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

Abstract

Breastfeeding education, across all disciplines, is often inconsistent and lacking in expertise and confidence. However, recommendations from health professionals, the sociocultural environment, and previous knowledge and experiences significantly influence women’s decision to breastfeed. This study aimed to identify factors that promote the assignment of greater importance to breastfeeding and associated practical benefits. This retrospective cross-sectional study included 276 participants who completed a self-administered questionnaire. Descriptive and bivariate analyses were performed, and multivariate linear models were applied to identify factors influencing the importance assigned to breastfeeding. Most participants were married or in a relationship, were native Spaniards, had secondary or higher education, and had an average age of 32.6 years. Seventy percent met the physical activity recommendations, and 91% felt comfortable with their body image during pregnancy. The importance assigned to breastfeeding was high across various aspects, except for postpartum weight loss and body image. Group prenatal care was only significantly associated with the importance assigned to the breastfeeding technique (how to breastfeed). The obesogenic environment and the importance assigned to nutritional aspects and physical activity also turned out to be predictors, although not for all models. In our region, the educational strategy of antenatal care groups could contain gaps regarding the mother’s health, which should be addressed in the future to improve results regarding the initiation and continuation of breastfeeding.

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Citation: Arnedillo-Sánchez, S.;
Suffo-Abouza, J.A.;
Carmona-Rodríguez, M.Á.;
Morilla-Romero-de-la-Osa, R.;
Arnedillo-Sánchez, I. Importance
Assigned to Breastfeeding by Spanish
Pregnant Women and Associated
Factors: A Survey-Based Multivariate
Linear Correlation Study. Nutrients
2024,16, 2116. https://doi.org/
10.3390/nu16132116
Academic Editor: Kingsley E. Agho
Received: 6 June 2024
Revised: 28 June 2024
Accepted: 30 June 2024
Published: 2 July 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
nutrients
Article
Importance Assigned to Breastfeeding by Spanish Pregnant
Women and Associated Factors: A Survey-Based Multivariate
Linear Correlation Study
Socorro Arnedillo-Sánchez 1,2,3 , Jose Antonio Suffo-Abouza 1, Miguel Ángel Carmona-Rodríguez 1,
Rubén Morilla-Romero-de-la-Osa 1,3,4,* and Inmaculada Arnedillo-Sánchez 5
1Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla,
41009 Seville, Spain; marnedillo@us.es (S.A.-S.); jsuffo@us.es (J.A.S.-A.); migcarrod@alum.us.es (M.Á.C.-R.)
2Midwifery Training Unit, Department of Materno-Fetal Medicine, Genetics and Reproduction, Hospital
Universitario Virgen del Rocio, 41013 Seville, Spain
3Institute of Biomedicine of Seville, Hospital Universitario Virgen del Rocío/Consejo Superior de
Investigaciones Científicas/Universidad de Sevilla, 41013 Seville, Spain
4Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP),
28029 Madrid, Spain
5School of Computer Science & Statistics, O’Reilly Institute, Trinity College Dublin, College Green 2,
D02 PN40 Dublin, Ireland; macu.arnedillo@tcd.ie
*Correspondence: rmorilla2@us.es
Abstract: Breastfeeding education, across all disciplines, is often inconsistent and lacking in ex-
pertise and confidence. However, recommendations from health professionals, the sociocultural
environment, and previous knowledge and experiences significantly influence women’s decision to
breastfeed. This study aimed to identify factors that promote the assignment of greater importance
to breastfeeding and associated practical benefits. This retrospective cross-sectional study included
276 participants who completed a self-administered questionnaire. Descriptive and bivariate analyses
were performed, and multivariate linear models were applied to identify factors influencing the
importance assigned to breastfeeding. Most participants were married or in a relationship, were
native Spaniards, had secondary or higher education, and had an average age of 32.6 years. Seventy
percent met the physical activity recommendations, and 91% felt comfortable with their body image
during pregnancy. The importance assigned to breastfeeding was high across various aspects, except
for postpartum weight loss and body image. Group prenatal care was only significantly associated
with the importance assigned to the breastfeeding technique (how to breastfeed). The obesogenic
environment and the importance assigned to nutritional aspects and physical activity also turned out
to be predictors, although not for all models. In our region, the educational strategy of antenatal care
groups could contain gaps regarding the mother’s health, which should be addressed in the future to
improve results regarding the initiation and continuation of breastfeeding.
