Psychometric Assessment and Precision Remodeling of the Iowa Infant Feeding Attitude Scale to Improve Clinical Use and Efficacy Among Prenatal Women in Canada.

BACKGROUND: The 17-item Iowa Infant Feeding Attitude Scale (IIFAS) has been widely used to assess maternal attitudes toward infant feeding and to predict breastfeeding intention. The IIFAS has been validated among prenatal women located in Newfoundland and Labrador in Canada, although its length may prove challenging to complete in a clinical setting. Research aim: The authors aimed to reduce the number of items from the original 17-item IIFAS scale while maintaining reliability and validity. METHODS: A nonexperimental cross-sectional design was used among 1,283 women in their third trimester residing in Newfoundland and Labrador. Data were collected from August 2011 to June 2016. An exploratory factor analysis using principal component analysis was performed to explore the underlying structure of the IIFAS. The internal consistency of both the 17-item and reduced version was assessed using Cronbach's alpha and item-total correlation. The area under the curve and linear regression model were used to assess predictive validity of intention to breastfeed. RESULTS: Our findings revealed that a 13-item IIFAS (Cronbach's α = .870) had relatively similar internal consistency to the original IIFAS (Cronbach's α = .868). Three themes were extracted from the factor analysis, resulting in the removal of four items. The reduced scale demonstrated an excellent ability to predict breastfeeding intention (area under the curve = 0.914). CONCLUSION: The reduced 13-item version of the IIFAS is a psychometrically sound instrument that maintains its accuracy and validity when measuring maternal feeding attitudes during pregnancy and can be more time efficient in clinical settings compared with the 17-item IIFAS.

Determinants of Nonmedically Indicated In-Hospital Supplementation of Infants Whose Birthing Parents Intended to Exclusively Breastfeed.

BACKGROUND: Despite high rates of intention to exclusively breastfeed, rates of exclusive breastfeeding in Canada are low. Supplementation may begin in hospital and is associated with reduced breastfeeding duration. Research aim: The aim of this investigation was to explore determinants of in-hospital nonmedically indicated supplementation of infants whose birthing parents intended to exclusively breastfeed. METHODS: This study is a cross-sectional one-group nonexperimental design, focused on participants who intended to exclusively breastfeed for 6 months ( n = 496). Data were collected between October 2011 and October 2015 in Newfoundland and Labrador. Variables measured included age; rural/urban location; education; income; race; marital status; parity; smoking status; having been breastfed as an infant; previous breastfeeding experience; Iowa Infant Feeding Attitude Scale score; delivery mode; infant birth weight; birth satisfaction; skin-to-skin contact; length of participant's hospital stay; breastfeeding advice from a lactation consultant, registered nurse, or physician; and first impression of breastfeeding. We evaluated determinants of in-hospital nonmedically indicated supplementation using bivariate and multivariate logistic regression analyses. RESULTS: Overall, 16.9% ( n = 84) of infants received nonmedically indicated supplementation in hospital. Multivariate modeling revealed four determinants: low total prenatal Iowa Infant Feeding Attitude Scale score (odds ratio [OR] = 1.96, 95% confidence interval [CI] [1.18, 3.27]), no previous breastfeeding experience (OR = 2.03, 95% CI [1.15, 3.61]), negative first impression of breastfeeding (OR = 2.67, 95% CI [1.61, 4.43]), and receiving breastfeeding advice from a hospital physician (OR = 2.86, 95% CI [1.59, 5.15]). CONCLUSION: Elements of the hospital experience, self-efficacy, and attitudes toward infant feeding are determinants of nonmedically indicated supplementation of infants whose birthing parents intended to exclusively breastfeed.

Poverty and Breastfeeding: Comparing Determinants of Early Breastfeeding Cessation Incidence in Socioeconomically Marginalized and Privileged Populations in the FiNaL Study.

Purpose: Infant feeding differences are strongly tied to socioeconomic status. The goal of this study is to compare determinants of early breastfeeding cessation incidence in socioeconomically marginalized (SEM) and socioeconomically privileged (SEP) populations, focusing on birthing parents who intended to breastfeed. Methods: This cohort study includes data from 451 birthing parents in the Canadian province of Newfoundland and Labrador who reported intention to breastfeed in the baseline prenatal survey. Multivariate logistic regression techniques were used to assess the determinants of breastfeeding cessation at 1 month in both SEM and SEP populations. Results: The analysis data included 73 SEM and 378 SEP birthing parents who reported intention to breastfeed at baseline. At 1 month, 24.7% (18/73) in the SEM group had ceased breastfeeding compared to 6.9% (26/378) in the SEP group. In the SEP population, score on the Iowa Infant Feeding Attitude Scale (IIFAS) (odds ratio [OR] 3.33, p=0.01) was the sole significant determinant. In the SEM population, three significant determinants were identified: unpartnered marital status (OR 5.10, p=0.05), <1 h of skin-to-skin contact after birth (OR 11.92, p=0.02), and negative first impression of breastfeeding (OR 11.07, p=0.01). Conclusion: These results indicate that determinants of breastfeeding cessation differ between SEM and SEP populations intending to breastfeed. Interventions intended on improving the SEM population's postpartum breastfeeding experience using best practices, increasing support, and ensuring at least 1 h of skin-skin contact may increase breastfeeding rates.

