exclusively breastfed up to five months of age.
      UNICEF
      Infant and young child feeding (IYCF) data. Webpage.
      Cuba rates are similar to the global average of exclusive breastfeeding up to five months of age (44%) and slightly higher than the Latin American & Caribbean average at 37%.
      UNICEF
      Infant and young child feeding (IYCF) data. Webpage.
      Thus, our findings are consistent with the national rates and provide valuable insight into the decline in exclusive breastfeeding between birth and sixmonths postpartum. The multivariate logistic regression identified two factors that influenced the duration of exclusive breastfeeding, and both focused on infant weight. The unsatisfaction of the mothers with the progress of the infant's growth at one month of age and the birth weight less than 3.3 kg were early predictors of shorter duration of exclusive breastfeeding, increasing the probability more than twice. Other studies have found that mothers who have concern around infant weight gain can be a potential risk factor for cessation of exclusive breastfeeding.
      • DiTomasso D.
      • Wambach K.A.
      • Roberts M.B.
      • Erickson-Owens D.A.
      • Quigley A.
      • Newbury J.M.
      Maternal worry about infant weight and its influence on artificial milk supplementation and breastfeeding cessation.
      It is not necessarily the weight itself that is an issue, as 3.3 kg is reflects the mean of this sample rather than a clinically low birth weight; but more so mothers' perceptions about growth of their children if they are less than the average in the population. This could be possibly influenced by social reasons in that mothers consider “bigger is better” whereby they associate the presence of overweight in the infant with better health, which leads them to use early milk formula and complementary foods to increase the weight of the infant.
      • Nasser A.
      • Omer F.
      • Al-Lenqawi F.
      • et al.
      Predictors of continued breastfeeding at one year among women attending primary healthcare centers in Qatar: a cross-sectional study.
      Similarly, evidence suggest that infants with lower birth weight are more likely to have a shorter duration of exclusive breastfeeding.
      • Flaherman V.J.
      • McKean M.
      • Cabana M.D.
      Higher birth weight improves rates of exclusive breastfeeding through 3 Months.
      ,
      • Matias S.L.
      • Nommsen-Rivers L.A.
      • Dewey K.G.
      Determinants of exclusive breastfeeding in a cohort of primiparous periurban peruvian mothers.
      Thus, the current findings, along with existing evidence, suggest that these risk factors should alert health professionals about the increased risk of early abandonment of exclusive breastfeeding. Further interventions should focus on identifying strategies to improve exclusive breastfeeding among mothers concerned about their infant's weight.
      Results of this study are interesting in that no association was found between maternal age, education, partner support or family functioning and breastfeeding exclusivity. This is contradictory to previous research which has highlighted the importance of maternal demographic factors and her support system.
      • Meedya S.
      • Fahy K.
      • Kable A.
      Factors that positively influence breastfeeding duration to 6 months: a literature review.
      The universal coverage of the Cuban Health System and the guidelines of the Maternal and Child Health Program (MCHP), which provides ten antenatal visits among women with uncomplicated pregnancies, and biweekly follow-up visits in the first three months moving to monthly afterwards for the first year postpartum
      • Castro-Pacheco B.L.
      • Cuellar Alvarez R.
      • Ibargollen Negrin L.
      • Equivel Lauzurique M.
      • Machado Lubian M.
      • Matinez Corredera A.
      Cuban Experience in Child Health Care 1959-2006.
      ,
      • Esquivel M.
      • Álvarez G.
      • Izquierdo M.E.
      • Martínez D.
      • Tamayo V.
      Well child care: a comprehensive strategy for Cuban children and adolescents.
      may have attenuated the differences that other authors have identified in relation to demographic and social variables.
      Among delivery and hospital practice variables analyzed, only breastfeeding initiated within the first hour of birth showed a significant association with the duration of exclusive breastfeeding. Early initiation of breastfeeding is one of the Baby Friendly Hospital Initiative recommendations suggested by the WHO to support the continuation of breastfeeding.
      UNICEF
      Breastfeeding: A Mother's Gift for Every Child.
      Considering national data, only 64.1% of Cuban mothers met this WHO recommendations
      Ministerio de Salud Pública
      Dirección de Registros Médicos y estadísticas de Salud.
