research hypothesis on exclusive breastfeeding

Disclaimer » Advertising

• HealthyChildren.org

• Previous Article
• Next Article

Milk Production and Transfer

Neonatal weight and output assessment, glucose stabilization, hyperbilirubinemia, immune development and the microbiome, supplementation, health system interventions: the baby-friendly hospital initiative, limitations and implications for future research, conclusions, acknowledgment, evidence-based updates on the first week of exclusive breastfeeding among infants ≥35 weeks.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• CME Quiz Close Quiz
• Open the PDF for in another window
• Get Permissions
• Cite Icon Cite
• Search Site

Lori Feldman-Winter , Ann Kellams , Sigal Peter-Wohl , Julie Scott Taylor , Kimberly G. Lee , Mary J. Terrell , Lawrence Noble , Angela R. Maynor , Joan Younger Meek , Alison M. Stuebe; Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks. Pediatrics April 2020; 145 (4): e20183696. 10.1542/peds.2018-3696

Download citation file:

• Ris (Zotero)
• Reference Manager

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks’ gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Exclusive breastfeeding significantly improves maternal and child health. Although US pediatricians’ recommendations are increasingly aligned with American Academy of Pediatrics (AAP) policies, their optimism about the potential for breastfeeding success has declined. 1   To maintain familiarity with the benefits of breastfeeding and the skills necessary to promote this positive health intervention, providers caring for neonates and/or new mothers need updated evidence-based information and tools to assess and manage breastfeeding.

In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, glucose stabilization, hyperbilirubinemia, immune development and the microbiome, supplementation, and health system interventions. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks’ gestation managed in the routine postpartum unit. 2 – 6     Tables 1 through 3 and Fig 1 provide summaries based on evidence and authors’ recommendations to provide concise and clear bullets on optimal management. The search strategy and tables of evidence for milk production and transfer, neonatal weight and output assessment, management of glucose, and hyperbilirubinemia are summarized in the Supplemental Information .

Breastfeeding Assessment During the First Postnatal Week

—, not applicable.

Mother, Infant, and Systems-Level Risk Factors for Breastfeeding Difficulties

Adapted from Evans A, Marinelli KA, Taylor JS; Academy of Breastfeeding Medicine. ABM clinical protocol #2: guidelines for hospital discharge of the breastfeeding term newborn and mother: “The going home protocol,” revised 2014. Breastfeed Med . 2014;9(1):4.

Risk Factors for Hypoglycemia

Adapted from Thornton PS, Stanley CA, De Leon DD, et al; Pediatric Endocrine Society. Recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children. J Pediatr . 2015;167(2):241 and Adamkin DH; Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics . 2011;127(3):576.

Supplementation decision algorithm.

Three stages of milk production, lactogenesis I to III, are defined on the basis of volume and composition of milk. For volume, Fig 2 shows estimated daily milk production. 16   In relation to composition, human milk changes dramatically over the first week of lactation. Colostrum, which is produced during the initial stage of lactation (lactogenesis I) in the first days after birth, contains more protein than mature milk. This highly dense early milk has a high concentration of immunoglobulins, activated macrophages, lymphocytes, neutrophils, and growth factors with essential roles in development of gut-associated lymphoid tissue. 17   As milk volume increases (lactogenesis II), sodium concentration and the sodium/potassium ratio decline rapidly with increased secretory activity of the lactocytes and closure of tight cellular junctions. 18   Production of fat-rich, higher-calorie mature milk typically occurs by ∼10 days post partum (lactogenesis III).

Milk volume estimated by breast milk transfer over the first 6 days in vaginal and cesarean births. *Adjusted difference P < .05. Adapted from Evans KC, Evans RG, Royal R, Esterman AJ, James SL. Effect of caesarean section on breast milk transfer to the normal term newborn over the first week of life. Arch Dis Child Fetal Neonatal Ed . 2003;88(5):F382.

Most, but not all, women experience lactogenesis II, referred to as “milk coming in,” by 72 hours post partum. In the Infant Feeding Practices Survey II, 19% of multiparous women and 35% of primiparous women reported milk coming in on day 4 or later. 19   Reasons for delayed lactogenesis II include primiparity, cesarean delivery, and BMI > 27. 20 – 22   Conditions associated with obesity, such as advanced maternal age (possibly related to reduced fertility associated with obesity-variant polycystic ovarian syndrome) and excessive gestational weight gain, may also lead to a delay. 23 , 24   Delayed lactogenesis II is associated with neonatal weight loss >10%. 20  

Occasionally, a woman does not experience lactogenesis II and only produces small volumes of milk (prevalence 5%–8%). 19 , 25   The differential diagnosis includes breast pathology, previous breast surgery (with damage to ducts or augmentation for hypoglandular breasts), developmental anomalies of the breast tissue, hormonal disruptions (such as retained placental fragments and pituitary insufficiency, including Sheehan’s syndrome, hypothyroidism, polycystic ovarian syndrome, or theca-lutein ovarian cysts), and toxins (such as excessive tobacco exposure). 26   Occasionally, strategies described here to improve milk production and transfer are not effective, and long-term supplementation with either donor milk or infant formula is medically necessary.

Milk expression is safely and effectively achieved by both manual and mechanical methods and can be used to maintain milk supply in the event of separation from the infant. 27   Hand expression also facilitates milk transfer for the infant learning to breastfeed; both latch and an effective suckling pattern are key. Among mothers of term infants who were feeding poorly, those randomly assigned to hand expression versus electric pumps were more likely to still be breastfeeding at 2 months (96.1% vs 72.7%; P = .02). 28   Infrequent or inadequate signaling due to ineffective or infrequent breastfeeding or milk expression may trigger the autocrine-paracrine mechanisms of halting milk production and dismantling the mammary gland architecture. 29   Milk removal, either via direct breastfeeding or expression, is essential for continuation of milk production.

Some women experience engorgement with lactogenesis II. There is limited evidence regarding the optimal management of engorgement. However, because severe engorgement can impede infant removal of milk, breastfeeding mothers should learn hand expression and reverse pressure softening, which is positive pressure to the central subareolar region, 30   before discharge from maternity care. 31 , 32   If a mother is unable to hand express or her infant is unable to latch, she may require a breast massage 33   and/or use of an electric breast pump.

The components of a comprehensive breastfeeding assessment are described in Table 1 . 12 , 34   It is important to note that a mother’s pumped milk volume may be an inaccurate estimate of milk transfer because transfer also depends on the infant’s capabilities. Associated risk factors for suboptimal milk transfer are listed in Table 2 .

Painful latching deserves special attention as a contributor to low supply, impaired milk transfer, and early cessation of breastfeeding. 35   In an ultrasound study in which breastfeeding mothers with nipple pain were compared with those without, nipple pain was associated with abnormal infant tongue movement, restricted nipple expansion, and lower rates of milk transfer. 36   In a retrospective audit of an Australian breastfeeding center, 36% of visits were for nipple pain. 37   A US study revealed that nipple pain and trauma were among the most frequently cited reasons for early weaning. In a study of >1600 women with singleton births, ∼10% had nipple pain that persisted at postpartum day 7; 72% was attributed to inappropriate positioning and latching, 23% to tongue-tie in the infant, and 4% to oversupply. Women who received treatment recovered within 1 to 2 weeks, and 6-week exclusive breastfeeding rates were no different from those of mothers without nipple pain. 38   Although high-quality randomized controlled trials (RCTs) are needed, frenotomy has been shown to reduce maternal nipple pain in infants with congenital ankyloglossia. 39   There is no evidence that any one topical treatment is superior 40   ; the mainstay of management for nipple pain and fissuring is assistance with positioning and latching. 41  

Healthy newborns experience physiologic weight loss after birth, 42 , 43   which, in the exclusively breastfed infant, typically plateaus as the mother’s milk transitions from lactogenesis I to lactogenesis II. The addition of infant formula, either as a supplement or in the form of exclusive formula feeding, is associated with rapid weight gain. This nonphysiologic weight trajectory is associated with childhood obesity. 44   Exclusive direct breastfeeding is inversely associated with the velocity of weight gain throughout the first year of life. 45   In one prospective cohort study of >300 newborns, weight gain >100 g during the first week after birth was independently associated with overweight status at age 2 (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.1 to 4.8). 44  

Early infant weight loss should be evaluated in the context of the clinical status of the infant and the mother. Nomograms for newborn weight have been developed by using data from >100 000 healthy, exclusively breastfed infants in California. 46   Individual infant weights can be plotted against these nomograms by using the Newborn Early Weight Tool (NEWT) ( https://www.newbornweight.org ). Weight loss trajectory over time, combined with clinical information, provides a robust context for evidence-based decision-making. 47   Weight loss in the >75th percentile on NEWT nomograms for mode of delivery and infant age should prompt a thorough evaluation.

A term newborn’s weight is 75% water, compared with 60% for an adult. Urine output is usually low in the first 1 to 2 days after birth, after which a physiologic diuresis and loss of up to 7% to 10% of birth weight occurs. 48 , 49   Insufficient milk production and/or transfer in the exclusively breastfed newborn can contribute to excessive weight loss in the first few days of life. Low milk supply, often exacerbated by poor feeding or difficulty in suckling, correlates with elevated milk sodium levels. 50   Exclusively breastfed infants, especially those born via cesarean delivery, are at increased risk for greater weight loss, dehydration, and hypernatremia. 51 , 52   In a systematic review of hypernatremia among breastfed infants, significant risk factors included weight loss >10%, cesarean delivery, primiparity, breast anomalies, reported breastfeeding problems, excessive prepregnancy maternal weight, delayed first breastfeeding, lack of previous breastfeeding experience, and low maternal education. 53   Prevention strategies included daily weights coupled with lactation support during the first 4 to 5 days after birth.

Early weight loss nomograms for exclusively breastfed newborns can help identify those infants at risk for hypernatremic dehydration (HD), 54 , 55   a rare condition characterized by lethargy, restlessness, hyperreflexia, spasticity, hyperthermia, and seizures, with an estimated incidence of 20 to 70 per 100 000 births and up to 223 per 100 000 births among primiparous mothers. 56   Use of charts for weight loss with SD scores specifically to detect HD, combined with a policy of weight checks on days 2, 4, and 7 of life, had high sensitivity (97%) and specificity (98.5%) to detect HD. 47   However, given the low incidence of HD, the positive predictive value (PPV) of repeated weight checks alone was only 4.4%. 56  

Importantly, elimination patterns during the first 2 days of life are neither sensitive nor specific as measures of infant intake. 49   Infants may be voiding and stooling despite insufficient intake or, more commonly, have decreased voiding and stooling compared with exclusively formula-fed infants despite adequate intake. In a cohort study of 313 infants, the frequency of urination and stooling was significantly decreased among exclusively breastfed infants compared with exclusively formula-fed infants during the first 3 days of life then rose and significantly surpassed that of exclusively formula-fed infants by day 6 of life. 49   Another prospective cohort study of 280 mother-infant pairs examined elimination patterns in relation to excessive weight loss (>10%) between 72 and 96 hours after birth. 48   The strongest association with weight loss >10% was with <4 stools after 72 hours or maternal perception of delayed lactogenesis II. Although term and late-preterm infants generally pass meconium within 48 hours (76%–83% in a study of 198 infants), delayed passage of meconium can be a marker for insufficient milk intake. 57   Correlations between infants’ intake and elimination are more reliable after the first 3 days (lactogenesis II).

To prepare for transitional energy needs, the third-trimester fetus stores glycogen, manufactures catecholamines, and deposits brown fat. Healthy newborns use these stores to maintain thermoregulation and meet their energy needs through metabolism of brown fat and the release of counterregulatory hormones such as glucagon, epinephrine, cortisol, and growth hormone. Combined with declining insulin secretion, these hormones mobilize glucose and alternative fuels, such as lactate and ketone bodies, to support organ functions. 58 , 59  

Because oral intake is not the main energy source for healthy term neonates in the first days after birth, physiologic volumes of colostrum (16 kcal/oz) are sufficient to meet metabolic demands. As glycogen stores are depleted, coinciding with the transition from colostrum to mature milk, newborns transition from a catabolic state to reliance on enteral feeds, with approximately half of the caloric content derived from fat. 60  

After placental detachment, neonatal glucose levels reach a physiologic nadir in the first hours after birth and then typically rise to adult levels a few days later. The threshold for neonatal glucose that is associated with neurotoxicity is unclear; a 2008 National Institutes of Health workshop concluded that “there is no evidence-based study to identify any specific plasma glucose concentration (or range of glucose values) to define pathologic hypoglycemia.” 61   In one cohort study, treatment of asymptomatic newborn hypoglycemia to maintain blood glucose levels >47 mg/dL had no effect on cognitive performance at 2 years; however, at 4.5 years, there were dose-dependent concerns regarding visual motor and executive function, with the highest risk in children exposed to severe (<36 mg/dL),and recurrent (≥3 episodes) hypoglycemia. 62 , 63  

In the first hours after birth, healthy term neonates compensate for relatively low glucose levels by decreasing insulin production and increasing glycolysis, gluconeogenesis, and ketone production. Among at-risk newborns, early skin-to-skin care plus early feeding and blood glucose assessment at 90 minutes supports glucose homeostasis and is associated with decreased risk of hypoglycemia and NICU admission. 64   In a Cochrane review, early skin-to-skin contact increased glucose levels by 10.49 (95% CI 8.39 to 12.59) mg/dL or 0.6 (0.5 to 0.7) mmol/L. 65   Conversely, practices that separate the mother and infant and delay the first feeding increase hypoglycemia risk.

Glucose monitoring is recommended for infants with risk factors ( Table 3 ) and for any infant who exhibits symptoms of hypoglycemia. 66   Because operational thresholds for treating hypoglycemia and target glucose levels are not defined, clinical recommendations vary. Infants who require early or more frequent feedings should be supported to breastfeed and/or receive expressed milk. Authors of multiple studies confirm the benefits of using glucose gel rather than formula as an initial treatment of low glucose levels, and this practice has become increasingly commonplace. 67 – 73   Some institutions use pasteurized donor human milk (PDHM) as a treatment of hypoglycemia; however, there are, as yet, no published studies describing outcomes of this practice. The option of antenatal milk expression for lower-risk women with preexisting or gestational diabetes may also be considered because this technique may preserve exclusive breastfeeding without adversely affecting perinatal outcomes. 74   Infants requiring intravenous glucose should breastfeed, when able, during the therapy.

Persistent or late-onset hypoglycemia (>48 hours after birth) can occur in the setting of congenital endocrine disorders or, more commonly, perinatal stress due to birth asphyxia, intrauterine growth restriction, maternal preeclampsia, 75   or persistent problems establishing breastfeeding. 76   Infants with these risk factors may be more vulnerable to insufficient feeding, so skilled assessment is essential.

Management of hyperbilirubinemia in the exclusively breastfed newborn depends on whether the excess in bilirubin is pathologic or physiologic. Neonatal bilirubin levels rise after birth because of physiologic immaturity of glucuronyl transferase, which is exaggerated with each decreasing week of gestational age. Exclusively breastfed infants have higher serum bilirubin levels than formula-fed infants, possibly because of differences in fluid intake and bilirubin excretion and increased enterohepatic resorption of bilirubin. 77   Some individuals may also have a genetic predisposition to higher bilirubin levels. 78 , 79   Bilirubin is an antioxidant, and it has been hypothesized that moderate increases in bilirubin levels may be protective for the transition to extrauterine life. 77 , 80  

In contrast, pathologic hyperbilirubinemia resulting from insufficient breastfeeding, sometimes referred to as breastfeeding jaundice, is better defined as suboptimal intake jaundice. 77   In the United States and Canada, it is recommended that all neonates undergo bilirubin risk screening at least once before hospital discharge. 81   The Academy of Breastfeeding Medicine and the AAP advise the use of Bhutani curves to assess risk and need for treatment of hyperbilirubinemia; clinical tools are available on mobile device applications. 77 , 81 , 82   This approach has led to a decrease in severe pathologic hyperbilirubinemia 83   ; however, concerns for overtreatment and the potential harm of phototherapy have arisen recently. 84   Using subthreshold bilirubin levels to initiate phototherapy as a mechanism to prevent readmission is not recommended because this approach increases length of stay and results in many infants receiving unnecessary treatment to reduce each case of readmission. 85  

Breastfed infants with hyperbilirubinemia require assessment of milk production and transfer, feeding frequency, and neonatal weight loss. 86 – 91   If there is pathologic hyperbilirubinemia, and infant intake at the breast is sufficient, exclusive breastfeeding should be continued while the infant receives phototherapy. Although supplementation with infant formula may decrease the bilirubin level and risk of readmission for phototherapy, 85   it will also interfere with the establishment and continuation of breastfeeding. 92   If intake at the breast is insufficient and supplementation is medically necessary, expressed maternal milk is preferred. Despite the current lack of data on its benefits in reducing hyperbilirubinemia in term infants, the use of PDHM to preserve exclusive human-milk feeding is increasing. 93  

Phototherapy for neonatal jaundice and concerns about insufficient milk can be anxiety provoking for parents, even in a supportive environment, and can be disruptive to successful breastfeeding. 94   Practices to minimize mother-infant separation, including providing phototherapy in the same room and maintaining safe skin-to-skin care with the infant’s mother, also promote exclusive breastfeeding. 95  

Early colostrum and exclusive breastfeeding establish an optimal and intact immune system. Unlike infant formula, human milk has a dynamic composition of both macro- and micronutrients that varies within a feed, diurnally, and over the course of lactation. Protective proteins abound in human milk, including lactoferrin, secretory immunoglobulin A, transforming growth factor-β, and α-lactalbumin. These factors promote development of the infant’s immune system. 96   Additionally, lactoferrin has unique antibacterial properties important in the prevention of sepsis. Unique nonnutritive oligosaccharides that are specific to the mother-infant pair’s shared environment and exposures prevent binding of pathogenic bacteria and promote a healthy microbiome in the gut. 97   Differences in immune cell distributions based on neonatal diet can be detected through 6 months of age, with natural killer cells most significantly affected. 98  

During vaginal birth, the newborn’s intestine and mucosal surfaces are colonized with maternal microbes that act synergistically with bioactive factors in mother’s milk to establish a robust lymphoid follicle replete with a healthy balance of T helper cells. 99 , 100   Surgical delivery is associated with aberrant colonization, which may lead to differences in the mother’s milk microbiome 101   only partially restored by vaginal secretions. 102   Formula supplementation may effect the most change in the newborn’s microbiome 103 , 104   and immune development. These basic science findings are supported by clinical studies.

Given the multiple mechanisms through which exclusive human milk impacts gut development, formula supplementation should always be avoided when the mother’s own milk is available. Although an exploratory study of early limited supplementation with extensively hydrolyzed formula followed by a return to exclusive breastfeeding did not reveal differences in the developing microbiome ( N = 15), 105   a longitudinal study among infants exclusively breastfeeding at 3 months ( N = 579) revealed alterations in the microbiome among infants exposed to formula as neonates ( n = 179). 106   Just as antimicrobial stewardship requires appropriate use of antibiotics, 107   supplementation stewardship requires judicious use of formula when medically indicated.

A systematic review of healthy, term, breastfed newborns revealed no benefit from routine supplementation with foods or fluids in the early postpartum period. 108   These findings are consistent with consensus recommendations for exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with the addition of complementary foods until at least 12 months of age. 2 , 109 – 111   Early introduction of supplemental formula is associated with a greater than twofold increase in risk of early cessation of breastfeeding even when controlling for confounding variables. 112 – 114   Among almost 1500 women in the Infant Feeding Practices Study II, only early exclusive breastfeeding remained significant for achieving intended breastfeeding duration (aOR 2.3; 95% CI 1.8 to 3.1) after adjustment for relevant hospital practices. 113   This finding may be due in part to the supply and demand nature of milk production and the role of suckling, oxytocin release, and milk removal in establishing lactation.

If supplemental feeds are medically indicated, they should be accompanied by manual or mechanical milk expression, recognizing that direct breastfeeding usually provides more complete milk removal. 115   In a pilot RCT ( N = 40), early limited formula supplementation for infants with ≥5% weight loss increased exclusive breastfeeding at 3 months post partum. 116   In a subsequent larger study ( N = 164), early limited supplementation did not affect overall breastfeeding at 1 or 6 months but slightly increased rates of formula use at 1 month (36.7% vs 22.4%; P = .08), 105   decreased breastfeeding at 12 months (30% vs 48%; risk difference −18% [CI −34% to −3%]), and shortened the time to breastfeeding cessation (hazard ratio 0.65; 95% CI 0.43 to 0.97). 117  

Because evidence continues to accrue that supplementation in the first days after birth has major health risks, 103 , 106   judicious use of supplementation is a critical goal, with a return to exclusivity whenever possible. If supplementation is indicated ( Fig 1 ), options in order of preference are (1) expressed milk from the infant’s own mother, 4   (2) PDHM, and (3) commercial infant formulas. The potential risks and benefits of these options should be considered in the context of the infant’s age, the volume required, and the impact on the establishment of breastfeeding. 4  

Methods of supplemental feeding include spoon or cup feeds, supplemental nursing systems, syringe feeds, and paced bottle feeds. Methods should be tailored to staff training and family preferences. 7   Among late-preterm newborns, there is evidence that some may be more susceptible to feeding problems when supplemented via a bottle; in an RCT in which the 2 methods were compared, cup feeding was associated with a longer duration of exclusive breastfeeding compared with bottle-feeding. 118   Among term newborns, the manner in which supplementation is delivered, whether a bottle or alternative devices, has no apparent impact on continuation of breastfeeding. 119   If the supplement is the mother’s own expressed milk, avoidance of bottles and nipples may preserve a longer duration of breastfeeding, especially among late-preterm newborns. 120  

To ensure milk removal, which is key to establishing a milk supply, a mother should be assisted to express milk each time her infant is supplemented, even if the infant is also “practicing” at the breast. 4   “Hands on” pumping, combining breast massage with pumping, has been shown to increase milk production in mothers of preterm infants who are hospitalized. 121  

Physiologic early infant feeding is facilitated by keeping mothers close to their infants, beginning with skin-to-skin care immediately after birth and continuing with 24-hour rooming-in and feeding on cue. These are core practices of the recently updated World Health Organization’s Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative (BFHI). 7   Feeding on cue or “responsive feeding” is associated with more frequent breastfeeding throughout the day, more exclusive breastfeeding up to 6 months and beyond, 122 – 124   and decreased likelihood of abnormal rapid weight gain in infancy. 125  

Several major health organizations, including the US Preventive Services Task Force and the Agency for Healthcare Research and Quality, have generated systematic reviews and quality improvement (QI) reports that demonstrate the positive impact of the BFHI on breastfeeding outcomes. 10 , 13 , 14   Implementation of maternity care practices aligned with any component of the BFHI is associated with improved in-hospital and postdischarge breastfeeding rates. 11 , 13 , 126   Best Fed Beginnings increased exclusive breastfeeding initiation from 39% to 61% ( t = 9.72; P < .001) at 89 hospitals over 2 years. 127   The Community and Hospitals Advancing Maternity Care Practices initiative reported that the BFHI helped to reduce racial disparities in breastfeeding in southern US states. 128  

Since the initial implementation of the BFHI, safety concerns have emerged, including case reports of inadvertent bed-sharing, suffocation, falls, and increased risk of neonatal jaundice. 3 , 129   In this context, the World Health Organization conducted an extensive evidence-based review. 7 , 130   Key differences in the revised Ten Steps include highlighting the Code of Marketing of Breastmilk Substitutes, the need to collect ongoing data, a focus on safety and surveillance (especially as it relates to skin-to-skin care and rooming-in), and acknowledgment that there is insufficient evidence to limit pacifiers and other artificial nipples.

Step 10 of the BFHI requires a direct connection between the delivery hospital and the community for ongoing support. Referral for outpatient support as well as provision of contact information for those who can manage breastfeeding problems is paramount.

Given the importance of exclusive breastfeeding for maternal and child health, both intent and initiation are increasing. However, maternal conditions linked with delayed lactogenesis, such as advanced maternal age, obesity, and fertility treatment, are increasingly common. Priority research areas to help families meet their breastfeeding goals include accurate identification of women with risk factors for delay or absence of lactogenesis, more sensitive methods of identifying at-risk newborns, and exploration of the implications of early limited formula supplementation on infant outcomes such as ontogeny of the immune system and the microbiome, maternal self-efficacy, and continued breastfeeding.

Health care professionals’ support is critical for families to meet their infant feeding goals and achieve optimal health outcomes. All physicians who care for new mothers and infants need skills to evaluate early breastfeeding, perform maternal and infant risk stratification, understand the range of potential interventions in the context of the risk/benefit ratio of supplementation, and ensure appropriate follow-up.

Most mothers can produce adequate colostrum and mature milk, and most newborns are able to breastfeed exclusively. Nevertheless, conditions that require medical supplementation are common and important to recognize. The decision to supplement with infant formula requires thoughtful analysis of the risks and benefits, with consideration of the family’s informed choice. Early-term and late-preterm newborns are at a higher risk of complications. Therefore, more careful monitoring, detailed assessments, and case-based interventions are warranted. Further research is needed to identify the best methods to support exclusive breastfeeding in high-risk populations.

We thank Delali Lougou for organizing the articles used in this article to provide the original framework for the authors’ review.

Drs Feldman-Winter, Kellams, and Stuebe conceptualized and designed the review of the literature, conducted the literature review and analysis, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Peter-Wohl made substantial contributions to the acquisition of data and to the analysis and interpretation of data, drafted the article, and revised it critically for important intellectual content; Dr Taylor made substantial contributions to conception and design and made critical revisions; Drs Lee and Terrell made substantial contributions to the design and to the acquisition of data and made critical revisions for important intellectual content; Drs Meek and Noble and Ms Maynor made substantial contributions to the conception, design, and analysis and interpretation of data and revised the article critically for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

American Academy of Pediatrics

adjusted odds ratio

Baby-Friendly Hospital Initiative

confidence interval

hypernatremic dehydration

Newborn Early Weight Tool

pasteurized donor human milk

positive predictive value

quality improvement

randomized controlled trial

Competing Interests

Supplementary data.

Advertising Disclaimer »

Citing articles via

Email alerts.

Affiliations

• Editorial Board
• Editorial Policies
• Journal Blogs
• Pediatrics On Call
• Online ISSN 1098-4275
• Print ISSN 0031-4005
• Pediatrics Open Science
• Hospital Pediatrics
• Pediatrics in Review
• AAP Grand Rounds
• Latest News
• Pediatric Care Online
• Red Book Online
• Pediatric Patient Education
• AAP Toolkits
• AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations, advertising.

• Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
• © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Exploring the determinants of exclusive breastfeeding among infants under-six months in Ethiopia using multilevel analysis

Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Department of Public Health, Dessie Health Science College, Dessie, Ethiopia

Roles Formal analysis, Investigation, Methodology, Software, Writing – original draft, Writing – review & editing

Affiliation Department of Nutrition, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Affiliation Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

• Shambel Aychew Tsegaw, 
• Yeshimebet Ali Dawed, 
• Erkihun Tadesse Amsalu

• Published: January 13, 2021
• https://doi.org/10.1371/journal.pone.0245034
• Peer Review
• Reader Comments

Introduction

Exclusive breastfeeding (EBF) is the safest and healthiest option of feeding among infants in the first 6 months throughout the world. Thus, the promotion of EBF is essential to prevent complex infant health problems even at the adulthood level. But the majority of previous studies focused on individual- level determinants of EBF by using basic regression models in localized areas. This study aimed to identify the determinants of EBF at the individual and community level which would be helpful to design appropriate strategies for improving the practice of EBF.

It is a secondary data analysis using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total of 1185 infants under 6 months of age were included in the analysis. A Multilevel logistic regression model was employed to investigate factors significantly associated with EBF among under-six infants in Ethiopia. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to measure the association of variables whereas Intracluster correlation (ICC), median odds ratio (MOR), and proportional change in variance (PCV) were used to measure random effects (variation).

In multilevel logistic regression; 4–5 months age infant (AOR = 0.04, 95%CI:0.02–0.07), female infants (AOR = 2.51, 95%CI:1.61–3.91), infant comorbidities (AOR = 0.35, 95%CI: 0.21–0.57), richest household wealth index (AOR = 10.34, 95%CI: 3.14–34.03) and antenatal care (AOR = 2.25, 95%CI:1.32–3.82) were individual- level determinants significantly associated with exclusive breastfeeding. Whereas, contextual region (AOR = 0.30, 95%CI: 0.10–0.87), community- level of postnatal visit (AOR = 2.77, 95%CI: 1.26–6.58) and community -level of maternal employment (AOR = 2.8, 95%CI: 1.21–6.47) were community level determinants significantly associated with EBF. The full model showed that46.8% of the variation of exclusive breastfeeding was explained by the combined factors at the individual and community levels. Similarly, it showed that the variation in exclusive breastfeeding across communities remained statistically significant (ICC = 8.77% and variance = 0.32 with P<0.001).

Conclusion and recommendation

Our study showed that both individual and community level determinants were significantly associated with EBF practice among under 6 infants. Based on our findings, it is recommended to promote and enhance antenatal and postnatal care services utilization of mothers to improve exclusive breastfeeding practice and more emphasis should be given to infants with comorbid conditions and those who were living in the pastoralist regions.

Citation: Tsegaw SA, Ali Dawed Y, Tadesse Amsalu E (2021) Exploring the determinants of exclusive breastfeeding among infants under-six months in Ethiopia using multilevel analysis. PLoS ONE 16(1): e0245034. https://doi.org/10.1371/journal.pone.0245034

Editor: Mohammad Rifat Haider, Ohio University College of Health Sciences and Professions, UNITED STATES

Received: July 28, 2020; Accepted: December 8, 2020; Published: January 13, 2021

Copyright: © 2021 Tsegaw et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: AIC, Akaike Information Criteria; ANC, Antenatal Care; BF, Breast Feeding; BIC, Bayesian Information Criteria; CI, Confidence Interval; CSA, Central Statics Agency; DIC, Deviance Information Criteria; EBF, Exclusive Breast Feeding; EDHS, Ethiopian Demographic and Health Survey; EFMoH, Ethiopian Federal Ministry of Health; ICC, Intracluster Correlation; ICYF, Infant and Young Child Feeding; MCH, Maternal and Child Health; MOR, Median Odds Ratio; PCV, Proportional Change in Variance; PNC, Postnatal Care; VIF, Variance Inflation Factor

All necessary nutrients essential for survival, growth, and development, as well as immunologic, antimicrobial, and anti-inflammatory factors, are obtained from breast milk for the first six months of life [ 1 , 2 ]. The World Health Organization (WHO) defines exclusive breastfeeding (EBF) as when ’an infant receives only breast milk, no other liquids or solids are given not even water, except for oral rehydration solution, or drops/syrups of vitamins, minerals or medicines [ 3 , 4 ]. World Health Organization recommends EBF for the first six months of life, followed by continued breastfeeding with appropriate complementary foods until two years and above [ 5 ]. Breastfeeding reduces the risk of acquiring gastrointestinal (GIT) and respiratory tract infections. In later life, it also helps to prevent the risk of developing breast and uterine cancer, obesity, osteoporosis, and type 2 diabetes mellitus [ 4 , 6 , 7 ].

