Validity and Clinical Effectiveness of the Breastfeeding History Questionnaire  to Determine the Risk of In-Hospital Formula Supplementation in Multiparous Women

Validity and Clinical Effectiveness of the Breastfeeding History Questionnaire to Determine the Risk of In-Hospital Formula Supplementation in Multiparous Women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validity and Clinical Effectiveness of the Breastfeeding History Questionnaire to Determine the Risk of In-Hospital Formula Supplementation in Multiparous Women Emine Serap Cagan, Aysun Ekşioğlu, Ayşe Akyar, Esin Ceber Turfan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4986685/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Early detection of women at risk of not breastfeeding their babies is important in terms of supporting maternal and infant health. In particular, the breastfeeding experience of multiparous mothers may be considered as a sufficient factor in breastfeeding success, leading to neglect of breastfeeding support. The study was aimed at testing the psychometric properties of the Breastfeeding History Questionnaire (BAP) and to evaluate clinic effectiveness in detecting the risk of in-hospital formula supplementation among multiparous women. Methods: The study is a cross-sectional study conducted in a mother-friendly tertiary health care facility in western Turkey, involving 358 women. First of all, expert opinion was obtained for content validity, then the risk of using formula was investigated cross-sectionally. Chi-square test and Student's t-test and multivariate logistic regression analysis were used for data analysis. Results: The sensitivity and the specificity of the BAP used for the prediction of formula supplement use in the hospital by those whose BAP score was ≤ 1 were 74.6% and 88.2%, respectively. In those with a BAP score of ≤1, while the positive predictive value was 78.22%, the negative predictive value was 85.89%. Of the multiparous women, those with a BAP score of ≤1were 12.8 times more likely to supplement formula during the postpartum hospital stay than were those with a BAP score of ≥2 (RR = 12.88, 95% CI [5.76-27.78]; p < .001). Conclusions: The BAP is a valid tool and it offers practical evaluation suitable for clinical use. Breastfeeding multiparous hospital validity formula feeding Background One of the important issues in public health is breastfeeding, and feeding the baby with breast milk [ 1 ]. Breast milk positively contributes not only to the growth and development of the baby but also socioeconomically to the family and the society in which they live [ 2 ]. Mortality rates are 14 times higher in children who are not breastfed than in children who are breastfed [ 3 ]. It is important to ensure that the baby is exclusively breastfed, especially in the postpartum period, before the mother and baby are discharged from the hospital. Most of the problems that prevent the continuation of breastfeeding start during the postpartum hospital stay and may lead to the discontinuation of breastfeeding, or the use of formula [ 4 ]. In order to sustain breastfeeding which is vital for the growth and development of the baby, the Baby-Friendly Hospital application consisting of ten items was started by the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) in 1991, and it has become widespread all over the world; however, breastfeeding rates still have not reached the desired targets [ 2 , 5 ]. In Article 6 of the Baby-Friendly Hospital application, it is stated that no liquid and food other than breast milk should be given to the newborn unless there is a medical necessity [ 1 , 6 ]. Thus, formula supplementation is considered an obstacle to the formation of a functional breastfeeding relationship between the mother and baby [ 7 ]. One of goals of the Healthy People 2020 is to reduce the percentage of infants fed with formula during the postnatal hospital stay from 19.4–14.2% [ 3 ]. According to the 2018 Breastfeeding Report of the Centers for Disease Control (CDC), 17% of breastfeeding mothers in the United States fed their babies with formula during the first two days after birth [ 8 ]. In a study that included more than 90,000 newborns who were breastfed after birth, it was determined that 61% of the infants were exclusively breastfed when they were discharged from the hospital [ 9 ]. According to the results of the Turkey Demographic and Health Survey (TDHS 2018), 41.7% of newborns are given food other than breast milk before the first breastfeeding in the hospitals [ 10 ]. Among the reasons mothers prefer other options instead of breast milk are the perception that their breast milk is insufficient, delayed delivery of breast milk after cesarean section, suggestion by a health worker, baby-related reasons, and the thought that formula is equivalent to breast milk [ 11 , 12 ]. In her study conducted in a maternity hospital in Ankara, the capital of Turkey, Demirtaş determined that the history of breastfeeding problems in the previous baby was the determinant of feeding the baby with formula supplement in the hospital [ 13 ]. Bai et al., on the other hand, reported that a long previous breastfeeding experience positively affected the duration of subsequent breastfeeding [ 14 ]. According to the results of the study conducted by Bartle and Harvey, breastfeeding intention is stronger in women who have a successful breastfeeding experience [ 15 ]. Grano et al. reported that women whose breastfeeding experience is more had better perceptions of behavioral control and stronger intentions to breastfeed the baby until age 2 [ 16 ]. Although in several studies, breastfeeding experience is stated as an effective factor in maintaining breastfeeding, in some other studies, it is also noted that the risk of using formula is high in multiparous mothers [ 13 ]. In the study conducted by Mızrak (2017- unpublished results), of the multiparous mothers, 53.2% breastfed their baby in the first half hour after birth, but 27.2% gave formula to their baby during their postpartum hospital stay (Mızrak B, 2017- unpublished results). In multiparous mothers, education level, lack of breastfeeding support and risk of depression are factors associated with breastfeeding motivation [ 17 ]. It is stated that women who have previous successful breastfeeding experiences will be less likely to feed their babies with formula while they are in the hospital compared to women who do not [ 8 ]. Therefore, early identification of women at risk of not breastfeeding their babies is important in terms of supporting maternal and infant health Methods Aim The aim of this cross-sectional and methodological study was to test the psychometric properties of the Breastfeeding History Questionnaire developed by Burns et al. (2018), to determine whether multiparous mothers have a higher risk of feeding their babies with formula supplements in the hospital in the postnatal period, and to evaluate the clinical effectiveness of the questionnaire. Measure Breastfeeding History Questionnaire (BAP) : The BAP was developed by Burns et al. (2018) to assess whether multiparous mothers were at risk of feeding their babies with formula supplement in the hospital [ 7 ]. Responses given to the items of the BAP, which was created with the thought that a woman's previous breastfeeding history may affect her later breastfeeding experiences, are given a numerical value. The letters in the acronym BAP stand for the following: B: the number of babies previously breastfed by the mother, A: the number of babies the mother felt she was able to breastfeed successfully and C: the number of babies the mother had problems in breastfeeding. The score for the overall BAP is calculated with the following formula: (B + A) – P (by subtracting P from the sum of B and A). For example, if a mother who has breastfed three babies, B is 3. If she feels she is successful in breastfeeding each of these children, A is 3. If she has had no problems in breastfeeding any of her babies, P is 0. Thus, her score for the overall BAP is 6 [(3 + 3) − 0 = 6]. If a mother has some problems while breastfeeding in 1 of her 3 children, P is 1. Then her score for the overall BAP is 5 [(3 + 3) -1 = 5). If a woman has breastfed two babies (B = 2) but feels unsuccessful in both (A = 0) because of feeding problems in both children (P = 2), she will have a total BAP score of zero [(2 + 0) -2 = 0]. Given the importance of breastfeeding confidence in achieving breastfeeding goals, a BAP score of ≥ 2 indicates that previous breastfeeding experiences were successful [ 7 ]. How the BAP score is calculated is shown in Table 1 . Table 1 BAP (Breastfeeding History Questionnaire) and Formula B Number of babies mother has previously breastfed A Number of infants mother felt she was able to breastfeed successfully P Number of infants mother had problems breastfeeding BAP score (B + A)–P Population and Data Collection : The study was carried out in a province located in the Western region of Turkey between June 2022 and January 2023. Inclusion criteria for the participating mothers were as follows: being multiparous, having no health problems preventing them from breastfeeding their babies, have no breastfeeding contraindications, being over 18 years old and having no communication barriers. Mothers with multiple pregnancies and babies who were admitted to the neonatal intensive care unit were not included in the study because of the high risk of supplementing formula. Babies who were supplemented with formula due to a medical indication such as hypoglycemia, weight loss, etc. were included in the “exclusively breastfed infants group”. The BAP questionnaire was administered while the mother was in labor before giving birth. Data were collected with the face-to-face interview method. Adaptation of the BAP into Turkish and Evaluation of its Psychometric Properties The Turkish version of the BAP tool was evaluated in terms of validity. After the BAP was translated into Turkish by three researchers, a bilingual researcher translated it back to English. The form translated back to English was sent to the researchers who developed the original scale and their approval was obtained. For face validity, the BAP was administered to 20 patients in the clinic, and its suitability in terms of clarity and intelligibility was evaluated. In order to evaluate the content validity, the opinions of eight specialists providing services in the field of pediatrics and obstetrics were obtained. Their opinions were analyzed with the Davis technique, and the content validity rate and content validity index were obtained as 1.00. Data Analysis In the study, firstly, the Kolmogorov-Smirnov test was used to examine whether the data fit the normal distribution or not. Descriptive statistics were performed for the demographic characteristics of mother-infant dyads. Then, to calculate the risk status of qualitative and quantitative variables (predictive factors) for the BAP score, the bivariate analysis was performed using the Chi-square test and Student's t-test, respectively. Of these variables, those with p-values < 0.05 were included in the binary logistic regression model. The validity of the BAP was evaluated with the predictive validity. Logistic regression analysis was used to determine the predictive level of the BAP in assessing the risk of formula supplement use. Sensitivity, specificity, positive and negative predictive values were calculated to find out whether the BAP could be used to determine the risk of using formula. Results Characteristics of the participants In the study, 358 women were included. Their mean age was 29.11 ± 5.20 years. The mean number of the living children was 2.78 ± 0.94. Of them, 58% had primary education. The mean gestational age was 38.44 ± 2.98 weeks. The mean time of starting the first breastfeeding after delivery was 2.28 ± 2.00 hours. At discharge, of the participating women, 71% fed their babies only with breast milk, 24.6% with breast milk and formula, and 4.5% with only formula. One out of every three babies was given formula, 62.8% of the mothers started their first breastfeeding within 1 hour after birth. Of the deliveries, 60% were performed by cesarean section. Of the infants who received formula, 37.4% were given formula once, 31.3% twice, 20.6% 3 times, and 10.7% 4 or more times. The reasons why the mothers used in-hospital formula supplements are shown in Graph 1. The most common reason was that the mother thought that her milk supply was not enough, followed by hypoglycemia and insufficient weight. Graph 1 The mean score obtained from the BAP by the participating multiparous women was 2.07 ± 1.88 ranging from 0 to 10. The demographic and obstetric characteristics of the participants were compared by categorizing them according to their BAP scores as ≤ 1 and 2≥. The results of the bivariate analysis are given in Table 2 . The results obtained for the variables such as education, employment status, mode of delivery, family type, supplementing formula in the hospital, and breastfeeding goal were significant. Of the babies, 36.3% were fed with formula in the hospital after birth. Formula use was significantly higher in those whose BAP score was ≤ 1 (Table 2 ). Table 2 Evaluation of Sample Characteristics According to BAP Score Variables Total/Mean BAP Score ≤ 1 ( n = 111) BAP Score ≥ 2 ( n = 247) t/X 2 p N % N (%) N (%) Education level Elementary school 211 58.9 37 32.7 110 44.9 4.721 0.019 High school and above 147 41.1 76 67.3 135 55.1 Working status Not employee 286 79.9 97 85.8 189 77.1 3.641 0.036 Employee 72 20.1 16 14.2 56 22.9 Type of birth Vaginal 142 39.7 27 24.5 115 46.4 15.19 0.000 Cesarean 216 60.3 78 75.5 138 53.6 Family type Nuclar 304 84.9 103 91.2 201 82.0 5.010 0.016 Extended 54 15.1 10 8.8 44 18.0 Formula supplement in hospital Yes 130 36.3 60 53.1 70 28.6 20.114 0.000 No 228 63.7 53 46.9 175 71.4 Breastfeeding intention less than 24 months 57 15.9 34 30.1 23 9.4 24.755 0.000 24 months or more 301 84.1 79 69.9 222 90.6 Number of living children (mean) 2.39 (SD:0.94) 2.20(SD:0.76) 2.48(SD:1.00) 2.576 0.010 Age (mean) 29.11(SD:5.20) 27.64 (SD:5.77) 29.78 (SD:4.78) 3.693 0.000 Table 2 The BAP score was higher in the participants who had a high school or higher education, did not work, lived in an extended family, had a breastfeeding goal of 24 months or more, gave birth vaginally, exclusively breastfed their babies, started breastfeeding within the first hour, and did not give formula after birth (Graph 2). To test the predictive validity of the BAP, variables thought to be associated with formula supplementation were evaluated in the model created through logistic regression analysis (Table 3 ). The significance level obtained with the Hosmer-Lemeshow Test was higher than 0.05, which supported our model. Table 3 Risk estimation model for Formula Use during Postpartum Hospital Stay (N = 358) OR P [%95 CI] BAP Score (BAP score ≤ 1 = 1, BAP score ≥ 2 = 0) 12.88 < .001 [5.766–28.780] Breastfeeding intention (less than 1 year = 1, 2 years and above = 0) .517 < .001 [.232-1.124] Type of birth (Cesarean section = 1, Vaginal = 0) 3.73 < .001 [1.801–7.730] Table 3 According to the model obtained by logistic regression analysis, the sensitivity and the specificity of the BAP were 74.6% and 88.2%, respectively in predicting the use of formula in the hospital in the participants whose BAP score was ≤ 1. In those with a BAP score of ≤ 1, the positive predictive value was 78.22% whereas the negative predictive value was 85.89%. Of the independent variables, the mother’s desire to breastfeed (p < 0.01) and the mode of delivery were significant predictors of of formula use. Having a BAP score of ≤ 1 and cesarean delivery increased the likelihood of formula use. On the other hand, willingness to breastfeed reduced this likelihood. Of the participating multiparous women, those with a BAP score of ≤ 1 were 12.88 times more likely to use formula than were those with a BAP score of ≥ 2 (RR = 12.88, 95% CI [5.76–27.78]; p < .001). Discussion In the present study, the aim is to test the validity of the