Artigos

Introduction
The global prevalence of chronic maternal diseases has surged over the years. In 2013, the prevalence of chronic diseases among mothers was 15.76%1. Among the most prevalent chronic conditions affecting women during pregnancy and postpartum are diabetes mellitus, asthma, epilepsy, hypertension, and mental health issues1,2.
Chronic maternal diseases during the pregnancy-puerperal period can result in severe consequences for children, including an elevated risk of premature birth3, low birth weight4, intrauterine growth retardation5, birth defects6, and adverse impacts on breastfeeding7.
The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) advocate for exclusive breastfeeding for the initial six months of an infant's life, followed by continued breastfeeding (post-introduction of solid foods at six months) until the second year according to the wishes of the mother and child8. Substantial evidence underscores the myriad benefits of breastfeeding for infants, encompassing disease prevention, enhanced cognitive development, and improved emotional wellbeing9,10. Additionally, breastfeeding confers advantages to the mother, serving as a protective measure against cardiovascular diseases11 and type 2 diabetes mellitus12. The promotion of breastfeeding has emerged as a primary strategy in mitigating infant mortality and remains pivotal in infection control, even within contemporary healthcare settings13.
A study involving Canadian women revealed that postpartum women with chronic illnesses encountered breastfeeding challenges such as low milk production or ineffective attachment during the initial six weeks postpartum7. Substantial evidence indicates that mothers with pre-existing physical health issues exhibit a heightened risk of early breastfeeding discontinuation compared to the general maternal population14,15. Notably, a knowledge gap persists regarding the management of women with non-communicable diseases (NCDs) during lactation16.
In Brazil, breastfeeding practices have shown improvement in recent decades and the country is considered successful in implementing policies and programs to promote breastfeeding. Presently, breastfeeding prevalence among children under six months in Brazil stands at 45.8%17. Despite these advancements, Brazil wants to achieve the target of 50% exclusive breastfeeding within the first six months by 202518. However, this is under the required global target of 70% recommended by the WHO 19. Brazil also grapples with challenges in curbing maternal deaths resulting from indirect causes, primarily stemming from chronic non-communicable diseases. In 2019, over 487,000 women succumbed to chronic non-communicable diseases20.
Acknowledging the hurdles Brazil faces in fostering breastfeeding practices within the general maternal population and considering the prevalence of chronic diseases among women of reproductive age1, the pertinent inquiry arises: What impact do chronic diseases exert on breastfeeding among Brazilian women who are mothers of children aged 0 to 24 months?
The aim of this study was to assess the prevalence of breastfeeding within the preceding 24 hours among mothers of children below two years of age, categorizing them based on the presence or absence of an NCD in 2013 and 2019.

Methods
Study design
A cross-sectional study was conducted using secondary data obtained from Brazil's National Health Survey (PNS), guided by the STROBE tool. The PNS, conducted in 2013 and 2019, is a population-based household survey21,22 and represents the primary population survey in Brazil. Spearheaded by the Brazilian Ministry of Health, it was executed by the Oswaldo Cruz Foundation (Fiocruz) in collaboration with the Brazilian Institute of Geography and Statistics (IBGE)22.
Within the PNS framework, questionnaires were administered to occupants of permanent private homes, gathering information about the households and all residents. Additionally, a specialized health questionnaire was directed at a resident aged ?18 years in 2013 and ?15 years in 2019, chosen randomly from among all household members21,22. Data from the interviewees were recorded on digital mobile communication devices (DMCs).
The PNS employs a complex probabilistic sampling methodology utilizing selected areas (census sectors) in Brazil. The sampling process involved a three-stage probabilistic selection using conglomerates, stratified by chosen areas. Household units constitute the secondary units, while the residents (?18 years old in 2013 and ?15 years old in 2019) selected within each household represent the tertiary unit. Methodological specifics21,22, applied questionnaires, and a variables dictionary are available in published resources (https://www.pns.icict.fiocruz.br/questionarios/).
