Health determinants associated with exclusive breastfeeding: a scoping review

ABSTRACT Purpose: to map health determinants associated with exclusive breastfeeding. Methods: a scoping review conducted according to the JBI methodology and recommendations in PRISMA-Extension for Scoping Reviews. Data were collected in the MEDLINE/PubMed, LILACS, CINAHL, Scopus, and EMBASE databases and in the Brazilian Digital Library of Theses and Dissertations for the grey literature. The results were synthesized and organized into three theoretical models: distal, intermediate, and proximal. Literature Review altogether, 3,998 titles were found, of which 145 were included in the review, after all selection stages. They had various methodological designs and were published between 2002 and 2022. The following health determinants associated with exclusive breastfeeding were mapped: maternal educational attainment, family income, attendance to and frequency of prenatal care, breastfeeding guidance and practices, time until first breastfeeding, newborn’s sex, maternal employment and maternity leave, pacifier use, and exclusive breastfeeding guidance at health services. Conclusion: determinants that can facilitate or hinder exclusive breastfeeding are extrinsic and intrinsic to the mother and infant. Public policies are needed to protect every person’s right to breastfeeding.


INTRODUCTION
The World Health Organization (WHO) 1 set the goal of increasing exclusive breastfeeding (EBF) rates in the first 6 months of life to 50% by 2025.However, despite the countless efforts to promote, protect, and encourage breastfeeding, these rates are still short of recommendations.
Measures already taken by WHO include ratifying the importance of the following four main actions: establishing 6-month paid maternity leave to all working mothers and policies that encourage breastfeeding at work and public settings; strengthening health systems; supporting mothers and instructing them on EBF; and having competent agencies monitor and limit the publi-

Data extraction
In the process of selecting studies to comprise the scoping review, search results were sent to the Endnote Web reference manager program 8 to have duplicates removed.Then, two reviewers (ALBS and CRSF) selected studies independently through the Rayyan selection platform 9 .Articles were initially selected through title and abstract reading; those that met the eligibility criteria by consensus of the two reviewers were separated for full-text reading to be either included in or excluded from the review.Divergences regarding study eligibility were solved by a third reviewer (PGS).If a study was excluded, the reason for it was recorded in all phases of the study selection process.
Data were extracted and transferred to tables with the following information: year of publication, origin/ The grey literature was identified in the Brazilian Digital Library of Theses and Dissertations (BDTD), of the Brazilian Institute of Science and Technology Information.There was no restriction on their time (given the trajectory of the concept related to health determinants) or language.

Data selection
The search strategy included controlled terms and keywords related to the items that make up the PCC acronym, associated with the Boolean operators AND and OR.The search strategy, including all keywords and indexing terms identified, was adapted to each source of information (Chart 1).

Synthesis of Results
The studies that made up the synthesis of this review were listed in tables and a chart.The variables associated with EBF were classified according to Boccolini's conceptual model 7 , as follows: distal (characteristics of the family/home and the mother), intermediate (characteristics of the pregnancy, prenatal care, delivery, the mother during hospital stay, and the newborn), and proximal (characteristics of the family/ breastfeeding mothers, infants, and health services).
Extracted data were included in the table with EBF determinants, according to their hierarchical levels (Chart 2).

Characteristics of the studies
A total of 145 studies (Appendix) were selected for this scoping review, of which 42% (61) were from South America, and 26% (38) were from Africa.As for study The studies included in this review were published between 2002 and 2022 (Figure 2).This scientific production was asymmetrically distributed in the last decade, reaching a peak in 2021, with 16 publications.

Individual evidence of determinants associated with EBF
The mapping of EBF health determinants is shown in Table 2. Maternal education attainment (n = 48), in the distal model, was the predominating determinant in the investigated studies, followed by maternal employment and maternity leave (n = 46), in the proximal model.EBF studies included in this scoping review were from six continents, mostly South America.Studies from underdeveloped countries point out how social and economic determinants can facilitate or hinder EBF [10][11][12] , associating them with the low prevalence of EBF -which this review identified to be at 50%.The year with the most studies was 2021 when the coronavirus pandemic was ongoing.This negatively impacted various aspects related to breastfeeding, including adherence to EBF, which ratifies the need for scientific production on the topic 13 .Predominating health determinants -both protective and risk factors -are important indicators to reach the goals established by WHO 1 and improve EBF rates.The model of EBF determinants 7 makes it possible to investigate when and how these factors interfere with the process.The importance of mapping EBF health determinants based on Bocollini's model 7 is justified by the diversity of breastfeeding scenarios and the need to discuss them according to the model to which determinants belong, whether distal, intermediate, or proximal.