Globally, in 2017 around 41% of under-six infants were exclusively breastfed [ 8 ]. In low and middle- income countries, about 37% of infants were exclusively breastfed [ 7 ]. Studies also reported the magnitude of exclusive breast feeding ranged from 19% to 65% in the African context [ 9 – 12 ].

In the globe, more than 1.4 deaths were reported due to non-exclusive breastfeeding in the first six months of life where 41% in SSA (sub-Saharan Africa) and 34% in South Asia (SA) [ 3 , 5 , 8 ].

Improved breastfeeding practices can save about 1.5 million infants each year [ 8 ]. EBF can prevent up to 61% and 63% of admission secondary to pneumonia and diarrheal diseases respectively. It can also decrease type 1 diabetes [ 6 ].

Breastfeeding education and information during antenatal and postnatal visits were methods to improve EBF [ 13 ]. Besides, implementation of international code of breast milk marketing substitutes, community- based promotion and support, advocacy, and training were also strategies to enhance EBF practices [ 1 ].

Even if the government of Ethiopia tried to promote and implement EBF practice for infants under- six months of age but still there is a poor improvement [ 14 ]. This could be due to several contributing factors including the low level of educational status, maternal employment, operative delivery, late initiation of breastfeeding, low antenatal and postnatal visits, increased production of formula foods, and poor counseling of mother regarding EBF [ 10 , 15 – 18 ]. Furthermore, EBF practice was influenced by community- level factors including place of residence, contextual region, community level of maternal education, community level of ANC and PNC utilization, community- level of employment, and community level of media exposure [ 19 – 21 ].

Despite studies on exclusive breastfeeding practice were done in Ethiopia, most of them were focused on individual level factors using a basic logistic regression model covering limited areas with a small sample size [ 15 – 21 ]. But EBF practice was influenced by both individual and community- level factors since the behavior of individual towards EBF practice are not only attributed by individual factors but also by community- level factors and individual infants were nested within the communities. The independence assumption among individuals within the same cluster and the equal variance assumption across clusters are violated in the case of nested data. As EDHS data has a hierarchical nature and violate the independent assumption of basic logistic regression, considering clustering effect is preferred. Thus, the current study aims to identify the determinants of EBF practice both at the individual and community level among infants undersix months of age using multilevel logistic regression analysis.

Study setting

This study was done in Ethiopia, which is located in the North- Eastern part of Africa. Contextually, the country is categorized as agrarian, pastoralists, and city based population. It has a total of 104,957,000 populations, of which 36,296,657 were women [ 22 ]. The Majority of the population, 83.6% living in rural areas, and 16.7% of the population reside in urban areas. The average household size at the national level is 4.7 persons [ 14 , 23 ]. The country has a fertility rate of 4.6, infant mortality rate (per 1,000 live births) of 48, and child mortality rate (per 1,000 live births) of 67 [ 14 ].

Data source and population.

This study used data from the 2016 EDHS (Ethiopia Demographic and health survey) which was conducted from January 18 to June 27, 2016. Thus, a community- based cross-sectional study was employed to identify individual- level and community- level factors affecting exclusive breastfeeding among under-six month infants [ 14 ].

The source population for this study was all infants undersix months of age living in Ethiopia and all infants undersix months of age in the selected enumeration areas during the data collection period were the study population. Accordingly, a total of 1185 infants under six months of age who fulfill the eligibility criteria were included in the study using a stratified two stage cluster sampling technique. Enumeration areas (EAs) and households were the primary and secondary sampling units respectively. The detailed sampling procedure was published elsewhere [ 14 , 24 ].

We extracted the outcome and explanatory variables from the EDHS 2016 kids data after getting permission from Measure DHS International Program. A structure and pretested questionnaire was used for data collection during the survey. Comprehensive information about the 2016 EDHS data collection procedure has been published elsewhere [ 14 , 24 , 25 ].

Variables of the study and operational definition.

The outcome variable of the study was Exclusive Breastfeeding (EBF) among under-six month infants in Ethiopia. Infant related variables (Age of the infant, sex of the infant, birth order, birth weight, birth interval, infant comorbidities, and time of breastfeeding initiation), maternal socio-demographic variables (age of the mother, marital status, educational status of the mother, occupational status of the mother, household wealth index, media exposure, number of underfive children, and household family size), and Obstetric and Healthcare associated variables (ANC utilization, PNC utilization, place of delivery, mode of delivery, delivery assistance, and parity) were individual- level predictors of the study. Also, community -level variables included in the study were place of residence, contextual region, community media exposure, community wealth index, community women education, community ANC utilization, community level of employment, and community PNC utilization.

The World Health Organization (WHO) defines exclusive breastfeeding (EBF) as when ’an infant receives only breast milk, no other liquids or solids are given not even water, except for oral rehydration solution, or drops/syrups of vitamins, minerals or medicines [ 4 ]. It was measured using a 24-hour recall among mothers with infants under 6 months of age [ 4 ].

In this study, infant comorbidities were generated by aggregating variables (diarrhea, cough, fever, and shortness of breath of infants under six months of age) in the last two weeks preceding the survey, subsequently if at least one of the comorbid was found the response coded as “Yes” otherwise the response coded as “No. The occupational status of the mother was generated by using the occupation of the respondent and categorized as currently working (includes all types of work) and currently not working.

Community -level variables were generated by aggregating the individual characteristics in a cluster since EDHS did not collect data that can directly describe the characteristics of the clusters except the place of residence. The aggregates were computed using the proportion of a given variables’ subcategory. Since the aggregate value for all generated variables not normally distributed, it was categorized into groups based on the national median values and based on previous related studies [ 24 , 25 ].

Community ANC utilization was the proportion of mothers within specific cluster who visited ANC some number of times. It was categorized using national level quartiles in to low ANC utilized community (when≤25% of women are utilizing ANC), middle (when 25–75% of women are utilizing ANC), and high (when >75% of women are utilizing ANC) [ 25 ].

The Community level of PNC utilization was the proportion of women within specific cluster who visit PNC some number of times. It was categorized as low (when≤50% of women utilized PNC) and high (when>50% of women utilized PNC) [ 25 ].

Community- level of media exposure was an aggregate respondent level of exposure for different types of media categorized as “<25% = Low”, “25%-50% = Moderate” and “>50% = high media utilized communities” [ 25 ].

Community level of poverty was an aggregate wealth index categorized as “<25% = High”, 25%-50% = Moderate” and “>50% = Low poverty communities” [ 25 ].

Contextual region Ethiopia is demarcated for administrative purpose into 11 regions, which are classified as an agrarian, pastoralist, and city based according to the living status of the population. The regions Tigray, Amhara, Oromia, SNNP, Gambella, and Benshangul Gumuz were categorized as agrarian. Somali and Afar regions were grouped to form pastoralist region and Harari region, Addis Ababa and Dire Dawa city administrations were grouped to form city- based populations [ 14 , 25 ].

Community- level of women education was the proportion of women in the community who have primary or higher education, which was categorized as low (when≤25% of women were educated), middle (when 25–75% of women were educated), and high (when >75% of women were educated) [ 25 ].

Community level employment status was the proportion of women who were employed (had to work) in the specific cluster. It was categorized as low (when≤50% of mothers were employed) and high (when>50% of mothers were employed) [ 24 , 25 ].

Data management and analysis.

Sample weight was done to compensate for the unequal probability of selection between the strata that were geographically defined, as well as for non-responses. Weighing of individual interview produces the proper representation of exclusive breastfeeding and related factors. Coding, recoding, and exploratory analysis was performed. Categorization was done for continuous variables using information from different works of literatures and re-categorization was done for categorical variables accordingly. For data analysis, STATA version 14.1 was used and descriptive statistics were used to present frequencies, with percentages in tables and using texts.

Four models were considered in the multilevel analysis to determine the model that best fits the data; Model one (Null model) without explanatory variable was developed to evaluate the null hypothesis that there is no cluster level difference in exclusive breastfeeding practice that specified only the random intercept and it presented the total variance in exclusive breastfeeding practice among clusters. Model two adjusted for an individual variable which assumes a cluster level difference of EBF practice is zero. Model three to evaluate community level factors by aggregate cluster difference of exclusive breastfeeding practice. Model four included both adjusted individual and community level factors.

Where, i and j are the level 1 (individual) and level 2 (community) units, respectively; X and Z refer to individual and community-level variables, respectively; πij is the probability of exclusive breastfeeding for the i th infant in the j th community; the β’s is the fixed coefficients. Whereas, β0 is the intercept-the effect on the probability of exclusive breastfeeding use in the absence of influence of predictors and uj showed the random effect (effect of the community on exclusive breastfeeding) for the j th community, and eij showed random errors at the individual levels. By assuming each community had a different intercept (β0) and fixed coefficient (β), the clustered data nature and the within and between community, variations were taken into account.

Multilevel logistic regression analysis was used to analyze the data since it is appropriate for DHS data as it had a hierarchical nature. Multilevel modeling was providing unexplained variation in exclusive breastfeeding due to unobserved cluster factors called the random effect. All models included a random intercept at the cluster level to capture the heterogeneity among clusters.

The measures of association (fixed-effects) estimate the association between likelihood of infants to exclusively breastfeeding as the AOR with 95% CI of various explanatory variables were expressed. Crude association between independent variables and the dependent variable was done independently and variables having p ≤0.2 in Bi-variable analysis were used to fit multivariable analysis model. At multivariable analysis,variables with p≤0.05 with confidence interval not including the null value (OR = 1)were considered as statistically significant variables with exclusive breastfeeding practice.

In this study, MOR shows the extent to which the individual probability of being exclusively breastfed is determined by residential area. The proportional change in variance [PCV = ( VA − VB )/ VA ) * 100] where VA = Variance of initial model and VB = Variance of model with more terms measures the total variation attributed by individual level and community level factors in the multilevel model [ 26 ]. PCV was computed for each model concerning the empty model as a reference to show power of the factors in the model explains exclusive breastfeeding practice.

Log- likelihood test, Deviance Information Criteria (DIC), and Akaike Information Criteria (AIC) were used to estimate the goodness of fit of the adjusted final model in comparison to the preceding models (individual and community level models). Thus, the model with the highest value of Log likelihood test and with lowest values of DIC and AIC was considered to be the best fit model.

Ethical consideration.

Ethical clearance was obtained from the Ethical Review Committee of the College of Medicine and Health Sciences, Wollo University with approval and supporting letter. Permission to access the data set was obtained from the Measure DHS International Program. The data was only used for purpose of this study and not shared with a third party. All data used in this study were anonymous publicly available and aggregated secondary data with not having any personal identity. The data was fully available on the full DHS website ( www.measuredhs.com ).

Infant characteristics

A total of 1092 infants under six months of age were included in the 2016 EDHS survey. But after weighting the sample size became 1185, and all of them were included in the analysis. The mean age of respondents was 2.54 months (SD ± 0.51). The highest proportion of infants, about 418(35.26%) were in the age group of 4–5 months and 605(51.07%) were females. Regarding breastfeeding initiation majority, about 817 (68.95%) of the infants have initiated breastfeeding immediately after birth ( Table 1 ).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0245034.t001

Maternal socio-demographic and socioeconomic factors

Among 1185 infants under six months in the 2016 EDHS survey, the highest proportion, about 573 (48.41%) of the mothers were in the age group of 25–34 years old. Regarding the educational status of the mothers, more than half, 698(60.9%) of them had no formal education. Similarly, the majority of mothers, about 1141(96.3%) of them were in a marital union at the time of the survey.

More than half of mothers about, 738(62.28%) of them were not working and about 781(65.91%) of them had no media exposure about exclusive breastfeeding. The highest proportion of mothers, about 291(24.56%) of them were from the poorest household wealth index ( Table 2 ).

https://doi.org/10.1371/journal.pone.0245034.t002

Obstetric and healthcare -related factors

Regarding antenatal care visit the majority, about 770(64.95%) of mothers had ANC visits. Similarly, more than half of mothers, about 732(61.8%) of them were delivered at home. About 35 (2.95%) of mothers were delivered by caesarian section and more than half of mothers 74(6.23%) had PNC visit in the last 2 months before the survey ( Table 3 ).

https://doi.org/10.1371/journal.pone.0245034.t003

Community -level factors

In our study, most of the respondents, about 1048(88.44%) of them were rural residents and about 1086(91.66%) of them were from agrarian regions. The highest proportion, about 495(41.77%) of respondents were from low poverty level of the community and about 840(70.89%) of them had low community media utilization. Regarding community postnatal care utilization, 1168 (98.56%) of the mothers had low community postnatal care utilization. Similarly, the majority of the mothers, about 840 (70.85%) and 838(70.73%) belong to low community educational level and low community employment status respectively ( Table 4 ).

https://doi.org/10.1371/journal.pone.0245034.t004

Determinants of exclusive breastfeeding practice

Fixed effects (measures of association)..

Bi-variable multilevel logistic analysis computed and p-value up to 0.2 was selected to fit the multi-variablemultilevel logistic regression model to control confounding. Accordingly, Age of infant, sex of infant, birth weight, birth interval, birth order, infant comorbidities, breastfeeding initiation, marital status, maternal occupation, maternal education, household family size, number of under-five children, wealth index, parity, ANC visit, caesarian delivery, PNC visit, residence, contextual region, community ANC utilization, community PNC utilization, community media exposure, community level of poverty, community level of employment status and community level of women education pass Bi-variable multilevel logistic regression model at p- value≤ 0.2.

Four models were fitted hierarchically in this multi-level logistic regression analysis. Model one or Null model (without predictors), model two (only individual- level factors), model three (only community- level factors) and model four (both individual and community level factors). Finally, p-value ≤ 0.05 and odds ratio not including the null value (OR = 1) was used to select variables that had a statistically significant association with exclusive breastfeeding practice in the final model.

As shown in Table 5 below, our study finding showed that age of infants, sex of infants, infant comorbidities, wealth index, antenatal care visit, contextual region, community postnatal care visit, and community level of employment status were statistically significant determinants of exclusive breastfeeding in the final model.

https://doi.org/10.1371/journal.pone.0245034.t005

The age of the infant was negatively associated with exclusive breastfeeding. Those infants whose age group was between 2–3 months were 60.9% [AOR = 0.39, 95% CI: (0.23, 0.65)] and 4–5 months were 95.8% [AOR = 0.04, 95% CI: (0.02, 0.07)] less likely to exclusive breastfeed as compared to infants whose age was up to one month.

The sex of the infant was significantly associated with exclusive breastfeeding. Female infants were 2.5 [AOR = 2.51, 95% CI: (1.61, 3.91)] times more likely to exclusively breastfeed as compared to male infants.

Infant comorbidities were negatively associated with exclusive breastfeeding. Those infants who had comorbidities were 66% [AOR = 0.34, 95%CI: (0.21, 0.57)] less likely to exclusively breastfeed as compared to infants who had no comorbidities.

Household wealth index was positively associated with exclusive breastfeeding. Those infants from the richest family wealth index were 10 times [AOR = 10.34, 95% CI: (3.14, 34.03)] more likely exclusive breastfeeding as compared to those infants from the poorest family wealth index.

The maternal antenatal visit was also positively associated with exclusive breastfeeding. Those infants whose mothers had ANC visits were 2.25 times [AOR = 2.25, 95%CI: (1.323, 3.82)] more likely to exclusively breastfeed compared to those infants whose mothers had no ANC visits.

The contextual region was significantly associated with exclusive breastfeeding practice. Consequently, infants who live in pastoralist regions were 70% less likely to exclusively breastfeeding [AOR = 0.30, 95% CI: (0.104, 0.86)] as compared to those infants who live in the agrarian regions.

Community level postnatal care utilization was significantly associated with EBF. As a result, those infants who live in community who had high level of PNC utilization were 2.8 [AOR = 2.77, 95% CI: 1.26, 6.58)] times more likely to exclusively breastfeed compared to infants who live in the community who had a low level of PNC service utilization.

Community level employment status was positively associated with exclusive breastfeeding practice. Thus, infants who live in a community with a high level of employment were 2.8 [AOR = 2.81, 95% CI: (1.20, 6.47)] times more likely to exclusively breastfed compared to those infants who live in a community with a low level of employment.

Random effects (Measures of variation).

This study also aimed to show if the characteristics of the clusters where under six infants resided would affect exclusive breastfeeding practice.A Model with the lowest DIC, the lowest AIC, and the highest log- likelihood ratio was selected which was model four that better explain exclusive breastfeeding practice. At the empty model, the ICC was 0.141 (ICC>5%) and the variance was 0.54 with 95% CI: 0.25–0.75) at a p-value of <0.001, which indicates about 14.1% of the variation in exclusive breastfeeding was linked to community-level factors and there was a significant variation in exclusive breastfeeding practice across the communities (clusters).

The full model, after adjusting for individual and community level factors, showed that the variation in exclusive breastfeeding across communities remained statistically significant (ICC = 8.77% and variance = 0.32).

In this study, the full model showed up with higher PCV (46.8%); that is, 46.8% of variation of exclusive breastfeeding was explained by the combined factors at the individual and community levels. The median odds ratio of the null model (MOR = 2.01) and the final model (MOR = 1.71) were significant. The MOR at a cluster where a high proportion of nonexclusive breastfeeding was 2.01 times higher compared to a cluster with a low proportion of non- exclusive breastfeeding at the null model, whereas the MOR at a cluster where a high proportion of non-exclusive breastfeeding was 1.71 times higher compared to a cluster with a low proportion of non-exclusive breastfeeding at the final model. This indicates that 0.3 (30%) of the heterogeneity was explained by both individual and community level factors, but still there are a residual effect not explained by individual and community level variables at the final full model (MOR = 1.71) ( Table 6 ).

https://doi.org/10.1371/journal.pone.0245034.t006

The age of the infant was negatively associated with exclusive breastfeeding. This finding was similar with studies done in Bahr- Dar, Hawassa, Jigjiga, Zimbabwe, and India [ 19 , 20 , 25 , 28 , 29 ]. The possible justification could be as the age of the infant increases mothers initiate additional food due to the perception that breast milk alone is not enough to meet the water and nutritional demands of their infants. Another possible explanation may be related to the perception of mothers that breast milk production decreased through time which is not sufficient for the growth of the infant. In addition, it could be related to poor knowledge of mothers about the importance of EBF and the adverse consequences of initiation of complementary feeding before six months of age. Furthermore, employed mothers returned to their work as the age of the infant increases which have no enough time to exclusive breastfeeding their infants [ 19 , 20 , 25 , 28 ].

The sex of the infant was also one of the individual level factors significantly associated with exclusive breastfeeding. Being female infants was positively associated with exclusively breastfeeding. The finding was consistent with studies done in Kenya, Cameroon, Angola, and Ghana [ 10 , 30 – 32 ]. The study showed that female infants were more likely to be exclusively breastfed compared to male infants i.e. male infants were more likely to start complementary feeding earlier compared to females. This may be related with the perception that breast milk alone does not meet their nutritional requirements and the belief that male infants have a more voracious appetite and needs additional food intake than female infants that leads the early initiation of complementary foods for male infants. The other reason may be the belief that female infants were considered as good breast suckers so breast milk alone may be enough to satisfy their feeding requirement so that additional feeding may not be initiated early [ 10 , 30 , 33 ].

Infant comorbidity was negatively associated with exclusive breastfeeding. This is concurrent with studies done in Bahr-Dar [ 34 ] and Egypt [ 9 ] that showed infants with comorbidities were less likely to be exclusively breastfed compared to healthy infants. The possible justification might be when the infant became sick; mothers may perceive that an additional diet is essential to boost the energy and immunity of the infant. Furthermore, they may perceive additional foods may also be used as a treatment option for the sick infant [ 9 ]. This implies that close follows up of the sick infant is essential to improve EBF practice.

Similarly, household wealth index showed a positive association with EBF. This is similar with studies done in Ghana, India, and Australia [ 17 , 20 , 35 ]. The possible reasons may be increased uptake of breastfeeding related information and better skills in negotiating flexible workplace hours even can stay at home that creates opportunities for exclusive breastfeeding [ 20 ]. Similarly, the low practice of EBF among the poorest wealth index could be related to poor awareness of EBF practice, stressful living situation to overcome the hardship of living. In addition, it can also be suggested that mothers from the poorest wealth index group might consider themselves as producing inadequate breast milk to satisfy their infant’s demand that makes them initiate additional foods [ 17 ]. Thus, mothers in the richest wealth index families do not need to go work during lactation so they have enough time to breastfeed their infants [ 36 ].

Among individual level factors, maternal antenatal care visit was also positively associated with EBF. This finding was concurrent with studies done in India, Ghana, and different parts of Ethiopia [ 17 , 19 – 21 , 30 , 37 ]. The possible justification could be that antenatal visit is the appropriate time for breastfeeding education and information that may improve EBF later after the birth of the infant. Accordingly, breastfeeding counseling during antenatal periods significantly improves exclusive breastfeeding practice [ 19 , 25 , 37 ]. This implies that antenatal care coverage must be enhanced accordingly to improve EBF practice.

The contextual region, community level of PNC utilization, and community level of employment status were community level determinants of exclusive breastfeeding practice among infants under six months of age in Ethiopia.

In this study, contextual region was significantly associated with EBF practice. Infants who live in pastoralist regions were less likely to exclusive breastfeeding as compared to infants found in agrarian regions. The regional variation of exclusive breastfeeding was also observed in previous studies in Ghana [ 17 ] and Malawi [ 38 ]. The variation in this study could be related that pastoralists were not well informed about the importance of exclusive breastfeeding due to the weak health care system and low women empowerment in the area. In addition, pastoralists have a mobile type of life style so they might not give attention to EBF of their infants rather they may initiate cow milk early [ 25 ]. Furthermore, there may be regional differences in some background characteristics such as culture, religion, living condition, availability and accessibility of maternal and child health services.

Community level postnatal care utilization was positively associated with EBF practice. This finding was concurrent with studies done in India, Ghana, and different parts of Ethiopia [ 16 , 17 , 19 , 37 , 39 ]. The possible explanation may be that postnatal care utilization is the best opportunity to increase the knowledge and attitude of mothers towards exclusive breastfeeding through counseling and health education since it is the appropriate period of counseling and educating mothers about essential feeding practices including EBF. Thus, as the number of women who visited postnatal care in the community increases the more likely to practice exclusive breastfeeding [ 18 , 19 ].

In the current study, the community level of maternal employment status was positively associated with EBF practice. This may be due to the reason that the employed community was at a higher educational level that lead them to have good information exchange about benefits of EBF through different media. In addition, an arrangement of breastfeeding time for the employees was one of the alarming mechanisms that may lead to improve EBF. The other reason may be the promotion and implementation of maternity leave according to international labor organization conventions and support of working mothers to exclusively breastfeed until six months of age [ 40 ]. But this finding is contrary to studies done in Bahr Dar [ 34 ], Hawassa [ 28 ], Tanzania [ 41 ], and Australia [ 20 ]. This may be due to the reason that studies might be done before the implementation of proclamations for maternal leave and they may also use breast milk substitutes early before six months to compensate for infant feeding during working time.

As strength the study used nationally representative data and conducted using a multilevel approach to identify individual and community level determinants of EBF that helps to provide information to design interventions strategies. Additionally, appropriate estimation adjustments like weighting and accounting for sample design were applied for analysis to represent the national population. Despite its strengths, this study has its limitations. The data used for this analysis were from a cross sectional survey, consequently, only associations were examined and it was difficult conclude about causality and it also brought recall bias. This study used a 24- hour recall method to measure exclusive breastfeeding and also the participants were infants under six months of age, no evidence to continue exclusive breastfeeding after the survey. In addition, this study was limited only to the variables collected by EDHS; some important variables were not included like health status of the mother, maternal knowledge and attitude towards exclusive breastfeeding. Furthermore, community level factors of exclusive breastfeeding were not addressed previously which makes it difficult to compare and contrast the study findings.

In this study, both individual and community- level variables were significantly associated with exclusive breastfeeding among infants undersix months in Ethiopia. Thus, age of the infants, sex of the infants, infant comorbidities, wealth index and antenatal care visit were individual level factors significantly associated with exclusive breastfeeding. Accordingly, being female sex, the richest house hold wealth index, and ANC visit associated with increased exclusive breastfeeding practice, whereas, age of the infant and infant comorbidities showed a negative association with exclusive breastfeeding. The contextual region, community level of PNC utilization, and community level of employment status were community level variables that showed statistically significant association with exclusive breastfeeding. Thus, infants from a higher level of community PNC utilization and employment status associated with increased exclusive breastfeeding, whereas, infants from pastoralist regions were less likely to exclusive breastfeeding.

Implications of the study

Exclusive breastfeeding is one of the core indicators of infant and young child feeding, among strategies of reducing infant mortality and morbidity. It determines future growths and developments of the infants both physical and mental. The study demonstrates that addressing individual and community- level factors associated with exclusive breastfeeding practice through policies and programs was essential to improve exclusive breastfeeding practice. Therefore, emphasis should be given on encouraging women to have ANC and PNC follow- ups, where they may get information and education that will improve exclusive breastfeeding. The infants with comorbid conditions need attention since they have low exclusive breastfeeding tendency. Since maternal employment and wealth status have a higher likelihood of exclusive breastfeeding, empowering women both economically and in their employment status is implicated. Therefore, interventions on individuals and community levels were demanded saving the lives of the infants and reducing economic losses of a country.

Supporting information

S1 dataset..

https://doi.org/10.1371/journal.pone.0245034.s001

Acknowledgments

We would like to thank the measure DHS program for their permission to access the data. We would also acknowledge all individuals who are involved in the accomplishment of this work.

• 1. WHO. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. 2017.
• 2. Thomas JV. Barriers to exclusive breastfeeding among mothers during the first four weeks postpartum. 2016.
• View Article
• PubMed/NCBI
• Google Scholar
• 4. WHO U. Increasing commitment to breastfeeding through funding and improved policies and programmes: Global breastfeeding scorecard 2019. 2019.
• 5. Nussbaumer-Streit B, Gartlehner G. WHO Guideline: Counselling of women to Improve Breastfeeding Practices. Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)). 2019.
• 8. UNICEF. Infant and young child feeding, Improving Exclusive Breastfeeding Practices Communication for Development in Infant and Young Child Feeding Programmes, 2018. Dostupno na: https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/ (0909 2018). 2017.
• 10. Tambe BA, Mimboe CS, Nchung JA, Bakwo CB, Nyobe EC, Pauline N, etal. The determinants of exclusive breastfeeding in Cameroon, Sub-Saharan Africa. 2018.
• 13. Su L-l, Chong Y-s, Chan Y-h, Chan Y-s, Fok D, Tun K-t, et al. Antenatal education and postnatal support strategies for. 2017:1–7.
• 14. ICF C. Ethiopia Demographic and Health Survey 2016, Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. DF-1.6; 2016.
• 22. Horn IOD. UNICEF Annual Report 2017. 2017;1–69.
• 23. FDRE Pacc. Summary and statistical report of the 2007 population and housing census: population size by age and sex, Federal Democratic Republic of Etrhiopia: Federal Democratic Republic of Ethiopia, Population Census Commission; 2008.
• 24. Tesfahunegn A, Hagos A, Tsadik M, Bekele A. Individual and community-level factors influencing optimal breastfeeding: A multilevel analysis from a national survey study in Ethiopia. 2019.
• 26. Hox JJ, Moerbeek M, Van de Schoot R. Multilevel analysis: Techniques and applications: Routledge; 2010.
• 40. FMoH. National Nutrition program II 2016–2020. 20.

• Open access
• Published: 28 December 2021

Level of exclusive breastfeeding and its enabling factors among lactating women who delivered in health facilities of Asosa town, Ethiopia: a cross sectional study

• Megersa Kumera 1 &
• Jemal Haidar 2  

BMC Women's Health volume  21 , Article number:  432 ( 2021 ) Cite this article

1806 Accesses

1 Citations

4 Altmetric

Metrics details

Despite the enormous benefit of exclusive breastfeeding (EBF) to mothers and infants, the practice of exclusive breastfeeding is globally low. In sub-Saharan Africa and Ethiopia, the prevalence of EBF stands at 35% and 59%, respectively. The low EBF practice in Ethiopia as well as in the studied region calls for further study and thus we studied the EBF practice in the study area since little is known about its current magnitude and factors influencing its practice for some programmatic improvements.

A facility based cross-sectional study linked to a community was conducted from June-July 2019 among 412 mothers who had antenatal follow-up and delivered in health facilities of Asosa town over a period of one year prior to the study. Data on socio demographic characteristics and other important variables were collected through face to face interview while gestational age in weeks was recorded from their medical chart by trained health extension workers in accordance with relevant ethical guidelines and regulations. The collected data were then cleaned and entered into Epi-data software version 3.02. Analysis was done by SPSS version 20. Binary and multivariate logistic regression were performed to identify the contributing factors. P-value of less than 0.05 and 95% confidence interval was considered to determine statistical significance.

Of the 412 respondents, the majority (88.1%) were multi-gravida and above. Slightly higher than a quarter (26.0%) and over half (55.4%) had neither received antenatal nor postnatal care. The proportion of mothers who exclusively breastfed their children was 76.0% and the overall aggregated good practice of EBF score was 64.1%. Mothers who completed primary school [AOR = 4.5; 95% CI = 1.1,18.2], had four or more ANC [AOR = 1.8;95CI = 0.79–0.98], and postnatal follow-up [AOR = 0.21;95% CI = 0.07–0.67], and had male infants [AOR = 2.3; 95% CI = 1.0–4.95] were among the factors influencing the exclusive breastfeeding practice score.

While three in four mothers exclusively breastfed their newborns and about two-thirds had good EBF score, the observed women’s retention on the continuum of the maternal care pathway is low with one in four had no antenatal and over half had no postnatal care which are important derivers for EBF practice. To improve the EBF score and narrow the observed maternal and child health disparities, it is essential to promote maternal education and increase the recomended coverage of antenatal and postnatal care for mothers.

Peer Review reports

Exclusive breastfeeding (EBF) refers to provision of breast milk only to infants from their biological mothers or wet nurses’ expressed milk with the exception of medicines [ 1 ]. Feeding breast milk (BM) alone for the first six months of life is adequate because it contains all the necessary nutrient requirements in terms of quantity as well as quality in addition to its immunological properties which protecs the infants from frequent illnesses and improves his/her chance of survival [ 2 ].

It is widely documented that the first year of life is very central for all growing child in improving the quality of life and thus nature has provided them with a pefect natural food that contains all the essential nutrients needed for growth and development. To maximize the benefits obtained from BM, infants need to be fed on demand at least 8 times in 24 h [ 3 ]. Infants that are exclusively breastfed are often healthier than their counterparts during their first year of life and consequently retards their growth [ 4 ]. Other benfits documented are economical such as reducing healthcare costs [ 5 , 6 ] improving maternal-child bonding, lowering the risk of developing non communicable diasese and beyond [ 7 ].