Population
The study's population comprised pairs of individuals identified by the survey as women/guardians aged 18 to 49 years and children under 2 years old. Information regarding these children was sourced from their respective mothers, who self-reported data through the questionnaire modules designated for them. This approach facilitated the creation of paired data sets encompassing children and their mothers within the same database. Inclusion criteria encompassed: (1) children born between 07/28/2011 and 07/27/2013 in 2013, and 07/28/2017 to 07/27/2019 in 2019; (2) women who had given birth within the same time frame; (3) participants identified as mothers/guardians of children under 2 years old and who responded "yes" or "no" to the query: "Did the child consume breastmilk or other breast-related nourishment from yesterday morning until this morning?" (Module L) (Yes or No); and (4) mothers medically diagnosed with one of the Chronic Non-Communicable Diseases (NCDs): hypertension, diabetes, cholesterol issues, heart disease, stroke, asthma, rheumatism, back pain, Work-Related Musculoskeletal Disorders (WMSD), depression, mental illness, lung disease, cancer, or kidney disease (Yes or No). Further methodological insights are available in publications related to the National Health Surveys (NHS)22. It is important to highlight that our study did not analyze the exclusive breastfeeding period from 0 to 6 months as we used data available on the NHS.
Study variables
Sources, inclusion, and exclusion criteria
The survey conducted interviews with 222,385 individuals in 2013 and 279,382 in 2019. For this analysis, only data pertaining to the selected resident of each household (?18 years old in 2013 (n=60,202) and ?15 years old in 2019 (n=90,846)) were considered. Among these, only information from women who were pregnant in the two years preceding the PNS data collection dates was included (in 2013: n=1,918; in 2019: n=2,910). To ensure comparability across years, women within the same age range (18 to 49 years old) who received prenatal care and identified as caregivers of the resulting children were retained. Following this criterion, women were not excluded based on any other factors. Hence, the sample size for 2013 and 2019 comprised 1,586 and 2,064 women, respectively. Extrapolating the samples using selection weights enabled inferences for a population of 2,586,151 in 2013 and 2,741,364 in 2019.
The analyses utilized a set of socioeconomic, demographic, and NCD variables, encompassing age ranges (18 to 29, 30 to 39, and 40 to 49 years); racial/ethnic categorization (white, brown, black, others); possession of health insurance (yes, no); educational attainment (categorized into levels: incomplete primary education or equivalent, incomplete secondary education or equivalent, incomplete higher education or equivalent, completed higher education); geographic macro-regions (North, Northeast, Central-West, Southeast, and South); city types (capital/metropolitan region, interior); per capita income quintiles (1st quintile, 2nd quintile, 3rd quintile, 4th quintile, and 5th quintile). In 2013, the median income for the lowest quintile stood at 102.50 real (20.68 USD), while for the highest quintile, it was 1,191.50 real (240.37 USD). In 2019, the median income was 102.00 real (20.58 USD) for the lowest quintile and 1,619.00 real (326.62 USD) for the highest quintile.
The National Health Survey (PNS) assessed NCDs through self-reported previous diagnoses by a doctor or psychologist for various conditions: systemic arterial hypertension (SAH); diabetes mellitus; heart disease; cerebrovascular accident (CVA); asthma; arthritis/rheumatism; work-related musculoskeletal disease (WMSD); back issues; high cholesterol; renal insufficiency; lung disease/chronic obstructive pulmonary disease (COPD); cancer; depression; and mental illness (yes; no). These conditions were also grouped to evaluate the presence of multimorbidities (?2 NCDs).
Analysis
For both survey years of the National Health Survey (PNS), estimations were made for the maternal population and the prevalence of socioeconomic, demographic, and NCD variables within this cohort. The prevalence, along with their respective 95% confidence intervals (95% CI), of breastfeeding within the last 24 hours was assessed based on these characteristics. Differences in the frequency distribution of these variables were examined for each PNS year. Statistically significant differences were defined at the 5% level, confirmed when 95% CIs did not overlap. Moreover, the prevalence of breastfeeding within the last 24 hours was evaluated concerning the age of children and the presence of NCDs.
