Factors associated with breastfeeding maintenance for 12 months or more: a systematic review

Santana, Géssica S.; Giugliani, Elsa Regina J.; Vieira, Tatiana de O.; Vieira, Graciete O.

doi:10.1016/j.jped.2017.06.013

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Review article • J. Pediatr. (Rio J.) 94 (2) • Mar-Apr 2018 • https://doi.org/10.1016/j.jped.2017.06.013 copy

Factors associated with breastfeeding maintenance for 12 months or more: a systematic review^☆ ☆ Please cite this article as: Santana GS, Giugliani ER, Vieira TO, Vieira GO. Factors associated with breastfeeding maintenance for 12 months or more: a systematic review. J Pediatr (Rio J). 2018;94:104-122

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Synthesize the information about the factors associated with maintenance of breastfeeding for 12 months or more.

Data source

A systematic review was conducted in the Pubmed/Medline, Scielo, and Lilacs databases, including articles published in Portuguese or English since 2004 on the factors associated with breastfeeding maintenance for at least 12 months; review articles and those with qualitative design were excluded. The factors were organized into four levels, according to the chronological proximity to the outcome: distal, distal intermediate, proximal intermediate, and proximal; nationality and place/area of residence were considered contextual factors.

Summary of data

1174 articles were identified, of which 19 were included in this review, comprising seven cohort studies and 12 cross-sectional studies. A total of 39 of the 75 assessed factors were associated with the outcome at least once. The factors with the highest percentages of associations with maintenance of breastfeeding for 12 months or more, considering the number of times they were tested were: children whose parents are the caregivers (100%), none type of maternal exposure to smoke (54%), children and/or parents are immigrants/foreigners (50%), live in urban areas (42.9%), older maternal age (40%), married women (37.5%), higher level of maternal education (31.3%), greater parity (30.8%), and lower income (30%).

Conclusions

The maintenance of breastfeeding for 12 months or more is associated with multiple factors, emphasizing the contextual factors and those related to some maternal sociodemographic characteristics. Associations differ in effect and magnitude between the different populations studied.