Distal Model
Educational attainment, one of the maternal characteristics, predominated in relation to all other mapped determinants.The studies in this review pointed it out as an EBF facilitator.In Saudi Arabia 10 , it was demonstrated that mothers with at least 7 years of school attendance were twice as likely to provide EBF than others with less education time.In Ethiopia 11 , mothers who had attended at least high school were 3.86 times as likely to provide EBF.And in Brazil, adherence to EBF is greater in the South Region, due to its women's higher educational attainment 12 .Although seen as a facilitating factor in developing countries, higher educational attainments and the resulting higher degrees and better work positions lead to less time at home.This results in an accelerated urban transition without appropriate support networks and public policies to protect the mother and baby, which may decrease EBF in these countries 10 .Nevertheless, greater knowledge enables mothers to resist to practices and pressures that expose them to the risk of early weaning, as better education helps them give greater importance to child development practices, like EBF.Therefore, this scenario must be thoroughly approached, providing quality education and equal access to job opportunities 11,12,14 .
Addressing the whole scenario helps us understand that family income, related to family or home characteristics in this review's distal model, was a determinant that can hinder EBF.Out of the total 36 studies, 18 indicated it as a risk factor for EBF.Currently, women are more likely to wean early when they have lower educational attainment, little knowledge of the benefits of breastfeeding, low family income, little support, difficulties accessing health assistance, and employment in a job market that is unprepared to support them after delivery 12,[14][15][16] .
It was found that low family income in Brazil increased by 1.22 the odds of discontinuing EBF, demonstrating that social inequalities such as those involving economic issues directly impact the mother and child's health conditions 17 .However, other studies indicate low income as a protective factor for EBF, as breastmilk is often the only food available to infants in poor countries 10,11 .
A study conducted in Peru also identifies low income as a protective factor for EBF.However, it highlights that the country, despite having reached 70% of the EBF recommended by WHO, has the predominant characteristic of low educational attainment and income and, since this prevalence varies between the different parts of the country, the cultural and regional differences in such prevalence must be analyzed 18 .The authors emphasize that EBF assessment must not be limited to percentages -the mother and infant's quality of life should also be analyzed to ensure more successful breastfeeding.

Intermediate Model
In the intermediate perspective of the EBF model (regarding pregnancy characteristics), 16 studies indicated that the mother's attendance to prenatal care and the number of visits were determinants and that timely prenatal care, health education, and EBF guidance were the main factors.
Listening to patients is the best way to strengthen their ties with the health unit, and doing so with quality may help the mother be a protagonist of their breastfeeding, as they decide to carry it on 15 .Having at least six prenatal care visits was positively associated with EBF 12,19 .Beginning such care in the 1 st trimester of pregnancy, with breastfeeding guidance and health education, is a protective factor 12 .
Concerning delivery care, the most investigated determinants were breastfeeding guidance and practices.The studies emphasized that deficient knowledge or the lack of guidance on breastfeeding significantly contributes to early weaning 20,21 .Studies that identified breastfeeding practices related to successful or unsuccessful EBF reported that mothers with good such practices are more likely to provide EBF.These include mothers with adequate knowledge of colostrum and EBF and higher scores in the perception of breastfeeding benefits 22,23 .These determinants are significantly associated with the health professionals' follow-up on this phase of the women's lives, from conception to post-partum.Every contact with such women in health services is an opportunity to instruct them about breastfeeding and its benefits, not only with information but mostly with actions implemented for them and their families 24 .
As for the mother's characteristics during the hospital stay, what determined EBF was the time it took until the first breastfeeding, associated in 17 studies in this review.Various studies associate successful EBF, among other determinants, with beginning breastfeeding up to 1 hour after delivery 12,22,25 .The United Nations Children's Fund along with WHO suggested this strategy, as they instituted the Baby Friendly Hospital Initiative with 10 steps for successful breastfeeding practices.The fourth one recommends providing contact between the infant and the mother immediately after delivery for at least 1 hour 26 .
Unfortunately, this is not widely practiced yet.A study conducted in Brazil showed that early breastfeeding fell short of WHO recommendations, even though the investigation took place in a Baby Friendly Hospital.The study also revealed that normal delivery, the presence of a nurse to give assistance during delivery, and skin-to-skin contact between the mother and infant were the main factors associated with breastfeeding in the 1 st hour of life 27 .
Regarding the newborns' characteristics, the sex of the baby was the most investigated variable, approached in 10 studies.Three of these showed a positive association between females and EBF [28][29][30] , whereas one study demonstrated that female infants were more likely to have EBF discontinued early than male ones 17 .Thus, as in other studies' results 7,28 , there is no consensus yet on which sex of the newborn determines EBF.This is because this determinant involves various factors, including cultural and family ones, such as the belief that male newborns have greater appetites than female ones.This would justify their greater food intake, inducing mothers to introduce complementary foods earlier.Hence, further studies are needed to better explain this phenomenon 28 .