Changes in the prevalence of breastfeeding between the survey years were quantified using the absolute difference to determine the variation magnitude over the period. This computation utilized Generalized Linear Models (GLM) with a Gaussian distribution, aggregating data from both surveys into a unified database. Calculating the change in prevalence from 2013 to 2019 involved modeling the effect of the year on the breastfeeding practice variable. The percentage change in prevalence was derived by exponentiating the coefficient minus one, then multiplying by 100.
Regarding the presence of NCDs, the prevalence and 95% CI of breastfeeding were estimated according to socioeconomic and demographic characteristics for each survey year. Poisson regression models with robust variance adjustments were employed to estimate the Prevalence Ratio (PR) and 95% CI, exploring the association between these characteristics and breastfeeding practice based on NCD presence. Additionally, the prevalence and 95% CI of breastfeeding were calculated concerning each type of NCD for both years. The association of these conditions with the practice of breastfeeding within the last 24 hours was also examined using PR and 95% CI.
All statistical analyses were conducted using RStudio software version 2023.3.1.4446 (R Foundation for Statistical Computing, Boston, United States of America), considering the differences in sample sizes across survey years and the complex sampling design characteristics of the PNS in 2013 and 2019.
Ethical aspects
The data from the National Health Survey (PNS) in 2013 and 2019 are publicly available and can be utilized for research purposes aligned with specific interests. This research received approval from the National Research Ethics Commission/National Health Council (process no. 328,159 on June 26, 2013; and process no. 3,529,376 on August 23, 2019). All participants were duly informed about the study and willingly consented to partake by signing a consent form.

Results
In 2013, analysis encompassed 1,586 women who were mothers of children under two years old, increasing to 2,064 in 2019, representing a population of 2,586,151 women in 2013 and 2,698,102 in 2019.
Figure 1 illustrates the prevalence of breastfeeding (any infants receiving any breastmilk rather than exclusive breastfeeding) according to the child's age across the two PNS years. It was observed that there were no statistically significant differences between the two years of the children’s age in any period. The overall prevalence (0 to 24 months) remained unchanged: 53.5% (95%CI: 49.3-57.6) in 2013 and 53.6% (95%CI: 49.8-57.4) in 2019. However, a notable decline in breastfeeding duration correlated with increasing child age each year. In 2013, a significantly lower prevalence was noted among children aged 12 to 24 months, recording 35.3% (95%CI: 29.4-41.1) (p-value<0.01). In 2019, the prevalence reduction displayed a gradient, notably dropping from 75.4% (95%CI: 68.8-81.9) in children up to six months to 55.2% (95%CI: 47.4-63.1) between 6 to 12 months, eventually reaching 40.3% (95%CI: 35.3-45.2) among children aged 12 to 24 months (p-value<0.01).
Table 1 shows the population's characteristics based on socioeconomic and demographic variables alongside the prevalence of breastfeeding practice within the last 24 hours. In both 2013 and 2019, young mothers aged 18 to 29, individuals of non-white ethnicity, lacking health insurance, inactive in the job market, without higher education, positioned within middle-income quintiles, residing in Brazil's southeast and northeast regions, within interior cities, and without NCDs were observed. The prevalence of breastfeeding exhibited disparities among categories of socioeconomic and demographic variables. In 2013, breastfeeding was more pronounced among non-white mothers who were non-working in paid employment, situated in the lowest income quintile, and residing in the North or capital/MR regions. In 2019, these differences diminished, persisting predominantly among mothers who were not engaged in employment. Notably, a change in breastfeeding was statistically significant only among mothers in the northern region, depicting a reduction of 15.2% (95% CI: -22.4; -4.9) between 2013 and 2019.

Tab.1

Table 2 displays the adjusted prevalence and prevalence ratios of breastfeeding within the last 24 hours among mothers of children under two years of age in 2013 and 2019, categorized by socioeconomic and demographic variables, while considering the presence of NCDs in these mothers. There were no statistically significant differences in breastfeeding prevalence between women with and without NCDs within each year or between the two years.

