INTRODUCTION

Breastfeeding (BF) is a natural biological process in women during pregnancy and its purpose is to feed and protect the newborn baby until six months of age. Evidence of the benefits of exclusive breastfeeding (EBF) has been widely disseminated, some of them are its association with decreased infant mortality, also the prevention of acute diarrheal diseases (ADD), acute respiratory infections (ARI), improved intelligence level of the child; Benefits for the mother: breast and ovarian cancer and prevention of diabetes M2¹.

Several publications report that at discharge from the hospital where the child is born, a high percentage of mothers start breastfeeding on the first day, but in the following months it gradually decreases to very low levels^2,3, among the causes of abandonment of EBF, The mother's return to work or study⁴and hypogalactia (perception of producing little milk and that the child is left hungry)⁴also the lack of support from the baby's father or family (help with domestic tasks that deplete their energy, producing fatigue)⁵.

In our country, according to the Demographic and Family Health Survey 2018 of the National Institute of Statistics and Informatics⁶the prevalence of ARI from 2009 to 2018 has ranged between 13.3 and 16.8 %, corresponding to 14.4 % by 2018, nationally. In the case of the prevalence of ADD, from 2007 to 2018 it has remained relatively stable, oscillating between 14.9% and 10.9%, corresponding to 10.7% for 2018, nationally. With differences according to areas, urban 10.3% and rural 12.1%. However, according to the Oficina de Epidemiología de la Dirección de Redes Integradas de Salud (DIRIS) Lima Centro, of the 14 districts that integrate it, those with the highest percentage of cases of ARI, except pneumonia, are the districts of San Juan De Lurigancho (41.5%), Lima Cercado (14.9%) and La Victoria (9.2%), the other districts are below 4%. For cases of ADD are also higher percentages of cases for the districts of San Juan De Lurigancho (34.3%), Lima Cercado (20.1%) and La Victoria (5.4%), the other districts are below 3%.⁷These morbidities, as already mentioned, are related to EBF.

Also, knowing that vaginal delivery favors EBF⁹, another worrying aspect is the increase in the number of cesarean deliveries from 26.4% in 2008 to 41.0% by 2018 in the urban area (ENDES 2018). The WHO establishes that a maximum of interventions for cesarean deliveries should be 15%⁸.

It has also been reported that there is a strong inverse association between BF and breast cancer¹⁰, According to the 2018 Cancer Health Situation Analysis, breast cancer is the main neoplasm in women in our country¹¹, this situation could be reduced if BF is promoted and practiced more frequently and for a longer period of time, since the effects of BF in the prevention of breast cancer are well known¹

It have been published numerous articles related to the practice of breastfeeding and the factors that may favor or hinder it. A study in Spain reports that the lack of support and information negatively influences the EBF, also mentions that some health professionals are not well informed of the benefits of BF, however, women who have been prepared during the prenatal stage about the benefits of BF, are successful in providing their milk to the baby for a longer time and exclusive¹².

For these reasons it was decided to investigate the factors that were associated with the practice of EBF in mothers who attended health facilities of the DIRIS Lima Centro, in three districts in which the prevalence of ARI and ADD were high. The objective of this study was to find the association between exclusive breastfeeding and various factors in different periods of time: during pregnancy, during childbirth and postpartum in mothers who go to health centers of the DIRIS Lima Centro.

METHODS

RESULTS

DISCUSSION

The prevalence of EBF found in the studied group is 46.4%, this figure is lower than that reported by ENDES 2018⁶, which indicates 66.4% as the national average and 61.2% for the urban area, while in 2016 was 66.7% the national average¹⁴. There are reports^1,10,11that at first there is a good willingness of mothers to give natural milk to their child, but after discharge from the institution where they have given birth, for various reasons gradually abandon the exclusivity of breastfeeding and the percentage of mothers who reach the sixth month of life of their babies providing only breast milk is very low.

In our study, 90.7% breastfed on the first day of birth, of which 58.3% were breastfed up to six months of age. In Peru, according to ENDES 2018⁶, 49.7% lactated during the first hour of birth, although there are differences according to urban (43.4%), rural (68.7%) areas. Those who breastfed within the first day constitute 92.3%.