Keywords: breast feeding; antenatal care; health education; maternal health; observational study
1. Introduction
Pregnancy is a key opportunity to reach women with essential services for their own
health and that of their unborn child [
1
]. Antenatal care (ANC) is a careful, systematic
assessment and follow-up of a pregnant women that includes education, counselling,
screening, and treatment to assure the best possible health of the mother and her child [
2
].
Antenatal care (ANC) is crucial for protecting the health of mothers and children [3].
Education constitutes a vital aspect of prenatal care, especially for primigravid women.
Pregnant women should be offered information based on the current available evidence,
together with support to enable them to make informed decisions about their care [
4
].
ANC offers an essential setting for dialogue between pregnant women and healthcare
Nutrients 2024,16, 2116. https://doi.org/10.3390/nu16132116 https://www.mdpi.com/journal/nutrients

Nutrients 2024,16, 2116 2 of 13
providers (HCP) concerning health behaviors. HCP should offer information on postpartum
and newborn care, breastfeeding practices, signs of alarm, and the appropriate course of
action [
5
]. This education imparted during the antenatal period varies extensively in terms
of delivery methods and content. It may enclose structured antenatal classes conducted in
group or individual settings [6].
An essential part of ANC education is breastfeeding (BF) education. BF is widely
acknowledged as the optimal nutritional source for infants [
7
]. It has been associated with
enhanced child health, maternal health, and mother–infant bonding [
8
]. WHO and UNICEF
recommend that BF be initiated within the first hour after birth and continued exclusively
for the first six months of life and with safe and adequate complementary foods for up to
2 years or beyond [
9
]. The American College of Obstetricians and Gynecologists supports
breastfeeding due to its benefits for the health of the mother and child, considering it a
public health asset due to the health benefits it brings to the mother and child, with minimal
contraindications to this practice [10].
Antenatal BF education is characterized by the provision of information during preg-
nancy. This may occur on an individual or group basis, including home visiting programs,
peer education initiatives, and clinic appointments, and it may or may not involve partners.
BF education typically entails a structured, defined, descriptive, and goal-oriented program
designed for a specific purpose and audience [11].
It is important to acknowledge that HCP’s BF education, in all disciplines, is often
inconsistent, lacking in expertise and confidence [
12
–
16
]. This can reduce the effectiveness
of this type of educational intervention, and therefore, support tools are developed for
providers who have shown statistically significant improvements in the intention and
duration of breastfeeding [
15
]. Hospital counselling on breastfeeding showed a positive
association with the initiation of this practice (aOR = 2.7, 95% CI = 1.60–3.96) that was
significant across all races/ethnicities, which is a survey-based study conducted in Los
Angeles [17].
However, the recommendations of HCP influence pregnant women’s decision to
breastfeed [
18
]. Scientific evidence has been reported of the effectiveness of counselling
in the initiation of breastfeeding depending on the type of provider. Thus, advice from
midwives and obstetricians is more effective than that from other specialists. Additionally,
women cared for by midwives were 68% less likely to never breastfeed than those cared for
by an obstetrician [19].
BF intention, attitude, and knowledge have been shown to be strong predictors of initi-
ation [
20
–
22
]. In Saudi Arabia, sociodemographic factors have been identified as predictors;
housewives were four times more likely to have a high EBF intention compared to working
mothers [aOR = 4.216 (1.906–9.326), p< 0.001]. Similar results for housewives were reported
in a longitudinal study carried out with women form Lebanon and Qatar [
21
]. Having
adequate knowledge and a positive attitude towards breastfeeding were also positive
predictors ([aOR = 1.193 (1.183–1.421),
p= 0.009]
and [aOR = 1.282 (1.205–1.365),
p= 0.000],
respectively) [
20
]. Women who were encouraged to breastfeed have more chances of BF
compared to those who did not receive this support [
11
]. As per the conclusions drawn
from a Cochrane review, provider encouragement led to an increase in exclusive BF at
3 months and a prolonged BF duration up to 4 months [23].
Despite the many advantages and extensive promotion of BF, the trend towards BF in
many countries has been slowly increasing. Globally, the prevalence of exclusive BF during
the initial six months of life has risen by 10% over the last decade, reaching 48% in 2023 and
nearing the World Health Assembly’s objective of 50% by 2025 [24].
It has been shown that analyzing the importance that women give to breastfeeding
based on their knowledge and previous experiences, both for its initiation and continuation,
should be an object of study at the regional level due to possible sociocultural influences
and those specific to the healthcare systems. However, these aspects remain unclear in
our region.