However, in the analysis adjusted for the child's age and the year of PNS, among mothers with NCDs who breastfed, a negative association was observed between breastfeeding and the following variables: employment status (PR: 0.78; 95% CI: 0.65-0.93), completion of higher education (PR: 0.80; 95% CI: 0.65-0.98), middle-income quintiles (PR: 0.80; 95% CI: 0.67-0.96), and high-income quintiles (PR: 0.75; 95% CI: 0.59-0.95), as well as residence in the central-west (PR: 0.77; 95% CI: 0.72-0.83) and southern regions of the country (PR: 0.80; 95% CI: 0.69-0.94).
Among mothers without reported NCDs who breastfed, a distinct association was observed between breastfeeding and the following variables: non-white women (PR: 1.28; 95% CI: 1.11-1.47), those without health insurance (PR: 1.38; 95% CI: 1.10-1.73), and those living in rural areas (PR: 1.15; 95% CI: 1.04-1.27) who were observed to breastfeed more compared to their respective comparison groups. Conversely, a negative association with breastfeeding was noted among mothers without reported NCDs who were employed (PR: 0.84; 95% CI: 0.74-0.96), had incomplete higher education (PR: 0.85; 95% CI: 0.76-0.96), fell within the two highest income quintiles (4th quintile: PR: 0.82; 95% CI: 0.71-0.94; and 5th quintile: PR: 0.78; 95% CI: 0.63-0.98), and resided in the wealthiest regions of the country (south: PR: 0.81; 95% CI: 0.69-0.94; southeast: PR: 0.74; 95% CI: 0.61-0.89) (Table 2).
Figure 2 illustrates the prevalence of breastfeeding across different age groups of children among women with and without NCDs in the years 2013 and 2019. Comparing these populations revealed no statistically significant difference between them overall. However, within women with NCDs, a notable decline in breastfeeding was observed specifically among children aged 12 to 24 months, when compared with children below 6 months of age. In 2013, the prevalence dropped to 35.0% (95% CI: 22.7-47.3), and in 2019, it decreased further to 39.0% (95% CI: 31.2-46.8) compared to other age groups (p-value<0.05).
Similarly, among women without NCDs, a reduction in breastfeeding was evident in the same age group. In 2013, the prevalence reached 35.4% (95% CI: 28.9-41.9), and in 2019, it declined further to 41.2% (95% CI: 35.1-47.4) (p-value<0.05) compared to other age groups.

Discussion
This is one of the first studies to compare the prevalence of breastfeeding within the last 24 hours in children aged 0-24 months in different time periods. The results showed stability in the prevalence of any type of breastfeeding within the last 24 hours between the years 2013 and 2019. It was observed that there was no difference in the initiation of breastfeeding between women with and without non-communicable diseases (NCDs). However, between the ages of 12 and 24 months, a statistically significant difference in discontinuation of breastfeeding was observed, suggesting that NCDs may affect the long-term continuation of breastfeeding. On the other hand, cessation of breastfeeding was observed with increasing age of the child in both women with and without NCDs. Maternal characteristics influencing breastfeeding practices in women with and without NCDs were identified, highlighting the health needs and support required to sustain any type of breastfeeding up to 24 months.
Approximately half of the mothers of children aged 0-24 months included in the study had engaged in some form of breastfeeding within the last 24 hours prior to the interview. These findings suggest that the recommendations for breastfeeding up to two years of age are not being fully met23. Especially in low-and middle-income countries, where it is estimated that more than 800,000 infant deaths (11.6% of all deaths) are associated with non-breastfeeding, achieving universal coverage is critical24.
Because of non-available data, our study did not look at exclusive breastfeeding. Nevertheless, about 70% of children under 6 months received some form of breastfeeding within the last 24 hours. Although a significant percentage of mothers breastfed their infants under 6 months, a decline in this practice was observed with increasing infant age over the two study periods.