Assessing Infant Feeding Attitudes of Expectant Women in a Provincial Population in Canada: Validation of the Iowa Infant Feeding Attitude Scale.

BACKGROUND: Maternal attitudes to infant feeding are predictive of intent and initiation of breastfeeding. OBJECTIVES: The Iowa Infant Feeding Attitude Scale (IIFAS) has not been validated in the Canadian population. This study was conducted in Newfoundland and Labrador, a Canadian province with low breastfeeding rates. Objectives were to assess the reliability and validity of the IIFAS in expectant mothers; to compare attitudes to infant feeding in urban and rural areas; and to examine whether attitudes are associated with intent to breastfeed. METHODS: The IIFAS assessment tool was administered to 793 pregnant women. Differences in the total IIFAS scores were compared between urban and rural areas. Reliability and validity analysis was conducted on the IIFAS. The receiver operating characteristic (ROC) of the IIFAS was assessed against mother's intent to breastfeed. RESULTS: The mean ± SD of the total IIFAS score of the overall sample was 64.0 ± 10.4. There were no significant differences in attitudes between urban (63.9 ± 10.5) and rural (64.4 ± 9.9) populations. There were significant differences in total IIFAS scores between women who intend to breastfeed (67.3 ± 8.3) and those who do not (51.6 ± 7.7), regardless of population region. The high value of the area under the curve (AUC) of the ROC (AUC = 0.92) demonstrates excellent ability of the IIFAS to predict intent to breastfeed. The internal consistency of the IIFAS was strong, with a Cronbach's alpha greater than .80 in the overall sample. CONCLUSION: The IIFAS examined in this provincial population provides a valid and reliable assessment of maternal attitudes toward infant feeding. This tool could be used to identify mothers less likely to breastfeed and to inform health promotion programs.

Infant Feeding in Newfoundland and Labrador, Canada: Perceptions and Experiences of Maternal Grandmothers.

The purpose of this study was to examine the primary factors that influenced grandmothers' choices of infant feeding and to explore the role that grandmothers feel they played in their daughters' choices about infant feeding. Twenty-two maternal grandmothers who bottle fed their children and whose daughters also bottle fed their babies were recruited to participate in 4 focus groups and/or 2 interviews. Using the constant comparative method of data analysis, 3 themes emerged that described how grandmothers felt about their infant feeding experiences: "powerlessness," "modesty," and "ambivalence." These themes and their implications are discussed in this article.

Maternal and perinatal outcomes of extreme obesity in pregnancy.

OBJECTIVE: To evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m2) in pregnancy on maternal and perinatal outcomes. METHODS: We conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m2). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: A total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs. 4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs. 1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs. 1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs. 25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs. 4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs. 2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs. 2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs. 7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs. 0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs. 41.5%) (aOR 1.57; 95% CI 1.35 to 1.83). CONCLUSION: Women with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.

