Breastfeeding is one of the public health strategies that provides important benefits for maternal and infant health (1). Human milk is composed of water, lipids (long-chain polyunsaturated acids), carbohydrates (oligosaccharides), low concentrations of proteins, minerals and vitamins, as well as growth and immunological factors (2, 3). These components reduce infant morbidity and mortality from infectious diseases (infant diarrhea and acute respiratory infection), while in breastfeeding mothers they prevent the onset of chronic diseases (breast cancer, ovarian cancer, diabetes, among others) and prolong the inter-gestational period of births (1, 4). Although the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) promote exclusive breastfeeding (EBF) for the first 6 months of life and continuing this practice up to 24 months of age (5), it is estimated that less than 50% of infants under 6 months of age have received EBF in the world. (6). In addition, the absence of EBF in children is reported to have generated more than 13 million disability-adjusted life years and more than 140 thousand deaths in 2019 (7). These indicators are reflected in higher health spending for healthcare systems due to the burden of disease that may be preventable with EBF (8, 9).

Low- and middle-income countries (LMICs) have a higher prevalence and duration of EBF compared to high-income countries. However, LMICs have EBF figures (38.7% in 2018) that are well below the figure recommended (70%) by the WHO for 2030, and have a higher number of child deaths attributed to the absence of EBF (4, 7, 10). More than 30 million children in LMICs do not receive EBF due to socioeconomic, cultural and individual determinants that affect EBF practice decisions and behaviors (10). These determinants are related to the woman’s age, maternal education, maternal employment, maternal nutritional status, number of antenatal care visits, place and route of delivery, newborn characteristics, social influence and traditional practices that affect the onset and duration of EBF (11–13), which vary between and within countries, accentuating health inequalities (8). These inequalities are present in most countries, where poorer and less educated mothers have a higher frequency and duration of EBF than their counterparts (1). In this sense, since EBF is one of the most cost-effective practices in health, the strategies that promote EBF are oriented to all women to reduce the negative effects on child health indicators; however, there are socioeconomic inequalities that influence EBF practices and generate an unequal distribution of this practice among women (14, 15).

Latin America and the Caribbean (LAC) is one of the regions made up of LMIC countries, in which the prevalence of EBF has increased from 37.3% in 2000 to 51.7% in 2019, being one of the regions with the highest prevalence of EBF (16). However, the frequency of EBF decreases the older the age of the child (67.6% in children aged 0 months vs. 22.2% in children aged 5 months), reflecting a shorter duration of EBF in this region (17). Within the LAC countries, socioeconomic determinants influencing EBF practices have been observed, with a high educational and economic level of the mother being positively associated with the frequency and duration of EBF (18, 19). In Peru, the Demographic and Family Health Survey (ENDES–acronym in Spanish) shows that EBF increased from 65.2% in 2015 to 68.4% in 2020 (20). However, a pattern similar to that of other LAC countries is observed, in which the frequency of EBF decreases the older the child is (74% in 1-month-old children vs. 35% in 6-month-old children) reflecting a limited duration of EBF (21). Peru is an unequal and heterogeneous country, presenting socioeconomic characteristics that differ from one person to another, and predispose the emergence of inequalities in various health areas, such as EBF practices. Thus, the assessment of socioeconomic inequalities would help to define, describe and understand the nature of this problem in the Peruvian territory in order to develop strategies and policies to address these inequalities.

The information obtained from the Peruvian population in the year 2021 would help to understand the possible changes that have occurred in EBF practices. Likewise, this updated information would allow identifying the progress that has been made toward the achievement (70%) of EBF by 2030, especially considering that the LAC region presented a figure much lower than expected for that year. Therefore, the objective of the present study was to examine the socioeconomic determinants and perform a decomposition analysis of socioeconomic inequalities in EBF in Peruvian children aged 6 to 59 months using the 2021 ENDES.

The present study sought to determine the associated factors and quantify the contribution of contextual and compositional factors on socioeconomic inequalities in EBF practices in Peruvian children aged 6–59 months. It was found that 7 out of 10 Peruvian children aged 6 to 59 months received EBF, with children of mothers with no or a primary education, residing in a rural area and in the departments that make up the highlands and jungle having the highest prevalences of EBF. Regarding the factors associated with EBF, several maternal, child and household characteristics were found to increase the probability of EBF in their children aged 6 to 59 months. In terms of the inequality analysis, the practice of EBF was concentrated among the poorest women, while the main contributors in the decomposition analysis were the natural region of residence and the wealth index.

