Breastfeeding is a fundamental pillar of child nutrition, with important implications for the health welfare due to its impact on morbidity and mortality, especially among children under 1 year of age. Therefore, there is consensus among different organizations dedicated to the health of children about the importance of breast milk as a food of choice during the first 6 months of life, and it is considered a fundamental public health policy. The World Health Organization (WHO) recommends early initiation of breastfeeding within the first hour after birth and exclusive breastfeeding during the first 6 months of life . Recently, the WHO defined the 2025 Global Nutrition Targets aimed at improving maternal, infant, and young child nutrition. Among these, breastfeeding has been prioritized in the fifth target: “increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%” .
The United Nations Children’s Fund (UNICEF) describes breastfeeding as an important indicator, noting that “Breastmilk alone is the perfect food for all infants in the first six months of life.” In addition to being an ideal nutritional source for infants, exclusive breastfeeding is associated with a lower chance of dying from diarrhea and acute respiratory infections and strengthens the infant immune system. It also protects against chronic diseases such as obesity and diabetes . However, UNICEF recently communicated that many countries continue to underestimate the benefits of breastfeeding even when the evidence supports its short- and long-term effects such as protective role against childhood infections, an increased intelligence, and lower prevalence of diabetes and being overweight .
What is more, the American Academy of Pediatrics reaffirms the recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as they introduce complementary foods, for 1 year or more, as mutually desired by the mother and baby, with medical contraindications to breastfeeding being rare . Additionally, in their last policy statement regarding breastfeeding, they recognized that the decision to breastfeed should not be conceived by the mother, doctor, or society as a lifestyle option but as a basic and critical health decision that affects the welfare of the baby and the mother and therefore should be considered regardless of the parenting style or as a simple nutritional problem. They also emphasized that professionals must go beyond the maternal–infant binomial and incorporate new principles and concepts in daily activities to be true advocates and supporters of breastfeeding [6, 7].
In lower income countries, breastfeeding is associated with a significant reduction in infant mortality and disease, and it is estimated that a high degree of protection, promotion, and support for breastfeeding can potentially prevent 1.3 million child deaths per year . It has been estimated that if children under 1 year of age were breastfed for at least 4 months, 56.4% of hospital admissions for infection of nonperinatal origin could be prevented . In addition, there is evidence that breastfeeding decreases the incidence and severity of digestive, respiratory, urinary, and middle ear infections, as well as atopic diseases; producing a lower incidence of sepsis and necrotizing enterocolitis in preterm infants . In the long term, breastfeeding has beneficial effects on cardiovascular risk factors, reduces the risk of obesity during childhood, and improves cognitive development. Additionally, breastfeeding women have a lower risk of developing breast cancer, better spacing of births, and lower risk of diabetes and ovarian cancer compared to women who have never breastfed .
2. Factors related to the breastfeeding initiation and duration
In general, the factors that influence the success or abandonment of breastfeeding have been classified into sociodemographic, biophysical, and psychosocial factors. Several factors have been linked to the initiation and duration of breastfeeding, which can be classified as nonmodifiable factors (Figure 1) and modifiable factors (Figure 2).
The main sociodemographic factors that influence the duration of breastfeeding are age, marital status, and income level. Therefore, successful long-term breastfeeding is less likely to occur in younger women with a low educational level, single women, and women with a lower income .
One review recently highlighted high impact factors such as smoking, mode of delivery, parity, separation of the mother-child dyad, maternal education, and maternal education on breastfeeding . As an example, women who graduated from high school or higher educational institutions received education regarding breastfeeding, breastfeed within 1 hour after birth, and did not work had significantly higher rates of exclusive breastfeeding at 6 months. However, the breastfeeding rate in the first 6 months was significantly lower for women who lived with their parents and who were smokers . Maternal age is directly associated with the duration of breastfeeding, observing that adolescents have lower breastfeeding rates, as well as a shorter duration .
Adolescent mothers express that the decision to breastfeed is taken before birth and that the opinions of their partner and family members about the breastfeeding process may affect its onset. Influences on breastfeeding include its impact on social and intimate relationships, the availability of social support, the physical demands of breastfeeding, knowledge of breastfeeding practices and their benefits, and the sensation of comfort perceived by the mother regarding breastfeeding . In this age group, mothers who have a better prenatal attitude to initiate breastfeeding, and with higher confidence levels in pre and postnatal care, are significantly more likely to maintain breastfeeding 4 weeks after birth .