KEYWORDS
Review; Breast feeding; Epidemiologic factors

First author, year of publication, study country	Design	Population/sample (No. of assessed mother-baby pairs)	Multivariate analysis	Outcome	Factors associated to outcome (association measure/95% CI/p-value)^a a Variables with significant values of OR or HR greater than 1.00 indicate a greater chance of breastfeeding maintenance, and OR or HR < 1.00 indicate a lower chance.	Factors not associated with the outcome	Evidence quality score^b BF, maternal breastfeeding; OR, odds ratio; aOR, adjusted odds ratio; 95% CI, 95% confidence interval; aHR, adjusted hazard ratio; p, p value; BMI, body mass index.
Laterra A, 2014, Haiti³⁹39 Laterra A, Ayoya MA, Beaulière J-M, Bienfait M, Pachón H. Infant and young child feeding in four departments in Haiti: mixed-method study on prevalence of recommended practices and related attitudes, beliefs, and other determinants. Rev Panam Salud Publica. 2014;36:306-13.	Cross-sectional	Mothers aged ≥18 years and children aged ≤2 years from four Haitian departments/administrative divisions/310	Yes	BF 20-24 months	None	Area of residence (urban or rural) Region of residence Maternal age Parity Maternal level of schooling Annual family income Place of last childbirth Birth attended by health professional Maternal work Maternal workload outside the home Age of the youngest child	19
Yalçin SS, 2014, Turkey⁴²42 Yalçın SS, Yalçın S, Kurtuluş-Yiğit E. Determinants of continued breastfeeding beyond 12 months in Turkey: secondary data analysis of the Demographic and Health Survey. Turk J Pediatr. 2014;56:581-91.	Population-based Cross-sectional	Children 12-35 months of age living with their mothers/1666	Yes	BF ≥ 12 months	Maternal age 30-34 years at the child's birth (aOR = 1.94; 95%CI 1.13-3.32) when compared to mothers <19 years Higher order of birth (≥5th) of the child associated with a longer interval between deliveries (≥24 months) (aOR = 2.20, 95% CI: 1.30-3.72) Wedding with religious ceremony (aOR = 2.54, 95% CI: 1.06-6.07) Passive maternal exposure to tobacco (aOR = 0.73, 95% CI: 0.56-0.95) when compared to non-smoking mothers Mother who smoked (aOR = 0.61, 95% CI: 0.45-0.83) when compared to non-smoking mothers Overweight mother (BMI 25-29.9 kg/m²) (aOR = 1.31, 95% CI: 1.02-1.68) Not using any contraceptive method (aOR = 0.52, 95% CI: 0.37-0.71) when compared to traditional methods Using modern non-hormonal contraceptive methods (aOR = 0.59, 95% CI: 0.45-0.77) when compared to traditional methods Using hormonal contraceptives (aOR = 0.47, 95% CI: 0.30-0.75) when compared to traditional methods Bottle-fed child (aOR = 0.36, 95% CI: 0.29-0.45) Exclusively breastfed infant in the first 3 days of life (aOR = 1.45, 95% CI: 1.16-1.82)	Place of residence Region of residence Birth order Birth interval Family with 6 or more members Maternal education Having a dowry at the wedding Family constitution Paternal age Paternal education Family income Having health insurance Number of prenatal visits Type of birth Place of birth Beginning of breastfeeding within the first hour of life Weight at birth Child's gender Maternal work Age of child (12-23 months versus 24-36 months) Weight/age of child Height/age of child Weight/height of the child BMI/age of child	20
Hure AJ, 2013, Australia⁴⁰40 Hure AJ, Powers JR, Chojenta CL, Byles JE, Loxton D. Poor adherence to national and international breastfeeding duration targets in an Australian longitudinal cohort. PLoS ONE. 2013;8:e54409.	Population-based cohort	Mothers aged 30-36 years/9773	No	BF ≥ 12 months and ≥24 months	Outcome ≥12 months: Older maternal age at delivery (p < 0.01) Higher order of birth of the child (p < 0.01) Higher maternal level of schooling (p < 0.01) Mother is married (p < 0.01) Full-term child and/or with adequate birth weight (p < 0.01) Lower level of maternal concern related to money (p < 0.01) Outcome ≥24 months: Older maternal age at delivery (p < 0.01) Higher order of birth of the child (p < 0.01) Higher maternal level of schooling (p < 0.01) Mother is single (p < 0.01)	Place of residence	23