Breast milk is the healthiest form of milk for human babies with few exceptions like when the mother is taking certain drugs or is infected with tuberculosis or HIV [ 8 ]. Because of its enormous benefits, researchers advise the use of human milk to feed their babies, especially the initial milk, called colostrum, rich in immunoglobulin’s that coat the gastrointestinal tract and protect the newborns until their own immune system starts properly functioning and creates a mild laxative effect, expelling meconium and preventing the buildup of bilirubin [ 9 ].

The World Health Organization (WHO) and UNICEF strongly recommend mothers breastfeed their newborns within one hour after birth and continue doing so exclusively for the first six months of life [ 10 , 11 ]. Despite the aforementioned recommendations, the proportion of mothers who practiced EBF was 52.0% in 2011, and 59.0% in 2016 based on the Ethiopian Demographic Health Survey reports [ 12 , 13 ]. Although the 2016 survey report showed a slightly increment in the proportion of EBF, the practice declined with age from 74% in 0–1 months to 36% in 4–5 months with some regional variations. A more recent pocket study in rural Ethiopia reported EBF practice of 43.6% which is even lower than the 2016 national fidings [ 14 ]. It is important to note that the observed gap in EBF practice is not only due to lack of awarenesses-it is compounded by low physical access to health care facilities, economic, societal and cultural settings [ 15 , 16 , 17 , 18 ] are among other barriers. Many questions remain about the who, where, and how we could improve EBF, particularly for poor and marginalized populations, and how to strengthen the service in varying settings whilst linking to the health system. Most studies have so far been done elsewhere and available information in this regard is scanty for the studied region. Therefore this study attempted to generate evidences on the level of EBF practice and its enablers which are vital for the well being of infants.

Study area and population

A facility based cross sectional study linked to a community was conducted from June to July 2019 in Assosa town, the capital city of Benishangul-Gumuz (BG) among lactating mothers. BG is amongst the nine regional states of the Federal democratic republic of Ethiopia. It is an emerging region that has 3 zones and 20 districts for administrative purposes. It is located in western Ethiopia to the border of Sudan. It was previously known as Region 6. The capital town has one public hospital and one health center serving for over 600, 000 inhabitants. The study participants were all postnatal volunteer mothers that had antenatal follow-up and delivered in the aforementioned facilities during the study period.

Sample size determination, data collection, processing and analysis

The sample size required was determined using single population proportion formula assuming a proportion of 34.7% of ogood practice of EBF score [ 19 ] with level of significance of 5% (α = 0.05), 95% confidence level (Z α/2 = 1.96) and absolute precision or margin of error of 5% (d = 0.05) and 10% for non-response rate which inflated the sample to 412. To allocate the required sample size for each facility, we initially included all mothers that delivered in both facilities during the preceding one year based on the medical chart (N = 1056). Then divded the total number (N) to the size of mothers who delivered in the health center (n = 206) and the hospital (n = 850) and subsequently distributed the required sample size proportionately to the health center and the hospital. Following this procedure, 80 (1056/206) were assigned for the health center and the rest 332 (1056/850) were allocated for the hospital. Once the allocation process was completed, the next step was to select and recruit all the eligible in the community with the help of the Health Extention Workers (HEWs) until the required sample size was reached.

To standardize the data collection process, 2 days training was given for five data collectors (HEWs) and one BSc Nurse supervisor on data collection techniques and work ethics. Data were then collected on sociodemographic, obstetric factor, neonatal factor and culture related variables from all sampled participants through face to face interview using a pre-tested structured tool adapted from similar study localy while gestational age in weeks was recorded from their antenatal follow-up chart. Six practice questions were included in the tool to assess practice of EBF and distributed as; (1) breastfeed your last child (2 items); (2) initiation of breastfeeding (3 items); (3) frequency of BF (3 items); (4) substance given before initiating BF (2 items); (5) types of Prelacteal feeding (4 items) and (6) child BF from 0–6 months only breast milk (2 items). The items in each construct were then added together, with equal weights, to generate the mean score and then categorized the collected information into good and poor EBF practices when the overall mean scores of is above and below the mean, respectively.

Data were entered and analyzed using SPSS software version 25.0. Bivariate logistic regression analysis was used to assess the degree of association between good EBF practice and its contributory factors and test significance of the association. In addition, variables which had significant association with the outcome variable were entered into multivariate analysis model, to identify the important determinants and used to control for possible confounding effects. Those tested variables with a significance level of 20% in the bivariate analysis were further entered in the multivariate logistic regression model to identify the predictors that retained their association with the outcome. A p-value less than 5% was declared as statistically significant.

Sociodemographic characteristics

All the 412 enrolled mothers were interviewed and responded adequately with 100% response rate. The proportion of mothers belonging to the age of 26-35 years was 70.1% and 165 (40%) were Orthodox Christians. Less than a quarter (20.1%) were unable to read and write and about one-third (30.3%) were housewives. About half (47.6%) were from rural settings and most (76.5%) of them were earning below 5000 ETB 52.4 (Table 1 ).

Maternal obstetrics and newborn characters

Of the 412 respondents, the majority (88.1%) were multi-gravida and above. Slightly higher than a quarter (26.0%) had no antenatal care. The proportion of mothers who had three and four ANC was 40.3% and 21.6%, respectively. Over half (55.4%) had no postnatal care showing women’s retention on the continuum of the maternal care pathway is low. The proportion of mothers who had normal range of gestational age in weeks, low birthweight and exclusively breastfed their children was 79.9%, 12.2% and 76.0%, respectively (Table 2 ).

Maternal practice towards exclusive breastfeeding

Table 3 displays the maternal experiences towards EBF. Most (70.1%) of the mothers breastfed their infants and 248 (60.2%) initiated BF immediately, and over one-third (39.8%) fed their infants regularly ever 3–4 h. Eighty two (19.9%) had provided pre-lacteal feeding of whome, 12.3% gave plain water, cow’s milk in 10.9%, butter in 24.4% and formula milk in 52.4%. The overall aggregated good EBF practice score was 64.1%,

Factors affecting good EBF practice

Prior to the regression analysis, maternal responses on the six dichotomized practice questions were fit into the binary regression model. The output revealed that mothers that had education, from urban setting, had antenatal and postnatal follow-up, and gave birth to male child were significantly associated with practicing good EBF. Nonetheless, in the multivariate regression analysis, only mothers who had completed primary schooling [AOR = 4.5; 95% CI = 1.1,18.2], had four and more ANC [AOR = 1.8;95CI = 0.79–0.98], postnatal follow-up [AOR = 0.218;95% CI = 0.07–0.67], and delivered male infant [AOR = 2.3; 95% CI = 1.0–4.95] retained their significant association with good exclusive breastfeeding practice score. Although more mothers that had received information from health facilities adhered to good EBF, there was no significant association with the EBF practice (Table 4 ).

The world health organization adopted a comprehensive strategy called the Continuum of Care to improve reproductive, maternal, neonatal, and child health [ 20 , 21 ]. In view of this, we studied the practice of EBF and its enabling factors among mothers who had their antenatal follow-up and delivered over a one year period in the two available health facilities linked to the community. Based on our findings, about three-fourth adhered to EBF which indicates that present finding is better than the the 2016 national figure reported by Ethiopian Demographic Health Survey report [ 13 ] which was 59%. It is likely to see such discrepancies since the nature of the sampled mothers enrolled in our study were from health facilities suggesting that all had probably accessed and utilized the reproductive health services that included counselling on breastfeeding and to some extent might had information about the importance of EBF.

Though breastfeeding is almost universal in Ethiopia and exclusive breastfeeding up to 6 months after birth is an important contraceptive method, the status of exclusive breastfeeding in the studied region as well as in the country is less than the global recommendations [ 22 ] still more focused advocacy work needs to be done in this regard.

The good practice when compared with previous research reports, our study is concordant with Mizan-Aman town findings which reported 60.2% of the mothers to initiate breastfeeding immediately within an hour (60.2% vs 60.1%). The similarity of the findings could be attributed to the fact that all the sampled mothersin both the studies are from health facilities where they had access to appropriate councelling on newborn feedings and other reproductive health services [ 19 , 23 ]. Although the present finding is relatively better than other emrging regions in the country, further work is needed to achiev a better coverage of EBF and maximize its health benefites for the child as well as the mothers.

In this study, pre-lacteal feeding (PF) observed is higher compared to the findings reported by other authors [ 18 , 22 , 23 , 24 ]. The differences may be attributed to time constrains emanating from work related activities—most mothers with better education often get better job with better income and often such mothers rush to their work and consequently forced to practice PF. There could be also other reasons which requires further expoloratory study. The most common PF given in this study was plain water, cow’s milk, butter and formula milk. Compared with the Mizan Aman findings on provision of water (12.3% vs 48.2%), and cow’s milk (24.4% vs 50.2%), our finding is better and the difference might be due to socioeconomic factors and to some extent to maternal awareness towards EBF though the assertion needs further study.

The major enabling factors to good EBF practice score were education, ANC of four and more and infant’s gender while postnatal care had an inverse relation. Mothers who had primary education were 4.5 time more likely to adher to EBF than their counterparts. Although the education system differs and various experiences exist across the world, studies have reported maternal and paternal educational attainment as a common predictor for maternal health service utilization in developing countries including Ethiopia [ 25 , 26 ].

Mothers who had four or more antenatal follow-up were 1.8 times more likely practicing EBF than those who had none. Surprisingly, having postnatal follow-up in this study showed an inverse relation with EBF. This observation however, needs to be interpreted carefully since PNC is an opportunity for nutrition/EBF promotion. It appears that the low coverage of PNC could have negatively influenced the EBF practice along the continuum of care and found to be among the weakest of all reproductive and child health programmes in the region as well as elsewhere among rural women due to the high domestic workload and little time left after attending to essential household chores until term and beyond [ 27 , 28 ]. To ensure a seamless continuum of care from home to hospital and most importantly good EBF practice, the PNC program needs to be strengthened accros the region as well as in the country.

Interestingly, mothers who delivered male infant were observed to practice 2.3 times more likely than those who delivered females probably due to cultural preferences for males. Other noteable finding of the present study is that mothers that had received information from health facilities adhered to EBF though the association with the EBF practice was not significantly probably due to an unfocussed councelling. This is in contrary to some previous studies where they reported some positive associations and thus the observation needs cautious interpretations [ 15 , 26 ] and warrants for further exploratory study to uncover why the sources of information did not bring the desired/expected change toward EBF practice.

Strength and limitations

The strength of the study is that it included the available health facilities in the town and has generated some new evidence for programmatic implications to improve the EBF practice in the region. The information generated would also serve as a bench mark for future studies. Despite the aforementioned strengths, the findings had some limitations and thus need to be interpreted cautiously since facility-based studies as well as the design employed may make estimates unstable and associations between dependent and independent variables undetectable.

The study has demonstrated that three in four mothers were practicing EBF with an overall good EBF practice score of 64.1%. The enabling factors identified are having education and attending the recommended antenatal care of four and above as well as delivering male infants. While the EBF practice is better than the national figure, the observed women’s retention on the continuum of the maternal care pathway is low with one in four to have no antenatal and over half had no postnatal care which are critical to the health and survival of a mother and her newborn. To narrow the disparities observed among mothers and their children, it is essential to intervene through focused actions that address the above determinants by all stakeholders since the issue is a cornerstone of public health and it has been reiterated at many international conferences and initiatives to lower morbidities and mortlities of mothers and children [ 28 , 29 ].

Availability of data and materials

All data generated or analysed are included in this published article.

Abbreviations

Antenatal care

Adjusted odds ratio

Benishengul-Gumuz

Exclussive breastfeeing

Ethiopian birr

Prelacteal feedings

Postnatal care

World Health Organization. Indicators for assessing breast-feeding practices. Report of an informal meeting. Geneva, Switzerland: 1991.

Salami L. Factors influencing breastfeeding practices in Edo state, Nigeria. Afr J Food Agric Nutr Dev. 2011. https://doi.org/10.4314/ajfand.v6i2.71755 .

Article   Google Scholar  

Lavender T, McFadden C, Baker L. Breastfeeding and family life. Matern Child Nutr. 2006;2(3):145–55. https://doi.org/10.1111/j.1740-8709.2006.00049 .

Article   PubMed   PubMed Central   Google Scholar  

McFadden A, Toole G. Exploring women’s views of breastfeeding: a focus group study within an area with high levels of socio-economic deprivation. Matern Child Nutr. 2006;2(3):156–68. https://doi.org/10.1111/j.1740-8709.2006.00054 .

Ball TM, Bennett DM. The economic impact of breastfeeding. Pediatr Clin North Am. 2001;48(1):253–62. https://doi.org/10.1016/S0031-3955(05)70298-4 .

Article   CAS   PubMed   Google Scholar  

Jones JM. The methodology of nutritional screening and assessment tools. J Hum Nutr Diet. 2002;15(1):59–71. https://doi.org/10.1046/j.1365-277X.2002.00327 .

Article   PubMed   Google Scholar  

Kull I, Wickman M, Lilja G, Nordvall SL, Pershagen G. Breast feeding and allergic diseases in infants—a prospective birth cohort study. Arch Dis Child. 2002;87(6):478–81. https://doi.org/10.1136/adc.87.6.478 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Tampah-Naah AM, Kumi-Kyereme A. Determinants of exclusive breastfeeding among mothers in Ghana: a cross-sectional study. Int Breastfeed J. 2013. https://doi.org/10.1186/1746-4358-8-13 .

Kong SKF, Lee DTF. Factors influencing decision to breastfeed. J Adv Nursing. 2004;46(4):369–79. https://doi.org/10.1111/j.1365-2648.2004.03003 .

World Health Organization. Innocent declaration on the protection, promotion and support of breastfeeding. Geneva, Switzerland: 1990.

World Health Organization. World Health Organization: 10 facts on child health. Geneva, Switzerland: World Health Organization; 2012.

Central Statistical Agency [Ethiopia] and ICF International, Ethiopia demographic and health survey, 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA.

Ethiopian Demographic and Health Survey, 2016. Key Indicators Report Central Statistical agency Addis Ababa, Ethiopia: the DHS Program ICF Rockville, Maryland, USA.

Tsedeke W, Gadisa D, Ababa W, Genet M, Girma N. Knowledge, attitude and practice of exclusive breast feeding among lactating mothers in Bedelle Town, Southwestern Ethiopia: descriptive cross sectional study 2014; [MPH Thesis].

Chukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):152.

Banke OE, Ameh CA. Factors influencing utilisation of maternal health services by adolescent mothers in Low-and middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2017;17(1):65.

Sheffel A, Karp C, Creanga AA. Use of Service Provision Assessments and Service Availability and Readiness Assessments for monitoring quality of maternal and newborn health services in low-income and middle-income countries. BMJ Glob Health. 2018;3(6):e001011.

Sakuma S, Yasuoka J, Phongluxa K, Jimba M. Determinants of continuum of care for maternal, newborn, and child health services in rural Khammouane, Lao PDR. PLoS ONE. 2019;14(4):e0215635.

Article   CAS   Google Scholar  

Niguse T, Frehiwot H, Dinu A, Eyerus D. Knowledge, attitude and practice towards exclusive breastfeeding among lactating mothers in Mizan-Aman town, Southwestern Ethiopia: descriptive cross-sectional study. Int Breastfeeding J. 2016;11:3. https://doi.org/10.1186/s13006-016-0062-0 .

WHO. The World Health Report 2005: make every mother and child count. World Health Organization; 2005.

WHO. WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization Geneva, Switzerland; 2016.

Alebel A, Tesma C, Temesgen B, Ferede A, Kibret GD. Exclusive breastfeeding practice in Ethiopia and its association with antenatal care and institutional delivery: a systematic review and meta-analysis. Int Breastfeed J. 2018;13(1):31.

Maeza M, Mesele A, Zelalem K. Factors associated with exclusive breastfeeding practices in DebreBerhan District, Central Ethiopia: a cross sectional community based study. Int Breastfeeding J. 2015;0:23.

Tadele N, Habta F, Akmel D, Deges E. Knowledge, attitude and practice towards exclusive breastfeeding among lactating mothers, Mizan-Aman Town, Southwestern Ethiopia: descriptive cross sectional study. J Health Edu Res Dev. 2015. https://doi.org/10.4172/2380-5439.1000149 .

Fekadu GA, Ambaw F, Kidanie SA. Facility delivery and postnatal care services use among mothers who attended four or more antenatal care visits in Ethiopia: further analysis of the 2016 demographic and health survey. BMC Pregnancy Childbirth. 2019;19(1):64.

Alemi K, Tekle-Haymanot A. Factors associated with institutional delivery service utilization in Ethiopia. Int J Women’s Health. 2016;8:463.

Ousman SK, Magnus JH, Sundby J, Gebremariam MK. Uptake of skilled maternal healthcare in Ethiopia: a positive deviance approach. Int J Environ Res Public Health. 2020;17(5):1712.

Rosenfield A, Min CJ. A history of international cooperation in maternal and child health. Maternal and child health. Berlin: Springer; 2009. p. 3–17.

Google Scholar  

Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. The Lancet. 2007;370(9595):1358–69.

Download references

Acknowledgements

The authors would like to thank the study participants and the respective health bureaus and health facilities including Sante medical college for their kind support to carry out this study.

The authors report no external funding source for this study.

Author information

Authors and affiliations.

Ethiopian Pediatric Society, Addis Ababa, Ethiopia

Megersa Kumera

College of Health Sciences, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

Jemal Haidar

You can also search for this author in PubMed   Google Scholar

Contributions

MK has collected the data and drafted the MS while JH has supervised the work and critically reviewed the draft for the intellect and submitted the MS. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jemal Haidar .

Ethics declarations

Ethics approval and consent to participate.

Ethical clearance and approval was obtained from Ethical approval committee of Sante medical college Research and Ethical Clearance Committee (SMC-RECC) as well as from the Benishengul-Gumuz regional health Bureau RECC. In addition, Assossa general Hospital Medical Director and Head-Assosa town health center were also communicated through the regional health bureau and allowed the execution of the study (to review the medical charts and subsequently trace the participants with the help of the recruited HEWs). Each study participant was adequately informed about the purpose, methods, and anticipated benefits of the study by the data collectors. Written informed consent for those able to read and write while oral consent and thumb print including informed consent from their guardians for the illiterates was also obtained from all respondents who volunteer and were available at the time of data collection. All participants were interviewed without writing their names to ensure confidentiality. In addition, mothers with poor EBF practice were councelled upon completion of the study. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kumera, M., Haidar, J. Level of exclusive breastfeeding and its enabling factors among lactating women who delivered in health facilities of Asosa town, Ethiopia: a cross sectional study. BMC Women's Health 21 , 432 (2021). https://doi.org/10.1186/s12905-021-01580-2

Download citation

Received : 16 April 2021

Accepted : 15 December 2021

Published : 28 December 2021

DOI : https://doi.org/10.1186/s12905-021-01580-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Lactating mothers
• Exclusive breastfeeding practice score
• Enabling factors

BMC Women's Health

ISSN: 1472-6874

• Submission enquiries: [email protected]
• General enquiries: [email protected]

  Pan African Medical Journal Journal / Pan African Medical Journal / Vol. 46 No. 1 (2023) / Articles (function() { function async_load(){ var s = document.createElement('script'); s.type = 'text/javascript'; s.async = true; var theUrl = 'https://www.journalquality.info/journalquality/ratings/2406-www-ajol-info-pamj'; s.src = theUrl + ( theUrl.indexOf("?") >= 0 ? "&" : "?") + 'ref=' + encodeURIComponent(window.location.href); var embedder = document.getElementById('jpps-embedder-ajol-pamj'); embedder.parentNode.insertBefore(s, embedder); } if (window.attachEvent) window.attachEvent('onload', async_load); else window.addEventListener('load', async_load, false); })();  

Article sidebar.

Article Details

Main article content, challenges and strategies to implement exclusive breastfeeding in the selected districts of limpopo province, south africa: professional nurses' perspectives, azwinndini gladys mudau, jabu tsakani mabunda, lindelani fhumudzani mushaphi.

Introduction:  despite the efforts of professional nurses, exclusive breastfeeding rate is very low in South Africa. Per statistic South Africa, EBF rate is 32% with Limpopo Province being rated 8% as one of the lowest in South Africa. Implementation of exclusive breastfeeding required professional nurses´ efforts, lactating mothers, families, and community need information and support from the health care system. The purpose of this study aimed at exploring professional nurses´ challenges regarding implementation of exclusive breastfeeding in Limpopo Province.

Methods:  qualitative research involving phenomenological design was employed to explore professional nurses´ challenges using one on one, unstructured, in-depth interview with 30 professional nurses; 27 females and three males, working in the six birthing facilities of two selected districts; Vhembe and Waterberg, in Limpopo Province.

Results:  the three higher order themes emerged were challenges experienced by nurses during promotion of exclusive breastfeeding; findings revealed challenges as cultural and religious beliefs, lack of family/community and health professional support, teen and HIV positive mothers, nurses found to have challenges to implement exclusive breastfeeding. Healthcare system and services such as shortage of staff and lack of proper training on lactation management and perceived measures to promote exclusive breastfeeding suggested by health professionals, which include ongoing health education, door to door campaigns, implementation of policy by health care professionals would promote exclusive breastfeeding strategies that are in place and encourage families and community to support lactating mothers to improve their confident on breastfeeding.

Conclusion:  professional nurses had challenges in promoting exclusive breastfeeding. An intervention is needed to promote exclusive breastfeeding.

AJOL is a Non Profit Organisation that cannot function without donations. AJOL and the millions of African and international researchers who rely on our free services are deeply grateful for your contribution. AJOL is annually audited and was also independently assessed in 2019 by E&Y.

Your donation is guaranteed to directly contribute to Africans sharing their research output with a global readership.

• For annual AJOL Supporter contributions, please view our Supporters page.

Journal Identifiers

[A quantitative and qualitative study of exclusive breastfeeding intention by high-risk pregnant women]

Affiliation.

• 1 Departamento de Odontologia Preventiva e Social, Faculdade de Odontologia de Araçatuba, Universidade Estadual Paulista Júlio de Mesquita Filho, Araçatuba, SP, Brazil, [email protected].
• PMID: 32876255
• DOI: 10.1590/1413-81232020259.30002018

The scope of this research was to assess the breastfeeding intention among high-risk pregnant women and related factors. It is a cross-sectional, qualitative and quantitative study, with 1,118 high-risk pregnant women who attended the prenatal care unit at a specialized center of the Unified Health System. The dependent variables were exclusive breastfeeding intention, intended duration and conditions that might interfere with breastfeeding. The Epi Info 7.4.1, Bioestat 5.3 and IRAMUTEQ 0.7.2.0 programs were used for data processing. The results showed that 8.76% of the pregnant women had conditions that could affect lactation. Among the women, 93.83% affirmed having exclusive breastfeeding intention, of which 69.86% intended to breastfeed until the child was six months old, revealing an association with sociodemographic variables (p<0.05). The intended breastfeeding duration was related to the age (p=0.0041), marital status (p=0.0053) and level of education (p=0.0116). The main reasons reported for not providing exclusive breastfeeding were the following: HIV, use of medications, work and lack of information. This research concluded that a small cohort of high-risk pregnant women presented conditions that could interfere with breastfeeding. Most of them intended to breastfeed exclusively for six months.

• Breast Feeding*
• Cohort Studies
• Cross-Sectional Studies
• Pregnant Women
• Risk Factors

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Matern Child Nutr
• v.13(3); 2017 Jul

Mothers' understanding of the term ‘exclusive breastfeeding’: a systematic review

1 Division of Applied Health Sciences, University of Aberdeen, United Kingdom

Debbie Marais

Jenna louise hollis.

2 The Rowett Institute of Nutrition and Health, University of Aberdeen, United Kingdom

Associated Data

Appendix 1: Critical appraisal tool

Appendix 2: List of articles unavailable through inter‐library loans/translator not available

There is a lack of knowledge and understanding of the term exclusive breastfeeding (EBF) among health professionals. The purpose of this review was to examine the best available literature on mothers' understanding of the term EBF. A systematic search of eight electronic databases (Medline, Embase, CINAHL, CDSR, CENTRAL, Cab Abstracts, Scopus and African Index Medicus) was conducted (Protocol registration in PROSPERO: CRD42015019402). All study designs were eligible for inclusion. Studies were included if they: (1) involved mothers aged 18 years or older; (2) assessed mothers' knowledge/understanding/awareness of the term ‘EBF’; (3) used the 1991 WHO definition of EBF and (4) were published between 1988 and 2015. Two reviewers retrieved articles, assessed study quality and performed data extraction. Of the 1700 articles identified, 21 articles met the inclusion criteria. Quantitative findings were pooled to calculate a proportion rate of 70.9% of mothers who could correctly define EBF, although the range varied between 3.1 and 100%. Qualitative findings revealed three themes: (1) EBF was understood by mothers as not mixing two milks; (2) the term ‘exclusive’ in EBF was incorrectly understood as not giving breast milk and (3) mothers believing that water can be given while exclusively breastfeeding. Research investigating aspects of self‐reported EBF may consequently be unreliable. A standardised tool to assess mothers' knowledge of EBF could provide more accurate data. Public health campaigns should emphasise EBF to target mothers, while addressing the education of health professionals to ensure that they do not provide conflicting advice.

Introduction

The World Health Organisation (WHO) defines exclusive breastfeeding (EBF) as when ‘an infant receives only breast milk, no other liquids or solids are given – not even water, with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines’ (World Health Organization 2016 ). Despite the well‐recognised benefits, EBF prevalence is poor worldwide; with the Global Nutrition Report indicating the global baseline EBF rate was 38% between 2008 and 2012 (Global Nutrition Report, 2015 2015 ). In low and middle‐income countries (LMIC), less than 40% of infants younger than six months of age are estimated to be exclusively breastfed (WHO, 2016 ). This is a concern considering that EBF is especially important in LMIC where poverty, under nutrition and disease burden are common because of limited resources and economic, environmental and cultural influences (Caulfield et al. 2006 ). There is evidence to suggest that in high‐income counties (HIC) the risk of acute respiratory infections and diarrhoea is also substantially reduced when an infant is breastfed exclusively (Wright et al. 1989 ; Ip et al. 2007 ). In spite of this, EBF prevalence varies globally with statistics in some HIC estimated to be 11.3% and as low as 1% (Centers For Disease Control And Prevention (CDC) 2007 ; World Health Organization 2014 ).

According to two recent collaborative reviews (Ip et al. 2007 ; Kramer and Kakuma, 2009 ), the definitions of EBF were found to be considerably different across all included studies, with the majority failing to differentiate between infants exclusively breastfed and infants partially breastfed. One study incorporated non‐nutritive supplements, such as water, sugar and herbal teas in their definition of EBF (Okolo et al. 1999 ). However even the minimal use of supplements has been shown to have an increased risk of gastrointestinal infections and mortality in infants (Arifeen et al. 2001 ; Kramer and Kakuma, 2004 ).

There is also a lack of knowledge and understanding of the term EBF among health professionals (Chopra et al. 2002 ; Shah et al. 2005 ; Taneja et al. 2005 ; Piwoz et al. 2006 ; Marais et al. 2010 ; Laanterä et al. 2011 ; Du Plessis & Pereira 2013 ) because of an apparent lack of consistency of definitions of breastfeeding terms (Labbok & Krasovec 1990 ). Considering that health professionals provide new mothers with breastfeeding information (Lewallen et al. 2006 ), if health professionals do not fully understand the meaning of EBF, they may subsequently communicate, confusing, mixed messages to mothers.

Although much research has investigated health professionals' knowledge and understanding of infant feeding practices (Mcintyre & Lawlor‐smith 1996 ; Chen et al. 2001 ; Chopra et al. 2002 ; Shah et al. 2005 ; Taneja et al. 2005 ; Piwoz et al. 2006 ; Tennant et al. 2006 ; Marais et al. 2010 ; Zakarija‐Grković & Burmaz 2010 ; Laanterä et al. 2011 ), there is limited research on mothers' understanding of EBF. To the authors' knowledge, no systematic review has examined mothers' understanding of the term EBF. Therefore, a systematic review was conducted to address this gap in the research with the aim to systematically evaluate the best available literature on mothers' understanding of the term EBF.

Key messages

• There are misconceptions among mothers about EBF, which has implications for interpreting findings from current research and for reporting on EBF practices and policy making.
• In‐depth questioning on EBF should therefore be stressed in field‐research to ensure good quality data on EBF.
• The WHO EBF indicator lacks sensitivity therefore overestimating the proportion of exclusively breastfed infants.
• The questionnaire suggested to calculate the WHO indicators for assessing infant and young child feeding practices could be used as a starting point to develop a validated tool for assessing EBF practices.

The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) checklist (PRISMA, 2009 ). Preliminary literature searches within three databases (Medline, Embase and Google Scholar) were conducted in March 2015 to provide an initial overview of the literature and to aid with developing the overall search strategy. The systematic review protocol was registered in PROSPERO (registration number: CRD42015019402). The protocol can be accessed at: http://www.crd.york.ac.uk/PROSPERO/register_new_review.asp?RecordID=19402&UserID=11187 .

Search strategy

A systematic search of published literature was conducted in March 2015 using key search terms (Table ​ (Table1) 1 ) within eight electronic scientific databases including: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cab Abstracts, Scopus and African Index Medicus. No language restrictions were imposed. The reference lists of included studies were hand searched and experts in the relevant field were contacted to identify any additional relevant papers not identified in the database search.

Full list of search terms used in the database search strategy

Inclusion and exclusion criteria

The review examined studies that: (1) involved mothers aged 18 years or older; (2) assessed mothers' knowledge/understanding/awareness of the term EBF; (3) used the 2001 WHO definition of EBF (WHO, 1991 ) and (4) were published between March 1988 and March 2015. The cut‐off year of March 1988 was selected as it was at this date that the term EBF originated (Labbok & Krasovec 1990 ). Studies were excluded if they: (1) reported on health care professionals' knowledge/understanding of the term EBF; (2) assessed any other type of definition of EBF or where EBF was not clearly defined; (3) reported on breastfeeding alone and not EBF and (4) reported findings in a thesis, dissertation, book, conference abstract or unpublished literature.

Two independent reviewers (RS and DM/JH) reviewed the title and abstract of each article for relevance against the inclusion and exclusion criteria. The full texts of potentially eligible articles were retrieved and independently assessed by the two reviewers to determine eligibility. Any disagreements for an article's inclusion were resolved through discussion between the two reviewers and if a consensus could not be reached, a third reviewer was consulted (DM/JH). Additional data were requested from study authors if it would determine study eligibility.

Quality appraisal

Two reviewers (RS and DM/JH) independently assessed the study quality of each included study using an 11‐item standardised quality appraisal tool (see Supporting information: Appendix 1 ) (Guyatt et al. 1993a , 1993b ). The quality appraisal tool assessed risk of bias and study quality in regards to the study aims, recruitment, participant description, measurement outcomes, data collection, and results and data analysis. Each domain was coded as either a tick for being clearly present, a ‘U’ for unclear and a cross for absent. Any difference in ratings was resolved through discussion between the two reviewers, or a third reviewer was consulted if a consensus could not be reached. Each domain was considered independently as recommended by the PRISMA (PRISMA, 2009 ).