      yet the current study found that 100% of infants were being exclusive breastfeed upon hospital discharge. Regardless, breastfeeding initiation soon after delivery requires attention and is an important area to target the improvement of postpartum care. Parity and type of delivery were not associated with breastfeeding exclusivity among Cuban women, a finding similar to some research
      • Fukui N.
      • Motegi T.
      • Watanabe Y.
      • et al.
      Exclusive breastfeeding is not associated with maternal-infant bonding in early postpartum, considering depression, anxiety, and parity.
      but not others.
      • Hussien J.
      • Assefa S.
      • Liben M.L.
      Breastfeeding performance in Afar regional state, northeastern Ethiopia: a cross sectional study.
      Most of the women reported being informed of the benefits of exclusive breastfeeding but this did not translate into continued exclusivity to six months postpartum. Interventions related to breastfeeding oftentimes have several components: social and media mobilization, development of legislation, policies, and financing and, in addition, counseling along with support and management at the individual level of breastfeeding.
      • Rollins N.C.
      • Bhandari N.
      • Hajeebhoy N.
      • et al.
      Why invest, and what it will take to improve breastfeeding practices?.
      In Cuba, as part of the social protection system, working mothers receive a paid prenatal leave from 34 weeks of gestation that extends through the first year postpartum.
      UNICEF
      Early childhood development in Cuba. Webpage.
      Clearly education alone is insufficient to improve breastfeeding outcomes and a multi-pronged approach is required, including counseling and health system changes.
      • Sinha B.
      • Chowdhury R.
      • Sankar M.J.
      • et al.
      Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis.
      Evidence suggests that breastfeeding interventions spanning the whole perinatal period (e.g., delivered across the antenatal and postnatal period) are often the most effective at improving exclusive breastfeeding,
      • Wong M.S.
      • Mou H.
      • Chien W.T.
      Effectiveness of educational and supportive intervention for primiparous women on breastfeeding related outcomes and breastfeeding self-efficacy: a systematic review and meta-analysis.
      ,
      • Imdad A.
      • Yakoob M.Y.
      • Bhutta Z.A.
      Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries.
      The variables that were related to the psychological state were of great interested given they have not been previously studied with Cuban women. Low breastfeeding self-efficacy and the presence of mental health concerns such as anxiety, depression, or co-morbidity in women at the immediate postpartum period and at one-month significantly increased the risk for a shorter duration of exclusive breastfeeding. Dennis
      • Dennis C.L.
      Theoretical underpinnings of breastfeeding confidence: a self-efficacy framework.
      defined breastfeeding self-efficacy as a mother's confidence in her ability to breastfeed and predicts whether a mother chooses to breastfeed, how much effort she will expend, whether she will have self-enhancing or self-defeating thought patterns, and how she will emotionally respond to breastfeeding difficulties. Our results confirm similar findings reported by the literature, with higher breastfeeding self-efficacy associated with increased exclusive breastfeeding rates.
      • Mituki D.
      • Tuitoek P.
      • Varpolatai A.
      • Taabu I.
      • Machado M.C.M.
      • Assis K.F.
      • Oliveira F. de CC.
      • et al.
      Determinants of the exclusive breastfeeding abandonment: psychosocial factors.
      • de Jager E.
      • Skouteris H.
      • Broadbent J.
      • Amir L.
      • Mellor K.
      Psychosocial correlates of exclusive breastfeeding: a systematic review.
      Systematic reviews have also found that postpartum depression and anxiety are associated with lower breastfeeding duration and exclusivity rates.
      • de Jager E.
      • Skouteris H.
      • Broadbent J.
      • Amir L.
      • Mellor K.
      Psychosocial correlates of exclusive breastfeeding: a systematic review.
      • Hoff C.E.
      • Movva N.
      • Rosen Vollmar A.K.
      • Pérez-Escamilla R.
      Impact of maternal anxiety on breastfeeding outcomes: a systematic review.
      • Kim S.
      • Park M.
      • Ahn S.
      The Impact of Antepartum Depression and Postpartum Depression on Exclusive Breastfeeding: A Systematic Review and Meta-Analysis.
      Overall, breastfeeding self-efficacy, anxiety, and depression were associated with a shorter duration of exclusive breastfeeding exclusive duration but not predictive, Further, research is warranted to examine the relationship between maternal mental health and infant feeding behaviours.

