Our study is the first known to explore barriers to achieving the Global Nutrition Target 2025 for Exclusive Breastfeeding in Latin America and the Caribbean. Our results showed an increase in EBF prevalence rates and a marked reduction in PBF in the three decades analyzed (1990s, 2000s and 2010s). As expected, we found that BF and infant feeding indicators vary depending on the infant’s age. Between zero and three months, there was an increase in the prevalence of EBF over the decades. Among the foods offered to infants, the significant reduction in the prevalence of milk and liquids in all age groups may have contributed, in part, to the increase in EBF among infants under three months of age. The increased prevalence of formulas and water may have contributed, in part, to the maintenance of supplemented BF, which remained virtually the same for all age groups, being less than 10% for those under the age of 2 months, reaching close to 50% at 5 months. Thus, strategies to promote BF with a focus on reducing the early supply of water and formulas are potential methods for the Latin American and Caribbean region to reach the threshold of 50% of EBF established by the Global Nutrition Target 2025.
We observed an increase in the prevalence of EBF over the decades, especially in the age range from birth to the second month of life. While these findings indicate that perhaps more infants have been exposed to EBF since birth, on the other hand, we found a high consumption of liquids, milk and especially water in the first month of life, possibly due to cultural issues, and the lack of guidance in BF after birth in hospitals. Although the Baby-Friendly Hospital Initiative (BFHI) has been implemented in all study countries, the numbers of births performed in hospitals with this initiative are still very low. Babies born in the BFHI are more likely to be breastfed upon hospital discharge and maintain EBF for up to six months (1, 13, 14). This is because the BFHI favors the training of health professionals to support mothers and infants on the initial difficulties of BF, through adequate guidance and support in hospitals right after birth, which also helps to increase EBF rates (13). In this sense, a higher percentage of BFHI in the countries studied may favor the practice of EBF, and reduce the early introduction of water, liquids and milk in the first months of life (1, 15).
From the third and fourth month on, there is a sharp drop in EBF rates in all years of study and in all countries. The drop in EBF from the third month on seems to coincide with the duration of maternity leave in the countries studied. The duration of maternity leave in the countries studied varies from 12 to 14 weeks, that is, the end of maternity leave may partly explain the drop in EBF in this age group, and contribute to the early introduction of food before six months of age (16). Evidence has shown that support in the workplace (17), such as flexible working hours and a suitable place to extract breast milk or breastfeed (18) can support the maintenance of EBF among working mothers (19, 20). On the other hand, the informal market in Latin America is very large and legal protection such as maternity leave is not available for those women, therefore measures to protect informal workers are necessary. An alternative to make maternity leave available to the women who are in the informal market in Latin America and the Caribbean is the transfer of maternity income (21). Another potential explanation for the drop in EBF from the third month of life onwards, it may be related to threats to the maternal self-efficacy in maintaining EBF due to changes in the baby’s eating and crying behaviors, in the volume of the breast (due to regulation of baby’s demand), family beliefs about introduction of complementary food, pacifier use among others (6, 7, 22, 23).
Although we observed the increase in the prevalence of EBF over the decades of this study, we also noticed its reduction according to the evolution of the monthly age groups between the 1990s and 2010s. These findings point to the need to invest in continued support for BF, through the implementation and scale up of individual and group infant and young child feeding counselling in community-based programs and Primary Healthcare Facilities (1). Community programs play an important role in improving BF practices, precisely because they support women in maintaining and overcoming barriers during the BF period (1). Evidence has shown that providing advice through qualified health professionals about the infant and young child feeding increases women’s knowledge, practice and confidence in BF (1). Indeed, infant and young child feeding counseling interventions can increase global EBF rates by 12–16% (24, 25). In 2019, UNICEF indicated that globally 47% of countries have community programs that include infant and young child feeding counselling, which is far from proposed target of 80% by 2030 (1). In order to achieve this goal, Latin America and the Caribbean must increase their capacity to finance BF programs (26).
In our study, we observed an increase in the prevalence rates of water in all decades according to the evolution of the monthly age groups, especially from the third month of life onwards. The consumption of water is present in a high percentage of infants under six months of age, and this consumption can place infants’s health at risk since there is the hypothesis of water contamination due to sanitation issues in Latin American and Caribbean countries (27). Water seems to be one of the foods that most contributes to the early introduction of food in infants under six months of age, and this supply of water and other liquids such as teas and juices is strongly related to the maternal and family belief in the relief of colic and gases, and to quench the baby’s thirst (28).
In the same sense, we observed an increase in the prevalence of infant formulas over the decades and in all age groups of infants. The supply of milk other than breast milk is also related to the maternal belief of weak milk, and the maternal expectation of offering more energy and nutrients to the baby (29). Additionally, problems related to the breasts in the immediate postpartum period may also influence the supply of formula or food supplement soon after birth (13, 30). Evidence points to formula as one of the foods that most contributes to the early introduction of food before six months of life (13, 30). On the other hand, consumption of infant formula is better for the infant’s health when compared to consumption of cow’s milk, other foods, and liquids before six months of age, but breast milk is the best food for the baby when compared to infant formula (12). Some authors have attributed this change in dietary patterns, that is, the increase in the supply of formulas, and the decrease in the supply of other milk found in our study, to the improvement in the socioeconomic situation of Latin American and Caribbean countries with increased access to and sales of infant formulas (31, 32).
Although all countries in our study, except for Haiti, adopt all components of the International Code of Marketing of Breast Milk Substitutes (Code), we have not identified public data on inspection and monitoring in the literature. In this context, strengthening the Code becomes even more critical in conjunction with other strategies to promote, protect, and support BF that can contribute to reducing the use of formulas (1, 33).
Our study has some limitations that need to be considered when interpreting the results. We highlight one limitation in relation to differences in the availability of food variables according to the year of study. One of the policy implications for Latin America and the Caribbean was the systematization of indicators by WHO in 2008, which possibly served as a guide for countries to increase the availability of food variables. We believe that increasing the number of food variables from the first to the last stages of the study could make the frequency of EBF lower than the data we found, as it gives the mother more food options to remember. Another limitation is the inaccuracy of the age at which the child was introduced to foods, as this question was not addressed in the DHS survey.
Nevertheless, the strengths of our study are the use of nationally representative surveys, analysis of six Latin American countries over a long period of time, and analysis by monthly age group of what was being offered to infants who were not exclusively breastfed, to understand if the type of food that interferes with BF has changed over time. Thus, our analyzes are important to support health professionals and especially health managers to understand the situation of infant feeding in the first six months of life in Latin America, as we observe that breast milk is being supplemented or replaced by formulas.