The prevalence of EBF in Peruvian children aged 6 to 59 months was 70.5%. This finding is higher than that reported in studies estimating the prevalence of EBF in LMIC (38.7%) (10), and high-income countries (18%) (38). Likewise, this result is higher than that reported in LAC, in which the prevalence was estimated at 51.7% in 2019 (16). In this region, the countries with the highest prevalence of EBF were Bolivia (60.4%), Guatemala (53.2%), and Haiti (39.9%), while the countries with the lowest prevalence were the Dominican Republic (4.7%), Guyana (23.3%), and Honduras (23.8%) (16). A previous study that estimated the prevalence of EBF in Peru showed an increase from 63.6% in 2000 to 69.2% in 2018 (10), indicating that EBF figures continue to increase over the years, reaching 70.5% in 2021. It should be noted that by 2021, Peru had reached the figure of 70% of EBF recommended by the WHO for 2030. However, this prevalence is dissimilar within the country because the highest prevalences were found in women with a low educational level, residing in rural areas and the departments that have a greater distribution in the highlands and jungle of Peru. These findings could be attributed to various cultural and sociodemographic factors observed in the Peruvian territory. It has been described that cultural beliefs and practices on infant feeding could be a determining factor in the inclusion of breastfeeding, especially in regions of the highlands and jungle, where cultural traditions persist over time (39, 40). In addition, a high level of education in LMIC women could be associated with higher labor participation which would generate poor breastfeeding practices (41–43). Therefore, governmental institutions should carry out strategies for working mothers aimed at the inclusion of breastfeeding in the workplace. In addition, orientation programs on EBF are required in regions such as the departments that have a greater distribution in the Coast region, where the prevalence of EBF is low.

It was found that married women, who self-identified as natives, received training on breastfeeding practices, resided in the highlands and jungle regions, and their child was the second or older in birth order were more likely to have perform EBF. These results are similar to those reported in studies conducted in Ethiopia (29), Iran (25), Kenya (27), and Malawi (28), in which women who were married, belonged to specific ethnic groups, received breastfeeding counseling, had a low economic income, and the child was third or fourth in birth order were associated with a higher likelihood of EBF. These findings could be explained by multiple cultural, socioeconomic, and demographic determinants that influence breastfeeding practices. Regarding the influence of marital status on EBF, the biomedical literature indicates that the social environment of married women affects postpartum health and behavior (44, 45), increasing the likelihood of EBF, and even the husband’s attitudes and beliefs may be relevant when making decisions about infant feeding because breastfeeding is strongly influenced by social and cultural aspects of the woman’s environment (46–48). Likewise, Peruvian women who self-identify as native guide breastfeeding practices based on culture-specific beliefs, with which mothers’ concepts about the baby’s development influence infant feeding. In addition, there are some natural resources (animals, plants, and minerals) in the Andean region of Peru that have nutritional properties and are implemented in the diet of breastfeeding mothers as a belief of increased production of breast milk (39, 40).

Several studies have reported that receiving counseling on breastfeeding practices during the prenatal and postnatal period increases the likelihood that offspring will receive EBF (49). In fact, breastfeeding counseling is a WHO global recommendation to increase breastfeeding initiation rates and ensure EBF because this intervention strengthens individual interactions between health workers and mothers (either face-to-face or by telephone), and enables mothers to make appropriate infant feeding decisions (49). These interactions allow counselors to respond in a timely manner to challenges the mother may face during breastfeeding to ensure adequate EBF (49). In relation to birth order, in contrast to our finding, the biomedical literature mentions that the higher the birth order, the less likely mothers are to breastfeed their children, with the fourth child or higher in the order being approximately 20% less likely to be breastfed compared to the first (50). However, our finding could be attributed to the fact that mothers who have older children have higher levels of confidence about breastfeeding and perceive less problematic feeding behavior than first-time mothers (51, 52). In this sense, the creation of strategies that promote EBF should ensure a safe family environment, include indigenous mothers in educational programs while respecting their cultural traditions, and prioritize breastfeeding counseling in the prenatal and postnatal periods.