Data extraction

Two independent reviewers (RS and DM/JH) performed data extraction using an adapted data extraction form created from a standardised tool from the Cochrane Collaboration for Randomised Controlled Trials (The Cochrane Collaboration 2015 ). The two reviewers discussed any discrepancies and consulted a third reviewer (DM/JH) if a consensus could not be reached. The extracted data provided details on: author details (name, date, year), the study methods (aims, inclusion criteria, assessment measures i.e. questionnaires), participants (number, age of mother, age of infants, socio‐economic status, marital status, educational and employment status, breastfeeding status and health status), description of the setting (country, setting i.e. clinic/hospital based), drop‐out rates where applicable, study findings, limitations of the study and authors' conclusions.

Data synthesis

For quantitative studies, characteristics and findings were synthesised narratively, summaries were presented as percentage of mothers who understood EBF and a pooled proportion rate was calculated. For qualitative studies, thematic analysis was conducted by identifying common themes from the results reported and according to the primary outcomes of the research. Common themes were clustered and categorised into three themes which related to misunderstanding of the term ‘EBF’.

The initial database search, hand search and additional sources search yielded 1700 articles after duplicates had been removed (Fig. ​ (Fig.1). 1 ). Articles not complying with the inclusion criteria were excluded during the title and abstract screening phase ( n  = 1517). Full texts were retrieved for the remaining 183 citations, of which 162 were excluded primarily as they did not use the WHO EBF definition (WHO, 1991 ) or did not assess mothers' knowledge of the definition of EBF. In total, 21 studies met the inclusion criteria and were included in the review.

Method of determining studies to be included in the review. CINAHL = Cumulative Index to Nursing and Allied Health Literature; CDSR = Cochrane Register of Systematic Reviews; CENTRAL = Cochrane Central Register of Controlled Trials; ILL = Inter Library Loans.

Characteristics of included studies

The majority of included studies were cross‐sectional in nature ( n  = 13) (Ogbonna & Daboer 2007 ; Petrie et al. 2008 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Ukegbu & Ukegbu 2010 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ; Ukegbu & Anyikaelekeh 2013 ; Adeyemi & Oyewole 2014 ; Danso 2014 ; Desai et al. 2014 ; Onah et al. 2014 ) with the remainder of studies either qualitative ( n  = 7) (Murray et al. 2008 ; Otoo et al. 2009 ; Nankunda et al. 2010 ; Ostergaard & Bula 2010 ; Ukegbu et al. 2011 ; Nor et al. 2012 ; Nduna et al. 2015 ) or a Randomised Control Trial (RCT) ( n  = 1) (Aksu et al. 2011 ) (Table ​ (Table2). 2 ). Publication dates ranged from 2007 (Ogbonna & Daboer 2007 ) to 2015 (Nduna et al. 2015 ). All studies were conducted in low and middle‐income countries (LMIC) ( n  = 21), predominantly in Africa ( n  = 19). A large number of studies were carried out in Nigeria ( n  = 9) (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Oche et al. 2011 ; Ukegbu et al. 2011 ; Alade et al. 2013 ; Ukegbu & Anyikaelekeh 2013 ; Adeyemi & Oyewole 2014 ; Onah et al. 2014 ).

Characteristics of studies included in the review ( n  = 21)

N/R = not reported; N/A = not applicable; EBF = exclusive breastfeeding; BF = breastfeeding; FGD = focus group discussions; PFBDG = Paediatric food based dietary guidelines; PMTCT = prevention of mother‐to‐child transmission.

The number of participants in the studies ranged from 10 (Nduna et al. 2015 ) to 1052 (Abul‐Fadl et al. 2012 ). The studies included mothers who had infants between zero and 24 months old ( n  = 12) (Ogbonna & Daboer 2007 ; Murray et al. 2008 ; Petrie et al. 2008 ; Otoo et al. 2009 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Ostergaard & Bula 2010 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ; Danso 2014 ; Desai et al. 2014 ; Onah et al. 2014 ), and the age of infants was not mentioned in nine studies (Nankunda et al. 2010 ; Ukegbu & Ukegbu 2010 ; Aksu et al. 2011 ; Oche et al. 2011 ; Ukegbu et al. 2011 ; Nor et al. 2012 ; Ukegbu & Anyikaelekeh 2013 ; Adeyemi & Oyewole 2014 ; Nduna et al. 2015 ). Two studies (Ostergaard & Bula 2010 ; Aksu et al. 2011 ) included mothers who intended to breastfeed, five (Marais et al. 2010 ; Ukegbu & Ukegbu 2010 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ) who were currently breastfeeding and two (Nankunda et al. 2010 ; Danso 2014 ) with personal breastfeeding experience. Twelve studies (Ogbonna & Daboer 2007 ; Murray et al. 2008 ; Petrie et al. 2008 ; Otoo et al. 2009 ; Uchendu et al. 2009 ; Ukegbu et al. 2011 ; Nor et al. 2012 ; Ukegbu & Anyikaelekeh 2013 ; Adeyemi & Oyewole 2014 ; Desai et al. 2014 ; Onah et al. 2014 ; Nduna et al. 2015 ) did not mention current breastfeeding status.

In five studies (Ogbonna & Daboer 2007 ; Ukegbu & Ukegbu 2010 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Ukegbu & Anyikaelekeh 2013 ) the majority of mothers worked as housewives, and six studies also indicated mothers worked as traders (Ogbonna & Daboer 2007 ; Otoo et al. 2009 ; Ukegbu & Ukegbu 2010 ; Alade et al. 2013 ), farmers (Ukegbu & Ukegbu 2010 ; Alade et al. 2013 ) and in the civil service (Oche et al. 2011 ; Alade et al. 2013 ; Ukegbu & Anyikaelekeh 2013 ). In one study (Danso 2014 ) all mothers were in professional employment (i.e. education, health and banking). The nature of employment was not described for 13 studies (Murray et al. 2008 ; Petrie et al. 2008 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Nankunda et al. 2010 ; Ostergaard & Bula 2010 ; Aksu et al. 2011 ; Ukegbu et al. 2011 ; Nor et al. 2012 ; Adeyemi & Oyewole 2014 ; Desai et al. 2014 ; Onah et al. 2014 ; Nduna et al. 2015 ). In 13 of the studies (Ogbonna & Daboer 2007 ; Petrie et al. 2008 ; Otoo et al. 2009 ; Nankunda et al. 2010 ; Ukegbu & Ukegbu 2010 ; Aksu et al. 2011 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ; Ukegbu & Anyikaelekeh 2013 ; Danso 2014 ; Desai et al. 2014 ; Onah et al. 2014 ) all mothers had completed some form of education (primary, secondary or tertiary), but the remaining studies ( n  = 8) (Murray et al. 2008 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Ostergaard & Bula 2010 ; Ukegbu et al. 2011 ; Nor et al. 2012 ; Adeyemi & Oyewole 2014 ; Nduna et al. 2015 ) did not report on educational attainment. In one study (Abul‐Fadl et al. 2012 ), however, one third of mothers had completed very little or no form of education.

The majority of studies assessed EBF knowledge via questionnaires ( n  = 15) (Ogbonna & Daboer 2007 ; Petrie et al. 2008 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Nankunda et al. 2010 ; Ukegbu & Ukegbu 2010 ; Aksu et al. 2011 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ; Ukegbu & Anyikaelekeh 2013 ; Adeyemi & Oyewole 2014 ; Danso 2014 ; Desai et al. 2014 ; Onah et al. 2014 ) and/or interviews ( n  = 8) (Ogbonna & Daboer 2007 ; Marais et al. 2010 ; Ostergaard & Bula 2010 ; Oche et al. 2011 ; Abul‐Fadl et al. 2012 ; Nor et al. 2012 ; Onah et al. 2014 ; Nduna et al. 2015 ). Three studies (Murray et al. 2008 ; Otoo et al. 2009 ; Ukegbu et al. 2011 ) used focus group discussions (FGD).

The methodological quality of the included studies was assessed (Table ​ (Table3). 3 ). A main area of strength was that all studies addressed a clear focused issue. The vast majority had clearly defined the population ( n  = 19), used appropriate methods to address the issue ( n  = 20), and results and data analysis were presented ( n  = 20) and were sufficiently rigorous ( n  = 19). An area of weakness for the majority of studies related to subject recruitment as 11 studies (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Marais et al. 2010 ; Nankunda et al. 2010 ; Ukegbu & Ukegbu 2010 ; Aksu et al. 2011 ; Ukegbu et al. 2011 ; Abul‐Fadl et al. 2012 ; Adeyemi & Oyewole 2014 ; Desai et al. 2014 ) did not explicitly state how participants were recruited or participants were not recruited in a truly random way, therefore increasing the risk of selection bias. Two studies (Murray et al. 2008 ; Abul‐Fadl et al. 2012 ) used convenience sampling so the findings may not be generalisable. There was an increased risk of selection bias as many of the studies were clinic based ( n  = 12); recruiting mothers who attended the clinics and missing those who had not. Four studies (Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Ukegbu et al. 2011 ; Nduna et al. 2015 ) did not report detailed population demographics, and one study (Ukegbu & Ukegbu 2010 ) reported a different number of participants in the abstract to the main article. The risk of participation bias is increased if the sample population is not clearly defined, as there could be differences between mothers who were invited to participate in the study and mothers who enrolled.

Quality appraisal of the included studies ( n  = 21)

Another domain that scored poorly for seven studies (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ostergaard & Bula 2010 ; Oche et al. 2011 ; Ukegbu et al. 2011 ; Alade et al. 2013 ; Danso 2014 ) related to whether ‘study methods were accurately assessed to reduce bias’. Measurement bias among those studies is likely to be increased because of the methods in which EBF knowledge was evaluated. The domain assessing ‘generalisability of results’ indicated a major limitation in all studies as many were conducted in specific geographical areas, with relatively small sample sizes; therefore findings are unlikely to be generalisable. The majority of studies reported on mothers who had breastfed before or were currently breastfeeding at the time of the study and therefore they may not be representative of the knowledge of mothers who had not breastfed. A question on ethical approval was not included within the quality appraisal tool; however, all studies apart from one (Ukegbu & Ukegbu 2010 ) reported ethical approval.

Defining EBF correctly

The percentage of mothers who knew the meaning of or could correctly define EBF (Table ​ (Table4) 4 ) varied greatly, ranging from 3.1% (Marais et al. 2010 ) to 100% (Danso 2014 ). The pooled proportion rate of mothers who could correctly define EBF was 70.9%. Five studies (Aksu et al. 2011 ; Abul‐Fadl et al. 2012 ; Alade et al. 2013 ; Adeyemi & Oyewole 2014 ; Desai et al. 2014 ) reported that between 50 and 58.1% of mothers knew the meaning of or could correctly define EBF. However, for seven studies (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Nankunda et al. 2010 ; Ukegbu & Ukegbu 2010 ; Ukegbu & Anyikaelekeh 2013 ; Danso 2014 ; Onah et al. 2014 ), the percentage of mothers who knew the meaning of EBF was higher, ranging from 72.7% (Nankunda et al. 2010 ) to 100% (Danso 2014 ). Five of these studies were conducted in Nigeria (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Ukegbu & Anyikaelekeh 2013 ; Onah et al. 2014 ) and the remaining conducted in Ghana (Danso 2014 ) and Uganda (Nankunda et al. 2010 ). In contrast, three studies reported findings as low as 30% in Nigeria (Oche et al. 2011 ) and 11.1% (Petrie et al. 2008 ) and 3.1% (Marais et al. 2010 ) in South Africa.

Number of mothers correctly defining EBF ( n  = 15)

EBF = exclusive breastfeeding; WHO = World Health Organisation; no = number.

Themes related to misconceptions about the term EBF

Two of the six qualitative studies indicated that mothers knew the meaning of EBF (Otoo et al. 2009 ; Ukegbu et al. 2011 ) (Table ​ (Table5). 5 ). However, four studies reported that mothers did not understand the term EBF, which could be categorised into three themes. The first theme identified from one study (Nor et al. 2012 ) was that EBF was understood as ‘not mixing two milks’ and did not exclude the addition of other foods and liquids. Quotes from mothers in this study (Nor et al. 2012 ) to illustrate the theme include:

‘We must not give the baby two milk things, the baby must drink only one thing’ ‘I am only breastfeeding her…I started giving her the tin (infant formula) when she was one month old…. even when I mixed it with infant porridge she would just not eat it’.

Themes identified from qualitative studies ( n  = 6)

The second theme that emerged from two of the studies (Murray et al. 2008 ; Ostergaard & Bula 2010 ) related to the actual wording of EBF, with ‘exclusive’ being understood as the opposite, that is ‘excluding’, not giving breast milk or to give breast milk with other fluids. Mothers also stated that EBF meant ‘not necessarily breastfeeding’, ‘breastfeeding and something else’, ‘regularly breastfeeding’ or mothers could not define what EBF meant (Murray et al. 2008 ). The second study (Ostergaard & Bula 2010 ) reported similar findings where all mothers could paraphrase what EBF meant, however they misunderstood what the ‘E’ stood for in the abbreviation EBF. One mother stated:

‘I managed to practice EBF for six months and only gave gripe water when my baby was crying a lot due to stomach pain. I also gave traditional drugs…nothing else but breast milk’

The third theme was related to mothers misinterpreting that it is acceptable to give water while exclusively breastfeeding. This theme emerged from four of the qualitative studies (Murray et al. 2008 ; Ostergaard & Bula 2010 ; Nor et al. 2012 ; Nduna et al. 2015 ) where mothers gave their infants water but considered themselves to have exclusively breastfed. In one study (Nduna et al. 2015 ), mothers considered themselves to be practicing EBF as long as they did not give solids to their infants even though they were regularly feeding infants water. One mother demonstrated this in the following quote:

‘I would prepare for them some water to drink…There was no other food apart from water and breast milk…A baby brought up with breast milk and water is far much better than one who gets food on top of breast milk’.

The mothers in this study believed infants needed water to ‘quench thirst’. The misinterpretation that it is acceptable to give water while exclusively breastfeeding was also reported in the remaining four studies (Murray et al. 2008 ; Ostergaard & Bula 2010 ; Nor et al. 2012 ).

This systematic review is the first to investigate mothers' understanding of EBF. The pooled rate of 70.9% suggests a moderate to high understanding of EBF among mothers. The findings of the review indicate, however, that the understanding of the term EBF is extremely diverse among mothers, varying between 3.1 and 100% of mothers who could correctly define EBF. The themes that emerged suggest there are several misunderstandings of the term.

Mothers confused ‘exclusive’ from the term to mean ‘not’ to give breast milk (Murray et al. 2008 ; Petrie et al. 2008 ), to give breast milk accompanied with other fluids (Murray et al. 2008 ), to regularly breastfeed (Murray et al. 2008 ) and to not mix two types of milk (specifically formula and breast milk) (Nor et al. 2012 ). Although some mothers correctly paraphrased the definition of EBF, many were unclear of what the ‘E’ in the abbreviation denotes (Ostergaard & Bula 2010 ). The studies were conducted in South Africa (Murray et al. 2008 ; Petrie et al. 2008 ; Nor et al. 2012 ) and Malawi (Ostergaard & Bula 2010 ), which may indicate a poorer knowledge of EBF among mothers in these countries. This is of concern considering the high prevalence of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in Malawi and South Africa and the association of mother to child transmission of HIV with mixed breastfeeding (De Cock et al. 2000 ; Wojcicki et al. 2015 ). Overall, these findings highlight a clear issue about the ‘wording’ and ‘terminology’, specifically the word ‘exclusive’ used by health professionals and the public health sector to promote EBF.

EBF may be interpreted incorrectly by mothers because of inaccurate EBF messages conveyed by health professionals to mothers at health centres, antenatal clinics and hospitals (Nor et al. 2012 ). Health professionals' play an important role in conveying breastfeeding information to mothers (Lewallen et al. 2006 ); however, evidence suggests that some health professionals misunderstand EBF (Chopra et al. 2002 ; Cantrill et al. 2003 ; Shah et al. 2005 ; Taneja et al. 2005 ; Marais et al. 2010 ), such as encouraging supplementary feeding while exclusively breastfeeding. This highlights the need to ensure that breastfeeding training for health professionals is adequate, which requires a greater emphasis on what constitutes EBF. Educating health professionals and mothers at both prenatal and antenatal clinic levels is one way to address the misunderstanding of EBF.

Disparities in terminology between different languages may also explain mothers' lack of understanding of the EBF term. In some countries where English is not the first language, the translation of ‘exclusive’ may have slightly different meanings and mothers could be interpreting it differently to what the WHO definition implies. The word ‘exclusive’ can also be defined as ‘excluding’ (Oxford dictionary of English 2010 ); therefore, EBF could be interpreted as ‘excluding’ breastfeeding and may be a reason why some mothers thought EBF meant to not breastfeed (Murray et al. 2008 ; Petrie et al. 2008 ). Language barriers in understanding the term ‘EBF’ could be addressed with a more precise term for EBF, such as ‘fed only on breast milk’ or as suggested by South African authors (Du Plessis and Pereira, 2013 ) in the formulation of paediatric food‐based dietary guidelines for the country: ‘Give only breast milk, and no other foods or liquids, to your baby for the first six months of life’. Another suggestion to bridge this language gap could include consumer testing of the terminology with users, in this case mothers/women, across various languages and cultural groups. The use of media and especially social media to ‘normalise’ the ‘tested’ terminology to the public as well as standardisation of terms used globally and across the sector is important so that the public are hearing the same term wherever they are and have been primed on the meaning by social marketing strategies. There are also other WHO terms that are not widely used or understood in the public domain, for example ‘complementary feeding’ (Newby et al. 2014 ). Knowledge of other WHO terms related to infant feeding, as well as EBF, among different languages, is therefore an area of research that could be assessed in future studies.

Another major finding of the review was that mothers regularly gave water to infants but still considered themselves to be exclusively breastfeeding. Giving gripe water or glucose water was common as it was deemed a traditional practice (Murray et al. 2008 ; Ostergaard & Bula 2010 ; Ukegbu & Anyikaelekeh 2013 ; Nduna et al. 2015 ). Mothers believed infants aged less than six months needed water to quench their thirst or sooth them when they were distressed. Similar findings have been shown in the literature (Das & Ahmed 1995 ; Tarek et al. 2011 ). This finding is of concern; as feeding an infant under six months old with water can put them at risk of diarrhoea and malnutrition, especially in LMIC, where safety of water sources is a concern (Wright et al. 1989 ; Ip et al. 2007 ).

Giving water to infants less than six months appeared to be influenced by the advice given to mothers from influential members of the family, such as grandmothers or mothers‐in‐law. Mothers had an inadequate understanding of EBF when grandmothers were their main source of information (Oche et al. 2011 ). However mothers had a better understanding of EBF when they received information and advice from antenatal clinics, some of which were accredited Baby Friendly Hospital (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Ukegbu & Anyikaelekeh 2013 ; Onah et al. 2014 ). It is essential that mothers are able to follow a safe and optimal feeding method for their infants and avoid being influenced by incorrect information from family members. Public campaigns and initiatives could benefit from promoting EBF toward all women, including grandmothers, in order to target all who are influential on mothers' feeding choices (Goosen et al. 2014 ).

Studies that found most mothers knew the correct meaning of EBF reported results ranging from 72.7 (Nankunda et al. 2010 ) to 100% (Danso 2014 ). The literature suggests positive associations between women's educational level and their knowledge and practice of EBF (Ameer et al. 2008 ). In one study with mothers from Ghana who were in professional full‐time employment, 100% of mothers could define EBF, which may be because of the mothers' high level of education (Danso 2014 ). Breastfeeding is socially acceptable in Ghana and seen as the ‘norm’ so mothers may be more likely to breastfeed (Aidam et al. 2005 ).

The majority of studies that reported that most mothers knew the correct meaning of the term ‘EBF’ were conducted in Nigeria (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Ukegbu & Anyikaelekeh 2013 ; Onah et al. 2014 ). The percentage of mothers who could define EBF ranged between 82 (Onah et al. 2014 ) and 91.7% (Ukegbu & Anyikaelekeh 2013 ). The high proportion of mothers who could define EBF may have resulted from EBF advice and education through the Baby Friendly Hospital Initiative during antenatal and postnatal clinics in Nigeria (Ogbonna & Daboer 2007 ; Uchendu et al. 2009 ; Ukegbu & Ukegbu 2010 ; Ukegbu & Anyikaelekeh 2013 ; Onah et al. 2014 ).

A major flaw regarding the measure of assessing EBF knowledge was apparent in one of the studies reviewed (Oche et al. 2011 ). EBF knowledge was assessed through two aspects: duration of EBF and feeding the infant with breast milk only. To score ‘adequately’ the mothers only had to achieve a score of 50% on this question, meaning they only needed to answer one of the two aspects of the EBF definition correctly. The study implied that 30% of mothers knew the definition of EBF, yet 30% of mothers could have answered correctly for the ‘duration’ aspect, but incorrectly for the ‘breast milk only and nothing else’ aspect and vice versa. This finding may have consequently over reported how many mothers understood the definition of EBF, defined as ‘feeding the infant with breast milk only’. This ‘scoring’ issue is also evident in other literature concerning mothers' knowledge of EBF. Tarek et al. ( 2011 ) assessed EBF knowledge through a closed‐ended question in a questionnaire. The question asked for an EBF definition; however, mothers only had to mention ‘for six months’ to score correctly and did not have to mention exclusivity of breast milk. This question assessed mothers on the recommendation of EBF rather than the actual definition and is subject to potential measurement biases. This highlights a need to develop a validated tool that can assess EBF knowledge in a consistent and accurate way. See Box 1 which suggests key consideration aspects for future research regarding mothers' misconceptions of the term EBF.

Box 1: Key consideration aspects for future research regarding mothers' misconceptions of the term EBF

• The use of EXCLUSIVE should be reconsidered as mothers' misconceptions especially relate to this word. Translations of the term and within different cultural contexts should be investigated.
• Emphasis needs to be placed on the fact that giving water results in non‐exclusive breastfeeding as mothers still believe that giving water is ‘allowed’ when exclusively breastfeeding.
• A standardised tool to assess mothers' knowledge and understanding of EBF, based on the WHO definition (not including duration), is required for any research related to EBF.
• Mothers' understanding of the term EBF needs to be investigated in high income countries.

Research implications

Mothers' misunderstanding of the wording of ‘EBF’ could have implications for research reporting on EBF practices, prevalence and trends, when self‐report measures have been used to assess EBF. If mothers reported they were exclusively breastfeeding, yet they were also giving supplementary fluids to their infant (Ostergaard & Bula 2010 ), the number of mothers truly exclusively breastfeeding is likely to be overestimated. For example, in Malawi, EBF prevalence is higher than most countries in the world at approximately 71.4% (Indexmundi 2014 ); however, EBF prevalence tend to be based on household surveys or similar measures involving self‐report methods. If mothers do not understand the true meaning of EBF, then the true prevalence of EBF may be lower than reported. Research which has investigated the barriers and facilitators of EBF for mothers is also likely to be inaccurate. This is a concern globally considering the extensive literature base that exists on practices, prevalence, trends and barriers of EBF, which could be incorrect if subjective measures have been employed.

Strengths and limitations

This is the first systematic review to examine whether mothers understand the term EBF. The review involved an exhaustive search of available and relevant literature using a comprehensive search strategy across eight databases, starting from when the term EBF originated and with no language restrictions imposed.

A key limitation of the systematic review is that the findings are based on outcomes that were often not the ‘main objective’ of the studies or on anecdotal reports within the study findings. The findings of the systematic review must be interpreted with caution considering the heterogeneity among the included studies. All of the included studies were conducted in LMIC, which may bias findings to this context and not be generalisable to HIC. Publication bias should also be considered, as some electronic journals were not accessible, resulting in six full text articles that were unable to be located through inter‐library loans ( Supporting information: Appendix 2 ). Although 12 articles were translated into English, one Croatian article was excluded, as a translator was not found and the full text was unable to be located through inter‐library loans ( Supporting information: Appendix 2 ). This is a limitation of the review, considering Croatia is considered a HIC (Country Income Groups (World Bank Classification) & Country and Lending Groups 2011 ).

Source of funding

Funding was received from the Graduate School, College of Life Sciences and Medicine, University of Aberdeen. JH is supported by funding from the Rural and Environment Science and Analytical Services Division (RESAS) programme of the Scottish Government.

Conflict of interest

The authors declare that they have no conflict of interest.

Contributor statement

All authors made substantial contributions to the conception and design of the review. RS conducted the review as first reviewer and drafted the article. DM and JH contributed as second reviewers during title and abstract screening, full text reading, data extraction and quality appraisal. DM and JH also provided critical feedback for revision of the article. All authors gave final approval of the version to be published.

Supporting information

Supporting info item

Acknowledgments

We thank the Public Health Nutrition Research Group at the University of Aberdeen for all their support and advice. We also thank the Librarians at the Medical Library, University of Aberdeen, for their advice with developing the search strategy and their assistance with inter library loans.

Still, R. , Marais, D. , and Hollis, J. L. (2017) Mothers' understanding of the term ‘exclusive breastfeeding’: a systematic review . Maternal & Child Nutrition , 13 : e12336. doi: 10.1111/mcn.12336. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