Nutrients 2024,16, 2116 3 of 13
The aim of this study was to determine how the sociodemographic, dietary, and
physical activity profiles of pregnant women, in our demographic context, may influence
the importance they assign to different aspects of BF. Additionally, after the participation
in group ANC, the efficacy of the disclosed messages regarding BF was evaluated by the
significance women assigned to them. These included postpartum weight management, the
prevention of childhood obesity, the infant’s overall health, as well as the factors influencing
their prioritization. Through this analysis, our aim was to enhance the understanding of
the influence of BFE in group ANC on pregnant women’s importance assigned to BF, with
the potential to detect strengths and gaps in the content of BF education in our context.
2. Materials and Methods
2.1. Research Design and Participants
This was an observational, retrospective, cross-sectional study. The study was con-
ducted according to the latest Consolidated Standards of Reporting Observational Studies
(STROBE) 2008 guidelines for reporting observational studies [25].
The study was conducted in a Spanish third-level hospital that cares for 5196 births
annually [
26
]. Woman of all ages and socioeconomic background attend the hospital, which
offers high complex services as well as basic obstetric care. Women receive ANC through
the Public Health System, which encompasses both primary care (midwife and General
Practitioner) and obstetric assistance. BF education is integrated into ANC, where the
intention towards BF is documented in health records from the first individual visit. BF
education primarily occurs within group ANC in the third trimester. This session covers
aspects including the anatomy, the benefits of BF, BF techniques, BF positions, breast milk
expression, myths surrounding BF, contraception, as well as the disadvantages of formula
feeding [
27
]. Despite recommendations by health authorities, midwives can arrange their
BF education according to their own preferences. The hospital is in the third phase of the
Mother Baby Friendly Hospital accreditation. At admission for delivery, all women are
asked about plans for infant feeding. Skin-to-skin contact and BF is initiated immediately
after vaginal delivery. When the clinical condition of the mother is stable after a caesarean
section, BF is initiated within 120–180 min of delivery. In addition, all women who give
birth in the hospital are given practical BF training by midwives, nurses, and pediatricians,
BF is observed, and support and BF counselling services are provided.
A consecutive sampling procedure was employed to select participants. To determine
the minimum sample size required for this study, Gpower software v3.1 (t-ref version)
was used. The following parameters were selected: family test (F-Test), statistical test:
Linear multiple regression: fixed model, R
2
deviation from zero. The type of analysis was
as follows: the required sample size-given alpha (0.05), power (0.95), and effect size (0.1)
were computed. No similar studies were found to determine a theoretical effect size, so a
minimum effect size was employed to maximize the sample size. The minimum number of
participants to include in the study was 204.
The study
´
s inclusion criteria were adult (
≥
18 years old) singleton pregnant women at
≥
37 gestational weeks who accepted and signed the informed consent form. The exclusion
criteria were pregnant women with mental instability and/or communication difficulties
due to language barriers or who were not willing to participate.
2.2. Data Collection Methods and Survey Period
Women were recruited during a prenatal visit to the hospital. The study’s objectives
and aims were explained by a midwife researcher. A self-administered questionnaire
was designed following a literature review. It consisted of three main sections: the socio-
demographic and obstetric profile, lifestyle habits, and the importance assigned to different
aspects of BF.
Sociodemographic and obstetric data included age, place of birth, education, civil
status, obesogenic environment, parity, attendance to group ANC, and smoking.

Nutrients 2024,16, 2116 4 of 13
Lifestyle habits included eating habits during pregnancy, physical activity, and adher-
ence to a Mediterranean diet (MD). Appropriate Physical activity was considered following
WHO recommendations (at least 150 min of moderate-intensity aerobic physical activity
throughout the week) [
28
]. Adherence to MD was accessed through the MEDAS scale [
29
].
It consists of 14 items, where participants report their habitual frequency or amount con-
sumed of 12 main components of MD, along with two food habits related to MD. Each of
the items scored either 1 or 0 based on participants’ adherence. The resulting MD score
derived from MEDAS ranges from 0 to 14 [30].
The participants were asked to indicate the importance they assigned to different
aspects of BF through a Likert scale, with five-point response options ranging from Not at
all important (1) to Very important (5). These aspects included the BF technique, BF and
postpartum weight loss, BF and baby’s health, and BF and childhood obesity.
