Internalized Weight Stigma, Breastfeeding Difficulties, and Self‐Efficacy as Mediators Between Pre‐Pregnancy Overweight/Obesity and Exclusive Breastfeeding at 6 Months Postpartum: A Prospective Cohort Study in China

This prospective cohort study aims to explore the mechanisms by examining the independent and sequential mediation effects of internalized weight stigma, breastfeeding difficulties, and breastfeeding self-efficacy in the relationship between pre-pregnancy overweight/obesity and exclusive breastfeeding at 6 months postpartum. In Nanjing, China, 296 primiparous women were stratified by pre-pregnancy body mass index (BMI) into two groups: pre-pregnancy overweight/obese (n = 146) and normal BMI (n = 150). Data were collected via questionnaires during the antenatal period and at 6 months postpartum. Women with pre-pregnancy overweight/obesity reported significantly higher levels of internalized weight stigma (M = 30.73, SD = 5.71) compared to their normal-weight counterparts (M = 22.42, SD = 3.75). Path analysis with bias‑corrected bootstrapping was used to test mediation, adjusting for baseline covariates. The study confirmed a negative correlation between pre-pregnancy overweight/obesity and exclusive breastfeeding at 6 months postpartum. Significant indirect paths were identified from pre-pregnancy overweight/obesity to exclusive breastfeeding at 6 months postpartum via internalized weight stigma, breastfeeding difficulties, and breastfeeding self-efficacy. A significant serial indirect path through breastfeeding difficulties and self-efficacy was also identified. This study highlights the critical mediating roles of internalized weight stigma, breastfeeding difficulties, and breastfeeding self-efficacy in the relationship between pre-pregnancy overweight/obesity and exclusive breastfeeding. The findings provide healthcare professionals with evidence-based targets for intervention, emphasizing the need to address weight stigma in prenatal care and enhance breastfeeding support strategies. Future studies in more diverse populations are warranted to confirm generalizability. Trial Registration: Registered at the Chinese Clinical Trial Registry (registry number: ChiCTR2200057038), trial registration date February 26, 2022.