BAP, developed to determine whether multiparous mothers are at high risk of feeding their babies with formula supplement during the postpartum period in a Turkish sample. Our results confirmed that the BAP could be used to identify multiparous mothers who are likely to feed their babies with formula during their postpartum hospital stay. The WHO states that the screening approach to be used to determine a disease or a condition with abnormal features should be either a test or a method that can be implemented quickly and easily [ 19 ]. The most important feature of the BAP as a screening tool is that it can be implemented quickly and its results can be calculated simply. In the present study, the sensitivity and the specificity of the BAP in identifying multiparous mothers who were at high risk of feeding their babies with formula were 75% and 88%, respectively. Our findings are consistent with those of Burns et al.’s study in which the BAP was developed, and those of Bender et al.’s study in which the validation of the BAP was evaluated [ 1 , 7 ]. Both in Burns et al.’s and in Bender et al.’s studies, the BAP was reported as a reliable tool for predicting the risk of feeding their babies with formula in multiparous women. The Turkish version of the BAP administered to mothers who had just given birth in the hospital was considered as a valid tool. The ease of application and scoring of the measurement tools used in the assessment of breastfeeding is important for the person who administers the tools [ 20 ]. In terms of ease of use, the BAP does not require technical assistance, it has a simple scoring system, and it can be quickly administered by healthcare professionals [ 1 , 7 ]. Other tools that provide practical assessment of breastfeeding are also available. Kronborg et al. stated that with a four-item tool they developed to predict the duration of breastfeeding, the breastfeeding experience of mothers was assessed in a short time. They stated that with the questions in the screening tool, sufficient predictions could be made about the breastfeeding duration of the mothers [ 21 ]. The LATCH scoring system is also a clinically practical tool. It is frequently used in Turkey to assess the breastfeeding success of the mother [ 22 ]. All of these aforementioned tools are suitable for clinical use. Burns (2018) emphasized that taking a history of breastfeeding systematically would provide more useful information than asking the following traditional question: "Have you breastfed?" [ 7 ]. Breastfeeding history plays an important role in predicting the nutrition-related decisions and behaviors of multiparous women. Although multiparous mothers seem to be more advantageous than are primiparous mothers in terms of breastfeeding indicators, the results in current literature are different. In their study in which primiparous and multiparous pregnant women were compared, Yanıkkerem et al. reported that primiparous mothers were more concerned about breastfeeding, but multiparous mothers were concerned that they would experience more breast problems than would primiparous mothers [ 23 ]. Wagner et al. reported that multiparous mothers with unsuccessful or no previous breastfeeding experience were less likely to continue breastfeeding than were primiparous mothers [ 24 ]. In their study, Buckman et al. predicted that the previous experience of multiparous mothers would increase the possibility of breastfeeding, but they concluded the probability of breastfeeding was higher in primiparous mothers (92%) than it was in multiparous mothers (86%)[ 25 ]. In another study, it was shown that primiparous mothers were more likely to start breastfeeding, and that multiparous mothers breastfed longer [ 26 ]. Li et al. emphasize that an unpleasant breastfeeding experience reflects badly on the breastfeeding of the next baby[ 27 ]. Li et al. especially emphasized that multiparous women with previous breastfeeding experience breastfed their babies for a long time thanks to their breastfeeding self-efficacy and ability to manage difficulties [ 28 ]. Burns et al. reported that the rate of formula use was 33.1% in primiparous women with a BAP score of 0, and 70.7% in multiparous women with a BAP score of 0 [ 7 ]. On the other hand, in some studies, it was argued against, and multiparous women were indicated to be more successful than were primiparous women [ 21 , 29 , 30 ]. These results reveal the importance of the evaluation of breastfeeding status and support needs in multiparous mothers. The BAP enables the health professional to make a rapid assessment in this regard and thus can facilitate clinical decision making. A BAP score of ≤ 1 indicates that the risk of using formula is high. The BAP score has good predictive performance in differentiating between multiparous mothers in terms of different variables. In the present study, the BAP score was lower in those who had primary education or below, those who worked, those who underwent a cesarean section, those who had a nuclear family, those who started the first breastfeeding late, those whose babies were given formula in the hospital, and those who wanted to breastfeed for less than 24 months. The risk of using formula was 13 times higher in the participants with a BAP score of 1 and below than it was in the participants with a BAP score of 2 and above. This risk was reported to be 8 times higher in Burns et al.’s study, and 2.6 times higher in Bender’s study [ 1 , 7 ]. It is important to consider this finding because the unsuccessful perception of the mother's previous breastfeeding experience shows that multiparous mothers need more effective support strategies for breastfeeding. In addition, the high rate of cesarean delivery in the present study may be an indirect factor in the risk of feeding with formula. Most of the mothers gave birth by cesarean section. Cesarean section anesthesia may have led to a delay lactogenesis and lower milk production [ 31 ], which may have increased the use of formula to feed the baby. On the other hand, the mother's concern that her milk supply was insufficient was also considered as a reason for the increased use of food supplementation in the hospital. Insufficient milk supply has been demonstrated as a factor that increases the risk of formula use in many previous studies [ 13 , 32 ]. Globally, about half of mothers report insufficient milk supply as the primary reason for starting formula and stopping breastfeeding early in the first few months of life [ 4 ]. It is thought that a better understanding of the relationship between milk supply and milk demand, and newborn behavior, especially in breastfeeding, may reduce the perception of insufficient milk supply. On the other hand, in the present study, willing to breastfeed for two years or more was determined as a preventive factor against the use of formula. The relationship between breastfeeding intention and formula use was also demonstrated in Chantry et al.’s study [ 32 ]. Within the scope of breastfeeding support services, breastfeeding intentions of multiparous women should be reviewed, they should be provided guidance to strengthen their intentions, and appropriate approaches should be displayed. Conclusion The Breastfeeding History Questionnaire (BAP) was considered as a valid tool in the Turkish sample. Our results demonstrated that the BAP was a highly sensitive and specific tool in predicting mothers at risk of feeding their babies with formula and the variables that may affect the risk, based on previous breastfeeding experiences. Multiparous women whose overall BAP score was ≤ 1 were more likely to use formula in the postpartum hospital stay than were those with a BAP score of ≥ 2. The BAP provides health professionals with the opportunity to make a practical and rapid assessment suitable for clinical use. Declarations Ethics approval and consent to participate The study was conducted in accordance with the principles of the Declaration of Helsinki. Before the study was conducted, approval was obtained from the Medical Research Ethics