The survey was pilot-tested for clarity by 50 respondents. The data collection took
place between March and December 2019. Pregnant women completed the questionnaire
during a prenatal visit, and anthropometric data were retrieved from the Pregnant Women
´
s
Health document.
2.3. Data Analysis
Statistical analyses were performed using SPSS software (version 23; IBM Corporation,
Armonk, NY, USA). Descriptive analyses were performed with the use of frequencies and
measures of central tendency and dispersion to characterize the study sample and the
results of the questionnaire. To identify factors associated with the importance assigned
to BF, bivariate analyses were performed by chi-square analysis and Fisher’s exact test for
qualitative variables, where appropriate, and parametric or non-parametric tests of mean
comparison according to normality and homoscedasticity criteria [
31
]. To evaluate the po-
tential confounder effects of the variables that reached statistical significance, multivariate
linear models were performed to estimate what factors influence the importance women
assigned to different aspects of BF. We followed a rule of thumb commonly used in statistics
and regression modeling that suggests that, at a minimum, you should have 10 events
per variable to adequately estimate the model parameters. In the context of multivariate
linear regression, this would translate into having at least 10 subjects for each covariate
in your model. This allowed, according to our sample size, to include 26 covariates in
initial models, and the Backward Elimination technique was applied (the covariates are
iteratively eliminated one by one, starting with the one with the highest pvalue, that is,
the least significant statistically). In both bivariate and multivariate analyses, statistical
significance was set at 5%.
2.4. Ethical Aspects
Ethics committee approval was obtained from the Ethics Committee (Protocol C.P.
MSA-FP-2019-01-C.I.). Written and verbal informed consent was obtained from the par-
ticipants. The participants signed an informed consent form declaring their voluntary
participation once they understood the objectives and dynamics of the study. They were
aware of the possibility of abandoning the study at any time and that the processing of
their information would be anonymous and under the precepts of current legislation on
the processing of personal data.
3. Results
Two hundred and seventy-six (276) participants responded to the questionnaire; how-
ever, not all women answered all questions. Tables 1and 2show missing data for each
item. The profile of women was mainly native Spaniards who were married or in a rela-
tionship, with secondary or high education and an average age of 32.6 (SD 5.8), ranging
between 18 and 47 years old. Regarding physical activity, 70% of the sample met WHO
physical activity recommendations for pregnant women. Only 9% felt uncomfortable with

Nutrients 2024,16, 2116 5 of 13
their body image during pregnancy. Table 1shows data for sociodemographic obstetric
characteristics and physical activity (Table 1).
Table 1. Sociodemographic and obstetric characteristics and physical activity.
Variables
Total Women % (IC 95)
N n
Nationality 263
Spanish 247 93.9 (90.4–96.2)
Eastern Europe 5 1.9 (0.8–4.4)
Hispa-American 10 3.8 (2.1–6.7)
Others 1 0.4 (0.1–2.1)
Educational level 275
Higher Education 109 39.6 (34.0–45.5)
Primary School 42 15.3 (11.5–20.0)
Secondary School 116 42.2 (36.5–48.1)
None 8 2.9 (1.5–5.6)
Civil Status 274
Marriage/couple 261 95.2 (92.1–97.2)
Single 5 1.8 (0.8–4.29)
Others 8 3 (1.5–5.7)
Nullipara 276 174 63 (57.2–68.5)
Smokes in pregnancy 275 31 11.3 (8.1–15.6)
Obesogenic Environ. 274 40 14.6 (11.0–19.3)
Group Antenatal Care 273 193 70.7 (65.0–75.8)
Pg Physical Activity 272 160 59 (53.0–65.0)
Info Physical Activity 271 213 78.6 (73.3–83.1)
Believes PA negative 269 28 10.4 (7.3–14.6)
Changes in PA 255 149 58.4 (52.3–64.3)
Meets WHO PA recom. 215 151 70.2 (63.8–76.0)
APP PA 243 44 18.1 (13.8–23.4)
Pregnancy body Image 275
Pretty 133 48.4 (42.5–54.3)
Neither pretty nor ugly 115 41.8 (36.1–47.7)
Uncomfortable 27 9.8 (6.8–13.9)
Note: Environ, environment; Pg, pre-gestational; PA, Physical Activity; WHO, World Health Organization; recom,
recommendation; APP, application.