• Abul‐Fadl A.M., Shawky M., El‐Taweel A., Cadwell K. & Turner‐Maffei C. (2012) Evaluation of mothers' knowledge, attitudes, and practice towards the ten steps to successful breastfeeding in Egypt . Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine 7 ( 3 ), 173–178. [ PubMed ] [ Google Scholar ]
• Adeyemi O.A. & Oyewole O.E. (2014) How can we really improve childcare practices in Nigeria? Health Promotion International 29 ( 2 ), 369–377. [ PubMed ] [ Google Scholar ]
• Aidam B.A., Perez‐Escamilla R., Lartey A. & Aidam J. (2005) Factors associated with exclusive breastfeeding in Accra, Ghana . European Journal of Clinical Nutrition 59 ( 6 ), 789–796. [ PubMed ] [ Google Scholar ]
• Aksu H., Küçük M. & Düzgün G. (2011) The effect of postnatal breastfeeding education/support offered at home 3 days after delivery on breastfeeding duration and knowledge: a randomized trial . Journal of Maternal‐Fetal and Neonatal Medicine 24 ( 2 ), 354–361. [ PubMed ] [ Google Scholar ]
• Alade O., Titiloye M.A., Oshiname F.O. & Arulogun O.S. (2013) Exclusive breastfeeding and related antecedent factors among lactating mothers in a rural community in Southwest Nigeria . International Journal of Nursing 5 ( 7 ), 132–138. [ Google Scholar ]
• Ameer A., Al‐Hadi A. & Abdulla M. (2008) Knowledge, attitudes and practices of Iraqi mothers and family child‐caring women regarding breastfeeding . East Mediterranean Health Journal 14 ( 5 ), 1003–1004. [ PubMed ] [ Google Scholar ]
• Arifeen S., Black R.E., Antelman G., Baqui A., Caulfield L. & Becker S. (2001) Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums . Pediatrics 108 ( 4 ), E67. [ PubMed ] [ Google Scholar ]
• Arimond M. & Ruel M.T. (2002) Progress in Developing an Infant and Child Feeding Index: An Example Using the Ethiopia Demographic and Health Survey 2000 . International Food Policy Research Institute: Washington, DC. [ Google Scholar ]
• Cantrill R.M., Creedy D.K. & Cooke M. (2003) An Australian study of midwives' breast‐feeding knowledge . Midwifery 19 ( 4 ), 310–317. [ PubMed ] [ Google Scholar ]
• Caulfield L.E., Richard S.A., Rivera J.A., Musgrove P. & Black R.E. (2006) Stunting, wasting, and micronutrient deficiency disorders (eds Jamison D.T., Breman J.G., Measham A.R. et al), Disease Control Priorities in Developing Countries . 2nd edition Washington (DC): World Bank; 2006. Chapter 28. Available at: http://www.ncbi.nlm.nih.gov/books/NBK11761/ [Accessed 15/08/15]. [ Google Scholar ]
• Centers For Disease Control And Prevention (CDC) (2007) Breastfeeding trends and updated national health objectives for exclusive breastfeeding – United States, birth years 2000–2004 . MMWR. Morbidity and Mortality Weekly Report 56 ( 30 ), 760–763. [ PubMed ] [ Google Scholar ]
• Chen C.H., Shu H.Q. & Chi C.S. (2001) Breastfeeding knowledge and attitudes of health professionals and students . Acta Paediatrica Taiwanica = Taiwan er ke yi xue hui za zhi 42 ( 4 ), 207–211. [ PubMed ] [ Google Scholar ]
• Chopra M., Piwoz E., Sengwana J., Schaay N., Dunnett L. & Sanders D. (2002) Effect of a mother‐to‐child HIV prevention programme on infant feeding and caring practices in South Africa . South African Medical Journal Cape Town Medical Association of South Africa 92 ( 4 ), 298–302. [ PubMed ] [ Google Scholar ]
• Country Income Groups (World Bank Classification) , Country and Lending Groups (2011) The World Bank Group . Available at: http://data.worldbank.org/about/country-classifications/country-and-lending-groups . [Accessed 11/03/16].
• Danso J. (2014) Examining the practice of exclusive breastfeeding among professional working mothers in Kumasi metropolis of Ghana . International Journal of Nursing 1 ( 1 ), 11–24. [ Google Scholar ]
• Das D.K. & Ahmed S. (1995) Knowledge and attitude of the Bangladeshi rural mothers regarding breastfeeding and weaning . Indian Journal of Pediatrics 62 ( 2 ), 213–217. [ PubMed ] [ Google Scholar ]
• De Cock K.M., Fowler M.G., Mercier E., De Vincenzi I., Saba J., Hoff E. et al (2000) Prevention of mother‐to‐child HIV transmission in resource‐poor countries: translating research into policy and practice . JAMA 283 ( 9 ), 1175–1182. [ PubMed ] [ Google Scholar ]
• Desai A., Mbuya M.N.N., Chigumira A., Chasekwa B., Humphrey J.H., Moulton L.H. et al (2014) Traditional oral remedies and perceived breast milk insufficiency are major barriers to exclusive breastfeeding in rural Zimbabwe . Journal of Nutrition 144 ( 7 ), 1113–1119. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Du Plessis L.M. & Pereira C. (2013) Commitment and capacity for the support of breastfeeding in South Africa . South African Journal of Clinical Nutrition 26 ( S ), 120–128. [ Google Scholar ]
• Global Nutrition Report (2015) Actions And Accountability To Advance Nutrition And Sustainable Development. International Food Policy Research Institute . 2015. Washington, DC. Available at: https://www.ifpri.org/publication/global-nutrition-report-2015 . [Accessed 17/06/2015] [ PMC free article ] [ PubMed ]
• Goosen C., McLachlan M.H. & Schubl C. (2014) Factors impeding exclusive breastfeeding in a low‐income area of the Western Cape province of South Africa . Africa Journal of Nursing and Midwifery 16 ( 1 ), 13–31. [ Google Scholar ]
• Guyatt G., Sackett D. & Cook D. (1993a) Users' guides to the medical literature, II: how to use an article about therapy or prevention, A: are the results of the study valid? JAMA 270 . [ PubMed ] [ Google Scholar ]
• Guyatt G.H., Sackett D.L., Cook D.J., Guyatt G., Bass E., Brill‐Edwards P. et al (1993b) Users' guides to the medical literature: II. How to use an article about therapy or prevention a. Are the results of the study valid? JAMA 270 ( 21 ), 2598–2601. [ PubMed ] [ Google Scholar ]
• Indexmundi (2014) (last update), Malawi: Exclusive Breastfeeding . Available: http://www.indexmundi.com/facts/malawi/exclusive-breastfeeding [Accessed 15/07/2015, 2015].
• Ip S., Chung M., Raman G., Chew P., Magula N., Devine D. et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries . Evidence Report/Technology Assessment 153 , 1–186. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kramer M. & Kakuma R. (2009) Optimal duration of exclusive breastfeeding (Review) . Cochrane Database of Systematic Reviews 2012 ( 8 ), CD003517. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kramer M.S. & Kakuma R. (2004) The optimal duration of exclusive breastfeeding In: Protecting Infants through Human Milk , Vol. 554 , pp 63–77. Springer: US. [ PubMed ] [ Google Scholar ]
• Laanterä S., Pölkki T. & Pietilä A. (2011) A descriptive qualitative review of the barriers relating to breast‐feeding counseling . International Journal of Nursing Practice 17 ( 1 ), 72–84. [ PubMed ] [ Google Scholar ]
• Labbok M. & Krasovec K. (1990) Toward consistency in breastfeeding definitions . Studies in Family Planning 21 ( 4 ), 226–230. [ PubMed ] [ Google Scholar ]
• Lewallen L.P., Dick M.J., Flowers J., Powell W., Zickefoose K.T., Wall Y.G. et al (2006) Breastfeeding support and early cessation . Journal of Obstetric, Gynecologic, and Neonatal Nursing 35 ( 2 ), 166–172. [ PubMed ] [ Google Scholar ]
• Marais D.B., Koornhof H.E., Du Plessis M.L., Naude C.E., Smit K., Treurnicht R., et al (2010) Breastfeeding policies and practices in healthcare facilities in the Western Cape Province, South Africa 23(1).
• Mcintyre E. & Lawlor‐smith C. (1996) Improving the breastfeeding knowledge of health professionals . Australian Family Physician 25 ( 9 Suppl 2 ), S68–70. [ PubMed ] [ Google Scholar ]
• Moher D., Liberati A., Tetzlaff J., Altman D.G; The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta‐Analyses: The PRISMA Statement . PLoS Med 6 ( 7 ): e1000097. doi: 10.1371/journal.pmed1000097 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Murray S., Tredoux S., Viljoen L., Herselman M. & Marais D. (2008) Consumer testing of the preliminary Paediatric Food‐Based Dietary Guidelines (PFBDG) among mothers with infants younger than 6 months in selected urban and rural areas in the Western Cape . South African Journal of Clinical Nutrition 21 ( 1 ), 34–38. [ Google Scholar ]
• Nankunda J., Tylleskar T., Ndeezi G., Semiyaga N. & Tumwine J.K. (2010) Establishing individual peer counselling for exclusive breastfeeding in Uganda: implications for scaling‐up . Maternal & Child Nutrition 6 ( 1 ), 53–66 34. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Nduna T., Marais D. & Van Wyk B. (2015) An explorative qualitative study of experiences and challenges to exclusive breastfeeding among mothers in rural Zimbabwe . ICAN: Infant, Child, & Adolescent Nutrition 7 ( 2 ), 69–76. [ Google Scholar ]
• Newby R., Brodribb W., Ware R.S. & Davies P.S. (2014) Infant feeding knowledge, attitudes, and beliefs predict antenatal intention among first‐time mothers in Queensland . Breastfeeding Medicine 9 ( 5 ), 266–272. [ PubMed ] [ Google Scholar ]
• Nor B., Ahlberg B.M., Doherty T., Zembe Y., Jackson D. & Ekstrom E.C. (2012) Mother's perceptions and experiences of infant feeding within a community‐based peer counselling intervention in South Africa . Maternal & Child Nutrition 8 ( 4 ), 448–458. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Oche M.O., Umar A.S. & Ahmed H. (2011) Knowledge and practice of exclusive breastfeeding in Kware, Nigeria . African Health Sciences 11 ( 3 ), 518–523 29. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ogbonna C. & Daboer J.C. (2007) Current knowledge and practice of exclusive breastfeeding among mothers in Jos, Nigeria . Nigerian Journal of Medicine: Journal of the National Association of Resident Doctors of Nigeria 16 ( 3 ), 256–260. [ PubMed ] [ Google Scholar ]
• Okolo S.N., Adewunmi Y.B. & Okonji M.C. (1999) Current breastfeeding knowledge, attitude, and practices of mothers in five rural communities in the Savannah region of Nigeria . Journal of Tropical Pediatrics 45 ( 6 ), 323–326. [ PubMed ] [ Google Scholar ]
• Onah S., Osuorah D.I.C., Ebenebe J., Ezechukwu C., Ekwochi U. & Ndukwu I. (2014) Infant feeding practices and maternal socio‐demographic factors that influence practice of exclusive breastfeeding among mothers in Nnewi South‐East Nigeria: a cross‐sectional and analytical study . International Breastfeeding Journal 9 ( 6 ). [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ostergaard L.R. & Bula A. (2010) “They call our children “Nevirapine babies?””: a qualitative study about exclusive breastfeeding among HIV positive mothers in Malawi . African Journal of Reproductive Health 14 ( 3 ), 213–222. [ PubMed ] [ Google Scholar ]
• Otoo G.E., Lartey A. & Perez‐Escamilla R. (2009) Perceived incentives and barriers to exclusive breastfeeding among peri‐urban Ghanaian women . Journal of Human Lactation 25 ( 1 ), 34–41. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Oxford dictionary of English (2010) In: Oxford Dictionary, 3rd ed. Oxford University Press: Oxford. [ Google Scholar ]
• Petrie K., Schmidt S., Schwarz C., Koornhof H. & Marais D. (2008) Knowledge, attitudes and practices of women regarding the prevention of mother‐to‐child transmission (PMTCT) programme at the Vanguard Community Health Centre, Western Cape – a pilot study . South African Journal of Clinical Nutrition 20 ( 2 ), 71–78. [ Google Scholar ]
• Piwoz E.G., Creed De Kanashiro H., Lopez De Romana G., Black R.E. & Brown K.H. (1995) Potential for misclassification of infants' usual feeding practices using 24‐hour dietary assessment methods . The Journal of Nutrition 125 , 57–65. [ PubMed ] [ Google Scholar ]
• Piwoz E.G., Ferguson Y.O., Bentley M.E., Corneli A.L., Moses A., Nkhoma J. et al (2006) Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counseling messages of health workers in Lilongwe, Malawi . International Breastfeeding Journal 1 ( 1 ), 2. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• PRISMA Checklist . (2009) Transparent reporting of Systematic Reviews and Meta‐Analyses2014‐last update . Available: http://www.prisma-statement.org . [Accessed 07/06/2015, 2015].
• Shah S., Rollins N.C., Bland R. & CHILD HEALTH GROUP (2005) Breastfeeding knowledge among health workers in rural South Africa . Journal of Tropical Pediatrics 51 ( 1 ), 33–38. [ PubMed ] [ Google Scholar ]
• Taneja D., Misra A. & Mathur N. (2005) Infant feeding – an evaluation of text and taught . Indian Journal of Pediatrics 72 ( 2 ), 127–129. [ PubMed ] [ Google Scholar ]
• Tarek A., Hatem H. & Alqader A.A. (2011) Determinants of initiation and exclusivity of breastfeeding in Al Hassa, Saudi Arabia . Breastfeeding Medicine 6 ( 2 ), 59–68. [ PubMed ] [ Google Scholar ]
• Tennant R., Wallaceba L.M. & Law S. (2006) Barriers to breastfeeding: a qualitative study of the views of health professionals and lay counsellors . Community Practitioner 79 ( 5 ), 152–156. [ PubMed ] [ Google Scholar ]
• The Cochrane Collaboration (2015) (last update) Data Collection Form, Intervention Review – RCT's only . Available at: http://webcache.googleusercontent.com/search?q=cache:o2JDIGgCqkEJ:hiv.cochrane.org/sites/hiv.cochrane.org/files/uploads/Data%2520extraction%2520form_RCTs.docx+&cd=2&hl=en&ct=clnk&gl=uk&client=safari . [Accessed 10/06/15].
• Uchendu U.O., Ikefuna A.N. & Emodi I.J. (2009) Exclusive breastfeeding – the relationship between maternal perception and practice . Nigerian Journal of Clinical Practice 12 ( 4 ), 403–406. [ PubMed ] [ Google Scholar ]
• Ukegbu A.U., Ebenebe E.U., Ukegbu P.O. & Onyeonoro U.U. (2011) Determinants of breastfeeding pattern among nursing mothers in Anambra State, Nigeria . East African Journal of Public Health 8 ( 3 ), 226–231. [ PubMed ] [ Google Scholar ]
• Ukegbu P.O. & Anyikaelekeh J.U. (2013) Influence of maternal characteristics on exclusive breastfeeding practice among urban mothers in Umuahia, Nigeria . Malaysian Journal of Nutrition 19 ( 3 ), 311–323. [ Google Scholar ]
• Ukegbu P.O. & Ukegbu A.U. (2010) Breastfeeding practices among rural mothers in Imo State, Nigeria . Journal of Sustainable Agriculture and Environment 12 ( 1 ), 68–77. [ Google Scholar ]
• Wojcicki J.M., Nxumalo N.C. & Masuku S. (2015) Preventing mother‐to‐child transmission of the human immunodeficiency virus in Southern Africa . Acta Paediatrica 104 ( 12 ), 1211–1214. [ PubMed ] [ Google Scholar ]
• World Health Organization (1991) Indicators for assessing breast feeding practices. Division Of Child Health And Development . WHO Document WHO/CDD/SER 91 , 14. [ Google Scholar ]
• World Health Organization (2008a) Indicators for Assessing Infant and Young Child Feeding Practices: Part I . World Health Organization; Geneva. Switzerland: [Online]. Available at: http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf?ua=1 . [Accessed 12/2/16]. [ Google Scholar ]
• World Health Organization . (2008b) Indicators for Assessing Infant and Young Child Feeding Practices: Part 3 . World Health Organization; Geneva: Switzerland. [Online]. Available at: http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf?ua=1 [Accessed 12/2/16]. [ Google Scholar ]
• World Health Organization (2014) (last update) The World Health Organization global data bank on infant and young child feeding Geneva : World Health Organization Available at: http://apps.who.int/gho/data/view.main.NUT1730?lang=en [Accessed 09/05/15].
• World Health Organization (2016) Exclusive Breastfeeding . Available at: http://www.who.int/elena/titles/exclusive_breastfeeding/en/ [Accessed 12/02/16].
• Wright A.L., Holberg C.J., Martinez F.D., Morgan W.J. & Taussig L.M. (1989) Breast feeding and lower respiratory tract illness in the first year of life. Group Health Medical Associates . BMJ (Clinical Research Ed.) 299 ( 6705 ), 946–949. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Zakarija‐Grković I. & Burmaz T. (2010) Effectiveness of the UNICEF/WHO 20‐hour course in improving health professionals' knowledge, practices, and attitudes to breastfeeding: before/after study of 5 maternity facilities in Croatia . Croatian Medical Journal 51 ( 5 ), 396–405. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Zohoori N., Popkin B.M. & Fernandez M.E. (1993) Breastfeeding patterns in the Philippines: a prospective analysis . Journal of Biosocial Science 25 , 127–138. [ PubMed ] [ Google Scholar ]

• Study Protocol
• Open access
• Published: 01 June 2024

Explaining the perception and experiences of breastfeeding in mothers who have a high risk pregnancy: a protocol study

• Kobra Mirzakhani 1 , 2 ,
• Atefeh Yas 3 &
• Talat Khadivzadeh 1 , 2  

Reproductive Health volume  21 , Article number:  74 ( 2024 ) Cite this article

99 Accesses

Metrics details

Introduction

Enhancing breastfeeding practices, even in affluent nations, significantly reduces child mortality rates. Nevertheless, three out of five newborns do not receive breastfeeding within the first hour of birth. Research indicates that under high-risk pregnancy circumstances, there may be challenges in initiating and sustaining breastfeeding. Infants born from high-risk pregnancies are particularly vulnerable to illnesses and mortality. Although breastfeeding serves as a protective measure against various infant and post-infancy ailments, many mothers encounter difficulties in commencing or maintaining breastfeeding due to complications associated with their conditions. The present study aims to illuminate the understanding and experience of breastfeeding in mothers with high-risk pregnancies, considering the cultural and social context of Iran.

This study is a qualitative research utilizing a conventional content analysis approach. In this qualitative study, mothers who have undergone a high-risk pregnancy and currently have infants under 6 months old will be chosen through purposeful and snowball sampling. Their breastfeeding experiences will be gathered through individual, semi-structured, and face-to-face interviews. In addition to interviews, observation and focus groups will also be used to collect data. Data analysis was performed using Graneheim and Lundman’s method with MAXQDA software version 10, VERBI Software GmbH, Berlin. The study will utilize the criteria of Lincoln and Guba (1985) for validity and reliability.

This qualitative study aims to investigate the experiences and challenges of breastfeeding in mothers with high-risk pregnancies to pinpoint breastfeeding barriers in this demographic and develop essential interventions and strategies to address these obstacles.

Breastfeeding is viewed as a distinctive method of nourishing infants, offering both short-term and long-term emotional, nutritional, and immunological advantages [ 1 ]. Boosting breastfeeding rates has the potential to save the lives of up to 800,000 children, even in high-income nations. It also contributes to maternal health, with estimates suggesting that breastfeeding prevents 20,000 deaths annually from breast cancer [ 2 , 3 ]. However, statistics reveal that 3 out of every 5 infants are not breastfed within the first hour after birth, increasing their vulnerability to mortality and illness [ 4 ]. Breastfeeding not only enhances the well-being of both mother and child but is also acknowledge d as a key strategy for attaining sustainable development goals [ 5 ]. Aligned with global health and development targets, the World Health Organization pledged in 2012 to raise the worldwide rate of exclusive breastfeeding in the initial 6 months of life from 37 to 50% by 2025 by supporting breastfeeding initiatives [ 6 ]. A systematic review in Iran showed that the prevalence of exclusive breastfeeding varies from 61 to 82% [ 7 ].

Studies indicate that the presence of risk factors during pregnancy can delay the initiation and continuation of breastfeeding, leading to reduced success for mothers [ 8 ]. Cordero et al. (2016) found that mothers with diabetes, substance abuse, and preterm labor have lower rates of breastfeeding initiation compared to healthy women [ 9 ]. Similarly, Scime et al. [ 10 ] demonstrated that prenatal medical risk is linked to shorter breastfeeding duration. Maternal obesity, a significant risk factor in high-risk pregnancies, is associated with various breastfeeding challenges, reduced initiation, and shorter exclusive breastfeeding duration [ 11 , 12 ]. High-risk pregnant mothers also experience physical and emotional distress due to health concerns, anxiety, and worries about their newborns [ 13 ]. Additionally, there are concerns about the impact of medication use on the quality of breast milk, which can disrupt maternal roles in this group of mothers [ 14 , 15 ]. Therefore, efforts to promote breastfeeding among mothers who have experienced high-risk pregnancies are essential [ 16 ].

In some cases, breastfeeding in high-risk pregnancies can have positive effects on maternal health, such as improving left ventricular function and maternal outcomes in diseases like peripartum cardiomyopathy (PPCM) [ 17 , 18 ]. Long-term breastfeeding in mothers with gestational diabetes can also reduce the risk of maternal diabetes postpartum [ 19 ]. Breastfeeding in mothers with gestational hypertension is associated with lower blood pressure in postpartum [ 20 ].

Research has focused on factors influencing the initiation and continuation of breastfeeding in high-risk pregnant women. Some evidence suggests that parents have the most influence on deciding to start or stop breastfeeding. Official support may also impact breastfeeding practices. Family and friends play a role in encouraging breastfeeding, and environmental support can be crucial [ 8 , 21 , 22 ]. Support in breastfeeding is vital in preventing maternal fatigue and increasing cardiac workload, especially in high-risk pregnancies such as congenital heart diseases (CDH) [ 15 ]. Integration of breastfeeding education and counseling in the care of high-risk pregnant women is necessary to address their knowledge and skill gaps [ 9 ]. Educational and supportive programs can prevent delays in breastfeeding initiation in women with preeclampsia [ 23 ].

Social-cultural factors such as a mother’s beliefs and those of her surroundings about infant nutrition are influential factors in exclusive breastfeeding [ 8 ]. Breastfeeding until the age of two has been emphasized in the Holy Quran. In Iran, it seems that breastfeeding is rooted more in Iranian and Islamic culture dominating society than in scientific advancements [ 7 , 16 ]. On the other hand, healthcare providers need to be aware of the determinants of exclusive breastfeeding with maternal milk to offer preventive solutions to overcome these barriers and help improve the health outcomes of mothers and children [ 8 ].

Improving breastfeeding rates among all mothers, with a focus on groups of the population with the lowest breastfeeding rates, is a key objective of the health sector. Comprehensive interventions involving hospitals, culture, and community are necessary to improve breastfeeding-related indicators [ 16 , 24 ].

Pregnant mothers in high-risk populations face various health consequences and risks. Therefore, understanding their perspective on breastfeeding is crucial for effective interventions. Exploring the breastfeeding experiences of these mothers, identifying barriers and facilitators, can offer valuable insights and guide midwives in designing interventions to enhance maternal and infant health and reduce health disparities. Due to the lack of comprehensive research on the breastfeeding experiences of at-risk pregnant mothers, it is essential to investigate their perceptions of initiating and sustaining breastfeeding and the support they require within the cultural and social context of Iranian society. Hence, a qualitative study has been planned to uncover the experiences of these mothers and develop necessary solutions and interventions to promote successful breastfeeding among high-risk pregnant mothers. Utilizing qualitative research with conventional content analysis methodology is recommended for its ability to elucidate the understanding and experiences of concepts, enabling researchers to address their research inquiries effectively. This approach allows researchers to interpret data authentically and scientifically [ 25 , 26 ].

Main objective

To elucidate the understanding and experience of breastfeeding in mothers with high-risk pregnancies.

Specific objectives

Clarifying the understanding of breastfeeding in mothers with high-risk pregnancies.

Elucidating the experience of breastfeeding in mothers with high-risk pregnancies.

Clarification of health care workers’ understanding of breastfeeding in mothers with high-risk pregnancies.

Primary research question

What is the understanding and experience of breastfeeding in mothers with high-risk pregnancies?

The present study is a qualitative research using a conventional content analysis approach. Qualitative content analysis is a flexible method for analyzing various types of data and information. It can be considered as a research method for interpreting the textual data, involving coding, identifying themes, or designing patterns. This approach aims to condense data, organize data, and develop theories and models. Qualitative content analysis is also applicable in cases where the study aims to achieve a comprehensive and extensive description of a phenomenon, introduce reality, create a new overall perspective or concepts, or create descriptive categories that describe the phenomenon [ 25 ].

Considering the researcher’s intention to comprehensively describe and explain mothers’ understanding and experience after a high-risk pregnancy regarding breastfeeding and their decision-making process for breastfeeding, and considering the sensitivity and cultural aspects of breastfeeding, conventional content analysis appears to be the most appropriate approach for this study.

Inclusion and exclusion criteria

Inclusion criteria include mothers aged 15 to 49 years with a baby under 6 months old, having at least one risk factor during pregnancy such as gestational diabetes, hypertension during pregnancy, BMI over 29, treated mental illness, bleeding during pregnancy, infection, premature birth, internal surgical diseases during pregnancy (e.g., heart, kidney, gastrointestinal diseases), having at least one attempt by the mother to breastfeed and speak in Persian. The exclusion criteria also includes the mother’s unwillingness to participate in the interview.

Setting and sampling

The research environment includes teaching hospitals and healthcare centers in the city of Mashhad. These environments are chosen for easy access and maximum participant diversity. Sampling will be purposeful and based on the snowball method to ensure maximum diversity.

Researchers will commence sampling after obtaining approval from the ethics committee of Mashhad University of Medical Sciences and obtaining a referral letter from the School of Nursing and Midwifery in Mashhad. They will initiate sampling by visiting the research environment officials, providing explanations and outlining the research objectives.

Researchers will aim to ensure maximum diversity in the samples concerning age, infant age, type of baby feeding, socio-economic status, type of pregnancy-related condition, and healthcare interventions. Using the snowball method, employed midwives in health centers will be asked to connect researchers with mothers knowledgeable about the research topic. Subsequently, researchers will contact selected participants via phone, explain the research goals, invite them to join the study, and interview interested mothers who meet the study criteria. Participants will receive necessary information about voluntary participation, confidentiality, and anonymity. The interviews will be conducted by two trained researchers who will establish rapport to gain participants’ trust and obtain written consent. Through semi-structured individual interviews and face-to-face interactions, researchers will explore participants’ emotions, perceptions, and thoughts.

Data collection

An interview with an open-ended question with mothers about their experience of initiating and sustaining breastfeeding will continue with exploratory questions to provide further explanation. An interview guide has been prepared for this purpose (Talk about your experience of starting and continuing breastfeeding, Talk about your experience about deciding to start breastfeeding, Talk about your experience about deciding to continue breastfeeding, Express your understanding of the influence of formal and informal support networks on the decision and continuation of breastfeeding).

During the interview, participants will be encouraged to describe their experiences regarding the initiation and continuation of breastfeeding to clarify the decision-making process and to express the obstacles and facilitating factors that have influenced their decision and ability to breastfeed or reduce and stop it. Participants’ understanding of the impact of their formal and informal support networks on their decisions regarding breastfeeding will also be examined. At the end of the interviews, participants will be asked to take note of any additional experiences or insights that come to mind later and provide them to the researcher. Following expressions of gratitude and appreciation, participants will be informed about the possibility of future face-to-face or remote interviews, and a suitable gift will be provided at the end of the session as a token of appreciation.

The duration of the interviews is estimated to be between 60–90 min, depending on the amount of information and participants’ circumstances. With participants’ permission, the interviews will be fully recorded using an MP3 player. The interviews will take place in a quiet room with adequate facilities for the comfort of breastfeeding mothers, considering the conditions of healthcare centers, homes, or any other location desired by the breastfeeding mother. Sampling will continue until no new information is obtained from the interviews and until data saturation is reached [ 27 ].

The breastfeeding behavior of mothers and communication between mothers and health care workers for breastfeeding will be observed in the hospital after the birth of the baby. A trained qualitative researcher (AY) will carry out the non-participant observations, a method in which the researcher does not participate actively, but just observes a situation without interfering. The observation takes place in natural settings, allowing the observer to evaluate non-verbal cues, thus increasing ecological validity. Prior to requesting consent for the observation, the researcher will clarify that she will be observing the entire session, taking notes, and recording the conversation with a smartphone.

A focus group will be used to explain the health providers’ understanding of breastfeeding in mothers with high-risk pregnancies. Health providers (including midwives, nurses and gynecologists and pediatricians) working in women’s hospital and health centers (with work experience of at least 5 years) will participate in the sessions. It is expected that 3–4 sessions will be held. Approximately 8–12 health care workers will be present in each session. The aims of the focus group will be explained, and consent will be sought for audio recording. The focus group will last approximately 2 h. Researchers will conduct the focus group, one observe and take notes of the discussion and two will conduct the conversation guided by a list of topics prepared prior to the group (How is breastfeeding in mothers with high-risk pregnancies? What factors affect the breastfeeding of this group of mothers?). The focus group’s audio recording will be transcribed verbatim. Then, the researchers team will read the transcripts separately and analysis the data.

Data analysis

Data analysis will be conducted simultaneously with data collection. MAXQDA software version 10, developed by VERBI Software GmbH in Berlin, will be used for managing and organizing the data.

Data analysis was conducted using Graneheim and Lundman’s method in four stages [ 28 ]. Stage 1 involved reading the interviews multiple times to grasp their content and gain insights by exploring both latent and manifest content. In Stage 2, the text of each interview transcript was divided into meaningful units such as words, sentences, and paragraphs, where connections between different texts were identified. Stage 3 focused on condensing the meaningful units and assigning codes to them. In Stage 4, the codes were compared for similarities and differences, with similar codes grouped into initial categories. As the analysis progressed, the initial categories were refined, and subcategories were formed. Finally, main categories emerged from the integration of similar subcategories.

Validity and reliability of the study

In the present research, the validity and reliability of the findings will be evaluated using criteria established by Lincoln and Guba (1985). The researchers have suggested four indicators to bolster the credibility of qualitative research: credibility, dependability, confirmability, and transferability [ 29 ].

To enhance the credibility and acceptance of the data, the researcher aims to offer recorded information and codes to the participants throughout the study to validate the main themes derived from mothers’ accounts of breastfeeding experiences, barriers to initiation, and factors supporting breastfeeding continuation. In this research, information and data are gathered from participants with diverse experiences. Sufficient data collection, selection of appropriate meaningful units, description of category and theme development, explanation of how judgments are made regarding similarities and differences between categories through the use of participants’ quotes all contribute to the credibility of the data.

Researchers will aim to establish effective communication with participants. Additionally, to boost data credibility, all interviews will be recorded verbatim and transcribed word by word. Throughout the research write-up, participants’ statements will be accurately documented, and data will be meticulously maintained. The researcher will clarify how units of meaning are summarized and condensed, how categories are formed, and how themes are developed. The research process and decisions taken along this journey will be reported to facilitate follow-up by other researchers. To ensure auditability, activities will be documented over time so that others can trace the subject by reading these writings. For the transferability of findings, the researcher will offer a detailed description of the research context, participant involvement, sampling methods, and data collection time and location to confirm data transferability for readers.

The prevalence of high-risk pregnancy in Iran has been reported to be 52–8/39% [ 30 , 31 ], and the rate of exclusive breastfeeding in Iran up to 6 months is 53% [ 32 ]. Studies indicate that in high-risk pregnancy conditions or the occurrence of pregnancy risk factors, there is a possibility of reduced success in breastfeeding. While infants born from high-risk pregnancies are at a higher risk of disease and mortality, breastfeeding protects them against many infant and post-infancy diseases. Therefore, identifying facilitators and barriers to breastfeeding in mothers with high-risk pregnancies is of particular importance, and the current research also helps in discovering and explaining the obstacles to breastfeeding in this group of mothers so that by implementing specific actions and interventions to address them, it can contribute to improving breastfeeding indicators.

Availability of data and materials

No datasets were generated or analysed during the current study.

Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(1):475–90.

Article   PubMed   Google Scholar  

Increasing breastfeeding could save 800 000 children and US$ 300 billion every year. 2016. http://www.who.int/maternal_child_adolescent/news_events/news/2016/exclusive-breastfeeding/en/ .

Stordal B. Breastfeeding reduces the risk of breast cancer: A call for action in high-income countries with low rates of breastfeeding. Cancer Med. 2023;12(4):4616–25.

Breastfeeding within an hour after birth is critical for saving newborn lives. 2018. https://www.who.int/news/item . Cited 2021.

Kmietowicz Z. Humanitarian leaders call for “redoubling” of aid for crisis engulfing Yemen. BMJ. 2017;358(2):36–42.

Google Scholar  

World Health Organization. Statement from UNICEF Executive Director Anthony Lake and WHO Director-General Margaret Chan on the cholera outbreak in Yemen as suspected cases exceed 200,000. 2017. Cited 2020.

Ranjbaran M, Nakhaei MR, Chizary M, Shamsi M. Prevalence of exclusive breastfeeding in Iran: systematic review and meta-analysis. Epidemiol Health System J. 2016;3(3):294–301.

Balogun OO, Dagvadorj A, Anigo KM, Ota E, Sasaki S. Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: a quantitative and qualitative systematic review. Matern Child Nutr. 2015;11(4):433–51.

Article   PubMed   PubMed Central   Google Scholar  

Cordero L, Oza-Frank R, Moore-Clingenpeel M, Landon M, Nankervis C. Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed. J Neonatal Perinatal Med. 2016;9(4):401–9.

Article   CAS   PubMed   Google Scholar  

Scime NV, Metcalfe A, Nettel-Aguirre A, Tough SC, Chaput KH. Association of prenatal medical risk with breastfeeding outcomes up to 12 months in the All Our Families community-based birth cohort. Int Breastfeed J. 2021;16:1–12.

Article   Google Scholar  

Bever Babendure J, Reifsnider E, Mendias E, Moramarco MW, Davila YR. Reduced breastfeeding rates among obese mothers: a review of contributing factors, clinical considerations and future directions. Int Breastfeed J. 2015;10(1):1–11.

Garner CD, McKenzie SA, Devine CM, Thornburg LL, Rasmussen KM. Obese women experience multiple challenges with breastfeeding that are either unique or exacerbated by their obesity: discoveries from a longitudinal, qualitative study. Matern Child Nutr. 2017;13(3):e12344.

Ramoo S, Trinh TA, Hirst JE, Jeffery HE. Breastfeeding practices in a hospital-based study of Vietnamese women. Breastfeed Med. 2014;9(9):479–85.

Elkayam U, Goland S, Pieper PG, Silversides CK. High-risk cardiac disease in pregnancy: part I. J Am Coll Cardiol. 2016;68(4):396–410.

Niwa K. Adult congenital heart disease with pregnancy. Korean Circ J. 2018;48(4):251.

Parsa P, Masoumi Z, Parsa N, Parsa B. Parents’ health beliefs influence breastfeeding patterns among Iranian women. Oman Med J. 2015;30(3):187.

McNamara DM, Elkayam U, Alharethi R, Damp J, Hsich E, Ewald G, et al. Clinical outcomes for peripartum cardiomyopathy in North America: results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J Am Coll Cardiol. 2015;66(8):905–14.

Safirstein JG, Ro AS, Grandhi S, Wang L, Fett JD, Staniloae C. Predictors of left ventricular recovery in a cohort of peripartum cardiomyopathy patients recruited via the internet. Int J Cardiol. 2012;154(1):27–31.

Gunderson EP, Hurston SR, Ning X, Lo JC, Crites Y, Walton D, et al. Lactation and progression to type 2 diabetes mellitus after gestational diabetes mellitus: a prospective cohort study. Ann Intern Med. 2015;163(12):889–98.

Countouris ME, Schwarz EB, Rossiter BC, Althouse AD, Berlacher KL, Jeyabalan A, et al. Effects of lactation on postpartum blood pressure among women with gestational hypertension and preeclampsia. Am J Obstet Gynecol. 2016;215(2):241.

Article   PubMed Central   Google Scholar  

Dennis CL. Breastfeeding initiation and duration: a 1990–2000 literature review. J Obstet Gynecol Neonatal Nurs. 2002;31(1):12–32.

