Biomedical Sciences, Biomed Biopharm Res., 2022; 19(1):19-30
Factors influencing breastfeeding duration among Portuguese mothers
Mariana Z. de Oliveira 1, Cíntia Ferreira-Pêgo 2*
1School of Sciences and Health Technologies, Universidade Lusófona de Humanidades e Tecnologias, Lisboa, Portugal
2CBIOS – Universidade Lusófona’s Research Center for Biosciences & Health Technologies, Campo Grande 376, 1749-024 Lisboa, Portugal.
Breastfeeding is extensively associated with significant benefits for maternal and child health. The World Health Organization recommends that infants be breastfed up to 24 months. The decision to breastfeed is affected by many factors. The present study aimed to assess the factors contributing to the duration of breastfeeding. An online questionnaire was applied to 351 Portuguese mothers of infants under five years old to collect data on socioeconomic, obstetric, and breastfeeding factors. Conditions that contribute to the duration of breastfeeding were information and education about the topic (p≤0.001), residence area (p≤0.001), number of children (p=0.002), duration of pregnancy (p=0.015), previous experience with breastfeeding (p≤0.001), and difficulties during breastfeeding (p=0.035). In conclusion, among the modifiable barriers which influence breastfeeding cessation, breastfeeding education and information is essential to improve breastfeeding rates.
Keywords: Breastfeeding, duration of breastfeeding, literacy, infant nutrition, Portugal
Received: 31/12/2021; Accepted: 12/03/2022
Breastfeeding is a birthright and crucial for the newborn's survival and is the most effective way to meet the baby's nutritional, immunological and psychological needs (1). Breastfeeding is extensively associated with the reduction of infant morbidity and mortality, as well as with significant benefits for maternal and child health (1–3). In Azores (Portugal), breastfeeding acted as a protective factor for childhood obesity (4). Exclusive breastfeeding also seems to have a potential protective influence on postpartum depression among women with prenatal depression, according to Portuguese researchers (5). Therefore, breastfeeding can be an effective, simple, and affordable tool (4), reducing public health costs by decreasing the use of services (6,7). The promotion and support of breastfeeding is a public health issue (2) and should not be seen as the exclusive responsibility of the woman and her family.
The current official recommendation is for breastfeeding exclusivity for the first six months of life, and to be accompanied by solid foods for at least two years, or for as long as mother and baby wish (9).
The worldwide prevalence of breastfeeding is lower than the recommendations of international organizations, especially in high-income countries, since the prevalence of breastfeeding at 12 months is lower than 20% in these countries (8). However, even in low-income and middle-income countries, only 37% of infants younger than 6 months are exclusively breastfed (8). In the United States of America and Australia only half of the mothers breastfeed their babies until they are six months old and, in the UK, only one-third do so (8,10). In Portugal, according to the Registry of Breastfeeding (Registo do Aleitamento Materno or RAM), in 2013, 98.6% of mothers started breastfeeding in the postpartum hospitalization, but only 76.7% continued the practice after being discharged from the hospital. The records from Primary Health Care show that exclusive breastfeeding between the fifth and sixth week was 88.1%; this percentage drops to 22.1% for five-month-old infants (11). Another publication refers that in Portugal in 2014, the prevalence of exclusive breastfeeding at 3, 4, and 6 months of age was 55.9, 48.5, and 30.3%, respectively (12).
Several factors contribute to the success of breastfeeding; these are described within a complex structure, which includes biological, psychological, and social factors that are linked together at various levels (8). The difficulties experienced by the puerperal woman during breastfeeding contribute significantly to the early interruption of breastfeeding and make mothers less likely to breastfeed a second child (13). However, to have more information about the barriers which mothers face when choosing to breastfeed their children is of great interest to health professionals to improve support and expand the assistance at a community level (14). In a pilot study developed in a region of Portugal, breastfeeding women receiving intensive support during the first 120 days postpartum showed promissory results in improving ‘perception of breastfeeding self-efficacy’ compared to conventional care, favoring breastfeeding duration and exclusivity, and cumulative breastfeeding competence of women/families (15).