dos S Neto ET, 2013, Brazil²⁹29 dos S Neto ET, Zandonade E, Emmerich AO. Analysis models for variables associated with breastfeeding duration. Rev Paul Pediatr. 2013;31:306-14.	Cohort	Children and mothers residing in two areas covered by the Family Health Strategy of the Unified Health System in the municipality of Vitória, ES/67	Yes	BF ≥ 12 months	Older maternal age (>35 years; p = 0.002) Did not start pacifier suction in the 1st month of life (p = 0.005) Did not start artificial feeding in the 1st month of life (p = 0.01)	Number of children born alive Number of siblings from the same mother Number of children under 5 in the house Interbirth interval Number of individuals living in the same house Maternal level of schooling Maternal marital status Marital stability Paternal occupation Monthly family income House finishing Number of rooms in the house Maternal occupation Child started using pacifier before the third month of life Child started using pacifier before the sixth month of life Child was bottle-fed Child received formula before the sixth month of life	17
Al-Kohji S, 2012, Qatar³⁸38 Al-Kohji S, Said HA, Selim NA. Breastfeeding practice and determinants among Arab mothers in Qatar. Saudi Med J. 2012;33:436-43.	Cross-sectional	Arab mothers and children under 24 months attending a Primary Health Care Center/770	No	BF ≥ 12 months	None	Nationality Maternal age Parity Maternal level of schooling Monthly family income Receiving guidance about infant feeding during prenatal care Mother received formula ads during prenatal care Type of birth Place of delivery (type of hospital) Rooming-in Easy access to get support for feeding problems after childbirth Mother received formula ads before discharge Meaning of exclusive breastfeeding for mothers Maternal opinion on the appropriate position for breastfeeding Child's gender Maternal occupation Planned feeding method for the child Breastfeeding on demand	20
Bertino E, 2012, Italy³⁴34 Bertino E, Varalda A, Magnetti F, Di Nicola P, Cester E, Occhi L, et al. Is breastfeeding duration influenced by maternal attitude and knowledge? A longitudinal study during the first year of life. J Matern Fetal Neonatal Med. 2012;25:32-6.	Cohort	Children born in a hospital in Turin, and their mothers/562	Yes	BF ≥ 12 months	High score of the maternal attitude toward breastfeeding (mothers favorable to breastfeeding compared with those favorable to using formula to feed their children; p = 0.003)	Maternal nationality Parity Maternal level of schooling Type of birth Rooming-in practice Maternal employment situation Maternal smoking before pregnancy Maternal smoking during pregnancy Paternal smoking during pregnancy Maternal BMI Child uses pacifier	16
Langellier BA, 2012, United States²¹21 Langellier BA, Pia Chaparro M, Whaley SE. Social and institutional factors that affect breastfeeding duration among WIC participants in Los Angeles County, California. Matern Child Health J. 2012;16:1887-95.	Cross-sectional	Mothers and children participating in Special Supplemental Nutrition Program for Woman, Infants and Children (WIC)/4725	Yes	BF ≥ 12 or ≥24 months	Outcome ≥12 months: Foreign mother (aOR = 1.86, 95% CI: 1.41-2.43) Interview carried out in Spanish (aOR = 1.50, 95% CI: 1.14-1.47) Mother intends to breastfeed (aOR = 2.80, 95% CI: 2.05-3.8) Non-exclusive breastfeeding at the maternity hospital (aOR = 3.52, 95% CI: 2.75-4.51) when compared with non-breastfeeding Exclusive breastfeeding in the maternity hospital (aOR = 8.04, 95% CI: 6.17-10.49) when compared to non-breastfeeding Mother resides with the child's father (aOR = 1.31; 95% CI: 1.06-1.61) Maternal return to work up to three months postpartum (aOR = 0.63, 95% CI: 0.45-0.8) Outcome ≥24 months: Interview carried out in Spanish (aOR = 1.89, 95% CI: 1.10-3.25) Mother intends to breastfeed (aOR = 2.07, 95% CI: 1.15-3.75) Non-exclusive breastfeeding at the maternity hospital (aOR = 2.72, 95% CI: 1.64-4.50) when compared to non-breastfeeding Exclusive breastfeeding at the maternity hospital (aOR = 5.72, 95% CI: 3.44-9.52) when compared to non-breastfeeding Maternal return to work up to three months postpartum (aOR = 0.49, 95% CI: 0.28-0.88)	Maternal age Maternal level of schooling Maternal ethnicity Child receiving formula at the hospital Participation in the WIC Child's gender Age of child	17
Martins EJ, 2012, Brazil²²22 Martins EJ, Giugliani ER. Which women breastfeed for 2 years or more?. J Pediatr (Rio J). 2012;88:67-73.	Cohort	Children born in a hospital in Porto Alegre, RS and their mothers/151	Yes	BF ≥ 24 months	Mother living with the child's father (aOR = 0.61, 95% CI: 0.37-0.99) Mother staying at home with the child in the first 6 months of life (aOR = 2.13, 95% CI: 1.12-4.05) Child not using a pacifier (aOR = 2.45, 95% CI: 1.58-3.81) Delay the introduction of water and/or teas to the child's diet (aOR = 1.005, 95% CI: 1.001-1.009) Delay the introduction of other types of milk to the child's diet (aOR = 1.001, 95% CI: 1.001-1.002)	Maternal age Parity Maternal level of schooling Mother's skin color/ethnicity Time of breastfeeding of previous children Receive guidance about BF in prenatal care Number of prenatal visits Type of birth Child received formula at the maternity hospital Child's gender Mother lives with her mother-in-law. Maternal smoking during pregnancy Age at which child started receiving solid/semi-solid foods	16