Almost half of the women had a healthy pregestational BMI, most did not have a
gestational weight gain (GWG) target, and GWG was evenly distributed among its three
categories, inadequate, healthy, and excessive. Over half of the sample changed their eating
habits, maintaining the same appetite and food amount. Half presented craving and 60%
presented nauseas. Only 18% of the sample had a low adherence to MD (Table 2).
Table 3shows the importance assigned to different aspects through a Likert scale,
with higher punctuations for more importance assigned. The average punctuation for
all variables was over four out of five points, except the importance assigned to BF for
postpartum weight loss and body image before and during pregnancy (near four points).
More than half of the participants had a good adherence to MD, with a median score
9.3 over 14 points.

Nutrients 2024,16, 2116 6 of 13
Table 2. Anthropometrics and eating habits.
Variables Total Women % (IC 95)
N n
pgBMI 275
Underweight 7 2.6 (1.2–5.2)
Normal 127 46.2 (40.4–52.1)
Overweight 84 30.5 (25.4–36.2)
Obesity 57 20.7 (16.4–26.0)
Gestational Weight Gain 275
Inadequate 87 31.6 (26.4–37.4)
Healthy 91 33.1 (27.8–38.9)
Excessive 97 35.3 (29.9–41.1)
GWG Target 267
Increase 11 4.2 (2.4–7.4)
Maintain 63 24 (19.4–29.7)
Lose 2 0.8 (0.2–2.8)
None 185 71 (65.1–76.1)
Eating Habits Change 264 142 53.8
Eat for two 267
No 253 94.8 (91.4–96.9)
Appetite 139
Increased 17 12.2 (0.8–1.9)
Same 73 52.5 (4.4–6.1)
Decreased 49 35.3 (2.8–4.3)
Change in Quantity 273
More 85 31.1 (2.6–3.7)
Same 139 51.0 (4.5–5.8)
Less 49 17.9 (1.4–2.3)
Snacking 270 162 60 (54.1–65.7)
Stress/anxiety 267
Eat more 119 44.6 (3.9–5.1)
Eat the same 97 36.3 (3.1–4.2)
Eat less 51 19.1 (1.5–2.4)
Craving 270 132 49 (43.0–55.0)
Nausea 270 169 62.6 (56.5–68.2)
Adherence to MD 216 155 71.8 (65.4–77.3)
Note: pgBMI, Pre-gestational Body Mass; GWG, Gestational Weight Gain; MD, Mediterranean Diet.
Table 3. Importance assigned to aspects of Breastfeeding and Descriptive Quantitative Variables.
Variable Media SD
Minimum
25% 50% 75%
Maximum
nNA
ADH_MD.9 9.3 2.1 1.0 8.0 10.0 11.0 14.0 216 60
Age 32.6 5.8 16.0 29.0 33.0 37.0 47.0 276 0
Image Before 3.7 1.0 1.0 3.0 4.0 4.0 5.0 272 4
Image Pregnancy 3.5 1.1 1.0 3.0 4.0 4.0 5.0 271 5
pgBMI 26.1 5.7 17.3 22.1 25.0 28.3 46.0 275 1
Importance PA 4.1 1.1 1.0 3.0 4.0 5.0 5.0 250 26
Importance Nut 4.3 1.1 1.0 4.0 5.0 5.0 5.0 253 23
Importance BF How 4.6 0.8 0.0 5.0 5.0 5.0 5.0 273 3
Importance BF PCO 4.1 1.2 2.0 3.0 5.0 5.0 5.0 246 30
Importance BF PWL 3.7 1.3 2.0 3.0 4.0 5.0 5.0 246 30
Importance BF BH 4.7 0.8 0.0 5.0 5.0 5.0 5.0 273 3
Note: SD, standard deviation; NA, not available; ADH_MD, Adherence to Mediterranean Diet; BMI, Body Mass
Index; PA, Physical Activity; Nut, Nutrition; BF, Breast Feeding; PCO, Prevent Child Obesity; PWL, Postpartum
Weight Loss; BH, Baby´s Health.

Nutrients 2024,16, 2116 7 of 13
Four multivariate linear regression models were evaluated, in which those variables
related to BF and different aspects such as the BF technique and importance as a protective
factor against childhood/maternal obesity and as a guarantor of the baby’s (general) health
were included as dependent variables (Table 4).
Table 4. Lineal models.