      5. Limitations

      This cohort was limited to women residing in one of the participating municipalities of the province of Havana, reducing generalizability to the larger Cuban population. Future work could replicate this study in women who live in other conditions or reside in other provinces to identify whether the short-term predictors of exclusive breastfeeding identified are similar. The data lost in some variables may also have produced some bias in the sample. The list of predictors was extensive but obviously did not exhaust all those factors that have been reported in the literature associated with the breastfeeding process.

      6. Conclusion

      This was the first study among Cuban women to explore factors predictive of the early discontinuation of exclusive breastfeeding. Infant birth weight below 3.3 kg and maternal dissatisfaction with the progress in the growth of the infant at one month of age were the only variables predictive of a shorter duration of exclusive breastfeeding. Interventions that target maternal perceptions of infant growth are needed to assist Cuban families to continue exclusive breastfeeding. Further research is warranted to examine breastfeeding self-efficacy and its influence of maternal confidence in infant growth. The relationship between maternal mental health and infant feeding behaviors also requires additional attention given the well-documented negative relationship. The results from this first-ever study provide invaluable information to guide policies aimed at increasing the use of exclusive breastfeeding in this population.

      Funding statement

      This work was supported through a Canada Research Chair held by C-L Dennis.

      Disclosure statement

      The authors report there are no competing interests to declare.

      Data availability statement

      The data that support the findings of this study are available from the corresponding author, CLD, upon reasonable request.