Senarath U, 2012, Sri Lanka³⁶36 Senarath U, Siriwardena I, Godakandage SS, Jayawickrama H, Fernando DN, Dibley MJ. Determinants of breastfeeding practices: an analysis of the Sri Lanka Demographic and Health Survey 2006-2007. Matern Child Nutr. 2012;8:315-29.	Cross-sectional	Mothers aged 15-49 with children up to 24 months of age/2735	Yes	BF ≥ 12 months	Living in rural areas compared to tea-producing properties (p < 0.01) Not residing in the Central Province compared to the West Province (p = 0.01) Vaginal delivery (p < 0.01) Receiving at least one home visit by postpartum health workers (p = 0.01)	Maternal age Child's birth order Birth interval between the two last births Maternal level of schooling Maternal marital status Paternal level of schooling Family income Number of prenatal visits in clinics Receiving home visits by health workers during pregnancy Place of delivery Birth weight Child's gender Maternal occupation Maternal BMI Maternal participation in family decisions	16
Demétrio F, 2012, Brazil²⁷27 Demétrio F, Pinto EJ, Assis AM. Factors associated with early breastfeeding cessation: a birth cohort study in two municipalities in the Recôncavo region, Bahia State, Brazil. Cad Saude Publica. 2012;28:641-50.	Cohort	Children born in public maternity hospitals in the municipalities of Laje and Mutuípe, BA/531	Yes	BF ≥ 24 months	Residing in the rural area (p < 0.05) Mother received prenatal care (p < 0.05)	Maternal age Maternal level of schooling Skin color Housing status index Type of birth Birth weight Child's gender Gestation time Maternal work outside the home after childbirth Maximum height of the mother Pre-gestational maternal anthropometric status Post-gestational maternal anthropometric status	17
Carletti C, 2011, Italy³⁵35 Carletti C, Pani P, Knowles A, Monasta L, Montico M, Cattaneo A. Breastfeeding to 24 months of age in the northeast of Italy: a cohort study. Breastfeed Med Off J Acad Breastfeed Med. 2011;6:177-82.	Cohort	Children born in a hospital in Trieste and their mothers/93	Yes	BF ≥ 12 months	Maternal age 30-34 years compared with mothers aged >34 years (p = 0.026)	Maternal nationality Parity Maternal level of schooling Maternal marital status Duration of previous breastfeeding Type of delivery Child admitted at the hospital after birth Child's birth weight Child's birth length Gestational age Child had jaundice at birth Child had respiratory difficulty at birth Maternal occupation Maternal return to work	16
Kristiansen AL, 2010, Norway³²32 Kristiansen AL, Lande B, Øverby NC, Andersen LF. Factors associated with exclusive breast-feeding and breast-feeding in Norway. Public Health Nutr. 2010;13:2087-96.	Population-based cohort	All children born in Norway from April 17 to May 8, 2006/1490	Yes	BF ≥ 12 months	Older maternal age (25-34 years old: aOR = 1.99, 95% CI: 1.13-3.50/≥35 years old: aOR = 2.40, 95% CI: 1.30-4.44) compared with mothers ≤24 years Mother of a second child (aOR = 0.75, 95% CI: 0.57-0.97) Higher maternal schooling (higher education ≤4 years: aOR = 2.33; 95% CI: 1.17-4.65/higher education >4 years: aOR = 2.81; 95%CI: 1.39-5.66) when compared to mothers with primary and secondary education Lower child's birth weight (aOR = 0.39, 95% CI: 0.21-0.72) Mother smoked during pregnancy (aOR = 0.49, 95% CI: 0.34-0.71) Child has a caregiver other than the parents (aOR = 0.64, 95% CI: 0.50-0.82)	Geographical region of residence Maternal marital status Paternal level of schooling Family history of asthma/allergy Maternal occupation at the child's birth Maternal occupation at 12 months of the child's life Mother smoking at 6 months of the child's life	24
Wallby T, 2009, Sweden³⁷37 Wallby T, Hjern A. Region of birth, income and breastfeeding in a Swedish county. Acta Paediatr. 2009;98:1799-804.	Cross-sectional	Children born between 1997 and 2001 living in the city of Uppsala/12.197	Yes	BF ≥ 12 months	Non-Swedish mother (from Eastern Europe and Balkan countries: aHR = 1.63; 95% CI: 1.29-2.06/from Africa: aHR = 2.14; 95% CI: 1.73-2.64/from the Middle East: aHR = 1.73, 95% CI: 1.49-2.01/from South and East Asia: aHR = 1.72, 95% CI: 1.38-2.15) Lower family income (Quartile 1: aHR = 1.24, 95% CI: 1.10-1.39) Smoking mother (aHR = 0.70, 95% CI: 0.61-0.80)	Type of delivery	20