Model 1: Dependent Variable: IA to How to BF
Independent Variables Estimate p-Value Models’ Parameters
Intercept (beta 0) 0.40 0.067 Adjusted R2: 0.62
F-statistic: 98.03
on 4 and 239 DF,
p-value: <0.001
Obesogenic Environment 0.24 0.006
Importance Nut 0.14 <0.001
Importance BF BH 0.74 <0.001
Group Antenatal Care 0.20 0.003
Model 2: Dependent Variable: IA to BF as a Tool for Losing Post-Partum Weight
Independent Variables Estimate p-Value Models’ Parameters
Intercept (beta 0) 0.73 0.024 Adjusted R2: 0.48
F-statistic: 46.02
on 4 and 227 DF,
p-value: <0.001
No pregnancy smoking −0.31 0.021
Obesogenic Environment 0.33 0.057
Image Pregnancy 0.14 0.036
Importance BF PCO 0.65 <0.001
Model 3: Dependent Variable: IA to BF as a Preventive Factor of Childhood Obesity
Independent Variables Estimate p-Value Models’ Parameters
Intercept (beta 0) −0.06 0.87 Adjusted R2: 0.47
F-statistic: 65.8
on 3 and 219 DF,
p-value: <0.001
Importance PA 0.19 0.004
Importance BF How 0.31 <0.001
IA to BF as a means of losing
pp-weight 0.52 <0.001
Model 4: Dependent Variable: IA to BF to Maintain Baby’s Health
Independent Variables Estimate p-Value Models’ Parameters
Intercept (beta 0) 1.14 <0.001
Adjusted R2: 0.62
F-statistic: 64.02
on 6 and 227 DF,
p-value: <0.001
Obesogenic environment −0.20 0.022
Importance BF How 0.76 <0.001
Importance BF PCO 0.05 0.065
Your health—baby’s [baby´s] −0.39 0.042
Your health—baby’s [main] −0.78 0.029
Your health—baby’s [none] −0.18 0.051
Note: IA, Importance assigned; BF, breast feeding; pp, post-partum.
The first aimed at seeing what factors influenced the importance assigned by mothers
to the BF technique. It showed that the presence of obese subjects in the family environment,
the importance assigned to nutrition during BF, BF as a guarantor of the baby
´
s health, as
well as attendance to group ANC were favorable factors, although they had little impact.
However, the model overall obtained a coefficient of determination of 0.62, resulting in a
significant model.
For the model that evaluated the importance assigned to BF as a tool for losing weight
in the postpartum, obesity in the family environment, concern about BI before pregnancy,
and participants that assigned a high importance to BF as a tool for preventing childhood
obesity were observed as factors with a direct relationship. However, a statistically sig-
nificant association was observed, indicating an inverse relationship with non-smoking
behaviors (neither prior to nor during pregnancy).
The third model investigated the importance assigned to BF as a protective factor
against childhood obesity. In it, the importance assigned to physical activity during

Nutrients 2024,16, 2116 8 of 13
pregnancy, the BF technique, and BF as a tool for losing weight in the postpartum period
appeared as promoting factors.
Finally, the last model assessed the importance assigned to BF as a means of maintain-
ing the baby’s health. A significant direct relationship was observed with the importance
assigned to the BF technique and to BF as a tool for preventing childhood obesity. However,
it was inversely related to the presence of an obesogenic environment. Negative coefficients
also resulted for considering physical activity during pregnancy as negative for the baby’s
health, one’s health, or neither, using the health of both (mother and baby) together as a
reference category.
4. Discussion
The result of this study suggests the effectiveness of information anchoring regarding
the BF technique obtained during group ANC, identifying this moment as a key time to
include additional information regarding BF that could mediate in women
´
s decisions
regarding BF, initiation, and maintenance rates. It highlights some factors that promote
the importance women assign to BF in relation to benefits for both mothers and babies.
Additionally, it is a descriptive study on sociodemographic, dietary, and physical activity
during pregnancy in women from our environment. These factors were explored as possible
promoters of the importance assigned to the discussed issues, with no significant results.
BFE places much emphasis on the BF technique, which is crucial for BF initiation
and maintenance [
32
]. The findings of this study suggest that certain aspects concerning
BF, like its influence on maternal health, are being inadequately addressed, potentially
hindering pregnant women from recognizing their significance. This is evident in the
models obtained, as attendance to group ANC only emerged as a promoting factor for
the importance assigned to the BF technique. Although women attribute medium to high
importance values (above three) to the rest of the issues (Table 2), attendance to group ANC
did not appear as a promoting factor in the respective models. Considering the positive
effect that group ANC had on the BF technique message, it would be clinically interesting to
include and promote other aspects. Given the importance that postpartum weight retention
has on the obesity epidemic, [
33
,
34
], as well as the negative consequences of childhood
obesity [35], these aspects should be emphasized.