The results of our study regarding the cessation of breastfeeding as the child grows in Brazil are consistent with the results of previous studies conducted in other countries. In Australia, among mothers who initiated breastfeeding, 49% breastfed until 6 months, 25% until 12 months, and only 2.9% from 12 to 24 months25. Similarly, in Canada, only 5.6% reported breastfeeding up to 24 months26. In the United States in 2019, 83.2% started breastfeeding and 35.9% breastfed until 12 months of age27. A study analyzing the global prevalence of infant feeding practices revealed substantial differences among the 57 countries studied. Of these, 27 countries achieved exclusive breastfeeding prevalence for children under 6 months of age at ?50%28, meeting the target set by WHO for 202529. However, in some countries (Albania, Philippines, Pakistan, Armenia, Angola, Bangladesh), the prevalence was below 15%28.
A systematic review of 19 articles evaluating factors associated with maintaining breastfeeding for 12 months found that older maternal age, higher education, being married, having more children and lower family income were strongly associated with maintaining breastfeeding30. In our study, mothers who breastfed more were non-white, did not work outside the home, and were in the lower income quintiles (Table 1). There were no statistically significant differences in breastfeeding within the last 24 hours between women with and without NCDs. However, socio-demographic factors influenced breastfeeding practices in both groups (Table 2). Promotion of exclusive breastfeeding has increased in many countries, but disparities persist, with lower rates among disadvantaged and marginalized populations, particularly black, indigenous and people of color31,32. In addition, black women are more vulnerable to chronic diseases such as heart disease, stroke, cancer, diabetes, maternal morbidities, obesity and stress, which can affect breastfeeding practices in this population33.
Disparities in access to maternity care services among black women were found in a study, whose hospitals in neighborhoods with black populations in the United States were less likely to initiate early breastfeeding and encourage rooming-in34. However, a study showed black women breastfeed more than white women24. In Brazil, black children were more likely to be breastfed than white children35. One possible explanation is that black children are likely to have lower socioeconomic status and less access to food and other milk, making breast milk one of the few free sources of nutrition.
A study in the United States examined racial differences in breastfeeding and found that mothers who worked outside the home had the shortest duration of breastfeeding. The authors found that for white mothers, not working increased the duration of breastfeeding, while for black women, employment was a protective factor for longer breastfeeding, especially in managerial positions36. Maternal employment was highlighted as one of the main barriers to breastfeeding in a review of 11,025 participants from 19 countries, both developed and developing37. Among the main barriers to continuing breastfeeding, a review study of 54 articles listed the following factors: shorter duration of maternity leave, increased workload for women after motherhood, and lack of occupational policies that support breastfeeding. In addition, the authors found that women who continue to breastfeed after returning to work appear to experience more conflict and overload between family and work38.
An epidemiological study analyzed data from 153 countries, including 116 middle- and low-income countries, found a higher prevalence and duration of breastfeeding24. However, there are some exceptions, such as a study conducted in South West Australia, where low income was considered a risk factor for breastfeeding cessation25. In Brazil, breastfeeding prevalence differs between richer and poorer regions. Our study found that regions with lower per capita income (North and Northeast)39 had higher breastfeeding prevalence rates. However, in a city in the Southern region of Brazil, which has the second highest per capita income, women from the highest income quintiles were more likely to breastfeed in a 2015 cohort study40.
Income may also influence the presence or absence of health insurance for mothers and infants. In our study, women without health insurance had a higher prevalence of breastfeeding within the last 24 hours. However, a study in the United States that examined changes in breastfeeding rates after the implementation of legislation to support breastfeeding found that mothers with private insurance were more likely to report breastfeeding than those without private insurance. In addition, insured mothers breastfed for about two months longer than uninsured mothers and exclusively breastfed for more than one month on average41.
A study analyzing socioeconomic inequalities in the self-reported prevalence of noncommunicable diseases in the Brazilian adult population found that NCDs were more prevalent among women, those without private health insurance, and those with lower levels of education42. In general, women with lower levels of education breastfeed more than those with higher levels of education30. Low education has also been identified as a risk factor for developing NCDs in the female population of the Netherlands43. In a study conducted in China, women with mental health problems, especially stress, and fewer years of education were less likely to exclusively breastfeed compared with mothers with more years of education and no stress symptoms (OR: 0.53; 95% CI: 0.25,1.10)44.