Based on the CC evaluated in the present study, it was found that EBF was concentrated among women with a poorer socioeconomic status. This finding is different from that described in studies conducted in Bangladesh, Nigeria, Norway, and the United States (11, 12, 53, 54), which reported that EBF was concentrated in women with a higher economic income. In accordance with the biomedical literature, there is a positive correlation between formal education and socioeconomic status (55). In LMIC, women with low levels of formal education are observed to have higher prevalences than their counterparts, which is related to a decrease in the inequality gap in nutrition and health between richer and poorer children (56). However, women who are richer in LMIC face challenges related to infant nutrition, with increased marketing and advertising of breast milk substitutes in health systems and other media having led to a decrease in EBF, especially in terms of the affordability of these products compared to women who are richer in LMIC (57, 58). Likewise, the decomposition analysis showed that the main contributors to the inequality gap between poorer and richer women were residing in the highland and jungle regions and belonging to the middle and rich wealth quintiles. According to the literature, most Peruvian women living in the highlands and jungle regions have low socioeconomic levels, which could be associated with low exposure to advertising and marketing of breast milk substitutes and where cultural practices increase EBF (26). In this sense, the existing inequality in EBF in Peruvian women is in agreement with that reported in LMIC and persisted even during the pandemic. In this regard, WHO considers that a key component of infant care is to ensure equitable access to breast milk for all infants regardless of the socioeconomic status of the mothers (59). Particularly in Peru, cultural practices should be considered as playing a relevant role in these inequalities and should be addressed when considering health policies.

Our findings have implications for public health. First, although the prevalence of EBF in Peru has reached the 70% recommended by the WHO for the year 2030, there are socioeconomic inequalities that define the higher prevalence of EBF in poorer women. This problem should be addressed through the promotion of EBF in all socioeconomic strata to ensure EBF in all Peruvian children and that the increase in prevalence is constant. Second, guidelines that ensure EBF should include the cultural traditions and language of indigenous women residing in the highlands and jungle of Peru in order to provide a multicultural approach to improve counseling on breastfeeding practices. Third, breastfeeding protection policies in the workplace should be a priority for government institutions, because these interventions promote and ensure EBF through individual, interpersonal and organizational interaction. Fourth, policies should be created to minimize the advertising and marketing of breast milk substitutes, especially among women who are able and unconstrained to breastfeed their infants. Finally, strategies that promote EBF should be in line with the World Breastfeeding Collective, which seeks to ensure breastfeeding in a period of crisis such as the current COVID-19 pandemic (60).

The present study has some limitations. Due to its cross-sectional nature, causality cannot be established between the study variables due to a lack of temporality in their measurement. In addition, there could be recall bias due to some data coming from events that have occurred in the past, as well as inaccuracy during data collection by the interviewer. By using secondary databases, some confounding variables that could have relevance when exploring EBF could have been omitted, such as women’s cultural practices, women’s nutritional status, father’s education, knowledge about breastfeeding, whether the child received oral rehydration salts, drops and syrups, social support from institutions or other variables related to COVID-19. Despite these limitations, this study is based on the analysis of a survey that is representative at the national level, by department and by urban and rural area, and its execution contains standardized procedures carried out by duly trained personnel, which ensure the quality and measurement of the information collected.

In conclusion, the prevalence of EBF in children aged 6–59 months was found to be 70.5%, being an adequate prevalence for the 70% recommended by the WHO for 2030. However, there are departments in Peru that have not reached this prevalence. Women who are natives, who live in the highlands and jungle, who received counseling on EBF and whose child was the second or older were more likely to perform EBF. Likewise, the CC showed that the EBF was concentrated among children whose mothers were poorer, while the inequality decomposition analysis found that the main contributors to inequality resided in the highland and jungle regions and belonged to the middle and rich wealth quintiles. In this sense, current strategies that promote EBF should prioritize the inclusion of the traditional practices of women, the protection of EBF in the workplace, the promotion of breastfeeding practices without considering the socioeconomic level of the woman and the regulation of inadequate commercialization of breast milk substitutes to achieve a similar percentage of EBF in all departments of Peru.

Publicly available datasets were analyzed in this study. This data can be found here: http://iinei.inei.gob.pe/microdatos/.

AH-V: conceptualization, data curation, formal analysis, investigation, project administration, software, and supervision. AH-V and RV-F: methodology, validation, visualization, and writing – original draft and review and editing. Both authors contributed to the article and approved the submitted version.