Although our findings indicate pregnant women are concerned about BF techniques,
a qualitative study among primary care Spanish midwives revealed that many women
attending group ANC tend to prioritize discussions on delivery and associated pain,
often relegating BF to a secondary concern [
36
]. This aligns with a recent study in first-
time mothers in England, who indicated that obtaining trustworthy information through
direct interactions with experts was essential for meeting their needs and boosting their
confidence. However, when questioned about the type of information that would serve this
purpose, their attention was only directed toward childbirth [
37
]. Paz-Pascual noted that
Spanish women often expressed a preference for exclusive BF to be addressed preferably in
postnatal classes, alongside topics like newborn care and motherhood, which we believe
would be too late. They also manifested the need for greater accompaniment in the
puerperium and less pressure concerning BF [
38
]. In this line, women identified themselves
and society (HCP, media, and partners) [
39
] as the main sources of pressure to BF. This
pressure was negatively associated with the BF experience (r =
−
0.34, p< 0.01) and self-
efficacy (r =
−
0.39, p< 0.01) [
40
], as well as with mental health symptoms [
39
]. This
leads us to consider that although BF support is essential in the puerperium, it could be
interesting to seek a more suitable time during pregnancy to address BF. We suggest that
during the second trimester, women are less focused on childbirth and could therefore
be more receptive to BFE. Supporting this proposition, some authors have described
that maternal concerns and pregnancy-related anxiety are more intense in early and late
pregnancy [
41
,
42
]. We also believe that it is necessary to implement educational strategies
that, while promoting BF as the optimal way to feed babies, relieves women from the
pressure they feel.

Nutrients 2024,16, 2116 9 of 13
The BF rates among participants in group ANC, when compared to individual care,
suggest that group ANC shows significantly higher rates of BF initiation and exclusive BF
at hospital discharge [
43
,
44
]. Gray (2024) reported that it increases BF at 6 months (odds
ratio = 2.66; p= 0.045) and leads to higher BF intention, competence, and autonomous
motivation initiation [
45
]. The Andalusia Birth and Parenting Preparation Guide [
27
]
recommends that BF be addressed during one group ANC visit, along with individual care.
However, we believe that a single visit may not sufficiently raise mothers’ awareness about
the importance of BF beyond the baby’s health. Effective BFE requires more attention to
significantly impact mothers’ awareness of its importance. Nasim reported a dose-response
effect; more ANC visits had higher rates of BF initiation and durations [
46
]. Stakeholders
should take note of these findings and ensure that ANC includes the appropriate number
of HCP and visits. It is worth noting that Spain has one of the lowest rates of midwives
in the European Union, with 17–21 practising midwifes per 100,000 inhabitants [
47
] and
a currently understaffed workforce. Midwife care has been associated with better health
results for mothers and children, including higher BF rates [
48
–
50
]. Likewise, insufficient
support from the health system reduces the probability of BF [13].
In our study, women assigned a lot of importance to BF in relation to the baby
´
s health
and BF technique, while the importance regarding the mother
´
s health and its influence on
puerperal weight loss had the least importance. This highlights that pregnant women seem
more concerned about their babies than themselves. We suggest, in line with other authors,
that ANC should embrace new perspectives that approach holistic maternal health issues,
not solely focusing on the child
´
s care [
51
]. A reorientation towards a health promotion
that is mother-centred is crucial to meet women
´
s needs and enhance health results [
52
].
Greater emphasis could be placed on women’s decision to breastfeed and its short- and
long-term benefits for both the mother and newborn.
Despite the fact that, as our results confirm, in line with other research [
53
], most
women felt comfortable or reported to look beautiful during pregnancy, body dissatisfaction
during the postpartum is common [
54
]. Expectations of the ideal Western beauty standard,
mediated by social norms, pressure mothers to quickly return to pre-pregnancy weight soon
after birth [
55
]. This is a goal that is often not achieved. Dissatisfaction with the maternal
body is linked to several negative outcomes, including postpartum depression [
56
,
57
] and
shorter BF durations [
58
]. In our model, women who assign more points to the importance
of BF as a tool for recovering pregestational weight also do so to the importance of BF for the
prevention of childhood obesity. Promoting these positive aspects of the BF experience in
ANC could serve as a catalyst for encouraging the early initiation and maintenance rates of
BF and its associated benefits. For example, we strongly believe that BFE should highlight
the importance of BF as a mediator of maternal health, including negative outcomes related
to body dissatisfaction related to postpartum weight retention.