For all these reasons, this study aimed to assess the factors which contribute to the prevalence of breastfeeding, namely the information available and education about this topic, support and difficulties which puerperal women may experience, and which of these factors influence early breastfeeding abandonment.
Sample and methods
Study design and population
A cross-sectional study was conducted, including a final sample of 351 volunteers. The inclusion criteria consisted of being mothers of children under five years old and having official residence in Portugal. No other non-inclusion criteria were established.
Data collection was performed using an online questionnaire through the Google-Forms platform and all the data was self-reported. The questionnaire consisted of five groups of questions. The first group was sociodemographic characterization, namely age at motherhood, marital status, academic degree, occupation, residence, and income. In the second group of questions, obstetric data were collected, including duration of pregnancy, type of delivery, obstetric violence, and number of children. The third group was composed of fifteen questions to measure knowledge about breastfeeding, adapted from the breastfeeding scale (16). The fourth group of questions referred to personal experience with breastfeeding, previous experience, breastfeeding method, duration of breastfeeding, and introduction of infant formula. The fifth and final group of questions referred to the difficulties experienced during the breastfeeding period. The questionnaire was shared on different social networks, mainly Facebook, Instagram, and WhatsApp.
Breastfeeding knowledge scores
The cut-off points of maternal knowledge concerning breastfeeding were made by identifying percentiles. Knowledge was considered “very poor” up to the 25th percentile (0 to 4 points), “poor” above the 25th percentile (5 to 8 points), “moderate” above the 50th percentile (9-11 points), and “good” above the 75th percentile (scores from 12 to 15).
Before data collection, all individuals agreed to participate in the study, giving their informed and written consent to participate. Consent was obtained on the first page of the questionnaire, which included all the information of a “standard” informed consent. Only after reading all the information and selecting the option “I read and agree to participate in the present study” did participants have access to the remainder of the questions. If an individual selected the option “I read the information, and do not agree to participate in the present study,” she was sent to the end of the questionnaire with no access to any question. All the data was confidential and anonymous, and no other information about the participating individuals was collected. The objective of the study, the variables to be evaluated, and the maintenance of anonymity of the data were made available to the participants at the beginning of the questionnaire. The present study was performed following the ethical standards as outlined within the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
The distribution of characteristics between groups was compared using Pearson χ2 tests for categorical variables, where the units were expressed in % (n). To analyze the relationship between different variables influencing the duration of breastfeeding, four analysis groups were created: <6 months, 6-12 months, 12-18 months, 18-24 months, and > 24 months. Statistical analysis was performed using IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. All statistical tests were two-tailed and the significance level was set at p<0.05.
Most of the participants were mothers between 31-35 years old (39.6%), married or living in cohabitation (92%), graduated (50.4%), and working (91.7%), with a monthly income of between €1,000 and €3,000 (71.8%), who lived in the metropolitan area of Lisbon (42.2%) and had only one child (55.8%) (Table 1).
According to the breastfeeding knowledge questionnaire, none of the women presented a “very poor” score (0-4 points), 9% had their knowledge qualified as “poor” (5-8 points), 33% were qualified with “reasonable” knowledge (9-11 points) and 58% had a “good” qualification according to the questionnaire (12-15 points) (Figure 1). Table 1 summarizes the characteristics of the study population according to questionnaire score. The breastfeeding knowledge questions and the percentages of correct/incorrect answers for each are displayed in Table 2. The question with the highest number of incorrect answers was “Women who breastfeed should avoid potential allergens” (51.9%), and the statement with the highest number of correct answers was “Formula milk is a better source of nutrients than breast milk” (99.4%). 57% of the population in this study no longer breastfed their children, while 43% of participants were still breastfeeding their babies at the time of the survey. (Figure 2). Among women who were no longer breastfeeding, 49% had breastfed their children for more than 24 months and 29% for less than 6 months. (Figure 3). The most frequent problems with breastfeeding reported were nipple (skin) cracking and pain during breastfeeding (28% and 27%, respectively) (Figure 4).
The main factors influencing the duration of breastfeeding were residence area, the number of children, duration of pregnancy, previous experience with breastfeeding, information and education about breastfeeding, and difficulties during breastfeeding (Table 3).