Committee of a University (decision number: 22-6T/34, decision date: June 09, 2022). The informed consent forms signed all the individuals participating in the study were obtained after they were informed about the study. Data availability The dataset used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Consent for publication Not applicable. Funding The authors received no financial support for the research and authorship of this article. Acknowledgements The authors would like to thanks all midwives who supported the study at Buca Seyfi Demirsoy Hospital, and especially to the participating mothers for their support in this research. Authors' contributions A.E., conceptualization of the study, contributed to the design, data acquisition, analysis and interpretation, writing of the manuscript and primary responsibility for the final content;. E.S.C., conceptualization of the study, methodology design, data collection and review of the manuscript, A.A., conceptualization of the study, methodology design, data collection and review of the manuscript, E.C.T. and W.R.B., conceptualization of the study, methodology design, and review of the manuscript. All authors contributed to interpretation of the results and to pre-submission revisions. All authors read and approved the final manuscript. References Bender WR, Koelper NC, Sammel MD, et al. Validation of a Breastfeeding History Questionnaire for the Risk of In-Hospital Formula Supplementation Among Multiparous Women. J Hum Lact. 2019;35(4):665-671. Uğurlu S, Şener E. Baby-Friendly Hospital Initiative: A Concept Analysis At Organizational Level. SDU Healthcare Management. 2020;2(2):65-79. US Department of Health and Human Services. Maternal, Infant, and Child Health Topics and Objectives: MICH-23. 2020. 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Méio MDBB, Villela LD, Gomes Júnior SCDS, et al. Amamentação em Lactentes Nascidos Pré-Termo Após Alta Hospitalar: Acompanhamento Durante o Primeiro Ano de Vida. Cien Saude Colet. 2018;23(8):2403-2412. Chantry CJ, Dewey KG, Peerson JM, et al. In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed. J Pediatr. 2014;164(6):1339-1345. Graph 1 Graph 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Graph1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4986685","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":359915561,"identity":"2cf6ee09-0507-44ea-8cb9-321af886f901","order_by":0,"name":"Emine Serap Cagan","email":"","orcid":"","institution":"Ağrı İbrahim Çeçen University","correspondingAuthor":false,"prefix":"","firstName":"Emine","middleName":"Serap","lastName":"Cagan","suffix":""},{"id":359915562,"identity":"63f4598f-13a7-4b1c-9962-0f6109fc3c9d","order_by":1,"name":"Aysun Ekşioğlu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYPCCAxDqA4QyIF4L4wy4lgQitTDzEKOFf0b6M+kChjvy8v1rzB7bVNTKMbA3b5Ng/HEPpxaJGzlm0jMYnhluuPHG3DjnzHFjBp5jZRIMCcW4rbmRwybNw3CYcYPEGTPp3LZjiQ0SOWZALbhdJn8D6DCgFvv5M4BaLP8dq2+Qf4Nfi8GNBDOQlsSG8z1m0owNNQkMEjz4tRieeWNszWPwLHnDDbYyyZ5jBwzbeNKKLRLScGuRO57+8DZPxR3b+f2Ht0n8qKmT52c/vPHGBxvcWhgEQHKg6JYAKzrMwAai8GgARswBFEYdPrWjYBSMglEwQgEA1yRRuF14cVkAAAAASUVORK5CYII=","orcid":"","institution":"Ege University","correspondingAuthor":true,"prefix":"","firstName":"Aysun","middleName":"","lastName":"Ekşioğlu","suffix":""},{"id":359915563,"identity":"e96d644a-1fd8-4f20-a000-8b137e7bbb04","order_by":2,"name":"Ayşe Akyar","email":"","orcid":"","institution":"Izmir Democracy University","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Akyar","suffix":""},{"id":359915564,"identity":"88e8d846-3999-4661-b811-a0018e399144","order_by":3,"name":"Esin Ceber Turfan","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Esin","middleName":"Ceber","lastName":"Turfan","suffix":""},{"id":359915565,"identity":"0ebbccd2-9da4-4194-a494-89fddcffb4a5","order_by":4,"name":"Whitney R Bender","email":"","orcid":"","institution":"Hospital of the University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Whitney","middleName":"R","lastName":"Bender","suffix":""}],"badges":[],"createdAt":"2024-08-27 20:16:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4986685/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4986685/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75209305,"identity":"573b7894-f272-4cc4-b03d-1cd18ed1a93d","added_by":"auto","created_at":"2025-02-01 04:31:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":713499,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4986685/v1/d303c873-c2f0-4ac6-af3a-7ce9447b13b7.pdf"},{"id":65831670,"identity":"dd8e7878-2608-4a1b-bbc5-610b28bb8835","added_by":"auto","created_at":"2024-10-03 09:46:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15985,"visible":true,"origin":"","legend":"","description":"","filename":"Graph1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4986685/v1/f7ec8914e919509300de7ea7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validity and Clinical Effectiveness of the Breastfeeding History Questionnaire to Determine the Risk of In-Hospital Formula Supplementation in Multiparous Women","fulltext":[{"header":"Background","content":"\u003cp\u003eOne of the important issues in public health is breastfeeding, and feeding the baby with breast milk [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Breast milk positively contributes not only to the growth and development of the baby but also socioeconomically to the family and the society in which they live [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Mortality rates are 14 times higher in children who are not breastfed than in children who are breastfed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is important to ensure that the baby is exclusively breastfed, especially in the postpartum period, before the mother and baby are discharged from the hospital. Most of the problems that prevent the continuation of breastfeeding start during the postpartum hospital stay and may lead to the discontinuation of breastfeeding, or the use of formula [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn order to sustain breastfeeding which is vital for the growth and development of the baby, the Baby-Friendly Hospital application consisting of ten items was started by the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) in 1991, and it has become widespread all over the world; however, breastfeeding rates still have not reached the desired targets [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Article 6 of the Baby-Friendly Hospital application, it is stated that no liquid and food other than breast milk should be given to the newborn unless there is a medical necessity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, formula supplementation is considered an obstacle to the formation of a functional breastfeeding relationship between the mother and baby [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. One of goals of the Healthy People 2020 is to reduce the percentage of infants fed with formula during the postnatal hospital stay from 19.4\u0026ndash;14.2% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the 2018 Breastfeeding Report of the Centers for Disease Control (CDC), 17% of breastfeeding mothers in the United States fed their babies with formula during the first two days after birth [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In a study that included more than 90,000 newborns who were breastfed after birth, it was determined that 61% of the infants were exclusively breastfed when they were discharged from the hospital [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to the results of the Turkey Demographic and Health Survey (TDHS 2018), 41.7% of newborns are given food other than breast milk before the first breastfeeding in the hospitals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the reasons mothers prefer other options instead of breast milk are the perception that their breast milk is insufficient, delayed delivery of breast milk after cesarean section, suggestion by a health worker, baby-related reasons, and the thought that formula is