However, even with higher education, the presence of NCDs may hinder prolonged breastfeeding. In Denmark, a study of 149 women showed a low prevalence of breastfeeding among women with type 2 diabetes (15%), despite the majority of participants having more than 10 years of education45.
Place of residence also emerged as a factor associated with breastfeeding practices in our study, with women living in urban or metropolitan areas less likely to have breastfed within the past 24 hours than women living in rural areas. This was observed in a study conducted in a state in the Northeast region of Brazil, where women in rural areas and lower social classes breastfed more than those in urban areas and higher income quintile46. Geographic variations in breastfeeding rates are influenced by differences in socioeconomic status, ethnicity, culture and hospital practices47.
The results of this study also indicate that the prevalence of breastfeeding within the last 24 hours among mothers with NCDs remained stable between 2013 and 2019, compared with mothers without NCDs during the same periods. In Canada, non-initiation of breastfeeding was found to be similar among women with (10.4%) and without (8.7%) NCDs14. Conversely, there is evidence that women with chronic diseases have lower breastfeeding rates than healthy women48,49.
When the duration of breastfeeding with the age of the child was analyzed, a decrease was observed in both women with and without NCDs, but this decrease was significant in women with NCDs. A Canadian study, also using a population survey, found that having a NCD may affect exclusivity of breastfeeding, but not duration of this practice for 6 months15. In our study, as mentioned earlier, exclusivity was not assessed, but rather breastfeeding within the previous 24 hours. Nevertheless, it was observed that continuation to 6 months decreased without statistical significance in women with and without non-communicable diseases. The most significant reduction occurred in children aged 12-24 months, suggesting that non-communicable diseases may affect long-term breastfeeding duration.
There is evidence that exclusive breastfeeding and any type of breastfeeding are reduced in women with pre-existing cardiometabolic disorders, such as diabetes mellitus and hypertension, compared with healthy women48-50. A Cohort conducted in Finland between 2009 and 2015 found that gestational diabetes mellitus didn't influence breastfeeding duration, highlighting that woman breastfed their infants for <8 months51. In addition, other chronic diseases may influence the duration of breastfeeding; women with rheumatic diseases52, polycystic ovary syndrome (PCOS)49, and epilepsy53,54 breastfed for shorter periods compared with unaffected women.
Physiologically, chronic diseases can affect breast milk production because of interruptions in breastfeeding caused by medications and hormonal treatments55,56. In addition, this delayed milk release may affect the initiation of formula feeding57.
Although our study did not show this difference in breastfeeding practice between those with and without NCDs, the presence of NCDs was found to influence the continuity of breastfeeding practice16. In addition to having or not having NCDs, breastfeeding practice is still influenced by socio-demographic factors, as shown in this study. Therefore, targeted support for this population is needed to achieve the Sustainable Development Goals on breastfeeding practice.
Our study is among the first to present data on the prevalence of breastfeeding practices, with and without NCDs, among mothers of children up to two years of age. Our results indicate that the prevalence of breastfeeding has remained stable in Brazil. A high prevalence of women initiate breastfeeding, and as the child's age progresses, this prevalence tends to decrease. The analysis of sociodemographic variables can support actions to obtain political, legal, financial and public support for breastfeeding. In addition, it can offer training courses for health professionals to provide qualified support to breastfeeding mothers and families, helping them to overcome problems that may affect breastfeeding, with the aim of combining efforts so that both mother and child can benefit from all the advantages of breastfeeding.
However, our study has several limitations. We only had data on any breastfeeding and not separately on exclusive, predominant and partial breastfeeding. The survey assessed breastfeeding in the last 24 hours, which may lead to maternal recall bias regarding breast milk intake. In addition, the prevalence of chronic diseases was self-reported. Despite the limitations of maternal recall and self-report, these measures continue to be used in most large surveys such as the Brazilian National Health Survey.

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