The present work was one of the first studies to look into which factors influenced the duration of breastfeeding according to World Health Organization guidelines (9) in Portuguese women with children younger than 5 years old.
The main results show a significant association between maternal information about breastfeeding and the duration of breastfeeding. Women who breastfed their children for more than 2 years also presented higher scores on the breastfeeding information questionnaire, while women who breastfed their children for less than 6 months showed lower scores. Similar results were also observed by different authors (17,18). Thereafter, we demonstrated that the highest level of knowledge about breastfeeding is a protective factor against the early cessation of breastfeeding. According to the percentages of incorrect answers, 47% of mothers are not informed about the recommendation (9) “Breastfeeding should be maintained until, at least, 2 years old; before that age, it is considered premature cessation”. Furthermore, 49.3% of them are unaware that “Formula-fed babies have an increased risk of becoming obese in adulthood” according to the last evidence (19). This performance shows that mothers who choose not to breastfeed may not be fully informed about the consequences of this choice. Over 50% of participants believe that “Lactating mothers should avoid potential allergens”, which do not correspond with the most recent published literature (20). A study conducted in Poland shows similar performance among participants, where 44.6% of the participants also believed they should avoid these foods. According to the same study, the authors conclude that the difficulties of a restrictive diet can be one of the causes for the early interruption of breastfeeding (21). This mechanism could be one of the explanations for the premature cessation of breastfeeding of our sample.
The difficulties during breastfeeding also have a significant relationship with the abandonment of breastfeeding. The problems reported by the participants in this study were registered in literature as transitory (13,22), which reinforces the need to provide more information about the management of these difficulties, so that they can be overcome and, consequently, not compromise the continuity of breastfeeding.
The number of children and the previous experience with breastfeeding seem to be two important factors that correlate and influence the duration of breastfeeding. It has been reported that the highest rates of early abandonment are of women who are breastfeeding for the first time, consequently, a previous positive experience and the knowledge acquired during a first breastfeeding experience are protective factors of the longest duration of breastfeeding (13,14).
The duration of pregnancy was also a non-modifiable factor that significantly influenced breastfeeding. In the present analysis, women who had their labor induced had the highest rates of early breastfeeding cessation. However, the scientific literature has not reached a consensus about the topic, since some authors claim that the form of birth influences breastfeeding duration (23), however, other authors found contrary results (14,24).
In conclusion, breastfeeding must be widely encouraged, due to its countless benefits for maternal-infant health and also for the whole society (2,25,26). Since the information about breastfeeding obtained by women comes mostly from health professionals (17), it is important to increase the awareness, commitment, and training of these professionals for the management of modifiable barriers that prevent the optimal duration of breastfeeding, so that they can implement the support which improves the practice.
Limitations of the study
Regarding the limitations of this study, it is important to mention the self-reported data collection, as the results may be subject to social desirability. The sample is composed mostly of married women or women within a stable union, presenting an average socioeconomic level, and the large number of women who breastfeed their children for more than 2 years might not be representative of the Portuguese population. The fact that the questionnaire was not previously validated nor a pre-test performed are also important limitations that should be assumed. We could also mention the memory bias; however, the literature sustains that maternal memory of the duration of breastfeeding is a reliable and valid estimate (27). Finally, it is important to refer that the cross-sectional design of the study is an important limitation as it is not possible to establish a cause-effect relationship.
After identifying the factors that influence early cessation of breastfeeding, we could conclude that knowledge is a modifiable factor which has a high impact on the duration of breastfeeding. For all these reasons, education is a fundamental part of public health; with knowledge, it is possible to understand the difficulties associated with breastfeeding, as well as clarify doubts that may prevent the beginning and continuation of breastfeeding. Training health professionals and having their commitment to the dissemination of breastfeeding recommendations are essential in the process of encouraging prolonged breastfeeding (28). Therefore, it is crucial to educate women and promote public health policies encouraging breastfeeding.