      References

        • World Health Organization
        Exclusive breastfeeding for six months best for babies everywhere. Statement.
        • UNICEF
        Breastfeeding: A Mother's Gift for Every Child.
        2018
        • Horta B.L.
        • Loret De Mola C.
        • Victora C.G.
        Breastfeeding and intelligence: a systematic review and meta-analysis.
        Acta Paediatr Int J Paediatr. 2015; 104: 14-19https://doi.org/10.1111/apa.13139
        • Yan J.
        • Liu L.
        • Zhu Y.
        • Huang G.
        • Wang P.P.
        The association between breastfeeding and childhood obesity: a meta-analysis.
        BMC Publ Health. 2014; 14: 1267https://doi.org/10.1186/1471-2458-14-1267
        • Horta B.L.
        • Loret De Mola C.
        • Victora C.G.
        Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and meta-analysis.
        Acta Paediatr Int J Paediatr. 2015; 104: 30-37https://doi.org/10.1111/apa.13133
        • Sankar M.J.
        • Sinha B.
        • Chowdhury R.
        • et al.
        Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis.
        Acta Paediatr Int J Paediatr. 2015; 104: 3-13https://doi.org/10.1111/apa.13147
        • Abarin T.
        • Yan Wu Y.
        • Warrington N.
        • Lye S.
        • Pennell C.
        • Briollais L.
        The impact of breastfeeding on FTO-related BMI growth trajectories: an application to the Raine pregnancy cohort study.
        Int J Epidemiol. 2012; 41: 1650-1660https://doi.org/10.1093/ije/dys171
        • Boivin M.
        • Pérusse D.
        • Dionne G.
        • et al.
        The genetic-environmental etiology of parents' perceptions and self-assessed behaviours toward their 5-month-old infants in a large twin and singleton sample.
        JCPP (J Child Psychol Psychiatry). 2005; 46: 612-630https://doi.org/10.1111/j.1469-7610.2004.00375.x
        • Yeste D.
        • Carrascosa A.
        [Obesity-related metabolic disorders in childhood and adolescence].
        Anales de pediatria (Barcelona, Spain : 2003). 2011; 75: 135.e1-135.e9https://doi.org/10.1016/j.anpedi.2011.03.025
        • Victora C.G.
        • Bahl R.
        • Barros A.J.D.
        • et al.
        Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.
        Lancet. 2016; 387: 475-490https://doi.org/10.1016/S0140-6736(15)01024-7
        • UNICEF. Global Breastfeeding Scorecard
        Tracking progress for breastfeeding policies and programmes. Webpage.
        (Published 2017)
        http://www.unicef.org/breastfeeding
        Date: 2017
        Date accessed: February 20, 2019
        • Dirección de Registros Médicos y Estadísticas de Salud
        Anuario Estadístico de Salud 2018.
        2019
        • World Health Organization
        Global targets 2025. To improve maternal, infant and young child nutrition. Webpage.
        2014 (nutrition/topics/nutrition_globaltargets2025/en/)
        Date accessed: January 23, 2019
        • Fernández Brizuela E. de J.
        Estudio bibliométrico sobre lactancia materna en las revistas médicas cubanas durante el período 2009-2013.
        Revista Cubana de Información en Ciencias de la Salud. 2014; 25: 270-284
        • World Health Organization
        Infant and yound child feeding. Webpage.
        • Louro I.
        Familia en el ejercicio de la medicina general integral.
        in: Alvares R. Hernández G. Báster J. García R. Medicina General Integral. 2da ed. Ecimed, 2008: 398-419
        • Dennis C.L.
        • Falah-Hassani K.
        • Shiri R.
        Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis.
        Br J Psychiatry. 2017; 210: 315-323
        • Grigoriadis S.
        • Graves L.
        • Peer M.
        • et al.
        Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: systematic review and meta-analysis.
        J Clin Psychiatr. 2018; 79https://doi.org/10.4088/JCP.17r12011
        • Dennis C.L.
        • Falah-Hassani K.
        • Shiri R.
        Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis.
        Br J Psychiatry. 2017; 210: 315-323https://doi.org/10.1192/bjp.bp.116.187179
        • Dennis C.L.
        • Creedy D.
        Psychosocial and psychological interventions for preventing postpartum depression.
        Cochrane Database Syst Rev. 2013; 4CD001134https://doi.org/10.1002/14651858.CD001134.pub2
        • Oliver-Roig A.
        • D'Anglade-González M.L.L.
        • García-García B.
        • Silva-Tubio J.R.R.
        • Richart-Martínez M.
        • Dennis C.L.L.
        The Spanish version of the breastfeeding self-efficacy scale-short form: reliability and validity assessment.
        Int J Nurs Stud. 2012; 49: 169-173https://doi.org/10.1016/j.ijnurstu.2011.08.005
        • UNICEF
        Infant and young child feeding (IYCF) data. Webpage.
        • DiTomasso D.
        • Wambach K.A.
        • Roberts M.B.
        • Erickson-Owens D.A.
        • Quigley A.
        • Newbury J.M.
        Maternal worry about infant weight and its influence on artificial milk supplementation and breastfeeding cessation.