In this way, breastfeeding has a multifactorial behavior. In addition to sociodemographic factors, clinical factors, and habits, a wide range of social, psychological, and cultural factors of each woman determines the decision and ability to successfully initiate breastfeeding; operating at different levels from the individual to society (Figure 3).
If the focus is placed on an anthropological approach to breastfeeding, the cultural norms of a society have a powerful influence on decisions regarding health, such as the choice of an infant feeding method. Therefore, attitudes and beliefs about breastfeeding are important and should be considered in public breastfeeding campaigns . In this sense, studies have been developed to understand the public’s beliefs about breastfeeding policies.
In the United States, breastfeeding policies in the workplace and breastfeeding rooms in public places are the most accepted policies, especially among African-Americans and low-income populations. Additionally, the general population seems to approve breastfeeding in public, but less educated or older people (over 45 years) tend to do so less. Globally, there is relatively less public support for breastfeeding education in secondary schools . There seem to be many beliefs and traditions surrounding breastfeeding, for example, in regard to the amount of breast milk a mother produces, which is a common concern and a major source of anxiety. The perception of insufficient breast milk is attributed to the mother’s interpretation of the crying baby as a sign of hunger, as well as the resolution of breast engorgement, which the mother interprets as a sign of concern. Additionally, family members (particularly the woman’s mother) are important sources of discouragement of breastfeeding; for example, it is believed that women are biologically incapable of breastfeeding.
The belief that the tendency to have insufficient milk production is inherited from mothers and mothers who have not breastfed their children may find it particularly difficult for their own daughters to breastfeed successfully, as they believe that this may reflect their own skills to nourish their children . It is then manifested that breastfeeding, besides being biological, is historical and social, with culture, beliefs, and taboos influencing its practice, interfering in the construction of sociocultural inheritance, and determining different meanings to breastfeeding for woman. Thus, the beliefs transmitted by relatives, medical guidelines, and the growth and development of the child are factors that may or may not stimulate breastfeeding .
Another socioanthropological aspect is that ethnicity is a determining factor for breastfeeding, as shown by a study conducted in Malaysian women, which found that Malay women with a higher education level and who received counseling regarding breastfeeding had a significantly more favorable attitude toward it, and that ethnicity was a significant determinant in the success of breastfeeding . In Cameroon, 90% of women initiate breastfeeding but only 34% of these women breastfeed exclusively during the first 6 months. It is highlighted here that there are relevant issues related to breastfeeding practices, such as the preparation of women for breastfeeding exclusively, the cultural influences toward breastfeeding, and the perceived restrictions to breastfeeding .
Another example, from a different culture, shows that France has low breastfeeding rates, which are considered a reflection of their cultural perception of motherhood, breastfeeding, and the body image . Understanding the local beliefs and customs that influence breastfeeding can help professionals provide culturally appropriate advice. Additionally, developing studies on beliefs and practices linked to breastfeeding within different communities could help health professionals provide culturally sensitive care for their patients. This information could help clinicians to encourage women to initiate and maintain breastfeeding .
3. Conceptual model of breastfeeding practice
When establishing a conceptual model of breastfeeding practice, all the factors that intervene in its development and the different levels that interact must be considered. It is possible to appreciate how the different levels interact and influence the individual decision to breastfeed or not (Figure 4).
In recent years, exclusive breastfeeding rates until the sixth month have improved because of policies and strategies for breastfeeding promotion. However, in different countries, multiple programs have been implemented to promote breastfeeding and counteract the lack of adherence observed in mothers for feeding their children exclusively with breast milk, as a result of factors such as the incorporation of women into work, multiple offers of milk formulas, and scarce training of health personnel to address the concerns of mothers. Although overall there is evidence of an increase in breastfeeding rates, there is wide variability between countries and even within the same country, noting that some of the data are far from the expected health goal. Therefore, it is essential to consider breastfeeding as a biological process that should be built socioculturally, where ideological, religious, cultural, and political convergences or divergences can be studied and interrelated. There is a need for integrated attention regarding the sociocultural context of the breastfeeding period, which should be broadened in order to support mothers and empower them to positively deal with adversity during this process. It is important to know what mothers think about breastfeeding in order to encourage the creation of practices to satisfactorily maintain this process as long as possible for both mothers and babies .
Conflict of interest
The author has no conflict of interests to declare.