Factors associated with exclusive breastfeeding in the first six months of life in Brazil: a systematic review

Boccolini, Cristiano Siqueira; Carvalho, Márcia Lazaro de; Oliveira, Maria Inês Couto de

doi:10.1590/S0034-8910.2015049005971

Brasil

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

Review • Rev. Saúde Pública 49 • 2015 • https://doi.org/10.1590/S0034-8910.2015049005971 linkcopy

Factors associated with exclusive breastfeeding in the first six months of life in Brazil: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE To identify factors associated with exclusive breastfeeding in the first six months of life in Brazil.

METHODS Systematic review of epidemiological studies conducted in Brazil with exclusive breastfeeding as outcome. Medline and LILACS databases were used. After the selection of articles, a hierarchical theoretical model was proposed according to the proximity of the variable to the outcome.

RESULTS Of the 67 articles identified, we selected 20 cross-sectional studies and seven cohort studies, conducted between 1998 and 2010, comprising 77,866 children. We identified 36 factors associated with exclusive breastfeeding, being more often associated the distal factors: place of residence, maternal age and education, and the proximal factors: maternal labor, age of the child, use of a pacifier, and financing of primary health care.

CONCLUSIONS The theoretical model developed may contribute to future research, and factors associated with exclusive breastfeeding may subsidize public policies on health and nutrition.