Objectif : Évaluer les effets de l'obésité extrême (IMC prégrossesse ≥ 50,0 kg/m2) pendant la grossesse sur les issues maternelles et périnatales. Méthodes : Nous avons mené une étude de cohorte en population générale au moyen de la Newfoundland and Labrador Perinatal Database en vue de comparer les issues obstétricales des femmes présentant une obésité extrême à celles des femmes dont l'IMC est normal (IMC prégrossesse allant de 18,50 à 24,99 kg/m2). Nous avons inclus les femmes qui connaissaient une grossesse monofœtale et qui ont accouché entre le 1er janvier 2002 et le 31 décembre 2011. Parmi les issues maternelles d'intérêt, on trouvait l'hypertension gestationnelle, le diabète gestationnel, la césarienne, la dystocie de l'épaule, la durée de l'hospitalisation, l'admission à l'unité maternelle de soins intensifs, l'hémorragie postpartum et la mort. Parmi les issues périnatales, on trouvait le poids de naissance, l'accouchement préterme, l'indice d'Apgar, les anomalies métaboliques néonatales, l'admission à l'UNSI, la mortinaissance et le décès néonatal. Une issue composite en matière de morbidité a été élaborée; on y retrouve au moins un des facteurs suivants : césarienne, hypertension gestationnelle, poids de naissance ≥ 4 000 g, poids de naissance < 2 500 g ou admission à l'UNSI. Des analyses univariées et des analyses de régression logistique multivariée (neutralisant l'effet de l'âge maternel, de la parité, du tabagisme, de l'état quant à la présence ou non d'un partenaire et de l'âge gestationnel) ont été menées, et des rapports de cotes corrigés (RCc) et des intervalles de confiance à 95 % ont été calculés. Résultats : Au total, 5 788 femmes ont été incluses à l'étude : 71 présentant une obésité extrême et 5 717 présentant un IMC normal. Les femmes extrêmement obèses étaient plus susceptibles de connaître ce qui suit : hypertension gestationnelle (19,7 % vs 4,8 %) (RCc 1,56; IC à 95 %, 1,33 - 1,82), diabète gestationnel (21,1 % vs 1,5 %) (RCc 2,04; IC à 95 %, 1,74 - 2,38), dystocie de l'épaule (7,1 % vs 1,4 %) (RCc 1,51; IC à 95 %, 1,05 - 2,19), césarienne (60,6 % vs 25,0 %) (RCc 1,46; IC à 95 %, 1,29 - 1,65), hospitalisation de plus de cinq jours (cas de césarienne exclus) (14,3 % vs 4,7 %) (RCc 1,42; IC à 95 %, 1,07 - 1,89), poids de naissance ≥ 4 000 g (38,0 % vs 11,9 %) (RCc 1,58; IC à 95 %, 1,38 - 1,80), poids de naissance ≥ 4 500 g (16,9 % vs 2,1 %) (RCc 1,87; IC à 95 %, 1,57 - 2,23), anomalie métabolique néonatale (8,5 % vs 2,0 %) (RCc 1,50; IC à 95 %, 1,20 - 1,86), admission à l'UNSI (16,9 % vs 7,8 %) (RCc 1,28; IC à 95 %, 1,07 - 1,52), mortinaissance (1,4 % vs 0,2 %) (RCc 1,68; IC à 95 %, 1,00 - 2,82) et issue indésirable composite (81,7 % vs 41,5 %) (RCc 1,57; IC à 95 %, 1,35 - 1,83). Conclusion : Les femmes qui présentent une obésité extrême sont exposées à des risques accrus de connaître une variété d'issues indésirables maternelles et périnatales. Puisque, au sein de notre population, environ six parturientes sur 1 000 présentent une obésité extrême, il est important de traiter de ces risques avant la conception et d'inciter les patientes à obtenir un IMC plus santé avant de devenir enceintes.

The effect of gestational weight gain by body mass index on maternal and neonatal outcomes.

OBJECTIVE: To evaluate the effects of gestational weight gain on maternal and neonatal outcomes in different body mass index (BMI) classes. METHODS: We compared maternal and neonatal outcomes based on gestational weight gain in underweight, normal weight, overweight, obese, and morbidly obese (BMI>or=40.00) women. The study group was a population-based cohort of women with singleton gestations who delivered between April 1, 2001, and March 31, 2007, drawn from the Newfoundland and Labrador Provincial Perinatal Program Database. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking status, partnered status, and gestational age) were performed and odds ratios (ORs) were calculated. RESULTS: Only 30.6% of women gained the recommended amount of weight during pregnancy; 52.3% of women gained more than recommended, and 17.1% gained less than recommended. In women with normal pre-pregnancy BMI, excess weight gain was associated with increased rates of gestational hypertension (OR 1.27; 95% CI 1.08-1.49), augmentation of labour (OR 1.09; 95% CI 1.01-1.18), and birth weight>or=4000 g (OR 1.21; 95% CI 1.10-1.34). In overweight women, excess weight gain was associated with increased rates of gestational hypertension (OR 1.31; 95% CI 1.10-1.55) and birth weight>or=4000 g (OR 1.30; 95% CI 1.15-1.47). In women who were obese or morbidly obese, excess weight gain was associated with increased rates of birth weight>or=4000 g (OR 1.20; 95% CI 1.07-1.34) and neonatal metabolic abnormality (OR 1.31; 95% CI 1.00-1.70). In morbidly obese women, poor weight gain was associated with less use of epidural analgesia (OR 0.34; 95% CI 0.12-0.95). In women who were of normal weight, overweight, or obese, the rate of adverse outcome (Caesarean section, gestational hypertension, birth weight<2500 g or birth weight>or=4000 g) was lower in women with recommended weight gain than in those with excess weight gain. Adverse outcomes were reduced in nulliparous morbidly obese women who had poor weight gain (OR 0.18; 95% CI 0.04-0.83). CONCLUSION: The effects of gestational weight gain on pregnancy outcome depend on the woman's pre-pregnancy BMI. Pregnancy weight gains of 6.7-11.2 kg (15-25 lb) in overweight and obese women, and less than 6.7 kg (15 lb) in morbidly obese women are associated with a reduction in the risk of adverse outcome.