Manion A, Wideman M, Tutlewski A. Breastfeeding attitudes among adolescent mothers attending a nutrition breastfeeding support group. Clin Nurs Stud. 2018;6(1):28–34.

Horsley K, Chaput K, Da Costa D, Nguyen TV, Dayan N, Tomfohr-Madsen L, et al. Hypertensive disorders of pregnancy and breastfeeding practices: a secondary analysis of data from the All Our Families Cohort. Acta Obstet Gynecol Scand. 2022;101(8):871–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Brockway M, Benzies K, Hayden KA. Interventions to improve breastfeeding self-efficacy and resultant breastfeeding rates: a systematic review and meta-analysis. J Hum Lact. 2017;33(3):486–99.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

White MD, Marsh EE. Content analysis: a flexible methodology. Libr Trends. 2006;55(1):22–45.

Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qual Res Sport Exerc Health. 2021;13(2):201–16.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

Polit DF, Beck C. Essentials of nursing research: appraising evidence for nursing practice. Lippincott Williams & Wilkins; 2010.

Azizi A. The prevalence of the causes of high-risk pregnancies in pregnant women of Sonqor city, 2011. Iran J Obstet Gynecol Infertil. 2015;18(153):10–9.

Kashani E, Hassanzad A, Ameri M. The rate of the prevalence of high-risk pregnancies and the results on pregnant mothers and the effect on parameters after the birth. Adv Environ Biol. 2012;6(3):1319–24.

Behzadifar M, Saki M, Behzadifar M, Mardani M, Yari F, Ebrahimzadeh F, et al. Prevalence of exclusive breastfeeding practice in the first six months of life and its determinants in Iran: a systematic review and meta-analysis. BMC Pediatr. 2019;19(1):1–10.

Download references

Acknowledgements

We thank the volunteer participants for sharing their experiences and giving their time and help to make this study possible.

This Study is funded by Mashhad University of Medical Sciences.

Author information

Authors and affiliations.

Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Kobra Mirzakhani & Talat Khadivzadeh

Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Student Research Committee, Mashhad University of Medical Science, Mashhad, Iran

You can also search for this author in PubMed   Google Scholar

Contributions

TKH, KM and AY contributed to the design of the protocol.  TKH and KM contributed to the implementation and analysis plan. TKH, KM and AY have written the first draft of this protocol article and all authors have critically read the text and contributed with inputs and revisions, and all authors read and approved the final manuscript.

Corresponding author

Correspondence to Talat Khadivzadeh .

Ethics declarations

Ethics approval and consent to participate.

Written informed consent will be obtained from each participant. This protocol has been approved by the Ethics Committee of the Mashhad University of Medical Sciences, Mashhad, Iran (ethical code number: IR.MUMS.NURSE.REC.1397.079).

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Mirzakhani, K., Yas, A. & Khadivzadeh, T. Explaining the perception and experiences of breastfeeding in mothers who have a high risk pregnancy: a protocol study. Reprod Health 21 , 74 (2024). https://doi.org/10.1186/s12978-024-01817-x

Download citation

Received : 14 May 2024

Accepted : 21 May 2024

Published : 01 June 2024

DOI : https://doi.org/10.1186/s12978-024-01817-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Breastfeeding
• High-risk pregnancy
• Content analysis
• Qualitative study

Reproductive Health

ISSN: 1742-4755

• General enquiries: [email protected]

• Open access
• Published: 01 May 2022

Promoting the practice of exclusive breastfeeding: a philosophic scoping review

• Tumilara Busayo Amoo   ORCID: orcid.org/0000-0001-6633-7499 1 ,
• Tosin Popoola   ORCID: orcid.org/0000-0003-2761-7783 2 &
• Ruth Lucas   ORCID: orcid.org/0000-0001-9757-5668 1  

BMC Pregnancy and Childbirth volume  22 , Article number:  380 ( 2022 ) Cite this article

5690 Accesses

6 Citations

2 Altmetric

Metrics details

The World Health Organization recommends exclusive breastfeeding for the first 6 months of an infant’s life and continued breastfeeding for 2 years. The global rate of exclusive breastfeeding is low at 33%. Thus, it is important to identify philosophical and theory-based strategies that can promote exclusive breastfeeding. The aim of the study was to identify philosophical schools of thought and theories used in research on promoting the practice of exclusive breastfeeding.

A scoping review using Arksey and O'Malley's framework explored the phenomenon of exclusive breastfeeding practice promotion. Searches were conducted using CINAHL Plus full-text, PubMed, APA PsycInfo, and Academic Search Premier. Search terms included theory, philosophy, framework, model, exclusive breastfeeding, promotion, support, English, and publication between 2001—2022.

The online search yielded 1,682 articles, however, only 44 met the inclusion criteria for the scoping review. The articles promoting exclusive breastfeeding used pragmatism ( n  = 1) or phenomenology ( n  = 2) philosophies and theories of self-efficacy ( n  = 10), theory of planned behaviour ( n  = 13), social cognitive theories ( n  = 18) and represented 16 countries. Theories of self-efficacy and planned behaviour were the most used theories.

Conclusions

This review suggests that theories and models are increasingly being used to promote exclusive breastfeeding. Orienting exclusive breastfeeding programmes within theoretical frameworks is a step in the right direction because theories can sensitize researchers and practitioners to contextually relevant factors and processes appropriate for effective exclusive breastfeeding strategies. Future research should examine the efficacy and effectiveness of theory-informed exclusive breastfeeding programmes over time. Such information is important for designing cost-effective EBF programmes.

Peer Review reports

Exclusively breastfeeding infants for 6 months is the global public health gold standard [ 1 , 2 ] because of its benefits for infants, women, and the society [ 3 , 4 ]. For example, exclusively breastfed infants have higher cognitive developmental scores, have reduced risk of gastrointestinal and respiratory diseases, and are less likely to develop lifelong obesity and diabetes [ 5 , 6 , 7 ]. Similarly, exclusive breastfeeding (EBF) promotes healthy weight, prolongs lactational amenorrhoea and reduces the risk of breast cancer among women [ 8 , 9 ]. The benefits of EBF are also enormous for the society. As an illustration, EBF is not only cost-effective, but it also decreases parental absenteeism from work and reduces the burden of formula cans on the environment [ 10 ]. Research from United Kingdom also suggested that if all infants were breastfed, a total lifetime cost savings to the National Health Service would be £46.7million and a total lifetime quality-adjusted life year (QALY) gain of 10,594 [ 11 ]. Additional research from Canada reported cost savings of $13,812 per additional QALY gained [ 12 ].

Despite these benefits, there has been little improvement in the global practice of EBF in two decades. For example, only 1 out of 3 children received EBF for 6 months [ 1 ]. Exclusive breastfeeding rates at 6 months differ across the globe, varying from 1% in the UK [ 13 ] to 69% in Peru [ 14 ]. The low rates of EBF (< 50%) at 6 months in many countries across the globe have been studied. Research suggests that lack of support from husbands, fear of infants becoming addicted to breast milk [ 15 ], non-approval from family members and maternal or infant lack of strength due to inadequate nutrition [ 16 ], lack of capacity to store human milk [ 17 ], lack of institutional and family support [ 18 ], and unfavourable work conditions [ 19 ] are barriers to EBF. Because of the benefits of EBF for infants, women and societies, many interventions have been implemented for the purpose of increasing the adoption of EBF practice [ 20 , 21 ]. Many of these interventions are a combination of baby friendly initiatives and provider led initiatives. However, there is limited information about the philosophical worldviews underpinning these interventions. EBF interventions like any intervention can be better understood and evaluated if the underlying philosophical thoughts of such programmes are understood. In view of the above, this study aimed to identify and evaluate the philosophies and theories used in research to promote exclusive breastfeeding through a scoping review [ 22 ]. Such information is important to inform clinical practice and improve knowledge.

Scoping reviews are ideal to determine the breadth of a body of literature on a topic of interest, identify and analyse knowledge gaps, clarify key concepts in literature, map features of primary research, and act as a precursor to focused systematic reviews [ 23 , 24 ]. Previous scoping reviews have identified breastfeeding social support models using Arksey and O’Malley’s framework [ 25 , 26 ]. However, these studies focused on any breastfeeding -breast milk in addition to food and other fluids [ 27 , 28 ] and did not provide the philosophical schools of thought or theories underlying those models. No study has investigated theories and/or philosophies used to support interventions to promote EBF. Therefore, this scoping review will fill the knowledge gap. The primary aim of this study was to identify and evaluate the philosophies and theories used in research to promote exclusive breastfeeding practice, to inform clinical practice and improve knowledge.

A scoping review following Arksey and O’Malley’s framework explored the phenomenon of EBF practice promotion. This framework has five stages: Identifying the research objectives, identifying relevant studies, study selection, charting the data, and collating, summarizing. and reporting the results [ 23 ]. A systematic literature search for relevant articles was conducted across four databases, PubMed, CINAHL Plus with full-text, APA PsycInfo, and Academic Search Premier. The search was conducted using text words in various combinations relating to promotion of EBF. The key search terms were breast feeding, breast-feeding, breastfeeding exclusivity, enhance, exclusive breastfeeding, increase, improve, promoting, promotion, philosophy, support, theory, model, and framework, see Table 1 for search strategy.

Study selection criteria

Articles of interest were those that focused on the promotion of EBF, not just promotion of breastfeeding. Four inclusion criteria were used to select relevant articles including (1) focused on exclusive breastfeeding: The phenomenon of interest is exclusive breastfeeding-breast milk only and no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines [ 29 ] (2) used philosophy/framework to address phenomenon: (3) published in English: Researchers prefer articles written in English for easy comprehension (4) published between 2001–2022: World Health Organization recommended exclusive breastfeeding for 6 months in 2001 (5) study methodology: quantitative and/or qualitative studies were included but review articles were excluded.

Search outcomes

The search identified 1,682 titles. After removal of duplicates, 480 articles underwent title/abstract screening, and 331 articles were excluded as they did not address exclusive breastfeeding promotion. Thus, 149 full-text articles were assessed for eligibility, and 52 articles were eligible for inclusion. The matching full-text articles were acquired for review. Eight articles could not be accessed and were not included in the review. Therefore, 44 articles were selected and included for analysis in the scoping review. Figure  1 (PRISMA flowchart) showed the process of article selection.

PRISMA flowchart of study selection process. Adapted from Moher et al (2009) [ 30 ]

Quality appraisal

Corresponding author assessed the quality of included studies using an adapted Critical Appraisal Skills Programme [CASP] checklist for randomised controlled trials (RCT) and qualitative studies. CASP RCT checklist consists of 4 sections containing 11 questions (see supplementary ) [ 30 ]. Other quantitative studies were evaluated using Holland and Rees’ (2010) framework for critiquing quantitative research articles (see supplementary ) [ 31 ]. CASP checklist for qualitative studies consists of 3 sections containing 10 questions that researchers need to ask when evaluating evidence from qualitative studies (see supplementary ) [ 32 ]. Section A examines result validity, section B examines the entire results, and section C examines applicability of results. In this review, question 10 in the CASP qualitative checklist ‘How valuable is the research?’ was adapted as ‘Is the research valuable?’ for scoring to be completed. Similarly, question 11 in the CASP RCT checklist was adapted as ‘Would the experimental intervention provide value to the people in your care? Ten relevant questions from Holland and Rees’ (2010) framework for critiquing quantitative research articles were used to appraise other quantitative studies. Response to each question was given a score of 1. Studies with overall score of 7 or above were eligible for inclusion.

Data extraction and analysis

TBA and TP conducted literature review, reviewed paper titles, and screened abstracts for eligibility to reduce subjectivity of analysis. Data from articles included in the scoping review were extracted manually using two templates developed by the first author. The first template contained general characteristics of the study, and the second template contained the philosophies and theories. Extracted information included study purpose, design, population characteristics, methods, philosophy or theoretical basis, and results. TBA and TP independently extracted data from the articles using the templates. In the case of disagreements, both authors reviewed study eligibility criteria and discussed reasons why the articles should or should not be included based on the criteria. At the end of discussion, consensus was reached on the article inclusion. Articles not related to exclusive breastfeeding promotion were excluded.

Extraction of the data continued until all the philosophies/frameworks and theories were identified. A table was then created to fit the extracted data. For this scoping review, studies were grouped based on similarities in philosophies and theoretical frameworks used to promote exclusive breastfeeding. A summary of the findings from the articles were presented and data were analysed using narrative synthesis. Narrative synthesis is the preferred method of data analysis in reviews of quantitative studies when it is not possible to conduct a statistical analysis [ 33 ]. The summaries in this scoping review illustrate the scope of evidence, rather than describing the quality of the studies. Ethical approval was not required for this scoping review.

Overview of theories

Ten theories, two philosophies, four frameworks and eleven models were extracted. The goal of theory of planned behaviour (TPB) is to predict and explain behaviour. TPB and Reasoned Action Approach developed by Fishbein and Ajzen (2010) originated from the theory of reasoned action . Reasoned action approach posited that attitude towards behaviour, perceived norm, and perceived behavioural control, determine intention, which predicts behaviour [ 34 ]. Bandura’s theory of self-efficacy and Dennis’ breastfeeding self-efficacy theory also originated from Bandura’s (1986) social cognitive theory [ 35 ]. Bandura defined self-efficacy as the belief in a person’s ability to organize and accomplish actions required to manage prospective situations [ 36 ]. Self-efficacy influences thinking and decision-making, effort and persistence, and choice. Dennis defined breastfeeding self-efficacy as a mother’s perceived ability to breastfeed her infant [ 37 ]. One of the sources of self-efficacy is information received through verbal persuasion [ 38 ]. Hence, utilizing the breastfeeding self-efficacy theory, health professionals may be able to influence the practice of breastfeeding by modifying this information [ 37 ]. Health professionals can lead a change with a top-down approach using Kotter’s theory of change which was specifically designed to be applied in leadership. Kotter described eight steps in the process of change including creating a sense of urgency, forming guiding coalitions, vision development, communicating the vision, removing obstacles and employee empowerment, creating short-term wins, consolidating gains, and strengthening change by anchoring change in the culture [ 39 ]. Mann’s adolescent decision-making competence theory (ADM) suggests that competent decision-making has nine elements including choice, comprehension, creativity, compromise, consequentiality, correctness, credibility, consistency, and commitment [ 40 ].

Granovetter’s strength of weak ties theory posited that individuals’ personal experiences is embedded within the larger social structure beyond the control of some individuals [ 41 ]. In their theory, Milligan and Wiles described landscapes of care as the result of interaction between socio-structural processes and structures that shape experiences and practices of care [ 42 ]. In addition, Mercer affirmed the significance of social support in her theory of maternal role attainment. The theory suggested that maternal role attainment is influenced by maternal age, socioeconomic status, perception of birth experience, early mother-infant separation, social stress, social support, personality traits, self-concept, child-rearing attitudes, perception of infant, role strain, and health status [ 43 ]. Social norms are informal, acceptable standards of behaviour in a society which may affect an individual positively or negatively. However, social support encompasses resources (human and non-human) available to assist an individual in the society.

Theories of self-efficacy, planned behaviour , maternal role attainment , adolescent decision-making and social cognitive theory primarily emphasized individual factors that influence performance of a behaviour. On the other hand, theories of strength of weak ties and landscapes of care and change theory apply to a population and describe social factors that influence performance of a behaviour in that population.

In cultures where breast pumps are not accepted or settings where breast pumps are not easily accessed, use of breastfeeding self-efficacy questionnaire may not be appropriate, as it contains an item about using breast pumps [ 37 ]. Theory of planned behaviour has no standard questionnaire [ 44 ], thus there were no unified variables to test the theories in the included studies.

Reasoned action approach provides an explanation as to why different background factors are related (or are not related) to a particular behaviour [ 45 ]. Therefore, it is useful to reduce disparities or increase rates of EBF especially among women who are least likely to achieve their breastfeeding goals.

Overview of philosophies

Pragmatism is an American philosophy first developed by Charles Pierce. It is a way of doing philosophy, it is concerned with actions [ 46 ]. Pragmatism evaluates the truth of the meaning of theories in terms of the successful application of those theories. That is, theories are meaningful only if they are practically applicable. Pragmatists subscribe to the notion of instrumentalism because they view theories as instruments for problem solving. In pragmatism, the whole of a concept or phenomenon is found in the consequences of the concept or phenomenon [ 47 ]. Phenomenology is a philosophy developed by Husserl which involves description of lived experience, free from preconceived ideas about the phenomenon. Phenomenology attempts to describe experience from the perspective of the person who had the experience first-hand [ 48 ]. The difference between pragmatism and phenomenology is that pragmatism attempts to solve a problem using practical methods whereas phenomenology aims to understand the problem/experience [ 49 ]. Pragmatism has been criticized for its restricted use in identifying and analysing structural social problems [ 50 ] whereas phenomenology is limited by difficulty its subjectivity and difficulty with data analysis and interpretation [ 51 ].

Overview of frameworks and models

Green’s proceed-precede model was first published as an evaluation framework in 1974 [ 52 ], as Precede in 1980 [ 53 ], and as a full framework in 1991 [ 54 ]. Precede-Proceed framework comprises eight phases to guide professionals to develop, implement and evaluate health promotion programmes [ 55 ], using socio-ecological model to assess individual characteristics and socio-political conditions [ 56 ]. Bronfenbrenner’s (1977) socio-ecological model explained that individuals are influence and are influenced by a complex range of social factors and environmental interactions [ 57 ]. The belief, attitudes, subjective norms and enabling factors (BASNEF) model, developed by Hubley (1988) originated from Precede model and TRA. It posited that belief, attitude and subjective norms determine behavioural intention, which supports enabling factors for a behaviour [ 58 ]. BASNEF model has been used to positively influence nutritional behaviours to reduce risk factors for cardiovascular diseases [ 59 ]. Similarly, attitude-social influence-self-efficacy model , influenced by TPB, reasoned action approach and Bandura’s theory of self-efficacy and developed by de Vries et al. (1988) suggests that attitude, social influence, and self-efficacy determine behavioural intention which in turn predicts behaviour [ 60 , 61 ]. Information-motivation-behavioural-skills (IMB) model also suggested that health-related information, motivation, and behavioural skills are primary determinants of performance of health behaviours [ 62 ]. Nicholson (1990) developed an analytical framework to facilitate adaptation— transition cycle. The cycle consisted of four stages including preparation, encounter, adjustment, and stabilization [ 63 ]. The stages are useful to enhance readiness, reduce negative emotions, support personal change and role development, and maintain successful adaptation outcomes [ 64 ]. In her model of infant feeding behaviours, Lutter recognized the importance of self-efficacy in the achievement of a behaviour. The model posited that infant feeding depends on two factors—the interaction between a woman’s choice to breastfeed and her ability to act upon the choice (self-efficacy). Lutter further described that these factors are influenced by three determinants including proximate, intermediate, and underlying determinants. Proximate determinants are primary conditions (maternal choices and ability to act on these choices) that must be present for breastfeeding to occur, these primary conditions are affected by intermediate determinants (information and support) which are in turn influenced by underlying determinants (social norms, socio-demographic characteristics) [ 65 ]. Lewin’s change management model posits that organizational change occurs in three stages including unfreeze, move/transition, and unfreeze [ 66 ].

The primary role of health professionals is to promote health. Thus, the health promotion model, developed by Pender (1982) promotes health professionals’ understanding of health behaviour determinants and empowers them to provide quality behavioural counselling [ 67 ]. GATHER framework (Greet, ask, tell, help, explain and return) is a framework used to provide competent and caring counselling. Moreover, Titler’s Iowa’s model of evidence-based practice was developed to empower health professionals to translate research findings into practice to provide quality care [ 68 ]. Novak’s concept mapping , developed by in 1972 is useful for organization and representation of knowledge. Concept maps illustrate specific label for a concept in a box with lines showing linking words that create a meaningful statement [ 69 ]. Further, Bartholomew’s (1998) intervention mapping is a framework designed to facilitate the development of health education interventions. The framework has five steps: matrix creation, intervention methods selection, program design, identifying adoption and implementation plans, and program evaluation plan generation [ 70 ].

Some models are applicable to systems. Baby-Friendly Hospital Initiative launched by World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) to increase support for breastfeeding in hospitals globally included ten steps can be implemented to achieve successful breastfeeding [ 71 ]. Similarly, the social franchise model for infant and young child feeding (IYCF) suggested that a franchise facility must provide these services—exclusive breastfeeding promotion, support and management, and complementary feeding education and management [ 72 ]. Institute of Healthcare Improvement also developed the breakthrough series (BTS) collaborative model to bring large number of hospital teams together to seek improvement in a specific topic or field [ 73 ]. A common weakness of the system intervention models is their unsuitability to design or evaluate individual-focused interventions.

Models of infant feeding behaviours, attitude-social influence-self-efficacy, information-motivation-behavioural-skills and BASNEF model explained individual characteristics that determine performance of a behaviour whereas the other frameworks/models apply to a population. For example, Baby-Friendly Hospital Initiative, social franchise model, and breakthrough series (BTS) collaborative model describe actions required from health professionals towards the implementation of interventions to promote health/health behaviour. Though the included studies in this review did not use Lean Six Sigma model, the model is a process improvement model involving five phases: define, measure, improve, analyse, and control. Lean Six Sigma model, which has been successfully used to develop interventions that reduced patient waiting time at clinics [ 74 ], may be applied to design system interventions to promote EBF.

Characteristics of the studies

The articles selected for this review varied in the study design and the setting in which the studies were conducted (Table 2 ). Most of the studies were conducted in United States ( n  = 10) and China ( n  = 10), followed by Indonesia ( n  = 4), Iran ( n  = 4), Vietnam ( n  = 3), Australia ( n  = 2), Netherlands ( n  = 2), Egypt ( n  = 1), New Zealand ( n  = 1), Norway ( n  = 1), Turkey ( n  = 1), Malaysia ( n  = 1), Niger ( n  = 1), Thailand ( n  = 1), Mexico ( n  = 1) and Taiwan ( n  = 1). Ten studies were published after 2019, 29 studies were published from 2010 – 2019, and five from 2002—2009. Study designs included randomized control trials (RCT; n  = 24), correlational ( n  = 7), quasi-experimental ( n  = 5), qualitative ( n  = 5), and mixed methods ( n  = 3).

Almost 9500 mother–child pairs and family pairs participated in the 44 studies. The sociodemographic characteristics were reported in 42 studies. Participants ranged from only mothers ( n  = 35), mother-infant pairs ( n  = 3), family ( n  = 2), health professionals ( n  = 2) and hospitals ( n  = 2). No study included fathers only or extended family. The setting of the articles ranged widely from the hospital [ 2 ], prenatal/maternity clinics ( n  = 33) primary health clinics [ 6 ], Local Implementing Agencies (LIAs) (ID-05) ( n  = 1) and communities [ 2 ]. Thirty-five studies assessed the prevalence of postpartum EBF at different time intervals while nine studies suggested measures to promote EBF. Most studies reported EBF at the individual level, only three studies reported at the family and hospital levels. Forty-two studies included term/healthy infants while two studies included preterm infants [ 75 , 76 ].

Application of theories/philosophies/frameworks to exclusive breastfeeding promotion

Ajzen’s theory of planned behaviour ( n  = 13) and Dennis’ breastfeeding self-efficacy theory ( n  = 10) were the most used theories in the studies [ 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ]. Findings from this review suggests that EBF programmes oriented within theories are effective in increasing EBF rates. While EBF rates increased in all included studies, statistically significant increase at 6 months were reported in few studies. For example, intervention groups had higher EBF rates compared with control groups in studies that applied theories of breastfeeding self-efficacy —37% vs. 14% [ 78 ], 32% vs. 14% [ 82 ], 56% vs. 37% [ 83 ], planned behaviour —2% vs. 0% [ 85 ], 42% vs. 10% [ 86 , 87 ], 88% vs. 77% [ 88 ], reasoned action approach - (72% vs 63%) [ 89 ], intervention mapping- (48% vs 27%) [ 90 ], social franchise model- (62% vs 40%) [ 91 ], attitude-social influence-self-efficacy model- (48% vs 27%) [ 92 ], and Baby-Friendly Hospital Initiative (18% vs. 14%) [ 93 ]. Theories of breastfeeding self-efficacy and planned behaviour have been tested to support and protect exclusive breastfeeding. Chipojola et al. (2020) tested the overall effects of both theories on EBF and reported significant increase in EBF rates in intervention group compared with control group across studies included in their review and meta-analysis [ 94 ].

Theories of self-efficacy and planned behaviour are useful for data collection, program content development and implementation. Dennis’ breastfeeding self-efficacy questionnaire in its short form [ 95 ] measured breastfeeding self-efficacy in women during pre-partum and/or postpartum and assessed the effect of an intervention on breastfeeding self-efficacy [ 96 ]. Social cognitive theory was used to select suitable educational strategies to promote EBF among women with preterm infants [ 76 ]. Moussa Abba et al. (2010) used the model of infant feeding behaviours to identify breastfeeding [ 97 ]. TPB was used to guide the design of study interventions, design questionnaires, predict and explain breastfeeding outcomes [ 87 , 98 , 99 ]. Reasoned action approach was used to design study interventions- interpersonal counselling and exposure to mass media- to promote EBF practices in Vietnam [ 89 ]. The Attitude-social influence-self-efficacy model was used to develop an educational programme (intervention) [ 92 ]. Likewise, Pender’s health promotion model was used in included studies to design an intervention—breastfeeding motivation program [ 100 ] and explain research findings [ 101 ]. Information-motivation-behavioural-skills model was used to design counselling sessions that focused on enhancing IMB breastfeeding determinants among HIV-infected women [ 102 ]. Mann’s Adolescent decision-making competence theory was used to design developmentally sensitive, education and counselling intervention [ 103 ].

Unlike theories of self-efficacy and planned behaviour that are primary based on maternal variables, social theories and theories for system interventions explain the influence of societal interactions/structures on exclusive breastfeeding. Alianmoghaddam and colleagues used the theories of strength of weak ties and landscapes of care to explain importance of social relationships, social interactions and social support within virtual communities that are associated with breastfeeding [ 104 ]. Support systems for women were identified using the theory of maternal role attainment [ 105 ]. Social Franchise Model was used to design breastfeeding intervention—infant and young child feeding (IYCF) counselling services [ 91 ]. Similarly, Breakthrough Series (BTS) collaborative model guided the planning of a programme—Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN)—which increased EBF duration [ 106 ]. Titler’s Iowa’s model of evidence-based practice guided the implementation of a new in-patient model of nursing care—mother–child dyad care [ 107 ]. Lewin’s change management model to manage the complex change processes in the transition from the traditional model of obstetric nursing to care of mother–child dyad. Kotter’s change theory was used to initiate culture change for a successful adoption of Baby-Friendly Hospital Initiative [ 108 ] which was adopted in community health service in another study and it significantly increased EBF rates in intervention [ 93 ].

Frameworks were also used for program development. Ahmed (2014) used the Precede model to design a five-session breastfeeding educational program [ 76 ] and explain family support factors that promoted exclusive breastfeeding rates [ 109 ]. Ahmadi et al. (2016) used BASNEF model to design questionnaire about breastfeeding attitude of women; the questionnaire had reliability score (Cronbach’s alpha) of 0.7. GATHER (Greet, ask, tell, help, explain and return) steps was also used to guide breastfeeding consultation sessions for the intervention group [ 75 ]. Transition cycle was used to illustrate and explain mothers’ transition to breastfeeding after childbirth [ 110 ]. Concept mapping was used during all three intervention meetings to provide information and findings regarding identifying and prioritising facilitators and barriers to 6-month exclusive breastfeeding [ 111 ]. Similarly, intervention mapping was used as a concept map to guide development of educational program [ 90 ].

Lastly, philosophies guided study designs and data collection. Baerug et al. (2016) used pragmatism as the basis for their quasi-randomized control trial study which examined the effect (consequence) of baby-friendly community health services on EBF [ 93 ]. On the other hand, phenomenology was used to describe participants’ involvement in EBF promotion activities [ 112 ], qualitatively analyse data collected from participants and to formulate essence descriptors of their breastfeeding experiences and daily routine [ 110 ].

The objective of this scoping review was to identify philosophical schools of thoughts and theories that guide research on promoting exclusive breastfeeding practice. The scoping review clearly established that a wide range of different interventions based on philosophies and theories are effective to promote exclusive breastfeeding practice for both healthy full-term and preterm infants. Theories of self-efficacy and planned behaviour were the most common theories that significantly increased EBF rates at 6 months [ 78 , 82 , 83 , 85 , 86 , 87 , 88 ]. Chipojola et al. (2020) reported similar finding and recommended the use of these two theories to design interventions in future studies to increase exclusive breastfeeding rates [ 94 ]. Philosophies provided the basis to explore different methods that may promote the practice of exclusive breastfeeding [ 93 , 110 , 112 ]. Whilst self-efficacy theories were used for intervention implementation and evaluation at individual levels [ 80 , 81 ], theories for systems intervention provided a larger context to examine effect of interventions on breastfeeding exclusivity [ 93 , 106 ]. Further, social theories provided opportunity to modify variables in the environment and test the influence of the modification on exclusive breastfeeding rates [ 91 , 105 ]. Thus, researchers may choose theories from these categories depending on the scope of their studies. The theory of planned behaviour was used primarily to implement interventions [ 86 , 87 , 103 ]. Whereas frameworks provided step-by-step instructions for program development and implementation [ 75 , 76 , 101 ] to ensure accurate implementation of interventions and provision of a foundation for evaluation of the interventions. The use of a framework/model to guide a study is limited as the included frameworks have several stages, but most studies need to implement only a few stages to meet their goals. Thus, limiting the generalizability of the frameworks across studies.

Some theories and frameworks were effective at promoting EBF among women who may be unable to achieve their breastfeeding goals. For example, TPB significantly increased EBF among women with low rates (30%) of EBF [ 86 ]. Similarly, Dennis’ theory of breastfeeding self-efficacy significantly increased EBF rates among African American women [ 96 ]. Bandura’s social cognitive theory was used to design an educational intervention which significantly increased EBF rates among women with preterm infants [ 76 ]. Kotter’s theory of change facilitated successful implementation of the baby-friendly hospital initiative which increased EBF among Latina women reported to be the most likely population to supplement early with formula due to perceived milk insufficiency [ 108 ]. Likewise, implementation of the baby-friendly hospital initiative increased EBF rates among women in rural and semi-urban districts in Norway [ 93 ].