Breast Feeding; Maternal Behavior; Risk Factors; Socioeconomic Factors; Review

Author/Publishing year	Local/year of implementation	Sample (n)/data source	Statistical analysis	Quality Score	EBF Prevalence (age group)	Outcome	Factors associated with outcome and association measure	Factors evaluated without statistical significance
Alves et al¹ (2013)	Barra Mansa, RJ, 2006	707 babies < 6 m/AMAMUNIC	Hierarchical Poisson Regression	Moderate	46.7% (< 6 m)	EBF	Mother's education ≤ 8^th grade [PR = 0.80] Childbirth type (caesarean) [PR = 0.84] Child's age in days [PR = 0.99] Use of a pacifier [PR = 059] Assistance by a Breastfeeding-Friendly Primary Care Unit [PR = 1.19]	Adolescent maternal age; parity; vaccination station in rural/urban environment; birth municipality; maternal work; To be born in Baby-Friendly Hospital; birth weight; sex of the baby; hospitalization because of diseases
Caminha et al⁶ (2010)	Pernambuco, 2006	1,568 babies < 6 m/ PESN	Hierarchical Poisson Regression	Moderate	8.5% (at 6 m)	EBF at 4 m	Metropolitan area [PR = 1.4] Maternal age (≥ 36 years) < 20 years [PR = 15] 20 to 35 years [PR = 1.6] Maternal education (none) From 1^st to 4^th grade [PR = 1.2] From 5^th to 8^th grade [PR = 1.7] 9^th grade or more [PR = 1.8] Baby of the female sex [PR = 1.3]	Area (urban/rural); water supply; per capita income; number of residents; prenatal information on BF; no. of prenatal visits; childbirth type; birth weight; maternal work; to be attended by FHS
Carvalhaes et al⁷ (2007)	Botucatu, SP, 2004	380 babies < 4 m/AMAMUNIC	Hierarchical logistic regression	Moderate	38.0% (< 4 m)	Interruption of EBF	Difficulty in starting breastfeeding [OR = 1.57] Use of a pacifier [OR = 2.63]	Maternal education; parity; maternal work; maternity leave; financing of the hospital; childbirth type; birth weight
Leone et al²¹ (2012)	Sao Paulo, SP, 2008	724 babies < 6 m/AMAMUNIC	Logistic regression	Moderate	39.6% (< 6 m)	Interruption of EBF	Maternal work [OR = 2.11] Child's age in days [OR = 1.01] Use of a pacifier [OR = 3.02]	Maternal education; childbirth type; birth in BFH; birth weight; sex of the baby; BF in the 1^st hour of life
Martins et al²³ (2011)	Feira de Santana, BA, 2004-2005	1,309 babies < 1 m/ household visit	Logistic regression	Moderate	59.3% (at the 1^st m)	Interruption of EBF	Maternal education: ≤ high school [OR = 1.35] Primiparity [OR = 1.41] Income < 1 minimum wage [OR = 1.27] Lack of guidance on BF in the hospital [OR = 1.53] Tiredness [OR = 1.18]	Maternal age; childbirth type
Nascimento et al²⁸ (2010)	Joinville, SC, 2005	1,470 babies < 6 m/ AMAMUNIC	Poisson Regression	Moderate	71.2% (1^st month) 61.0% (2^nd month) 46.3% (3^rd month) 44.2% (4^th month) 31.3% (5^th month) 13.3% (6^th month)	Interruption of EBF	Maternal education < 12 years [PR = 1.59] Child's age ≥ 90 days [PR = 1.53] Use of a pacifier [PR = 1.69]	Maternal age; parity; birth in BFH; childbirth type; sex of the baby; birth weight; primary care financing; professional who took care of the child; maternal work
Neves et al²⁹ (2014)	255 municipalities of N and NE regions, 2010	9,060 babies < 6 m/ Chamada Neonatal	Poisson Regression	Moderate	39.9% (< 6 m)	EBF	Place of residence: capital [PR = 1.17] Maternal age (< 20 years) 20-34 years [PR = 1.14] ≥ 35 years [PR = 1.28] Child's age (0 month) 1 month [PR = 0.77] 2 months [PR = 0.68] 3 months [PR = 0.53] 4 months [PR = 0.37] 5 months [PR = 0.16] BF in the 1^st hour of life [PR = 1.16	Maternal education; skin color; prenatal care; prenatal financing; prenatal guidance on BF; childbirth type; maternity financing; joint accommodation; sex of the baby; birth weight; recent visit of medical agent
Parizoto et al³⁰ (2009)	Bauru, SP, 2006	509 babies < 6 m/AMAMUNIC	Logistic regression	Moderate	24.2% (< 6 m) 3.9% (at 6 m)	Interruption of EBF	Use of a pacifier [OR = 2.03]	Maternal age; maternal education; parity; childbirth type; maternity financing; birth weight; maternal work
Pereira et al³¹ (2010)	Rio de Janeiro, RJ, 2007	1,029 babies < 6 m/patients of 27 basic units.	Hierarchical Poisson Regression	Moderate	58.1% (< 6 m)	EBF	White skin color [PR = 1.20] Living with the partner [PR = 1.72] Previous breastfeeding [PR = 1.27] Prenatal information on BF [PR = 1.27] EBF at discharge [PR = 2.01] Guidance on BF in group [PR = 1.14] Guidance on how to position the baby to suck [PR = 1.20] Baby's age in months [PR = 0.83]	Maternal age; parity; no. of goods in the residence; no. of prenatal visits; birth in Baby-Friendly Hospital (or in the process of accreditation); childbirth type; birth weight; sex of the baby; maternal work; primary care unit type; guidance on free demand, milk expression, EBF period, and nonuse of bottle; maternal satisfaction with the support received in the primary care unit to breastfeed;