Directions for future research
Additional studies should be conducted to identify the population at risk and to know which educational resources are the most effective to increase knowledge among the population. Future public health campaigns, as well as the presence of a breastfeeding consultant regularly close to the new mother, should be encouraged in a way to increase breastfeeding duration.
In conclusion, the main factors contributing to the duration of breastfeeding in the present analyses were residence, the number of children, duration of pregnancy, previous experience with breastfeeding, information and education about breastfeeding, and difficulties during breastfeeding.
Author’s Contributions Statement
M.O.: conceptualization and study design; experimental implementation; data analysis; figures and graphics; drafting; C.F.-P.: editing and reviewing; supervision and final writing.
Cíntia Ferreira Pêgo is funded by Foundation for Science and Technology (FCT) Scientific Employment Stimulus contract with the reference number CEEC/CBIOS/NUT/2018. This work is funded by national funds through FCT - Foundation for Science and Technology, I.P., under the UIDB/04567/2020 and UIDP/ 04567/2020 projects.
The authors thank all the participants of this study.
Conflict of Interests
The authors declare no conflict of interest.
1. Mosca, F., & Giannì, M. L. (2017). Human milk: composition and health benefits. Pediatria Medica e Chirurgica, 39(2). https://doi.org/10.4081 PMC.2017.155
2. Brown, A. (2017). Breastfeeding as a public health responsibility: a review of the evidence. Journal of Human Nutrition and Dietetics, 30(6), 759–770. https://doi.org/10.1111/jhn.12496
3. Shamir, R. (2016). The Benefits of Breast Feeding. Nestle Nutrition Institute Workshop Series, 86, 67–76. https://doi.org/10.1159/000442724
4. Ferreira, A. V., Rosendo, I., Santiago, L. M., & Simões, J. A. (2021). Breastfeeding and childhood obesity in the azores. Family Medicine and Primary Care Review, 23(1), 81–86. https://doi.org/10.5114/fmpcr.2021.103151
5. Figueiredo, B., Pinto, T. M., & Costa, R. (2021). Exclusive Breastfeeding Moderates the Association Between Prenatal and Postpartum Depression. Journal of Human Lactation, 37(4), 784–794. https://doi.org/10.1177/0890334421991051
6. Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., … Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal and Child Nutrition, 13(1), e12366. https://doi.org/10.1111/mcn.12366
7. Pokhrel, S., Quigley, M. A., Fox-Rushby, J., McCormick, F., Williams, A., Trueman, P., … Renfrew, M. J. (2015). Potential economic impacts from improving breastfeeding rates in the UK. Archives of Disease in Childhood, 100(4), 334–340. https://doi.org/10.1136/archdischild-2014-306701
8. Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., … Richter, L. (2016, January 30). Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet. Elsevier. https://doi.org/10.1016/S0140-6736(15)01024-7
9. World Health Organization. (2014). WHO | WHO Global Data Bank on Infant and Young Child Feeding. Who, 1–2. Retrieved from https://apps.who.int/nutrition/databases/infantfeeding/en/index.html
10. Levy, L., & Bertolo, H. (2012). Manual de Aleitamento Materno - Comite Portugues para UNICEF. Comissao Nacional de Iniciativa Hospitais Amigos dos bebes.