        J Hum Lactation. 2021; (00(0)): 1-13https://doi.org/10.1177/08903344211000284
        • Nasser A.
        • Omer F.
        • Al-Lenqawi F.
        • et al.
        Predictors of continued breastfeeding at one year among women attending primary healthcare centers in Qatar: a cross-sectional study.
        Nutrients. 2018; 10https://doi.org/10.3390/nu10080983
        • Flaherman V.J.
        • McKean M.
        • Cabana M.D.
        Higher birth weight improves rates of exclusive breastfeeding through 3 Months.
        Infant, Child, Adolesc Nutr. 2013; 5: 200-203https://doi.org/10.1177/1941406413495089
        • Matias S.L.
        • Nommsen-Rivers L.A.
        • Dewey K.G.
        Determinants of exclusive breastfeeding in a cohort of primiparous periurban peruvian mothers.
        J Hum Lactation. 2012; 28: 45-54https://doi.org/10.1177/0890334411422703
        • Meedya S.
        • Fahy K.
        • Kable A.
        Factors that positively influence breastfeeding duration to 6 months: a literature review.
        Women Birth. 2010; 23: 135-145https://doi.org/10.1016/j.wombi.2010.02.002
        • Castro-Pacheco B.L.
        • Cuellar Alvarez R.
        • Ibargollen Negrin L.
        • Equivel Lauzurique M.
        • Machado Lubian M.
        • Matinez Corredera A.
        Cuban Experience in Child Health Care 1959-2006.
        2010
        • Esquivel M.
        • Álvarez G.
        • Izquierdo M.E.
        • Martínez D.
        • Tamayo V.
        Well child care: a comprehensive strategy for Cuban children and adolescents.
        MEDICC Rev. 2014; 16: 7-11https://doi.org/10.37757/MR2014.V16.N1.3
        • Ministerio de Salud Pública
        Dirección de Registros Médicos y estadísticas de Salud.
        Encuesta de Indicadores Múltiples Por Conglomerados. 2020; (Cuba, 2019)
        • Fukui N.
        • Motegi T.
        • Watanabe Y.
        • et al.
        Exclusive breastfeeding is not associated with maternal-infant bonding in early postpartum, considering depression, anxiety, and parity.
        Nutrients. 2021; 13https://doi.org/10.3390/nu13041184
        • Hussien J.
        • Assefa S.
        • Liben M.L.
        Breastfeeding performance in Afar regional state, northeastern Ethiopia: a cross sectional study.
        BMC Pediatr. 2018; 18: 375https://doi.org/10.1186/s12887-018-1353-y
        • Rollins N.C.
        • Bhandari N.
        • Hajeebhoy N.
        • et al.
        Why invest, and what it will take to improve breastfeeding practices?.
        Lancet. 2016; 387: 491-504https://doi.org/10.1016/S0140-6736(15)01044-2
        • UNICEF
        Early childhood development in Cuba. Webpage.
        • Sinha B.
        • Chowdhury R.
        • Sankar M.J.
        • et al.
        Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis.
        Acta Paediatr Int J Paediatr. 2015; 104: 114-135https://doi.org/10.1111/apa.13127
        • Wong M.S.
        • Mou H.
        • Chien W.T.
        Effectiveness of educational and supportive intervention for primiparous women on breastfeeding related outcomes and breastfeeding self-efficacy: a systematic review and meta-analysis.
        Int J Nurs Stud. 2021; 117103874https://doi.org/10.1016/j.ijnurstu.2021.103874
        • Imdad A.
        • Yakoob M.Y.
        • Bhutta Z.A.
        Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries.
        BMC Publ Health. 2011; 11
        • Dennis C.L.
        Theoretical underpinnings of breastfeeding confidence: a self-efficacy framework.
        J Hum Lactation : official journal of International Lactation Consultant Association. 1999; 15: 195-201https://doi.org/10.1177/089033449901500303
        • Mituki D.
        • Tuitoek P.
        • Varpolatai A.
        • Taabu I.
        Translation and Validation of the Breast Feeding Self Efficacy Scale into the Kiswahili Language in Resource Restricted Setting in Thika Kenya. 2017
        • Machado M.C.M.
        • Assis K.F.
        • Oliveira F. de CC.
        • et al.
        Determinants of the exclusive breastfeeding abandonment: psychosocial factors.
        Rev Saude Publica. 2014; 48: 985-994https://doi.org/10.1590/S0034-8910.2014048005340
        • de Jager E.
        • Skouteris H.
        • Broadbent J.
        • Amir L.
        • Mellor K.
        Psychosocial correlates of exclusive breastfeeding: a systematic review.
        Midwifery. 2013; 29: 506-518https://doi.org/10.1016/j.midw.2012.04.009
        • Hoff C.E.
        • Movva N.
        • Rosen Vollmar A.K.
        • Pérez-Escamilla R.
        Impact of maternal anxiety on breastfeeding outcomes: a systematic review.
        Adv Nutr. 2019; 10: 816-826https://doi.org/10.1093/advances/nmy132
        • Kim S.
        • Park M.
        • Ahn S.
        The Impact of Antepartum Depression and Postpartum Depression on Exclusive Breastfeeding: A Systematic Review and Meta-Analysis.
        Clinical Nursing Research, 2021https://doi.org/10.1177/10547738211053507 (Published online)