equivalent to breast milk [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In her study conducted in a maternity hospital in Ankara, the capital of Turkey, Demirtaş determined that the history of breastfeeding problems in the previous baby was the determinant of feeding the baby with formula supplement in the hospital [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Bai et al., on the other hand, reported that a long previous breastfeeding experience positively affected the duration of subsequent breastfeeding [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. According to the results of the study conducted by Bartle and Harvey, breastfeeding intention is stronger in women who have a successful breastfeeding experience [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Grano et al. reported that women whose breastfeeding experience is more had better perceptions of behavioral control and stronger intentions to breastfeed the baby until age 2 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although in several studies, breastfeeding experience is stated as an effective factor in maintaining breastfeeding, in some other studies, it is also noted that the risk of using formula is high in multiparous mothers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the study conducted by Mızrak (2017- unpublished results), of the multiparous mothers, 53.2% breastfed their baby in the first half hour after birth, but 27.2% gave formula to their baby during their postpartum hospital stay (Mızrak B, 2017- unpublished results). In multiparous mothers, education level, lack of breastfeeding support and risk of depression are factors associated with breastfeeding motivation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It is stated that women who have previous successful breastfeeding experiences will be less likely to feed their babies with formula while they are in the hospital compared to women who do not [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, early identification of women at risk of not breastfeeding their babies is important in terms of supporting maternal and infant health\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe aim of this cross-sectional and methodological study was to test the psychometric properties of the Breastfeeding History Questionnaire developed by Burns et al. (2018), to determine whether multiparous mothers have a higher risk of feeding their babies with formula supplements in the hospital in the postnatal period, and to evaluate the clinical effectiveness of the questionnaire.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasure\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eBreastfeeding History Questionnaire (BAP)\u003c/b\u003e: The BAP was developed by Burns et al. (2018) to assess whether multiparous mothers were at risk of feeding their babies with formula supplement in the hospital [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Responses given to the items of the BAP, which was created with the thought that a woman's previous breastfeeding history may affect her later breastfeeding experiences, are given a numerical value. The letters in the acronym BAP stand for the following: B: the number of babies previously breastfed by the mother, A: the number of babies the mother felt she was able to breastfeed successfully and C: the number of babies the mother had problems in breastfeeding. The score for the overall BAP is calculated with the following formula: (B\u0026thinsp;+\u0026thinsp;A) \u0026ndash; P (by subtracting P from the sum of B and A). For example, if a mother who has breastfed three babies, B is 3. If she feels she is successful in breastfeeding each of these children, A is 3. If she has had no problems in breastfeeding any of her babies, P is 0. Thus, her score for the overall BAP is 6 [(3\u0026thinsp;+\u0026thinsp;3) \u0026minus;\u0026thinsp;0\u0026thinsp;=\u0026thinsp;6]. If a mother has some problems while breastfeeding in 1 of her 3 children, P is 1. Then her score for the overall BAP is 5 [(3\u0026thinsp;+\u0026thinsp;3) -1\u0026thinsp;=\u0026thinsp;5). If a woman has breastfed two babies (B\u0026thinsp;=\u0026thinsp;2) but feels unsuccessful in both (A\u0026thinsp;=\u0026thinsp;0) because of feeding problems in both children (P\u0026thinsp;=\u0026thinsp;2), she will have a total BAP score of zero [(2\u0026thinsp;+\u0026thinsp;0) -2\u0026thinsp;=\u0026thinsp;0]. Given the importance of breastfeeding confidence in achieving breastfeeding goals, a BAP score of \u0026ge;\u0026thinsp;2 indicates that previous breastfeeding experiences were successful [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHow the BAP score is calculated is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBAP (Breastfeeding History Questionnaire) and Formula\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of babies mother has previously breastfed\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of infants mother felt she was able to breastfeed successfully\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of infants mother had problems breastfeeding\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBAP score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(B\u0026thinsp;+\u0026thinsp;A)\u0026ndash;P\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePopulation and Data Collection\u003c/b\u003e: The study was carried out in a province located in the Western region of Turkey between June 2022 and January 2023. Inclusion criteria for the participating mothers were as follows: being multiparous, having no health problems preventing them from breastfeeding their babies, have no breastfeeding contraindications, being over 18 years old and having no communication barriers. Mothers with multiple pregnancies and babies who were admitted to the neonatal intensive care unit were not included in the study because of the high risk of supplementing formula. Babies who were supplemented with formula due to a medical indication such as hypoglycemia, weight loss, etc. were included in the \u0026ldquo;exclusively breastfed infants group\u0026rdquo;. The BAP questionnaire was administered while the mother was in labor before giving birth. Data were collected with the face-to-face interview method.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAdaptation of the BAP into Turkish and Evaluation of its Psychometric Properties\u003c/h2\u003e \u003cp\u003eThe Turkish version of the BAP tool was evaluated in terms of validity. After the BAP was translated into Turkish by three researchers, a bilingual researcher translated it back to English. The form translated back to English was sent to the researchers who developed the original scale and their approval was obtained. For face validity, the BAP was administered to 20 patients in the clinic, and its suitability in terms of clarity and intelligibility was evaluated. In order to evaluate the content validity, the opinions of eight specialists providing services in the field of pediatrics and obstetrics were obtained. Their opinions were analyzed with the Davis technique, and the content validity rate and content validity index were obtained as 1.00.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Analysis\u003c/strong\u003e \u003cp\u003eIn the study, firstly, the Kolmogorov-Smirnov test was used to examine whether the data fit the normal distribution or not. Descriptive statistics were performed for the demographic characteristics of mother-infant dyads. Then, to calculate the risk status of qualitative and quantitative variables (predictive factors) for the BAP score, the bivariate analysis was performed using the Chi-square test and Student's t-test, respectively. Of these variables, those with p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were included in the binary logistic regression model. The validity of the BAP was evaluated with the predictive validity. Logistic regression analysis was used to determine the predictive level of the BAP in assessing the risk of formula supplement use. Sensitivity, specificity, positive and negative predictive values were calculated to find out whether the BAP could be used to determine the risk of using formula.