Queluz et al³⁴ (2012)	Serrana, SP, 2009	275 babies < 6 m/AMAMUNIC	Logistic regression	Moderate	29.8% (< 6 m)	Interruption of EBF	Maternal work outside the home without maternity leave [OR = 3.08] Does not work outside the home [OR = 2.26]	Maternal age; parity; maternal education; birth in Baby-Friendly Hospital; childbirth type; birth weight; use of a pacifier; childcare financing
Rito et al³⁸ (2013)	Rio de Janeiro, RJ, 2007-2008	4,092 babies < 6 m/patients of 56 primary care units.	Poisson Regression	Moderate	47.6% (< 6 m)	EBF	Performance in the Breastfeeding-Friendly Primary Care Unit Initiative: superior [PR = 1.34] intermediate [PR = 1.17] Primary Care unit [PR = 1.10] No maternal work [OR = 1.75] Child's age in days [PR = 0.99]	To have received guidance/help from the hospital to breastfeed
Vannuchi et al⁴⁴ (2005)	Londrina, PR, 2002	988 babies < 6 m/AMAMUNIC	Logistic regression	Moderate	21.0% (< 6 m)	Interruption of EBF	Primiparity [OR = 1.63] Use of a pacifier [OR = 2.23] Outpatient monitoring in public network [OR = 2.08]	Birth weight; baby's age in days
Venâncio et al⁴⁶ (2002)	84 municipalities in the State of Sao Paulo, 1998	11,481 babies < 6 m/AMAMUNIC	Logistic regression	Moderate	From 0% (in 10 cities) to 54.0% (in 1 city)	Interruption of EBF	Adolescent maternal age [OR = 1.20] Maternal age (≥ 13 years) 9-12 years [OR = 1.54] 5-8 years [OR = 1.94] Until 4 years [OR = 2.28] Primiparity [OR = 1.27] Birth in Baby-Friendly Hospital [OR = 1.49] Municipality with Baby-Friendly Hospital [OR = 2.28]	Maternal work
Venâncio et al⁴⁷ (2006)	111 municipalities in the State of Sao Paulo, 1999	34,345 babies < 6 m/AMA	Multilevel Logistic Regression	Moderate	13.9% (< 6 m) 4.0% (at 6 m)	EBF	Maternal age (< elementary school) elementary school [OR = 1.15] some high school [OR = 1.18] high school [OR = 1.58] ≥ some college [OR = 1.91] Maternal age (from 11 to 17 years) 18-19 years [OR = 1.17] 20-24 years [OR = 1.43] 25-29 years [OR = 1.52] 30-34 years [OR = 1.52] ≥ 35 years [OR = 1.22] Multiparity [OR = 1.41] Birth weight (< 1.500 g) 2,000-2,499 g [OR = 1.29] 2,500-2,999 g [OR = 1.52] ≥ 3,000 g [OR = 1.73] Baby of the female sex [OR = 1.12] Childcare private financing [OR = 1.10] Municipalities with 4 to 5 pro-BF actions [OR = 1.53]	Municipality of residence; population size; human development index (SES/SP); childbirth type; Birth in Baby-Friendly Hospital; maternal work
Audi et al² (2003)	Itapira, SP, 1999	346 babies < 6 m/AMAMUNIC	Logistic regression	Weak	64.8% (at the 1^st m) 9.6% (between the 4^th and the 6^th month)	Interruption of EBF	Childbirth type (caesarean) [OR = 1.78] Use of a pacifier (yes) [OR = 4.41]	Place of residence; maternal age; maternal education; parity; financing of the hospital; birth weight; maternal work; maternity leave; childcare financing
Damião¹⁰ (2008)	Rio de Janeiro, RJ, 1998 and 2000	2,459 babies < 4 m/AMAMUNIC	Logistic regression	Weak	22.7% (< 4 m)	EBF	Maternal age in years [OR = 1.02] Maternal education college degree [OR = 1.93] Maternal work [OR = 0.59] child's age in days [OR = 0.99]	Parity; birth in a BFH; birth weight
Fernandes et al¹⁵ (2012)	Rio de Janeiro, RJ, 2005-2008	592 babies < 1 m/ patient of 4 basic units	Logistic regression	Weak	About 75.0% (< 1 m)	Interruption of EBF	Pregestational obesity [OR = 2.14] Overweight with excessive gestational weight gain (GWG) [OR = 2.29] Obesity with insufficient GWG [OR = 3.10] Obesity with excessive GWG [OR = 3.33] Excessive GWG [OR = 1.50]	Maternal education; smoking in pregnancy; no. of prenatal visits; childbirth type; birth weight; social support; social network
França et al¹⁶ (2007)	Cuiaba, MS, 2004	275 babies < 6 m/AMAMUNIC	Logistic regression	Weak	34.5% (< 6 m)	Interruption of EBF	Maternal age (≥ 35 years) < 20 years [OR = 3.54] from 20 to 34 years [OR = 3.13] Maternal education Elementary and high school [OR = 2.31] Primiparity [OR = 2.20] Use of a pacifier [OR = 3.26]	Birth in a hospital with Milk Bank; childbirth type; maternal work; primary care financing
Gusmão et al¹⁸ (2013)	Porto Alegre, RS, 2009	341 babies < 6 m children of adolescent mothers/Household survey	Hierarchical Poisson Regression	Weak	37.8% (< 6 m)	EBF	Maternal education: high school [PR = 1.53] Multiparity [PR = 1.57] Child's age in months [PR = 0.76]	Maternal age; Skin color; Grandmother's education; Attends school; Marital status; Owns an income; Social class; Prenatal financing; No. of prenatal visits; Birth in BFH; childbirth type; Desire for pregnancy; Partner's attitude; Family reaction; Emotional indicators; Expectation regarding the future; Self-worth; Psychological distress; Birth weight; 5^th minute Apgar; Sex of the baby; Caregiver; Degree of difficulty in taking care of the baby; Perception of the baby's health
Vieira et al⁵¹ (2010)	Feira de Santana, BA, 2004-2005.	1,309 babies with one month of life/interviews	Logistic regression	Weak	59.3% (at the end of the 1^st month)	Interruption of EBF	Lack of prior experience with breastfeeding [OR = 1.24] Pre-set schedule to breastfeed [OR = 1.42] Use of a pacifier [OR = 1.53] Presence of nipple fissures [OR = 1.25]	Birth weight; BF in the first hour of life