Senarath U, 2007, East Timor⁴³43 Senarath U, Dibley MJ, Agho KE. Breastfeeding practices and associated factors among children under 24 months of age in Timor-Leste. Eur J Clin Nutr. 2007;61:387-97.	Cross-sectional	Children aged 0-23 months living in urban and rural areas of the study country, selected from a population sample of a study carried out in 2003/2162	Yes, but only for the outcome BF ≥ 12	BF ≥ 12 months or ≥24 months	Outcome ≥12 months: Home delivery (p = 0.01) Mothers who worked in the 12 months prior to the interview (p = 0.01) Younger age of the child (p = 0.01) Outcome ≥24 months: Not residing in the eastern rural area (p = 0.001) Living in the mountains (p = 0.001) Mother aged <35 years old (p < 0.01) Number of children <4 (p < 0.05) Being illiterate or having attended only elementary school (p < 0.01) Not belonging to the wealthiest social stratum (p < 0.05)	Child's gender	20
Singh GK, 2007, United States³⁰30 Singh GK, Kogan MD, Dee DL. Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003. Pediatrics. 2007;119:S38-46.	Population-based cross-sectional	Children younger than 6 years/33,121	Yes	BF ≥ 12 months	Residing in a metropolitan region (p = 0.05) Children born in the United States, to immigrant parents, compared to US children born to American parents (p = 0.05) White, non-Hispanic mothers compared with non-Hispanic Black mothers (p = 0.05) Family composition: not being the child of a single mother and not being the child of adoptive parents when compared to the children of biological parents (p = 0.05) Parents' level of schooling ≥ 13 years (p = 0.05) Female child (p = 0.05) High level of family or social support (p = 0.05) Not having a smoker at home (p = 0.05)	Safety in the home district Child's birth order Level of family poverty Maternal physical health status Maternal emotional health status Maternal physical activity	25
Carrascoza KC, 2005, Brazil²⁸28 Carrascoza KC, Júnior C, Luiz Á, de Moraes ABA. The early weaning and extended breastfeeding influent factors. Estud Psicol Camp. 2005;22:433-40.	Cross-sectional	Children from a dental care center for special patients and their mothers/80	No	BF ≥ 12 months	Older maternal age (p = 0.0331) Higher number of children (p = 0.0175) Mother is married (p = 0.0078) Lower socioeconomic class (p < 0.05) Mother had previous experience with breastfeeding (p = 0.0058)	Mother received guidance on breastfeeding during pregnancy Mother's intention to breastfeed during pregnancy Type of delivery	13
Hajian-Tilaki KO, 2005, Iran⁴¹41 Hajian-Tilaki KO. Factors associated with the pattern of breastfeeding in the north of Iran. Ann Hum Biol. 2005;32:702-13.	Cross-sectional	Mothers of children aged 12-24 months/600	Yes	BF ≥ 24 months	Living in rural areas (p < 0.05) Greater parity (p < 0.05) Higher maternal schooling (p < 0.05) Mother did not work outside the home (p < 0.05) Lower maternal stress level (p < 0.05)	Maternal age Child's gender	17
Li R, 2005, United States³¹31 Li R, Darling N, Maurice E, Barker L, Grummer-Strawn LM. Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National Immunization Survey. Pediatrics. 2005;115:e31-7.	Cross-sectional	Children aged 19-35 months who participated in the National Immunization Survey of 2002/3507	No	BF ≥ 12 months	Residing in the Pacific region (p < 0.05) Older maternal age (p < 0.05) Higher maternal schooling (p < 0.05) Mother is married (p < 0.05) White non-Hispanic mother (p < 0.05) Mother/child not participating in the WIC program (p < 0.05) for mothers and children in the first year of life Child did not have a nanny at 6 months (p < 0.05)	Child's birth order Poverty level Child's Gender	21
Lande B, 2004, Norway³³33 Lande B, Andersen LF, Veierød MB, Baerug A, Johansson L, Trygg KU, et al. Breast-feeding at 12 months of age and dietary habits among breast-fed and non-breast-fed infants. Public Health Nutr. 2004;7:495-503.	Cross-sectional	12-month-old children born to Norwegian mothers or mothers from another Scandinavian country/1932	Yes	BF at 12 months	Residing in a place with a higher degree of urbanization (aOR = 1.34, 95% CI: 1.04-1.72) Older maternal age (25-34 years old: aOR = 1.45, 95% CI: 1.03-2.05/≥35 years old: aOR = 2.36, 95% CI: 1.58-3.51) when compared with mothers aged <25 years Higher maternal level of schooling (≥13 years) (aOR = 2.48, 95% CI: 1.63-3.77) Presence of allergy/asthma among family members (aOR = 1.40, 95% CI: 1.14-1.71) Mother smoking at six months of child's life (aOR = 0.57, 95% CI: 0.44-0.74) Child does not have a baby-sitter (aOR = 1.43, 95% CI: 1.15-1.77)	Child's gender	24

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[1] * Corresponding author. E-mail:gessicassantana@hotmail.com (G.S. Santana).