Overall, TPB was the most used theory that significantly increased exclusive breastfeeding rates at 6 months [ 85 , 86 , 87 , 88 ]. A reason for the frequent use of TPB may be its effectiveness at predicting behaviours and its usefulness in the development of educational programs or interventions. Indeed, Bai et al. (2019) reported in their critical review of theories supporting breastfeeding that based on the holistic effects of its propositions, TPB is more applicable to promote breastfeeding compared with Dennis’ breastfeeding self-efficacy theory, and Bandura’s self-efficacy and social cognitive theories [ 113 ]. Further, breastfeeding self-efficacy theory is limited by the interaction between self-efficacy and previous breastfeeding experience, which may have biased the actual effectiveness of the theory on EBF. McCarter-Spaulding and Gore (2009) reported that breastfeeding self-efficacy scores were higher among mothers who had previous breastfeeding experience [ 96 ]. TPB posited that perceived behavioural control and behavioural intention can be used to directly predict behavioural achievement [ 114 ]. Behavioural intention has three conceptually different determinants including attitude towards the behaviour - the extent to which a person has favourable or unfavourable evaluation of a specific behaviour-, subjective norm - perceived social pressure to perform a behaviour or not-, and perceived behavioural control – perceived ease or difficulty of performing a behaviour [ 115 ]. Perceived behavioural control on the other hand is assumed to reflect past experiences and anticipated challenges regarding performing a behaviour [ 114 ]. TPB is used to predict a behaviour based on two conditions- perceived behavioural control and behavioural intention. These two conditions may also be referred to as antecedents. The application of TPB in research to determine the effect of interventions implies testing the accuracy of the theory’s scientific prediction. Scientific prediction attempts to determine the effect of the initial conditions, otherwise referred to as antecedents/independent variables on specific dependent variables [ 116 ]. Hempel posited that a prediction is valid if it has logical and empirical adequacy [ 117 ]. That is, the explanans (premises) must contain at least one law of nature and the statements constituting the explanans must be true (empirically verified). Empiricists believe in verifiability, the only valid source of knowledge for them is empirical experience- what is perceived through the senses [ 118 ]. Therefore, they posited that a statement is meaningful only if it has been proven true or false through means of experience (experiment). Empirical verification can be achieved through scientific method, experimentation, or laboratory science. TPB was tested in previous studies and found to successfully predict dishonest actions [ 119 ], leisure behaviours [ 120 ], and implement interventions that will be effective to change behaviours [ 121 ]. Thus, propositions in TPB have been empirically verified, which may be another reason for its frequent use in the included studies.

Strength and limitations

Scoping reviews allow for more quality result than systematic review, because unlike the latter, it allows for identification of relevant studies irrespective of study designs [ 23 ]. To our knowledge, this is the first scoping review to map evidence specific to philosophies and/or frameworks used to address exclusive breastfeeding promotion. The review used rigorous and transparent methods throughout the study. Theories identified in this review are similar with those identified in previous studies [ 113 , 122 ]. Notwithstanding, this review included additional frameworks and theories that used decision-making and developmental models. Compared with other scoping reviews, this study included relatively large number of articles accessed from different databases. Hence, results of this scoping review have enabled development of specific search strategies for future reviews. However, our review may not have identified all studies in the literature, particularly studies that applied philosophical schools of thought to exclusive breastfeeding promotion, as most included articles were theory-based. Additionally, the culture in settings of included studies should be considered when selecting a theory/philosophy for future studies, as it may influence the effectiveness of the theory/philosophy. Hence, future studies may test theories and/or instruments developed from these theories to achieve effective cross-cultural adaptation.

This study established that strategies supported by philosophies and theories are useful to increase exclusive breastfeeding rates, especially in interventions involving breastfeeding education, empowerment, and counselling. Theories of planned behaviour and self-efficacy are useful to design and implement these interventions. We recommend that future studies aimed at reducing disparities in exclusive breastfeeding rates adopt theories of breastfeeding self-efficacy, planned behaviour, and social cognitive theory as these theories significantly increased exclusive breastfeeding among women that are least likely to breastfeed. Future scoping reviews should include comprehensive search of more databases to access and include more studies that use philosophical schools of thought to promote exclusive breastfeeding practice.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Abbreviations

Adolescent decision-making

Belief, Attitudes, Subjective Norms and Enabling factors

• Exclusive breastfeeding

Greet, Ask, Tell, Help, Explain and Return

Theory of Planned Behaviour

World Health Organization

World Health Organization. Breastfeed. [cited 2021 Feb 10]. Available from: https://www.who.int/health-topics/breastfeeding#tab=tab_2 .

World Health Organization. The optimal duration of exclusive breastfeeding, Report of an Expert Consultation. 2002.

Google Scholar  

Amoo T. Breastfeeding: Benefits and Challenges. Direct Res J Health Pharmacol. 2019;7(2):19–26.

Brahm P, Valdés V. Benefits of breastfeeding and risks associated with not breastfeeding. Rev Chil Pediatr. 2017;88(1):15–21.

Jedrychowski W, Perera F, Jankowski J, Butscher M, Mroz E, Flak E, et al. Effect of exclusive breastfeeding on the development of children’s cognitive function in the Krakow prospective birth cohort study. Eur J Pediatr. 2012;171(1):151–8.

Article   PubMed   Google Scholar  

Diallo FB, Bell L, Moutquin JM, Garant MP. The effects of exclusive versus non-exclusive breastfeeding on specific infant morbidities in Conakry (Guinea). Pan Afr Med J. 2009;2(2).

Villar J, Ochieng R, Staines-Urias E, Fernandes M, Ratcliff M, Purwar M, et al. Late weaning and maternal closeness, associated with advanced motor and visual maturation, reinforce autonomy in healthy, 2-year-old children. Sci Rep. 2020;10(1):5251.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Zhou Q, Chen H, Younger KM, Cassidy TM, Kearney JM. “i was determined to breastfeed, and i always found a solution”: Successful experiences of exclusive breastfeeding among Chinese mothers in Ireland. Int Breastfeed J. 2020;15(1):47.

Article   PubMed   PubMed Central   Google Scholar  

Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatrica Int J Paediatr. 2015;104:96–113.

Article   Google Scholar  

Anatolitou. Human milk benefits and breastfeeding. Pediat Neonat Individual Med. 2012;1(1):11–8.

Mahon J, Claxton L, Wood H. Modelling the cost-effectiveness of human milk and breastfeeding in preterm infants in the United Kingdom. Health Econ Rev. 2016;6(1).

Keshmiri R, Coyte PC, Laporte A, Sheth PM, Loutfy M, Carrera PM. Cost-effectiveness analysis of infant feeding modalities for virally suppressed mothers in Canada living with HIV. Medicine. 2019;98(23):e15841.

PubMed Central   Google Scholar  

McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew M. Infant Feeding Survey 2010. 2012 [cited 2021 Jun 18]. Available from: https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_report.pdf .

Bhattacharjee N v., Schaeffer LE, Hay SI, Lu D, Schipp MF, Lazzar-Atwood A. Mapping inequalities in exclusive breastfeeding in low- and middle-income countries, 2000–2018. Nat Hum Behav. 2021;5(8):1027–45.

Agunbiade OM, Ogunleye OV. Constraints to exclusive breastfeeding practice among breastfeeding mothers in Southwest Nigeria: Implications for scaling up. Int Breastfeed J. 2012;7(5).

Kanu W, Ezeji P. Socio-cultural drivers and barriers to adoption of Exclusive Breast-Feeding among Mothers in Rural Communities of Imo State, Nigeria. Int J Sci Eng Res. 2020;11(5):313–22.

Bisi-onyemaechi AI, Chikani UN, Ubesie AC, Chime PU, Mbanefo NR. Factors associated with low rate of exclusive breastfeeding among mothers in Enugu, Nigeria. Int J Res Med Sci. 2017;5(9):3776.

Mlay RS, Keddy B, Stern PN. Demands out of context: Tanzanian women combining exclusive breastfeeding with employment. Health Care Women Int. 2004;25(3):242–54.

Maponya N, Janse van Rensburg Z, du Plessis-Faurie A. Understanding South African mothers’ challenges to adhere to exclusive breastfeeding at the workplace: A qualitative study. Int J Nurs Sci. 2021;8(3):339–46.

PubMed   PubMed Central   Google Scholar  

Buckland C, Hector D, Kolt GS, Fahey P, Arora A. Interventions to promote exclusive breastfeeding among young mothers: a systematic review and meta-analysis. Int Breastfeed J. 2020;15(102).

Huang P, Yao J, Liu X, Luo B. Individualized intervention to improve rates of exclusive breastfeeding. Medicine. 2019;98(47):e17822.

Bluethmann SM, Bartholomew LK, Murphy CC, Vernon SW. Use of Theory in Behavior Change Interventions: An Analysis of Programs to Increase Physical Activity in Posttreatment Breast Cancer Survivors. Health Educ Behav. 2017;44(2):245–53.

Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005;8(1):19–32.

Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(143).

Chepkirui D, Nzinga J, Jemutai J, Tsofa B, Jones C, Mwangome M. A scoping review of breastfeeding peer support models applied in hospital settings. Int Breastfeed J. 2020;15(95).

Purwanggi A, Kurniawati HF. Social support for the breastfeeding mothers in breastfeeding: scoping review. Int J Adv Sci Technol. 2020;29(8):818–30.

Tarrant RC, Kearney JM. Session 1: Public health nutrition Breast-feeding practices in Ireland. Proc Nutr Soc. 2008;67(4):371–80.

Labbok MH, Starling A. Definitions of breastfeeding: Call for the development and use of consistent definitions in research and peer-reviewed literature. Breastfeed Med. 2012;7(6):397–402.

World Health Organization. Division of Diarrhoeal and Acute Respiratory Disease Control. Indicators for assessing breast-feeding practices: report of an informal meeting. Geneva: World Health Organization; 1991 [cited 2021 Jun 19]. p. 14. Report No.: WHO/CDD/SER/91.14, Corr. 1. Available from: https://apps.who.int/iris/handle/10665/62134 .

Critical Appraisal Skills Programme [CASP]. CASP Randomised Controlled Trial Standard Checklist. 2020 [cited 2020 Nov 27]. Available from: https://casp-uk.b-cdn.net/wp-content/uploads/2020/10/CASP_RCT_Checklist_PDF_Fillable_Form.pdf .

Holland K, Rees C. Evaluating and appraising evidence to underpin nursing practice. In: Nursing: Evidence-Based Practice Skills. New York: Oxford University Press; 2010. p. 167–96.

Critical Appraisal Skills Programme [CASP]. CASP Qualitative Checklist (2018). 2018 [cited 2021 Nov 22]. Available from: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf .

Campbell M, Katikireddi SV, Sowden A, McKenzie JE, Thomson H. Improving Conduct and Reporting of Narrative Synthesis of Quantitative Data (ICONS-Quant): Protocol for a mixed methods study to develop a reporting guideline. BMJ Open. 2018;8(2):e020064.

Fishbein M, Ajzen I. Predicting and changing behavior: The Reasoned Action Approach. New York: 2010.

Bandura A. Social foundations of thought and action: A social cognitive theory. New Jersey: Englewood Cliffs; 1986.

Bandura A. Self-efficacy: Toward a unifying theory of behavioural change. Psychol Rev. 1977;84(2):191–215.

Article   CAS   PubMed   Google Scholar  

Dennis C, Faux L. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health. 1999;22(5):399–409.

Bandura A. Exercise of personal and collective efficacy in changing societies. In: Bandura A, editor. Self-efficacy in Changing Societies. New York: Cambridge University Press; 1995. p. 1–45.

Chapter   Google Scholar  

Kotter J. Leading Change. Boston: Harvard Business School Press; 1996.

Mann L, Harmoni R, Power C. Adolescent decision-making: the development of competence. J Adolesc. 1989;12(3):265–78.

Granovetter M. The Strength of Weak Ties. Am J Sociol. 1973;78(6):1360–80.

Milligan C, Wiles J. Landscapes of care. Prog Hum Geogr. 2010;34(6):736–54.

Mercer RT. A theoretical framework for studying factors that impact on the maternal role. Nurs Res. 1981;30(2):73–7.

Ajzen I. The theory of planned behavior: Frequently asked questions. Hum Behav Emerg Technol. 2020;2(4):314–24.

Fishbein M. A Reasoned Action Approach to Health Promotion. Med Decis Mak. 2008;28(6):834–44.

James W. Pragmatism’s conception of truth. In: Menand L, editor. Pragmatism: A Reader. New York: Vintage Books; 1997. p. 94–131.

Warms CA, Schroeder CA. Bridging the gulf between science and action: The “new fuzzies” of neopragmatism. Adv Nurs Sci. 1999;22(2):1–10.

Article   CAS   Google Scholar  

Husserl E. Cartesian meditations. An introduction to phenomenology (D. Cairns, Trans.). Boston: Martinus Nijhoff Publisher; 1973.

Aikin SF. Pragmatism, Naturalism, and Phenomenology. Hum Stud. 2008;29(3):317–40.

Kaushik V, Walsh CA. Pragmatism as a research paradigm and its implications for Social Work research. Soc Sci. 2019;8(9):255.

Emiliussen J, Engelsen S, Christiansen R, Klausen SH. We are all in it!: Phenomenological Qualitative Research and Embeddedness. Int J Qual Methods. 2021;20:1–6.

Green LW. Toward Cost-Benefit Evaluations of Health Education: Some Concepts, Methods, and Examples. Health Educ Monogr. 1974;2(1_suppl):34–64.

Green LW, Kreuter MW, Deeds SG, Patridge KB. Health Education Planning: A Diagnostic Approach. Palo Alto: Mayfield Publishing; 1980. p. 306.

Green LW, Kreuter M. Health Promotion Planning: An Educational and Environmental Approach. Mountain View: Mayfield publishing; 1991.

Green LW, Kreuter M. Health Program Planning: An Educational And Ecological Approach. New York: McGraw-Hill; 2005.

Porter CM. Revisiting Precede-Proceed: A leading model for ecological and ethical health promotion. Health Educ J. 2016;75(6):753–64.

Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32:513–31.

Hubley J. Understanding behaviour: The key to successful health education. Trop Doct. 1988;18(3):134–8.

Mozafari R, Hamzeh B, Haghighizadeh M, Bigvand M. The impacts of Beliefs, Attitude, Subjective Norms, Enabling Factors - based educational program on cardiovascular risk factors through enhanced nutritional behaviors in water and wastewater organization employees. J Fam Med Primary Care. 2018;7:27–33.

de Vries H, Dijkstra M, Kuhlman P. Self-efficacy: The third factor besides attitude and subjective norm as a predictor of behavioural intentions. Health Educ Res. 1988;3(3):273–82.

de Vries H, Mudde AN. Predicting stage transitions for smoking cessation applying the attitude-social influence-efficacy model. Psychol Health. 1998;13(2):369–85.

Fisher WA, Fisher JD, Harman J. The Information-Motivation-Behavioral Skills Model: A General Social Psychological Approach to Understanding and Promoting Health Behavior. In: Suls J, Wallston KA, editors. Social Psychological Foundations of Health and Illness. United Kingdom: Blackwell Publishers; 2009. p. 82–106.

Nicholson N. The transition cycle: causes, outcomes, processes, and forms. In: Fisher S, Cooper C, editors. On the move: the psychology of change and transitioning. Chichester: John Wiley & Sons, Inc.; 1990. p. 89.

Musamali K. An Examination of Transition Models and Processes: Introduction of an Integrated Approach. Adv Soc Sci Res J. 2018;5(6):245–60.

Lutter C. Breastfeeding promotion–is its effectiveness supported by scientific evidence and global changes in breastfeeding behaviors? Adv Exp Med Biol. 2000;478:355–68.

CAS   PubMed   Google Scholar  

Lewin K. Field Theory in Social science: Selected Theoretical Papers (Edited by Dorwin Cartwright.). New York: Harper & Brothers; 1951. p. 346.

Pender N. Health promotion in nursing practice. New York: Appleton-Century-Crofts; 1982.

Titler MG, Kleiber C, Steelman VJ, Rakel BA, Budreau G, Everett LQ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497–509.

Novak JD, Cañas AJ. The origins of the concept mapping tool and the continuing evolution of the tool. Inf Vis. 2006;5(3):175–84.

Bartholomew LK, Parcel GS, Kok G. Intervention Mapping: A Process for Developing Theory- and Evidence-Based Health Education Programs. Health Educ Behav. 1998;25(5):545–63.

World Health Organization, United Nations Children’s Fund. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: implementing the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF); 2018. p. 64. Available from:  https://www.unicef.org/media/95191/file/Baby-friendly-hospital-initiative-implementation-guidance-2018.pdf .

Alive & Thrive. Overview of the social franchise model for delivering counseling services on infant and young child feeding. Hanoi: Alive & Thrive; 2013. Available from: https://www.aliveandthrive.org/sites/default/files/attachments/Overview-of-the-Social-Franchise-Model.pdf/ .

Institute for Healthcare Improvement. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. Boston: IHI Innovation Series white paper; 2003.

Kam AW, Collins S, Park T, Mihail M, Stanaway FF, Lewis NL, et al. Using Lean Six Sigma techniques to improve efficiency in outpatient ophthalmology clinics. BMC Health Serv Res. 2021;38(9):1688–98.

Ahmadi S, Kazemi F, Masoumi SZ, Parsa P, Roshanaei G. Intervention based on BASNEF model increases exclusive breastfeeding in preterm infants in Iran: A randomized controlled trial. Int Breastfeed J. 2016;11(30).

Ahmed AH. Breastfeeding preterm infants: an educational program to support mothers of preterm infants in Cairo. Egypt Pediatr Nurs. 2008;34(2):125–30 138.

PubMed   Google Scholar  

Blyth R, Creedy DK, Dennis CL, Moyle W, Pratt J, de Vries SM. Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory. Birth. 2002;29(4):278–84.

Chan MY, Ip WY, Choi KC. The effect of a self-efficacy-based educational programme on maternal breast feeding self-efficacy, breast feeding duration and exclusive breast feeding rates: A longitudinal study. Midwifery. 2016;36:92–8.

Liu L, Zhu J, Yang J, Wu M, Ye B. The Effect of a Perinatal Breastfeeding Support Program on Breastfeeding Outcomes in Primiparous Mothers. West J Nurs Res. 2017;39(7):906–23.

Mcqueen KA, Dennis CL, Stremler R, Norman CD. A Pilot Randomized Controlled Trial of a Breastfeeding Self-Efficacy Intervention With Primiparous Mothers. J Obstetr Gynecol Neonatal Nurs. 2011;40(1):35–46.

Nichols J, Schutte NS, Brown RF, Dennis CL, Price I. The impact of a self-efficacy intervention on short-term breast-feeding outcomes. Health Educ Behav. 2009;36(2):250–9.

Tseng JF, Chen SR, Au HK, Chipojola R, Lee GT, Lee PH, et al. Effectiveness of an integrated breastfeeding education program to improve self-efficacy and exclusive breastfeeding rate: A single-blind, randomised controlled study. Int J Nurs Stud. 2020;111:103770.

You H, Lei A, Xiang J, Wang Y, Luo B, Hu J. Effects of breastfeeding education based on the self-efficacy theory on women with gestational diabetes mellitus. Medicine. 2020;99(16): e19643.

Wu DS, Hu J, Mccoy TP, Efird JT. The effects of a breastfeeding self-efficacy intervention on short-term breastfeeding outcomes among primiparous mothers in Wuhan. Chin J Adv Nurs. 2014;70(8):1867–79.

Bich TH, Long TK, Hoa DP. Community-based father education intervention on breastfeeding practice—Results of a quasi-experimental study. Maternal Child Nutr. 2019;15(S1):e12705.

Gu Y, Zhu Y, Zhang Z, Wan H. Effectiveness of a theory-based breastfeeding promotion intervention on exclusive breastfeeding in China: a randomised controlled trial. Midwifery. 2016;42:93–9.

Wan H, Tiansawad S, Yimyam S, Sriarporn P. Effects of a theory-based breastfeeding promotion intervention on exclusive breastfeeding in China. Chiang Mai Univ J Nat Sci. 2016;15(1):49–66.

Rasoli H, Masoudy G, Ansari H, Bagheri H. Effect of Education Based on Extended Theory of Planned Behavior on Exclusive Breastfeeding in Pregnant Women in Darmian in 2017. Health Scope. 2020;9(3):e100277.

Nguyen PH, Kim SS, Nguyen TT, Hajeebhoy N, Tran LM, Alayon S, et al. Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers. Matern Child Nutr. 2016;12(4):713–25.

Mesters I, Gijsbers B, Bartholomew LK. Promoting sustained breastfeeding of infants at risk for asthma: Explaining the “active ingredients” of an effective program using intervention mapping. Front Public Health. 2018;6:87.

Nguyen PH, Menon P, Keithly SC, Kim SS, Hajeebhoy N, Tran LM, et al. Program impact pathway analysis of a social franchise model shows potential to improve infant and young child feeding practices in Vietnam. J Nutr. 2014;144(10):1627–36.

Gijsbers B, Mesters I, Knottnerus JA, Kester ADM, van Schayck CP. The Success of an Educational Program to Promote Exclusive Breastfeeding for 6 Months in Families with a History of Asthma: A Randomized Controlled Trial. Pediatr Asthma Allerg Immunol. 2006;19(4):214–22.

Bærug A, Langsrud Ø, Løland BF, Tufte E, Tylleskär T, Fretheim A. Effectiveness of Baby-friendly community health services on exclusive breastfeeding and maternal satisfaction: a pragmatic trial. Matern Child Nutr. 2016;12(3):428–39.

Chipojola R, Chiu HY, Huda MH, Lin YM, Kuo SY. Effectiveness of theory-based educational interventions on breastfeeding self-efficacy and exclusive breastfeeding: A systematic review and meta-analysis. Int J Nurs Stud. 2020;109:103675.

Dennis C. The breastfeeding self-efficacy scale: psychometric assessment of the short form. J Obstet Gynecol Neonatal Nurs. 2003;32(6):734–44.

McCarter-Spaulding D, Gore R. Breastfeeding self-efficacy in women of African descent. J Obstet Gynecol Neonatal Nurs. 2009;38(2):230–43.

Moussa Abba A, de Koninck M, Hamelin AM. A qualitative study of the promotion of exclusive breastfeeding by health professionals in Niamey. Niger Int Breastfeed J. 2010;5:1–7.

Zhu Y, Zhang Z, Ling Y, Wan H. Impact of intervention on breastfeeding outcomes and determinants based on theory of planned behavior. Women Birth. 2017;30(2):146–52.

Ismail TAT, Muda WAMW, Bakar MI. The extended theory of planned behavior in explaining exclusive breastfeeding intention and behavior among women in Kelantan. Malaysia Nutr Res Pract. 2016;10(1):49–55.

Cangöl E, Sahin NH. The Effect of a Breastfeeding Motivation Program Maintained during Pregnancy on Supporting Breastfeeding: A Randomized Controlled Trial. Breastfeed Med. 2017;12(4):218–26.

Yunitasari E, Andriani R, Wahyuni S. Exclusive Breastfeeding Based on The Health Promotion Model in Madura Island. Int J Pharm Res. 2020;12:1685–90.

Tuthill EL, Butler LM, Pellowski JA, McGrath JM, Cusson RM, Gable RK, et al. Exclusive breast-feeding promotion among HIV-infected women in South Africa: An Information-Motivation-Behavioural Skills model-based pilot intervention. Public Health Nutr. 2017;20(8):1481–90.

Wambach KA, Aaronson L, Breedlove G, Domian EW, Rojjanasrirat W, Yeh HW. A randomized controlled trial of breastfeeding support and education for adolescent mothers. West J Nurs Res. 2011;33(4):486–505.

Alianmoghaddam N, Phibbs S, Benn C. “I did a lot of Googling”: A qualitative study of exclusive breastfeeding support through social media. Women Birth. 2019;32(2):147–56.

Rahayu D, Yunarsih Y. Support System on Successful Exclusive Breastfeeding on Primipara Based on Theory of Maternal Role Attainment. 2017;2:411–5.

Arbour MC, Mackrain M, Fitzgerald E, Atwood S. National Quality Improvement Initiative in Home Visiting Services Improves Breastfeeding Initiation and Duration. Acad Pediatr. 2019;19(2):236–44.

Brockman V. Implementing the Mother-Baby Model of Nursing Care Using Models and Quality Improvement Tools. Nurs Women Health. 2015;19(6):490–503.

Henry LS, Christine Hansson M, Haughton VC, Waite AL, Bowers M, Siegrist V, et al. Application of Kotter’s Theory of Change to Achieve Baby-Friendly Designation. Nurs Women Health. 2017;21(5):372–82.

Seran M, Arief Y, Kurnia I. The Analysis of Family Support Factors in Exclusive Breastfeeding Based on Precede Proceed Theory. Int J Pharm Res. 2020;12:1728–34.

Froehlich J, Donovan A, Ravlin E, Fortier A, North J, Bloch MKS. Daily routines of breastfeeding mothers. Work. 2015;50(3):433–42.

Thepha T, Marais D, Bell J, Muangpin S. Concept mapping to reach consensus on a 6-month exclusive breastfeeding strategy model to improve the rate in Northeast Thailand. Maternal Child Nutr. 2019;15(4):e12823.

Lestari W, Kusnanto H, Paramastri I, Widyawati. A qualitative study: The promotion of exclusive breastfeeding (EBF) by integrated service post (ISP) cadres in suburban city. Enferm Clin. 2019;29:56–9.

Bai YK, Lee S, Overgaard K. Critical Review of Theory Use in Breastfeeding Interventions. J Hum Lact. 2019;35(3):478–500.

Ajzen I. The Theory of Planned Behavior. Organ Behav Hum Decis Proc. 1991;50:179–211.

Ajzen, Icek. From intentions to actions: a theory of planned behavior. Action control. 1985;11–39.

Hempel C. The function of General Laws in History. In: Polifroni E, Welch M, editors. Perspectives on Philosophy of science in nursing: an historical and contemporary anthology. Baltimore: Lippincott Williams & Wilkins; 1999. p. 179–88.

Hempel C. Aspects of scientific explanantion. In: Hempel C, editor. Aspects of scientific explanation and other essays in the philosophy of science. New York and London: The Free Press and Collier-Macmillan Ltd; 1965. p. 331–496.

Hossain FMA. A Critical Analysis of Empiricism. Open J Philos. 2014;04(03):225–30.

Beck L, Ajzen I. Predicting dishonest actions using the theory of planned behavior. J Res Pers. 1991;25:285–301.

Ajzen I, Driver BL. Application of the Theory of Planned Behavior to Leisure Choice. J Leis Res. 1992;24(3):207–24.

Hardeman W, Johnson M, Johnson D, Bonetti D, Wareham N, Kinmonth A. Theory of Planned Behaviour in Behaviour Change Interventions : A Systematic Review. Psychol Health. 2002;17(2):123–58.

Skouteris H, Nagle C, Fowler M, Kent B, Sahota P, Morris H. Interventions designed to promote exclusive breastfeeding in high-income countries: A systematic review. Breastfeed Med. 2014;9(3):113–27.

Download references

Acknowledgements

Not applicable.

Unfunded work.

Author information

Authors and affiliations.

School of Nursing, University of Connecticut, Storrs, CT, USA

Tumilara Busayo Amoo & Ruth Lucas

School of Nursing, Victoria University of Wellington, Wellington, New Zealand

Tosin Popoola

You can also search for this author in PubMed   Google Scholar

Contributions

TBA was responsible for research design, data analysis and writing of first draft of paper. TBA and TP conducted literature review and extracted data from studies. All authors contributed to edits and agreed on the final version of the paper before submission. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tumilara Busayo Amoo .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Amoo, T.B., Popoola, T. & Lucas, R. Promoting the practice of exclusive breastfeeding: a philosophic scoping review. BMC Pregnancy Childbirth 22 , 380 (2022). https://doi.org/10.1186/s12884-022-04689-w

Download citation

Received : 01 December 2021

Accepted : 08 April 2022

Published : 01 May 2022

DOI : https://doi.org/10.1186/s12884-022-04689-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Scoping review

BMC Pregnancy and Childbirth

ISSN: 1471-2393

• Submission enquiries: [email protected]
• General enquiries: [email protected]

School Thesis

Free Thesis Topics and Masters Research Papers PDF Download

Factors Affecting Exclusive Breastfeeding Practice Among Nursing Mothers

Quick Navigation for Final Year Undergraduates, Masters (Thesis), and Ph.D. Dissertation Students Who Need Our Services on Their Research Works

DOWNLOAD FULL PDF WORK

Chapter One of Factors Affecting Exclusive Breastfeeding Practice Among Nursing Mothers

INTRODUCTION

Background of the Study

Breastfeeding is unequaled way of providing ideal food for the health, growth and development of infants and most natural way of feeding them in all traditions. It is an integral part of the reproductive process with important implications for the health of the mother. Human milk is the most appropriate of all available types of milk, that is uniquely adapted for infant nutrition as it components consistently adopt to the child’s need and environmental challenges. Breast milk contains virtually all the nutrients antibodies and anti-oxidants an infant needs to thrive for the first six months of life (Abasiattai, Umana, Nyong and Eyo, 2014).

The benefits of breast feeding for mothers and infants have been widely recognized and researched studies have shown that breastfeeding is superior to infant formula feeding because of its protective properties against illness, in addition to its nutritional advantages (Sadoh, Oniyelu, 2011). Considering the extensive benefits of breastfeeding, the world Health organization and the American Dietetic Association recommended exclusive breast feeding of infants for the first six months and continued breastfeeding with complementary foods up to twelve (12) months of age (ADA Report, 2001). Despite widespread efforts to encourage breastfeeding, the rates in the United States (U.S) have remained low (Pugh, 2002).

Exclusive breastfeeding (EBF) refers to the exclusive intake of breast milk or expressed breast milk by an infant without the addition of any other liquid or solids, with the exception of oral drops or syrups containing vitamins, mineral supplements or medicines. Exclusive breastfeeding advocated the world over as the optimal mode of feeding for young infants in the first months of life, followed by breast milk and complimentary feeds thereafter till two years of age or beyond. When the infants are exclusively breastfed for the first six months of life, their immune system is stimulated and this goes hand in hand with protecting them from disease like diarrhea and acute respiratory infections, which are considered to be two of the major causes of infant mortality in developing world. When breastfeeding is practiced exclusively, it is associated with a lower risk of HIV transmission than mixed feeding.

Other advantages of exclusive breastfeeding include reduction in post partum bleeding, improvement in home status later in life and protection against breast and ovarian cancers. Other benefits include lactational amenorrhea which enhances child spacing, early mother-infant bonding and reduction in infant abandonment and child abuse. EBF also provides social and economic benefits to the family and the nation as well as a sense of satisfaction to most nursing-mothers (Madhu, Chowdary and Masti, 2009).

Breastfeeding is accepted as the natural form of infant feeding. For mothers to be able to breastfeed exclusively to the recommended six months, it is important to understand the factors that affect exclusive breastfeeding, studies of non pregnant high school students suggest that attitudes toward infant feeding begin to form well before pregnancy. Previous research has shown that maternal attitudes toward breastfeeding and perceptions of infant health benefits of breastfeeding influence the decision of breastfeed. Man demographic factors such as maternal age, marital status, education, race, nature of work, cultural factors, parity number of children at home and social support, urban versus rural residence and employment policies have been shown to potentially affect a nursing-mother’s decision (Dubois, Girard, 2003).