Author/Publishing year	Local/year of implementation	Sample (n)/data source	Statistical analysis	Quality Score	EBF Prevalence (age group)	Outcome	Factors associated with EBF	Factors evaluated without statistical significance
Chaves et al⁹ (2007)	Hospital Municipal de Itauna, MG, 2003	238 babies monitored until 6 m	Cox Regression	Strong	62.6% (1 month); 19.5% (4 months); 5.3% (6 months)	Interruption of EBF	Intention to breastfeed (> 24 months): < 12 months [RR = 1.67] from 12 to 23 months [RR = 1.74] Birth weight > 2,500 g [RR = 1.92] Use of a pacifier [RR = 1.49]	Basic sanitation; skin color; maternal education; marital status; parity; income; information on the BF technique; use of alcohol or tobacco; health insurance; no. of prenatal visits; gestational age; sex of the baby; maternal work; maternity leave; family support; time until the first breastfeed; complications after childbirth
Demétrio et al¹¹ (2012)	Laje and Mutuipe, BA, 2005-2008	531 babies monitored until 6 m/AMACOMP	Cox Regression	Strong	74.7 days (median)	Interruption of EBF	Urban residence [HR = 1.61] No prenatal care [HR = 2.73]	Housing condition; maternal age; skin color; maternal education; maternal stature; anthropometric nutritional status; childbirth type; birth weight; gestational age; sex of the baby; maternal work
Mascarenhas et al²⁴ (2006)	Pelotas, RS, 2002-2003	940 babies monitored until 3 m	Hierarchical logistic regression	Strong	39,0% (at 3 months)	Interruption of EBF before 3 m	Household income (> 6 Minimum Wages - MW): from 1.1 to 3 MW [OR = 1.60] Paternal education (≥ 9 years): from 0 to 4 years [OR = 1.61] Maternal work [OR = 1.76] Use of a pacifier [OR = 4.25]	Skin color; maternal age; maternal education; parity; no. of prenatal visits; smoking in pregnancy; birth weight; gestational age; sex of the baby
Santo et al⁴⁰ (2007)	Hospital das Clínicas (Porto Alegre, RS), 2003	220 babies with up to 6 m (with birth weight ≥ 2,500 g)	Cox Regression	Strong	54.0% (at the 1st m) 6.6% (at 6 m	Interruption of EBF	Adolescent maternal age [HR = 1.48] < 6 prenatal visits (< 6 visits) [HR = 1.60] Use of a pacifier [HR = 1.53] No. of negative evaluations of latching at maternity [HR = 1.29]	Skin color; maternal education; parity; marital status; duration of the BF of the prior child; living with the grandmother of the child; prenatal information on BF; participation in a group of pregnant women in prenatal care; postpartum mammillary lesion; no. of negative evaluations of positioning in the breast at maternity
Silva et al⁴³ (2008)	Pelotas, RS, 2002-2003	951 babies monitored until one month of age.	Hierarchical logistic regression	Strong	60.0% (at the first month of life)	Interruption of EBF in the 1^st month of life	Paternal education (≥ 9 years): from 5 to 8 years [OR = 1.31] from 0 to 4 years [OR = 1.63] Paternal age (greater than 35 years) from 20 to 34 years [OR = 1.45] less than 20 years [OR = 1.43] Use of a pacifier [OR = 2.45]	Skin color; no. of visits in the prenatal care; smoking in pregnancy; birth in Baby-Friendly Hospital; birth weight; sex of the baby; maternal work
Vieira et al⁵² (2014)	Feira de Santana, BA, 2004-2005	1,344 children monitored until 6 m of age	Hierarchical Cox Regression	Strong	89 days (median)	Interruption of EBF	Maternal education ≤ 8 years [HR = 1.34] < 6 prenatal visits [HR = 1.48] Prenatal public financing [HR = 1.34] Birth in Baby-Friendly Hospital [HR = 0.85] Guidance on BF in the hospital [HR = 0.80] Partner favorable to breastfeeding [HR = 0.62] Maternal work [HR = 1.73] The mother limits breastfeeding at night [HR = 1.58] Nipple fissure [HR = 2.54]	Skin color; maternal age; parity; prior experience with BF; the mother lives with the father of the child; the mother participated in a prenatal group on BF; childbirth type; BF in the first hour of life; sex of the baby
Bueno et al⁵ (2003)	University Hospital in Sao Paulo, SP, 1998-1999	383 babies monitored until 6 m	Cox Regression	Weak	23 days (median); 38.5% (1 m); 13.8% (3 m); 1.6% (6 m).	Interruption of EBF	Maternal age ≤ 25 years [HR = 1.22] Maternal education (college degree): Elementary school [HR = 2.13] High school [HR = 1.78] Baby of the female sex [RR = 1.22]	To live in a slum; skin color; parity; marital status; number of consumer goods; number of prenatal visits; smoking habit; childbirth type; birth weight