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e \u003cp\u003eIn the study, 358 women were included. Their mean age was 29.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.20 years. The mean number of the living children was 2.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94. Of them, 58% had primary education. The mean gestational age was 38.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.98 weeks. The mean time of starting the first breastfeeding after delivery was 2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 hours. At discharge, of the participating women, 71% fed their babies only with breast milk, 24.6% with breast milk and formula, and 4.5% with only formula. One out of every three babies was given formula, 62.8% of the mothers started their first breastfeeding within 1 hour after birth. Of the deliveries, 60% were performed by cesarean section.\u003c/p\u003e \u003cp\u003eOf the infants who received formula, 37.4% were given formula once, 31.3% twice, 20.6% 3 times, and 10.7% 4 or more times. The reasons why the mothers used in-hospital formula supplements are shown in Graph 1. The most common reason was that the mother thought that her milk supply was not enough, followed by hypoglycemia and insufficient weight.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGraph 1\u003c/h2\u003e \u003cp\u003eThe mean score obtained from the BAP by the participating multiparous women was 2.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 ranging from 0 to 10. The demographic and obstetric characteristics of the participants were compared by categorizing them according to their BAP scores as \u0026le;\u0026thinsp;1 and 2\u0026ge;. The results of the bivariate analysis are given in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The results obtained for the variables such as education, employment status, mode of delivery, family type, supplementing formula in the hospital, and breastfeeding goal were significant. Of the babies, 36.3% were fed with formula in the hospital after birth. Formula use was significantly higher in those whose BAP score was \u0026le;\u0026thinsp;1 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of Sample Characteristics According to BAP Score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal/Mean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eBAP Score\u0026thinsp;\u0026le;\u0026thinsp;1\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 111)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eBAP Score\u0026thinsp;\u0026ge;\u0026thinsp;2 (\u003cem\u003en\u003c/em\u003e\u0026nbsp;= 247)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003et/X\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula supplement in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding intention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eless than 24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24.755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of living children (mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.39 (SD:0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.20(SD:0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2.48(SD:1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.576\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e29.11(SD:5.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e27.64 (SD:5.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e29.78 (SD:4.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe BAP score was higher in the participants who had a high school or higher education, did not work, lived in an extended family, had a breastfeeding goal of 24 months or more, gave birth vaginally, exclusively breastfed their babies, started breastfeeding within the first hour, and did not give formula after birth (Graph 2).\u003c/p\u003e \u003cp\u003eTo test the predictive validity of the BAP, variables thought to be associated with formula supplementation were evaluated in the model created through logistic regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The significance level obtained with the Hosmer-Lemeshow Test was higher than 0.05, which supported our model.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk estimation model for Formula Use during Postpartum Hospital Stay (N\u0026thinsp;=\u0026thinsp;358)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[%95 CI]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAP Score\u003c/p\u003e \u003cp\u003e(BAP score\u0026thinsp;\u0026le;\u0026thinsp;1 =\u0026thinsp;1, BAP score\u0026thinsp;\u0026ge;\u0026thinsp;2\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[5.766\u0026ndash;28.780]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding intention\u003c/p\u003e \u003cp\u003e(less than 1 year\u0026thinsp;=\u0026thinsp;1, 2 years and above =\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[.232-1.124]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of birth\u003c/p\u003e \u003cp\u003e(Cesarean section\u0026thinsp;=\u0026thinsp;1, Vaginal\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[1.801\u0026ndash;7.730]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003eAccording to the model obtained by logistic regression analysis, the sensitivity and the specificity of the BAP were 74.6% and 88.2%, respectively in predicting the use of formula in the hospital in the participants whose BAP score was \u0026le;\u0026thinsp;1. In those with a BAP score of \u0026le;\u0026thinsp;1, the positive predictive value was 78.22% whereas the negative predictive value was 85.89%.\u003c/p\u003e \u003cp\u003eOf the independent variables, the mother\u0026rsquo;s desire to breastfeed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and the mode of delivery were significant predictors of of formula use. Having a BAP score of \u0026le;\u0026thinsp;1 and cesarean delivery increased the likelihood of formula use. On the other hand, willingness to breastfeed reduced this likelihood. Of the participating multiparous women, those with a BAP score of \u0026le;\u0026thinsp;1 were 12.88 times more likely to use formula than were those with a BAP score of \u0026ge;\u0026thinsp;2 (RR\u0026thinsp;=\u0026thinsp;12.88, 95% CI [5.76\u0026ndash;27.78]; p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, the aim is to test the validity of the BAP, developed to determine whether multiparous mothers are at high risk of feeding their babies with formula supplement during the postpartum period in a Turkish sample. Our results confirmed that the BAP could be used to identify multiparous mothers who are likely to feed their babies with formula during their postpartum hospital stay.\u003c/p\u003e \u003cp\u003eThe WHO states that the screening approach to be used to determine a disease or a condition with abnormal features should be either a test or a method that can be implemented quickly and easily [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The most important feature of the BAP as a screening tool is that it can be implemented quickly and its results can be calculated simply.\u003c/p\u003e \u003cp\u003eIn the present study, the sensitivity and the specificity of the BAP in identifying multiparous mothers who were at high risk of feeding their babies with formula were 75% and 88%, respectively. Our findings are consistent with those of Burns et al.\u0026rsquo;s study in which the BAP was developed, and those of Bender et al.\u0026rsquo;s study in which the validation of the BAP was evaluated [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Both in Burns et al.\u0026rsquo;s and in Bender et al.\u0026rsquo;s studies, the BAP was reported as a reliable tool for predicting the risk of feeding their babies with formula in multiparous women. The Turkish version of the BAP administered to mothers who had just given birth in the hospital was considered as a valid tool.