Our results show that adherence to MD in our sample was high, with better results
than those reported for Italy for pregnant women [
59
]. No association between adherence
to MD and importance assigned by pregnant women to different health-related aspects
was found. However, the MD pattern is associated with benefits during pregnancy and
the prevention of certain diseases, including cardiovascular diseases [
60
]. Its promotion
among pregnant women could serve as a beneficial public health strategy for preventing
overweight and nutrient deficiencies [
61
]. Research also suggests that women who choose
to BF tend to follow healthier diets, have better dietary knowledge, and promote an overall
healthier diet in their children [
62
]. Breastfeeding for 6 months or longer is associated
with a higher adherence to the MD during the preschool years [63]. Women who adhered
to the MD and breastfed not only achieved physical benefits such as a lower proportion
of corporal fatty tissue [
64
] but also achieved emotional benefits such as a lower risk of
depressive episodes [
65
]. Due to the benefits that MD has on mothers and newborns in
the long and short term, its promotion should be a fundamental aspect in ANC. While
mastering BF technique is crucial for new mothers to initiate and sustain lactation, BFE

Nutrients 2024,16, 2116 10 of 13
should also emphasize maternal health benefits, incorporate body image concerns, and
promote MD [66].
We suggest that our results are interesting for HCP and midwives in our context,
highlighting the need to shift BFE towards a more women-centered approach, employing
pedagogic models grounded in principles of adult learning. Such education should furnish
women with realistic, detailed, and positively affirming information.
This study has some limitations. First, the design, an observational study, while
serving as a useful means to establish prevalence rates and identify risk factors, may not
offer the strongest scientific evidence. However, it has been demonstrated to address
knowledge gaps and provide information needed to improve decision-making. Second,
the use of non-randomized sampling could introduce bias. Nonetheless, we believe that
employing multivariate analysis helped mitigate this issue. Although researchers were
aware of the recommendations for group ANC and BFE by health authorities, they did not
have information on the specific content and duration of BFE.
5. Conclusions
The variability explained by our models ranges between, approximately, 46% and
66%, which represents successful results. Through the analysis of the importance Span-
ish pregnant women assigned to different aspects of BF and care during pregnancy, we
suggest that group ANC is effective in anchoring information regarding the BF technique.
However, attendance at group ANC did not appear as a predictor in other importance
assignment models, which could imply that the education received contains gaps that must
be addressed. In this sense, BF education often overlooks maternal health benefits. The
obesogenic environment appeared as a positive predictor in the importance assigned to
how to BF and breastfeeding as a tool for losing post-partum weight. However, it was a
negative predictor for the importance assigned to BF in maintaining the baby’s health.
Although the importance assigned to nutrition was a predictor of how to breastfeed,
pregestational BMI, adherence to a Mediterranean diet, and sociodemographic features did
not appear as predictors in any model.
Since, in our region, breastfeeding education has long emphasized the breastfeeding
technique, as has been positively reflected in the results, antenatal BF education should be
complemented with other important aspects related to breastfeeding so that women benefit
from this information—for example, regarding maternal health.
Author Contributions: Conceptualization, S.A.-S. and R.M.-R.-d.-l.-O.; methodology, S.A.-S. and
R.M.-R.-d.-l.-O.; validation, S.A.-S., R.M.-R.-d.-l.-O. and I.A.-S.; formal analysis, S.A.-S., M.Á.C.-R.,
J.A.S.-A. and R.M.-R.-d.-l.-O.; investigation, all authors; resources, S.A.-S.; data curation, J.A.S.-A.
and M.Á.C.-R.; writing—original draft preparation, all authors; writing—review and editing, S.A.-S.,
R.M.-R.-d.-l.-O. and I.A-S.; supervision, S.A.-S. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Hospitales Universitarios Virgen Macarena y
Virgen del Rocío (protocol code: MSA-FP-2019–01-C.I.; date of approval: 19 January 2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The original contributions presented in the study are included in the
article, further inquiries can be directed to the corresponding author.
Acknowledgments: We are deeply grateful to all the women who so kindly participated in the study
and to the hospital staff members for their co-operation.
Conflicts of Interest: The authors declare no conflicts of interest.

Nutrients 2024,16, 2116 11 of 13
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