Factor and level	Studies	Association	Factor and level	Studies	Association	Factor and level	Studies	Association	Factor and level	Studies	Association

Contextual	n	N	Distal intermediate	N	n	Proximal intermediate	n	n	Proximal	n	n
Total of actions in breastfeeding	1	1	Anthropometric nutritional status	2	1	Birth in Baby-Friendly Hospital	12	1	Maternal work	20	6
Population size	1	0	Desire for pregnancy	1	0	Birth in a hospital with Human Milk Bank	1	0	Maternity leave	4	1
Compound population indexes	2	0	Smoking	4	0	Type of financing of the maternity or hospital	4	0	Tiredness and emotional indicators	2	1
Place of residence	7	3	Alcoholism	1	0	Guidance on breastfeeding in the maternity or professional service	4	2	Knowledge about breastfeeding technique	1	0
Basic sanitation	3	0	Prenatal visits	12	3	Number of negative evaluations of latching	1	1	Difficulties in breastfeeding	3	2
Distal			Information on breastfeeding in prenatal care	4	1	Number of negative evaluations of breastfeeding position	1	0	Family support	3	1
Distal			Information on breastfeeding in prenatal care	4	1	Number of negative evaluations of breastfeeding position	1	0	Baby's caregiver	1	0
Skin color or race	10	1	Participation in a prenatal group	2	0	Rooming-in	1	0	Living with the child's grandmother	1	0
Maternal age	20	8	Prenatal financing	4	1	Intention to breastfeed	1	1	Child's age	8	8
Maternal education	23	11				Childbirth type	19	2	Child's health	2	0
Parity	19	6				Time until the first breastfeed	5	2	Use of a pacifier	16	15
Prior experience with breastfeeding	4	2				Exclusive breastfeeding at discharge	1	1	Type of financing of primary health care	6	2
Marital status	6	1				Birth weight	21	3	Type of primary care unit	4	1
Paternal age	1	1				Gestational age	4	0	Guidance on breastfeeding in group	1	1
Paternal or grandmother's education	3	2				Immediate postpartum complications and Apgar	2	0	Guidance on latching or positioning	1	1
Household income	5	2				Sex of the newborn	14	3	Other guidelines on breastfeeding	1	0
Number of people in the house	1	0							Mother's satisfaction regarding the support received	1	0
Number of goods in the residence	2	0							Assistance by a Breastfeeding-Friendly Primary Care Unit	2	2

vertical_align_top file_download show_chart

more_horizclose
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

Acessibilidade / Reportar erro

[TFN1] EBF: Exclusive Breastfeeding; FHS: Family Health Strategy; BF: breastfeeding