\u003c/p\u003e \u003cp\u003eThe ease of application and scoring of the measurement tools used in the assessment of breastfeeding is important for the person who administers the tools [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In terms of ease of use, the BAP does not require technical assistance, it has a simple scoring system, and it can be quickly administered by healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other tools that provide practical assessment of breastfeeding are also available. Kronborg et al. stated that with a four-item tool they developed to predict the duration of breastfeeding, the breastfeeding experience of mothers was assessed in a short time. They stated that with the questions in the screening tool, sufficient predictions could be made about the breastfeeding duration of the mothers [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The LATCH scoring system is also a clinically practical tool. It is frequently used in Turkey to assess the breastfeeding success of the mother [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. All of these aforementioned tools are suitable for clinical use. Burns (2018) emphasized that taking a history of breastfeeding systematically would provide more useful information than asking the following traditional question: \"Have you breastfed?\" [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Breastfeeding history plays an important role in predicting the nutrition-related decisions and behaviors of multiparous women.\u003c/p\u003e \u003cp\u003eAlthough multiparous mothers seem to be more advantageous than are primiparous mothers in terms of breastfeeding indicators, the results in current literature are different. In their study in which primiparous and multiparous pregnant women were compared, Yanıkkerem et al. reported that primiparous mothers were more concerned about breastfeeding, but multiparous mothers were concerned that they would experience more breast problems than would primiparous mothers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Wagner et al. reported that multiparous mothers with unsuccessful or no previous breastfeeding experience were less likely to continue breastfeeding than were primiparous mothers [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In their study, Buckman et al. predicted that the previous experience of multiparous mothers would increase the possibility of breastfeeding, but they concluded the probability of breastfeeding was higher in primiparous mothers (92%) than it was in multiparous mothers (86%)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In another study, it was shown that primiparous mothers were more likely to start breastfeeding, and that multiparous mothers breastfed longer [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Li et al. emphasize that an unpleasant breastfeeding experience reflects badly on the breastfeeding of the next baby[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Li et al. especially emphasized that multiparous women with previous breastfeeding experience breastfed their babies for a long time thanks to their breastfeeding self-efficacy and ability to manage difficulties [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Burns et al. reported that the rate of formula use was 33.1% in primiparous women with a BAP score of 0, and 70.7% in multiparous women with a BAP score of 0 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, in some studies, it was argued against, and multiparous women were indicated to be more successful than were primiparous women [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These results reveal the importance of the evaluation of breastfeeding status and support needs in multiparous mothers. The BAP enables the health professional to make a rapid assessment in this regard and thus can facilitate clinical decision making.\u003c/p\u003e \u003cp\u003eA BAP score of \u0026le;\u0026thinsp;1 indicates that the risk of using formula is high. The BAP score has good predictive performance in differentiating between multiparous mothers in terms of different variables. In the present study, the BAP score was lower in those who had primary education or below, those who worked, those who underwent a cesarean section, those who had a nuclear family, those who started the first breastfeeding late, those whose babies were given formula in the hospital, and those who wanted to breastfeed for less than 24 months. The risk of using formula was 13 times higher in the participants with a BAP score of 1 and below than it was in the participants with a BAP score of 2 and above. This risk was reported to be 8 times higher in Burns et al.\u0026rsquo;s study, and 2.6 times higher in Bender\u0026rsquo;s study [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is important to consider this finding because the unsuccessful perception of the mother's previous breastfeeding experience shows that multiparous mothers need more effective support strategies for breastfeeding. In addition, the high rate of cesarean delivery in the present study may be an indirect factor in the risk of feeding with formula. Most of the mothers gave birth by cesarean section. Cesarean section anesthesia may have led to a delay lactogenesis and lower milk production [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], which may have increased the use of formula to feed the baby. On the other hand, the mother's concern that her milk supply was insufficient was also considered as a reason for the increased use of food supplementation in the hospital.\u003c/p\u003e \u003cp\u003eInsufficient milk supply has been demonstrated as a factor that increases the risk of formula use in many previous studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Globally, about half of mothers report insufficient milk supply as the primary reason for starting formula and stopping breastfeeding early in the first few months of life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is thought that a better understanding of the relationship between milk supply and milk demand, and newborn behavior, especially in breastfeeding, may reduce the perception of insufficient milk supply. On the other hand, in the present study, willing to breastfeed for two years or more was determined as a preventive factor against the use of formula. The relationship between breastfeeding intention and formula use was also demonstrated in Chantry et al.\u0026rsquo;s study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Within the scope of breastfeeding support services, breastfeeding intentions of multiparous women should be reviewed, they should be provided guidance to strengthen their intentions, and appropriate approaches should be displayed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Breastfeeding History Questionnaire (BAP) was considered as a valid tool in the Turkish sample. Our results demonstrated that the BAP was a highly sensitive and specific tool in predicting mothers at risk of feeding their babies with formula and the variables that may affect the risk, based on previous breastfeeding experiences. Multiparous women whose overall BAP score was \u0026le;\u0026thinsp;1 were more likely to use formula in the postpartum hospital stay than were those with a BAP score of \u0026ge;\u0026thinsp;2. The BAP provides health professionals with the opportunity to make a practical and rapid assessment suitable for clinical use.