11. Direção Geral de Saúde. (2009). Direção-Geral da Saúde. Retrieved from https://www.dgs.pt/documentos-e-publicacoes/iv-relatorio-com-os-dados-do-registo-do-aleitamento-materno-2013.aspx
12. Conselho Nacional de Saúde. (2018). Gerações Mais Saudáveis: Políticas públicas de promoção da saúde das crianças e jovens em Portugal. Retrieved from http://www.cns.min-saude.pt/wp-content/uploads/2018/12/GERACOES-MAIS-SAUDAVEIS.pdf
13. Palmér, L. (2019). Previous breastfeeding difficulties: an existential breastfeeding trauma with two intertwined pathways for future breastfeeding—fear and longing. International Journal of Qualitative Studies on Health and Well-Being, 14(1). https://doi.org/10.1080/17482631.2019.1588034
14. Sayres, S., & Visentin, L. (2018, August 1). Breastfeeding: Uncovering barriers and offering solutions. Current Opinion in Pediatrics. Lippincott Williams and Wilkins. https://doi.org/10.1097/MOP.0000000000000647
15. Pádua, A. R., Melo, E. M., & Alvarelhão, J. J. (2022). An Intervention Program Based on Regular Home Visits for Improving Maternal Breastfeeding Self-efficacy: A Pilot Study in Portugal. Maternal and Child Health Journal, 1–12. https://doi.org/10.1007/s10995-021-03361-7
16. Minosso, K. C., De Oliveira Toso, B. R. G., Piva, E. K., & Christoffel, M. M. (2020). Validation of the knowledge breastfeeding scale into brazilian portuguese. ACTA Paulista de Enfermagem, 33. https://doi.org/10.37689/ACTA-APE/2020AO0067
17. Suárez-Cotelo, M. del C., Movilla-Fernández, M. J., Pita-García, P., Arias, B. F., & Novío, S. (2019). Breastfeeding knowledge and relation to prevalence. Revista Da Escola de Enfermagem, 53. https://doi.org/10.1590/S1980-220X2018004503433
18. Wallenborn, J. T., Ihongbe, T., Rozario, S., & Masho, S. W. (2017). Knowledge of Breastfeeding Recommendations and Breastfeeding Duration: A Survival Analysis on Infant Feeding Practices II. Breastfeeding Medicine, 12(3), 156–162. https://doi.org/10.1089/bfm.2016.0170
19. Bogen, D. L., Hanusa, B. H., & Whitaker, R. C. (2004). The effect of breast-feeding with and without formula use on the risk of obesity at 4 years of age. Obesity Research, 12(9), 1527–1535. https://doi.org/10.1038/oby.2004.190
20. Greer, F. R., Sicherer, S. H., Wesley Burks, A., Abrams, S. A., Fuchs, G. J., Kim, J. H., … Schwarzenberg, S. J. (2019). The effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods. Pediatrics, 143(4). https://doi.org/10.1542/peds.2019-0281
21. Zielińska, M. A., Sobczak, A., & Hamułka, J. (2017). Breastfeeding knowledge and exclusive breastfeeding of infants in first six months of life. Roczniki Panstwowego Zakladu Higieny, 68(1), 51–59.
22. Gianni, M. L., Bettinelli, M. E., Manfra, P., Sorrentino, G., Bezze, E., Plevani, L., … Mosca, F. (2019). Breastfeeding difficulties and risk for early breastfeeding cessation. Nutrients, 11(10), 2266. https://doi.org/10.3390/nu11102266
23. Santacruz-Salas, E., Aranda-Reneo, I., Segura-Fragoso, A., Cobo-Cuenca, A. I., Laredo-Aguilera, J. A., & Carmona-Torres, J. M. (2020). Mothers’ expectations and factors influencing exclusive breastfeeding during the first 6 months. International Journal of Environmental Research and Public Health, 17(1). https://doi.org/10.3390/ijerph17010077
24. Robert, E., Coppieters, Y., Swennen, B., & Dramaix, M. (2014). Breastfeeding duration: A survival analysis - Data from a regional immunization survey. BioMed Research International, 2014. https://doi.org/10.1155/2014/529790
25. Binns, C., Lee, M., & Low, W. Y. (2016). The Long-Term Public Health Benefits of Breastfeeding. Asia-Pacific Journal of Public Health, 28(1), 7–14. https://doi.org/10.1177/1010539515624964
26. Spiro, A. (2017). The public health benefits of breastfeeding. Perspectives in Public Health, 137(6), 307–308. https://doi.org/10.1177/1757913917734139
27. Natland, S. T., Andersen, L. F., Nilsen, T. I. L., Forsmo, S., & Jacobsen, G. W. (2012). Maternal recall of breastfeeding duration twenty years after delivery. BMC Medical Research Methodology, 12. https://doi.org/10.1186/1471-2288-12-179
28. American College of Obstetricians and Gynecologists. (2016). Committee Opinion No. 658: Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstetrics and Gynecology, 127(2), e86–e92. https://doi.org/10.1097/AOG.0000000000001318