Proximal Model
In the proximal model, maternal employment and maternity leave were the determinants most categorically associated with EBF and took second place among determinants in Bocollini's general model 7 , detected in 46 studies.Different articles pointed out that the mother's work away from home is the main cause of discontinuing EBF before the infant is 6 months old 29,[31][32][33] .A study from Ethiopia also showed that stayat-home mothers were more likely to reach EBF goals than formally employed ones.This association results from the greater time unemployed or stay-at-home mothers have to be with their infants than those who work away from home.Thus, some measures must be taken to ensure that the latter has the availability and support to stay at home or, if they return to work, support to breastfeed in the workplace 34 .Some examples can be cited, such as 6-month paid maternity leave and breastfeeding rooms in the workplace 17 .These strategies strongly protect EBF among formally employed mothers 35 .
Moreover, using pacifiers was one of the infants' characteristics verified as a determinant markedly closer to EBF, negatively associated in 27 studies in this scoping review.This phenomenon was likewise found in other studies 20,21,36 .
A cohort study that aimed to investigate the relationship between early weaning and pacifier use showed that discontinuing EBF early and using pacifiers gradually increased with the infant's age.The research pointed out that by the 4 th month, more than half of the babies had already weaned and used pacifiers 37 .WHO discourages this practice in the publication "Ten steps to successful breastfeeding" and emphasizes the importance of instructing mothers on the use and risks of baby bottles, nipples, and pacifiers 38 .This association also needs further investigation, as such a phenomenon involves other maternal, physiological, and family contexts.
Few studies investigated determinants related to the characteristics of health services.As for the investigated ones, breastfeeding guidance in these settings was the determinant most often positively associated with EBF, present in nine studies.A study conducted in Ethiopia also found this relationship, showing that women that get breastfeeding instructions in health units are twice as likely to provide EBF 25 .
Another study, carried out in China 22 , addressed information on breastfeeding in health units and pointed out that these settings' and other sources' not suggesting to feed the baby with infant formula was likewise an important determinant.It showed that mothers who did not receive such instructions were more likely to provide EBF.Infant formula commercialization raises concern among organizations working for breastfeeding -such as WHO, which reinforces that, along with other norms, health services must fully comply with the International Code of Marketing of Breast-milk Substitutes, whose objectives include safe and adequate infant nutrition.It requires breastfeeding protection and promotion measures, ensuring that breastmilk substitutes are only and appropriately used when absolutely necessary, particularly based on adequate instructions 38 .
Even though the study was rather encompassing, it was limited by not finding any public policy document or conference proceedings in the selection process.Furthermore, it identified few studies on the topic from developed countries, which may have kept the review from including some relevant studies.Therefore, to minimize such bias and possible losses, two researchers (with the participation of a third one for decision-making, when necessary) searched a wide range of databases to find as many articles as possible to be read in full text.The quality of the studies regarding scientific rigor was not assessed because it is not a characteristic of scoping reviews.Hence, future studies should map these determinants with other methodologies.

CONCLUSION
This scoping review mapped EBF health determinants in various realities from different continents, predominating studies from South America, in countries with various social and economic facets that hinder EBF.From the perspective of the breastfeeding model used in distal determinants, it was verified that absent or low educational attainment (which was the predominant variable) and low income negatively impact EBF.Intermediate determinants, such as having prenatal care and number of such visits, EBF guidance and practices in prenatal care, and time until the first breastfeeding are measures that health professionals should take and can be put into practice with quality, increasing the odds of prolonged EBF.
Although mapped in studies, there was no consensus on the role of the infant's sex on EBF.Hence, further studies are needed to better relate these two variables.In the proximal model, maternal employment and maternity leave were the second most recurrent determinant.The role of women after being included in the job market without an adequate support network also stood out.Other determinants were identified, such as pacifier use and breastfeeding instructions.Thus, determinants that can facilitate or hinder EBF are both extrinsic and intrinsic to the mother and infant.Public policies are needed to protect every person's right to breastfeeding worldwide.

Figure 1 .
Figure 1.Flowchart of the study selection process for inclusion in the scoping review, following PRISMA-ScR recommendations 6 , 2023

Figure 2 .
Figure 2. Distribution per year of publication of articles selected for the scoping review, 2023

Table 1 .
Characteristics of the studies on health determinants associated with exclusive breastfeeding, 2023 Caption: % percentage

Table 2 .
Health determinants associated with exclusive breastfeeding found in the scoping review, 2023 Captions: EBF = exclusive breastfeeding; n = number of studies