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the principles of the Declaration of Helsinki. Before the study was conducted, approval was obtained from the Medical Research Ethics Committee of a University (decision number: 22-6T/34, decision date: June 09, 2022). The informed consent forms signed all the individuals participating in the study were obtained after they were informed about the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors received no financial support for the research and authorship of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thanks all midwives who supported the study at Buca Seyfi Demirsoy Hospital, and especially to the participating mothers for their support in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.E., conceptualization of the study, contributed to the design, data acquisition, analysis and interpretation, writing of the manuscript and primary responsibility for the final content;. E.S.C., conceptualization of the study, methodology design, data collection and review of the manuscript, A.A., conceptualization of the study, methodology design, data collection and review of the manuscript, E.C.T. and W.R.B., conceptualization of the study, methodology design, and review of the manuscript. All authors contributed to interpretation of the results and to pre-submission revisions. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBender WR, Koelper NC, Sammel MD, et al. Validation of a Breastfeeding History Questionnaire for the Risk of In-Hospital Formula Supplementation Among Multiparous Women. J Hum Lact. 2019;35(4):665-671.\u003c/li\u003e\n\u003cli\u003eUğurlu S, Şener E. Baby-Friendly Hospital Initiative: A Concept Analysis At Organizational Level. SDU Healthcare Management. 2020;2(2):65-79.\u003c/li\u003e\n\u003cli\u003eUS Department of Health and Human Services. Maternal, Infant, and Child Health Topics and Objectives: MICH-23. 2020. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives.\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez-Escamilla R, Tomori C, Hern\u0026aacute;ndez-Cordero S, et al. Breastfeeding: Crucially Important, But Increasingly Challenged in a Market-Driven World. Lancet. 2023;401(10376):472-485.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization/United Nations Children\u0026apos;s Fund. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Florence (Italy): WHO/UNICEF; 1990.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-Friendly Hospital Initiative. 2018. Available from: https://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation-2018.pdf.\u003c/li\u003e\n\u003cli\u003eBurns W, Rovnyak V, Friedman C, et al. BAP: Testing of a Breastfeeding History Questionnaire to Identify Mothers at Risk for Postpartum Formula Supplementation. Clin Lact. 2018;9(1):30-38.\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control. Breastfeeding Report Card. 2018. Available from: https://www.cdc.gov/breastfeeding/pdf/2018breastfeedingreportcard.pdf.\u003c/li\u003e\n\u003cli\u003eLutsiv O, Pullenayegum E, Foster G, et al. Women\u0026apos;s Intentions to Breastfeed: A Population-Based Cohort Study. BJOG. 2013;120(12):1490-1499. doi:10.1111/1471-0528.12376.\u003c/li\u003e\n\u003cli\u003eHacettepe University Institute of Population Studies. 2018 T\u0026uuml;rkiye Demographic and Health Survey, Key Findings. Ankara (Turkey): Hacettepe University Institute of Population Studies, TC Presidency Strategy and Budget Department and TUBITAK; 2019.\u003c/li\u003e\n\u003cli\u003eŞahin MB, \u0026Ouml;zerdoğan N. Nursing Care Initiatives Based on Theories of Social Cognition and Breastfeeding Self-Efficacy for Successful Breastfeeding. J Educ Res Nurs. 2014;11(1):11-15.\u003c/li\u003e\n\u003cli\u003eİnce T, Aktaş G, Aktepe N, et al. Evaluation of the Factors Affecting Mothers\u0026rsquo; Breastfeeding Self-Efficacy and Breastfeeding Success. J Dr Behcet Uz Child Hosp. 2017;7(1):27-31.\u003c/li\u003e\n\u003cli\u003eDemirtas B. Multiparous Mothers: Breastfeeding Support Provided by Nurses. Int J Nurs Pract. 2015;21(5):493-504.\u003c/li\u003e\n\u003cli\u003eBai DL, Fong DYT, Tarrant M. Previous Breastfeeding Experience and Duration of Any and Exclusive Breastfeeding Among Multiparous Mothers. Birth. 2015;42(1):70-77.\u003c/li\u003e\n\u003cli\u003eBartle NC, Harvey K. 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Pediatrics. 2013;132(4)\u003c/li\u003e\n\u003cli\u003eBuckman C, Diaz AL, Tumin D, et al. Parity and the Association Between Maternal Sociodemographic Characteristics and Breastfeeding. Breastfeed Med. 2020;15(6):443-452.\u003c/li\u003e\n\u003cli\u003eHuang Y, Ouyang YQ, Redding SR. Previous Breastfeeding Experience and Its Influence on Breastfeeding Outcomes in Subsequent Births: A Systematic Review. Women Birth. 2019;32(4):303-309.\u003c/li\u003e\n\u003cli\u003eLi T, Guo N, Jiang H, et al. Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study. J Hum Lact. 2019;35(3):583-591.\u003c/li\u003e\n\u003cli\u003eLi JY, Huang Y, Liu HQ, et al. The Relationship of Previous Breastfeeding Experiences and Factors Affecting Breastfeeding Rates: A Follow-Up Study. Breastfeed Med. 2020;15(12):789-797.\u003c/li\u003e\n\u003cli\u003eAmin T, Hablas H, Al Qader AA. Determinants of Initiation and Exclusivity of Breastfeeding in Al Hassa, Saudi Arabia. Breastfeed Med. 2011;6(2):59-68.\u003c/li\u003e\n\u003cli\u003eKitano N, Nomura K, Kido M, et al. Combined Effects of Maternal Age and Parity on Successful Initiation of Exclusive Breastfeeding. Prev Med Rep. 2016;3:121-126.\u003c/li\u003e\n\u003cli\u003eM\u0026eacute;io MDBB, Villela LD, Gomes J\u0026uacute;nior SCDS, et al. Amamenta\u0026ccedil;\u0026atilde;o em Lactentes Nascidos Pr\u0026eacute;-Termo Ap\u0026oacute;s Alta Hospitalar: Acompanhamento Durante o Primeiro Ano de Vida. Cien Saude Colet. 2018;23(8):2403-2412.\u003c/li\u003e\n\u003cli\u003eChantry CJ, Dewey KG, Peerson JM, et al. In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed. J Pediatr. 2014;164(6):1339-1345.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Graph 1","content":"\u003cp\u003eGraph 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding, multiparous, hospital, validity, formula feeding","lastPublishedDoi":"10.21203/rs.3.rs-4986685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4986685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEarly detection of women at risk of not breastfeeding their babies is important in terms of supporting maternal and infant health. In particular, the breastfeeding experience of multiparous mothers may be considered as a sufficient factor in breastfeeding success, leading to neglect of breastfeeding support. The study was aimed at testing the psychometric properties of the Breastfeeding History Questionnaire (BAP) and to evaluate clinic effectiveness in detecting the risk of in-hospital formula supplementation among multiparous women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study is a cross-sectional study conducted in a mother-friendly tertiary health care facility in western Turkey, involving 358 women. First of all, expert opinion was obtained for content validity, then the risk of using formula was investigated cross-sectionally. Chi-square test and Student's t-test and multivariate logistic regression analysis were used for data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe sensitivity and the specificity of the BAP used for the prediction of formula supplement use in the hospital by those whose BAP score was ≤ 1 were 74.6% and 88.2%, respectively. In those with a BAP score of ≤1, while the positive predictive value was 78.22%, the negative predictive value was 85.89%. Of the multiparous women, those with a BAP score of ≤1were 12.8 times more likely to supplement formula during the postpartum hospital stay than were those with a BAP score of ≥2 (RR = 12.88, 95% CI [5.76-27.78]; p \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe BAP is a valid tool and it offers practical evaluation suitable for clinical use.\u003c/p\u003e","manuscriptTitle":"Validity and Clinical Effectiveness of the Breastfeeding History Questionnaire to Determine the Risk of In-Hospital Formula Supplementation in Multiparous Women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-03 09:46:19","doi":"10.21203/rs.3.rs-4986685/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9a63b37-4c91-45ed-aa97-ab9f51c1c7cb","owner":[],"postedDate":"October 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-01T04:23:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-03 09:46:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4986685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4986685","identity":"rs-4986685","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}