Regarding factors that occur before birth, a statistically significant association was found between attendance at six or more prenatal visits and the practice of EBF up to six months. Mothers who do not attend their checkups sometimes because they forget their appointments. In a study carried out in two hospitals in Huaral and Chancay, it was found that forgetting appointments was associated with adherence to prenatal control¹⁵. On the other hand, ENDES 2018⁶, reports that 92.5% of pregnant women, at the level of Lima and Callao, received six or more controls. This situation is very positive because it expresses the interest of pregnant women in taking care of their health and anticipating risks.

Although no significance was found among the aspects addressed about successful breastfeeding during the controls, in all cases, the proportion of mothers who received these instructions was higher than those who did not. Other studies, such as those of Bellido-Roque and col.¹⁶in Lima, found that mothers had medium knowledge about the EBF. The Reglamento de Alimentación Infantil¹⁷establishes that in each health facility where care is provided to pregnant women, a Breastfeeding Committee must be formed to reinforce information on the benefits of breast milk for the child, for the mother in the short and long term. It is important that all health facilities comply with these directives. A post in Bangladesh¹⁸on the impact of an educational intervention with emphasis on nutrition gave very good results for the promotion of EBF.

During the birthing process, the factor vaginal birth was associated with EBF in our study, a similar result was found by Silva Ocampo et al.⁹in Chile, since this type of birth is considered normal, it allows, immediately the baby is expelled, to approach the mother for early contact, encouraging her to seek the nipple to feed for the first time. The WHO establishes that the frequency of caesarean delivery⁵should be a maximum of 15%, however, in our country it has increased in recent years to 46% by 2018 in the area of Metropolitan Lima according to ENDES 2018-Salud Materna. This is worrying since caesarean section is not recommended unless is absolutely necessary and justifiable.

In the postpartum period, an association was found between the use of formula in bottles and EBF, which is a very high risk factor for not giving EBF. Lamberti and col²⁰found that children fed with formula have nearly 15 times more mortality from pneumonia and respiratory diseases. Rollins and col.²¹calculated that by 2019 sales of alternative BF products would increase to more than 70 billion dollars. In general, the recommendations are ignored and they continue to promote their products wherever they can find mothers who are not very convinced of the benefits of providing their own milk to their children. The Marketing Code for Milk Substitutes has been updated recently²².

Another study²³found an association between the abandonment of the EBF with the use of the bottle, however, there are women who declare that the EBF is the best for the baby, but in practice do not full²⁴Another factor frequently mentioned by various authors is the perception of having little milk (hypogalactia), or that their child is left hungry as reported by Ramiro-Gonzalez, in Spain²⁵, in Cuba²⁶and in Colombia²⁷.

Of those who said they had some illness that prevented them from giving their milk to the baby, only 8 out of 140, however, half of them, that is to say four states that they have given EBF until their babies were six months old. A publication in Argentina reports that depressive and anxiety symptoms decrease the likelihood of prolonging breastfeeding until 6 months⁽²⁸⁾.

The majority of mothers interviewed in our study (78.57%) reported not having an adequate environment, i.e. with little noise, spacious place, without interruptions, of this group of mothers despite this inconvenience 59.1% gave EBF as reported.

Only 24.3% of mothers reported having received home visits from the health staff, of whom 61.8% answered that they gave EBF to their baby for six months, the problem is that many times, due to lack of professional staff does not make these visits that constitute the extension of the care process to the mother. In this respect, the intervention of the health personnel who visit the mother at home is important, to observe the environment and give some recommendations to minimize stress situations.

CONCLUSIONS

In conclusion, three factors associated with EBF were found: attendance to six prenatal controls, vaginal delivery and, as a risk factor, the use of milk formulas, one in each period of time, before, during and after childbirth.

The recommendation for higher education institutions and universities that train health professionals is that in the curricula there are subjects that promote and deepen the importance of the practice of exclusive breastfeeding until six months as it contributes to the improvement of public health.

On the other hand, it is important the proportion of caesarean delivery be reduced and only performed when absolutely necessary.

Campaigns should also be continued to avoid bottle feeding as far as possible, although in some cases it may be necessary, it should not be common practice.