Among all of these factors, mother’s education had greater impact on nutritional status of children. However, it does not mean that mothers with high education level had healthy children only. Many studies outside the south-south region and very few within the region have been carried out to ascertain most factors that affect exclusive breastfeeding practices among nursing mothers. For instance, Tan (2011) researched on factors associated with exclusive breastfeeding among infant under six months of age in Peninsular Malaysia, he found that the prevalence of exclusive breastfeeding among mothers with infant aged between one and six months was one percent (Abasiattai et al, 2014). In the study on knowledge and practice of exclusive breast-feeding among antenatal attendees in Uyo, southern Nigeria revealed that the level of knowledge and practice of exclusive breastfeeding by women in Uyo is poor and as such none of the women belonged to a breastfeeding support group and the most common source of information on exclusive breastfeeding was the antenatal health talk.

Other efforts made toward the determination of factors affecting exclusive breastfeeding practices among nursing mothers are the works of Setegn, Belachew, Gerbaba, Deribe, Denshaw and Biadgilign (2012) on factors associated with exclusive breastfeeding practices among mothers in Goba District, discovered that the prevalence of exclusive breastfeeding for infant aged less than six months in the study area was 71-3 percent as measured by last 24 hours recalled period preceding the survey date.

A critical examination of the above cited study by different authors and researchers show that there is no consistency to ascertain to which extent the factors mentioned above affect exclusive breastfeeding practices among nursing-mothers and which of the factors has the prevalence effects or influence.

The researcher in the current study is interested to investigate the effect of educational level, nature of work and the mother’s age on the practices of exclusive breastfeeding among nursing-mothers in Uyo Local Government Area in Akwa Ibom State.

Statement of the Problem

Poor knowledge and attitudes of nursing-mothers toward breastfeeding has generated a lot of controversy in our modern society, influence practices and constitute barriers to optimizing the benefits of the Baby friendly initiative (BFI) aims to provide a supportive environment for breast-feeding and also encourages mothers to know and practice the ten steps to clinics (Abasiattai et al., 2014).

Despites the known benefits of exclusive breastfeeding to nursing mothers and infants based on anecdotal and empirical evidence, which the World Health Organisation (WHO) has recommended 2 years breastfeeding. First 6 months exclusive breastfeeding; more than 8 times breastfeeding of the baby for day in the first 3 months of the infants life. The attitude of most nursing-mothers of the infant’s life. The attitude of most nursing-mothers is a reverse of this recommendation WHO/UNICEF Article February 2nd, 2014).

Studies have revealed that most nursing-mothers in the urban area denied their babies exclusive breastfeeding up to four months from birth, and that most of the highly socio-economic status nursing mothers have not exclusively breastfed their babies. Moreover, it is observed that most poor nursing-mothers especially in the rural areas over exclusively breastfed their babies beyond six months and over two years of breastfeeding infants. The unequal situations have posed a lot of questions to medical health scholars and health researchers against which factors are responsible or militate against these attitudes of nursing-mother toward exclusive breastfeeding.

However, a gamut of factors not limited to race and cultural characteristics, infant health problems, socio-economic status and some psychosocial factors may hamper the full realization of the baby friend initiative and also information about the beliefs and knowledge that may constitute barriers and in turn affect practices needed in order to optimally utilize the benefits of the baby friendly initiative. Consequently, a number of studies have assessed knowledge, attitude and practice of breastfeeding in different parts of the world, states and local governments. However, such studies are not limited to nursing-mothers in Uyo Local Government Area.

Against the above premise the study investigated the factors affecting exclusive breastfeeding practice among nursing-mothers in Uyo local government area of Akwa Ibom State.

Purpose of the Study

The overall purpose of the study was to investigate the factors affecting exclusive breastfeeding among-nursing mothers in Uyo local government area.

Specifically the study has the following objectives:

To investigate the effect of educational level of mothers on exclusive breastfeeding.

To investigate the effect of the nature of work of the mothers on exclusive breastfeeding

To investigate the effect of nursing mother’s age on exclusive breastfeeding.

Research Questions

With regard to the problem of this study, the researcher developed three main research questions to guide the work.

What is effect of educational level of nursing-mothers on exclusive breastfeeding practice.

What is effect of the nature of work of the nursing-mothers on exclusive breastfeeding practice.

What is effect of nursing-mothers’ age on exclusive breastfeeding practice.

Research Hypothesis

The following Null hypotheses were formulated to guide the study and were tested at .05 significant level. They are:

Ho1: There is no significant relationship in exclusive breastfeeding practice between educated and uneducated nursing-mothers in Uyo Local Government Area.

Ho2: There is no significant relationship between the nature of work of nursing mothers and exclusive breastfeeding practice in Uyo Local Government Area.

Ho3: There is no significant relationship between the nursing-mothers age and exclusive breastfeeding practice in Uyo Local Government Area.

Significance of the Study

The problem of exclusive breastfeeding practice is an embraced investigation that hunts for solution and benefits for families and individuals in our society.

The study will eradicate the perception of nursing mothers that babies during the first six months of exclusive breastfeeding continue to be hungry.

The study will also be useful to health personnel and medical health officers for effective advise and counselling during ante-natal and post-natal clinics.

The study will also help government and State Ministry of Health to plan for orientation programmes for nursing-mothers in various communities.

Scope of the Study

The study is an investigation of factors affecting exclusive breastfeeding practice among nursing-mothers in Uyo Local Government Area.

The study is delimited to the nursing-mothers within Uyo metropolis.

The study investigates only the educational level, nature of work and age factors on exclusive breastfeeding practice among nursing-mothers in Uyo Local Government Area.

This research material is intended for academic use only and should be used as a guide in constructing your research project and seminar presentation. You should never duplicate the content word for word (verbatim), as  SCHOOLTHESIS.COM  will not be held liable for anyone who does.

The purpose of publishing this material is to alleviate the stress of hopping from one school library to the next in search of research materials. This service is lawful because all educational institutions allow students to read past projects, papers, books, and articles while working on their own.

SCHOOL THESIS  is merely giving this information as a research reference. Use the document as a reference or structure for your own research paper. This paper’s content should be able to assist you in coming up with new ideas and thoughts for your own study

Factors Affecting Exclusive Breastfeeding Practice Among Nursing Mothers research paper, should only be used as a guide.

• Open access
• Published: 26 May 2024

State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child

• Julia Rosenberg 1 ,
• Deanna Nardella 1 , 2 &
• Veronika Shabanova 1 , 3  

International Breastfeeding Journal volume  19 , Article number:  37 ( 2024 ) Cite this article

338 Accesses

10 Altmetric

Metrics details

Paid parental leave policies may promote breastfeeding, which can have short- and long-term health benefits for both members of the birthing person-infant dyad. In the United States, where 56% of the workforce qualifies for unpaid federal medical leave, certain states have recently enacted paid parental and family leave policies. We aimed to assess the extent to which living in states with versus without paid family leave was associated with feeding regimens that included breastfeeding.

In this cross-sectional analysis of the 2021 National Immunization Survey-Child, we assessed feeding outcomes: (1) exclusively breastfed (only fed breastmilk—never infant formula—both before and after six months of age), (2) late mixed breastfeeding (formula after six months), (3) early mixed breastfeeding (breastfed, formula before six months), and (4) never breastfed. We conducted Pearson χ 2 to compare social-demographic characteristics and multivariable nominal regression to assess extent to paid family leave was associated with breastfeeding regimens, compared with never breastfeeding.

Of the 35,995 respondents, 5,806 (25% of weighted respondents) were from states with paid family leave policies. Compared with never breastfeeding, all feeding that incorporated breastfeeding—exclusive breastfeeding, late mixed feeding (breastfed, formula introduced after six months), and early mixed feeding (breastfed, formula introduced before six months)—were more prevalent in states with paid family leave policies. The adjusted prevalence ratio (aPR) and differences in adjusted prevalence compared with never breastfeeding in states with versus without paid family leave policies were: aPR 1.41 (95% CI 1.15, 1.73), 5.36% difference for exclusive breastfeeding; aPR 1.25 (95% CI 1.01, 1.53), 3.19% difference for late mixed feeding, aPR 1.32 (95% CI 1.32, 1.97), 5.42% difference for early mixed feeding.

States with paid family leave policies have higher rates of any breastfeeding and of exclusive breastfeeding than states without such policies. Because all feeding types that incorporate breastfeeding were higher in states with paid family leave policies, expansion of paid family leave may improve breastfeeding rates.

The short- and long-term benefits of breastfeeding for both members of the birthing person-infant dyad have been well-established. The American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the World Health Organization promote exclusive breastfeeding for six months followed by continued breastfeeding until one to two years of age [ 1 , 2 , 3 ]. For newborns, sustained breastfeeding is associated with decreased adverse health consequences including lower rates of infant mortality and lower incidence of sudden infant death syndrome; respiratory, ear, and gastrointestinal infections; asthma; eczema; autoimmune conditions; and diabetes [ 2 ]. While exclusive breastfeeding without infant formula introduction is recommended to maximize benefits, data suggest protective effects of any breastfeeding against gastrointestinal illnesses, ear infections, asthma, and obesity [ 4 , 5 , 6 ]. For birthing people, breastfeeding is associated with decreased rates of hypertension, diabetes, and certain types of cancer [ 1 , 2 ]. In addition to the individual benefits, breastfeeding promotes dyadic health with opportunities for bonding and benefits for mental and physical health [ 7 ]. According to the Centers for Disease Control and Prevention (CDC) breastfeeding report card, in 2019, only 25% of infants born in the United States (US) exclusively breastfed until six months of age and about 36% were breastfeeding at one year [ 8 ], falling short of the US Healthy People 2030 targets of 42.4% and 54.1%, respectively [ 9 ].

A major barrier to sustained breastfeeding can be caregivers returning to work. Globally, longer maternity leave is associated with higher rates of breastfeeding [ 10 ]. In the US, exclusive breastfeeding decreases by approximately 25% within the first week of life, nearly 50% by three months, and 70% by six months, correlating with return to work for many parents [ 8 ].

With nearly two-thirds of females participating in the US workforce having a child under three years of age [ 11 ], the need to establish and evaluate policies that protect breastfeeding for working lactating persons has been underscored in formal recommendations, including through the Surgeon General’s Calls to Action to Support Breastfeeding and to Improve Maternal Health and the 2022 White House National Strategy on Hunger, Nutrition and Health [ 12 , 13 , 14 ]. Despite these recommendations, the US is the only country in the Organization for Economic Cooperation and Development (OECD) to not offer a paid federal family leave policy [ 15 , 16 ].

Federal US Legislation supporting unpaid leave and lactation includes the 1993 Family Medical Leave Act (FMLA), the 2010 Patient Protection and Affordable Care Act, and the 2021 Providing Urgent Maternal Protections for Nursing Mothers (PUMP) Act [ 17 ]. Federal FMLA stipulates 12 weeks of unpaid, job-protective leave for care of a child [ 18 ]. A growing number of states and regions have enacted paid family leave policies. As of 2024, 17 US states and Washington, DC have active paid family leave policies, with five states’ legislation to be enacted in future years (Fig.  1 ) [ 19 ].

Primary exposure of interest: paid family leave policy status by US state

In this cross-sectional study, we aimed to assess the relationship of paid family leave with a spectrum of breastfeeding outcomes, including metrics of breastfeeding duration and exclusivity, at the population level. We hypothesized that residence in US states with paid family leave policies is associated with higher rates of both exclusive and any breastfeeding.

Data source

This cross-sectional, secondary dataset analysis was conducted using data from the 2021 National Immunization Survey-Child (NIS-C), which included the fifty US states and Washington, DC. The National Immunization Surveys (NIS), which includes NIS-C, are telephone surveys administered via random digit dialing to a stratified representative US sample, conducted by the CDC’s National Center for Immunization and Respiratory Disease. The NIS-C incorporates data from parent/guardian interviews and from questionnaires sent to medical providers to evaluate multiple domains of health, including immunization, breastfeeding, and usage of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. The 2021 NIS-C target population included US families of children who were 19–35 months old during calendar year 2021. The survey was translated into English and Spanish, and other languages were queried using telephonic interpretation [ 20 , 21 ].

The NIS-C is a publicly available, de-identified dataset. Its use is not considered Human Subjects Research, and we did not obtain a determination of this status from the Institutional Review Board. We followed the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines for cross-sectional observational data (Additional File 1 ) [ 22 ].

Study variable terminology

When analyzing and presenting data, we used terminology as reported in the NIS-C dataset, which includes terms such as breastfeeding and mother, rather than gender-inclusive terms such as chest feeding and birthing person [ 23 , 24 ].

States with and without paid family leave policies

The locations with paid family leave policies at the time of the 2021 NIS-C included California, Massachusetts, New Jersey, New York, Rhode Island, Washington, and Washington, DC (Fig.  1 ). All other states without active paid family leave policies were grouped together, and Puerto Rico was excluded. Three locations—Washington DC, Massachusetts, and Washington—had aspects of their policies enacted in 2020, so some of the surveyed families may have given birth before full enactment. Thus, post-hoc sensitivity analyses were also conducted with these locations removed from analyses.

Primary outcome

The primary outcome was a composite variable reflecting breastmilk and infant formula feeding. To construct this variable, we accounted for three NIS-C variables that assessed if the child ever was fed breastmilk, duration of breastfeeding, and the date of first formula introduction. The finalized infant feeding primary outcome is summarized in Fig.  2 and includes four categories: (1) exclusively breastfed for the duration captured by data (without formula introduction), (2) late mixed breastfeeding (breastfed exclusively until six months, introduced formula after 6 months), and (3) early mixed breastfeeding (breastfed, introduced formula either before six months of age or at unknown time), and (4) never breastfed. “Exclusively breastfed” refers to receiving breastmilk and never infant formula as source of nutrition but may include supplementary, non-infant formula foods. Because the primary outcome centered around breastfeeding, the 141 respondents with unknown breastfeeding data were excluded from the analysis (see Additional File 2 for characteristics of excluded respondents, who could be considered as non-respondents generally due to high rates of missingness for other variables).

Total days of breastfeeding duration and first day of formula by primary outcome of infant feeding category. Legend: “Exclusively breastfed” refers to receiving breastmilk and never infant formula as source of nutrition but may include supplementary, non-infant formula foods. Figure includes maximum (upper whisker) but not minimum values, as some respondents who reported exclusive breastfeeding had very few days of breastfeeding reported, which we assumed to be errors in reporting. Box indicates upper and lower quartiles. Line indicates median. Adjusted n’s: Exclusively Breastfed n  = 6,579.82, Late Mixed Feeding n  = 5,899.27, Early Mixed Feeding n  = 16,312.40, Never Breastfed n  = 5,9343.9

Covariate selection

Based on prior studies of breastfeeding outcomes and available data in the NIS-C, selected covariates included: maternal age, infant age, infant sex, infant race and ethnicity (as reported by the NIS-C dataset), household size, children in the home, maternal education, marital status, language of interviews, poverty level, and WIC enrollment [ 2 ]. In order to control for policies that may affect breastfeeding outcomes at the state level, we also developed a covariate to account for workplace lactation protection policies; thirty states and the District of Columbia have such protections in place [ 25 ].

Statistical analyses

Since the data were collected using stratified random sampling, survey responses have been weighted by the weights provided by the NIS-C, to reflect strata and non-response. Simple descriptive statistics (count, percent) and Pearson χ 2 tests were used to describe and compare the social and demographic characteristics of children and mothers from states that did and did not have active paid family leave policies in 2021 (Table  1 ).

We used multivariable nominal regression to examine the extent to which the primary exposure variable of residence in states with and without paid family leave policies in 2021 was associated with the primary outcome of any infant feeding regimen that included breastfeeding, compared with never breastfeeding. In this multivariable regression, we controlled for a priori chosen covariates, all of which were retained in the adjusted model and are displayed in Tables  1 and 2 . Results are reported as adjusted estimates of prevalence of each feeding regimen (as percentages within each outcome level); differences between adjusted prevalence of breastfeeding outcomes (exclusive, late mixed, early mixed) and adjusted prevalence of never breastfeed; and unadjusted and adjusted prevalence ratios (PR, aPR) with 95% confidence intervals (CI), which were obtained postestimation via linear combinations of relevant parameters and use of marginal mean statement [ 26 ]. As noted in the description of the independent variable (states with and without family leave policies), we also conducted post-hoc sensitivity analyses without states where implementation of policies occurred during the study period. Because we were interested in the effect of paid family leave on a spectrum of breastfeeding outcomes that corresponded to independent hypotheses, we did not adjust for multiple comparisons [ 27 , 28 ].

Given the predetermined sample size by the NIS-C, our conclusions are based on the magnitude of the PR and surrounding 95% CI, rather than the p-values [ 29 , 30 ]. We further defined a meaningful magnitude of difference in the prevalence of breastfeeding at the 1% point, which reflects the change noted in the prior three years of exclusive breastfeeding in the United States, per Healthy People 2030 [ 9 ].

We completed analyses in Stata Version 15 (StataCorp College Station, Texas).

Sociodemographic characteristics by state paid family leave policy

As shown in Table  1 , of the 34,722 NIS-C unweighted survey respondents from 2021, 5,806 were from states with paid family leave policies, and they accounted for 25% of weighted survey respondents. We did not observe a meaningful difference between states with and without paid family leave policies in terms of infant sex, infant age, or household size. Differences were noted when assessing breastfeeding workplace policies, maternal age, number of children in the home, parental education, marital status, language of the interview, poverty level, and WIC enrollment (Table  1 ). Families in states with paid parental leave policies were more likely to reside in states that had workplace breastfeeding protections, report that the mother was over 29 years old, the infant was of Hispanic/Latino ethnicity, there were fewer children in the home, the mother graduated college, the mother was married, and that the income was above poverty and above $75,000. They were less likely to report being enrolled in WIC (Table  1 ).

Infant feeding patterns by state paid family leave policy

Exclusive breastfeeding was more prevalent in states with paid family leave policies than in states without such policies: 20.36% (95% CI 18.46%, 22.26%) in states with policies vs. 18.48% (95% CI 17.74%, 19.22%) in states without policies. Late mixed breastfeeding was similar in states with vs. without paid family leave: 16.78% (95% CI 14.97%, 18.60%) vs. 17.09% (95% CI 16.30%, 17.88%). Early mixed breastfeeding was more prevalent in states with vs. without paid family leave: 48.48% (95% CI 46.00%, 50.97%) vs. 46.55% (95% CI 45.47%, 47.64%). Fewer reported never breastfeeding in states with paid family leave: 14.38% (95% CI 12.52%, 16.23%) vs. 17.87% (95% CI 16.98%, 18.76%) (Fig.  3 ).

Adjusted prevalence of breastfeeding outcomes by US state paid family leave policies, National Immunization Survey-Child, 2021. Legend: Reported values are estimated prevalence of each feeding type. Error bars correspond to 95% confidence intervals

As shown in Table  2 ; Fig.  4 , compared with never breastfeeding, the adjusted prevalence of exclusive breastfeeding was higher by 5.36% (aPR = 1.41) in states with paid family leave vs. in states without paid family leave. Similarly, the adjusted prevalence of late mixed breastfeeding was higher by 3.19% (aPR = 1.25), and early mixed breastfeeding was higher by 5.42% (aPR = 1.32).

Difference in adjusted prevalence of breastfeeding outcomes and prevalence of never breastfeeding by US state paid family leave policies, National Immunization Survey-Child, 2021. Legend: Reported values are estimated differences in adjusted prevalence of each feeding type. Error bars correspond to 95% confidence intervals

A sensitivity analysis which excluded states that enacted family leave policies during the study period (Washington DC, Washington, and Massachusetts) found similar results across all feeding types (Additional File 3 ).

Covariates associated with breastfeeding

As shown in Table  2 , several covariates remained associated with breastfeeding outcomes in the adjusted model.

Workplace breastfeeding policies were positively associated with all types of breastfeeding.

Women with income below poverty had lower aPR of late mixed breastfeeding. Women who were married had greater aPR of all breastfeeding outcomes. Respondents who reported the race/ethnicity of their child as non-Hispanic/Latino Black had lower aPR of exclusively breastfeeding compared with non-Hispanic/Latino White children. Respondents who identified their children as Hispanic/Latino had higher aPR of late mixed feeding compared with non-Hispanic/Latino White children. Compared with English-speaking respondents, Spanish-speaking respondents had higher aPR of all breastfeeding types. Respondents with lower education levels had lower aPR of all breastfeeding outcomes. WIC enrollees also had lower aPR of all types of breastfeeding.

In this secondary dataset analysis using a US representative sample, we found that, after adjusting for covariates, all feeding types that incorporate breastfeeding (exclusive breastfeeding, late mixed feeding, and/or early mixed feeding) were higher in states with paid family leave compared with states without paid family leave policies. These findings offer novel insight into various feeding approaches indicative of real-world infant feeding practices among breastfeeding persons in the labor force. Even after controlling for state-level workplace breastfeeding policies, paid family leave policies are associated with exclusive breastfeeding and with a spectrum of feeding types that incorporate breastfeeding. These results demonstrate that the paid family leave policies are positively associated with breastfeeding, and thus may reflect health benefits for the parent/baby dyad that accompany any degree of breastfeeding [ 2 , 4 , 5 , 6 ].

Paid family leave policies have previously been associated with improvements in breastfeeding duration and with health and economic benefits [ 31 , 32 , 33 , 34 , 35 , 36 ]. After California was the first US state to provide eight weeks of partial paid family leave in 2004, Huang et al. utilized the CDC Infant Feeding Practices Study and found contemporaneous increases in the rates of breastfeeding in California compared with other US states, with difference-in-differences of 15.8%, 17.4%, and 18.4% in the rates of any breastfeeding at three, six, and nine months, respectively [ 37 , 38 ]. Globally, parental leave after childbirth has been associated with reduced maternal and infant morbidity and mortality [ 15 , 39 , 40 , 41 , 42 ]. In high-income countries, paid parental leave has been associated with increases in exclusive breastfeeding, downstream earning potential, workforce retention, and infant vaccination rates and with reductions in maternal medical and mental health morbidity [ 16 , 43 ]. Data suggest higher degrees of benefit with increasingly generous leave, including longer breastfeeding duration and higher maternal pay [ 44 ].

Just over half (56%) of the US workforce qualifies for federal FMLA, which is unpaid [ 45 ]. There are also limited opportunities for paid leave in the United States, which results in suboptimal breastfeeding initiation and duration [ 41 ]. Cross-sectional US studies have found that 59% of women did not receive paid leave, and, even when it was received, paid leave averaged about three weeks, with reduced salary [ 46 ]. Current FMLA policies and qualifications tend to support families who can afford unpaid time off work and have stable employment from large employers [ 18 ]. Women facing social and structural barriers to breastfeeding, such as low income, lower educational attainment, and membership in minority racial and ethnic groups, disproportionately do not benefit from federal FMLA policies. In this multivariable analysis, we found disparities in breastfeeding was associated with multiple factors that are also related to disparities in medical leave policies.

When evaluating income, we found that, in the adjusted model, women below the poverty level were less likely to exclusively breastfeed for the first six months before introducing infant formula. Families with lower incomes have previously been shown to have less paid and unpaid leave. One 2014 cross-sectional study found that only 20% of families making under $35,000 per year received paid leave, averaging 1.5 weeks in duration, compared with a respective 55% and 4.5 weeks for families making over $75,000 per year [ 46 ]. The 2018 US Department of Labor FMLA surveys demonstrated that low-wage workers making $15 per hour or less were least likely to take needed medical leave, citing the inability to afford unpaid time off from work and fear of job loss [ 45 ].

Similar to other studies, we found that marital status was positively associated with breastfeeding [ 47 ]. The US Department of Labor reports that approximately 95% of fathers with children under three years of age are working, highlighting the potential importance of parental leave for all caregivers in the workforce [ 11 ].

Our findings also reflected known racial and ethnic disparities in breastfeeding stemming from complex policies and histories related to structural and ongoing racism [ 8 , 48 , 49 ]. After adjusting for covariates, we found that, compared with respondents who identified their children as non-Hispanic White, non-Hispanic Black respondents were less likely to exclusively breastfeed. Racial and ethnic disparities extend to FMLA eligibility; studies have found that more Black and Hispanic/Latino workforce members (60.2% and 66.9%, respectively) reported being ineligible for or unable to afford unpaid leave than White workers (55.3%) [ 39 ]. Because Black women experience higher rates of pregnancy complications and preterm delivery compared to other races, current federal FMLA policies, which count time from pregnancy complications as part of leave, may further exacerbate racial inequities [ 50 , 51 , 52 ]. We also found that Hispanic/Latino respondents had higher rates of late mixed feeding but lower rates of exclusive breastfeeding compared with non-Hispanic White women. A 2021 study examining feeding goals found that despite Hispanic/Latina women having higher intentions to breastfeeding compared with non-Hispanic/Latina White women, they had lower odds of meeting their goals [ 53 ]. Inequitable access to FMLA policies may be contributing to this gap, as Hispanic/Latina women are less likely to qualify for both paid and unpaid leave, which may be related to part-time work status or working for small employers [ 39 , 54 , 55 ].

Employment and education have also previously been associated with breastfeeding outcomes and may be related to access to FMLA [ 47 ]. While NIS-C does not include employment data, in the unadjusted and adjusted analyses, we found that women with lower education levels, which are associated with employment opportunities, were less likely to breastfeed. Return to work is among the top reasons for interrupted breastfeeding [ 33 , 56 ], and women who take six months or more of leave from work have a 30% higher likelihood of any breastfeeding at six months [ 57 ].

We also found that women enrolled in WIC were less likely to report breastfeeding across all adjusted and unadjusted analyses. For breastfeeding individuals, WIC distributes breast pumps, offers nutritional support, and supports breastfeeding peer counselor programs [ 58 ]. WIC also subsidizes formula purchases, which can result in sales benefits for formula manufactures [ 59 ]. Multi-level strategies have been found to enhance breastfeeding for WIC participants, including supporting early WIC enrollment, assessing breastfeeding intentions, and funding peer counseling [ 60 ]. However, formula provision may be an incentive for WIC enrollment for some income-eligible individuals, and prior studies have found that some enrollees perceive WIC as a formula provider and appreciate the financial support for formula supplementation [ 61 ]. These findings underscore the need to further enrich the lactation-supporting capacity of WIC while considering financial implications and regulations for formula provision.

Limitations of this cross-sectional, secondary dataset analysis included baseline differences between the states with and without paid family leave policies. Respondents in states with paid family leave policies were more likely to report older age, Hispanic/Latina ethnicity, smaller household size, college degree, married status, higher income levels, and lower WIC enrollment. While we adjusted for these characteristics and for workplace breastfeeding policies, there were potentially other unmeasured confounding factors that may have differed between states with and without paid family leave policies, including maternal employment status. Although more generous leave has been found to be associated with greater benefits for breastfeeding-related outcomes, this study did not account for state-by-state variation in leave policies [ 44 ]. Several states had policies that went into effect during the survey lookback period, but sensitivity analyses showed similar outcomes regardless of inclusion or exclusion of these states in analyses. Additionally, there were limited data for families who prefer languages other than English or Spanish, and birthing people with varying gender identities may have been excluded.

Despite the limitations of the cross-sectional analysis, it is important to assess differences in breastfeeding outcomes, including mixed breast and formula feeding, as more states enact paid family leave policies. Future prospective studies can evaluate changes in breastfeeding after policy enactment and can assess breastfeeding prevalence in the workforce.

Conclusions

In the United States, all feeding types that incorporate breastfeeding were higher in states with paid family leave compared with states without paid family leave policies. Although multilevel interventions are needed to support breastfeeding, expansion of policies that grant working families and caregivers paid time to raise children can positively affect breastfeeding, which in turn could improve preventative health and economic benefits for individuals and society.

Data availability

The datasets analyzed during the current study are available in the repository which is available from the Centers for Disease Control and Prevention at: https://www.cdc.gov/vaccines/imz-managers/nis/datasets.html.

Abbreviations

Adjusted prevalence ratio

Centers for Disease Control and Prevention

Confidence Interval

• Family Medical Leave Act

National Immunization Surveys

National Immunization Survey-Child

Organization for Economic Cooperation and Development

Prevalence Ratio

Providing Urgent Maternal Protections for Nursing Mothers Act

STrengthening the Reporting of OBservational studies in Epidemiology

United States

Special Supplemental Nutrition Program for Women, Infants, and Children

Practice advisory to update the duration of breastfeeding. https://www.acog.org/en/clinical/clinical-guidance/practice-advisory/articles/2023/02/duration-of-breastfeeding-update . Accessed 18 March 2024.

Meek JY, Noble L. Technical report: breastfeeding and the use of human milk. Pediatrics. 2022;150:e2022057989. https://doi.org/10.1542/peds.2022-057988 .

Article   PubMed   Google Scholar  

World Health Organization. Breastfeeding. https://www.who.int/westernpacific/health-topics/breastfeeding . Accessed 18 March 2024.

Frank NM, Lynch KF, Uusitalo U, Yang J, Lönnrot M, Virtanen SM, et al. The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children. BMC Pediatr. 2019;19:339. https://doi.org/10.1186/s12887-019-1693-2 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Güngör D, Nadaud P, Dreibelbis C, LaPergola C, Terry N, Wong YP et al. Shorter versus longer durations of exclusive human milk feeding prior to the introduction of infant formula and food allergies, allergic rhinitis, atopic dermatitis, and asthma: a systematic review. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2019. http://www.ncbi.nlm.nih.gov/books/NBK580356/ . Accessed 10 April 2023.

Dewey K, Bazzano L, Davis T, Donovan S, Taveras E, Kleinman R et al. The duration, frequency, and volume of exclusive human milk and/or infant formula consumption and overweight and obesity: a systematic review. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2020. http://www.ncbi.nlm.nih.gov/books/NBK578873/ . Accessed 10 April 2023.

Glazer KB, Zeitlin J, Howell EA. Intertwined disparities: applying the maternal-infant dyad lens to advance perinatal health equity. Semin Perinatol. 2021;45(4):151410. https://doi.org/10.1016/j.semperi.2021.151410 .

Article   PubMed   PubMed Central   Google Scholar  

CDC. 2022 Breastfeeding report card. Center for Disease Control and Prevention. 2022. https://www.cdc.gov/breastfeeding/data/reportcard.htm . Accessed 23 Feb 2023.

Increase the proportion of infants who. are breastfed exclusively through age 6 months — MICH–15 - Healthy People 2030 | health.gov. https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-exclusively-through-age-6-months-mich-15 . Accessed 23 Feb 2023.

Steurer LM. Maternity leave length and workplace policies’ impact on the sustainment of breastfeeding: global perspectives. Public Health Nurs. 2017;34:286–94. https://doi.org/10.1111/phn.12321 .

Labor force participation rates | U.S. Department of Labor. https://www.dol.gov/agencies/wb/data/latest-annual-data/labor-force-participation-rates#Labor-Force-Participation-Rate-of-Mothers-and-Fathers-by-Age-of-Youngest-Child . Accessed 1 May 2023.

CDC. The Surgeon General’s call to action to support breastfeeding. Centers for Disease Control and Prevention. 2021. https://www.cdc.gov/breastfeeding/resources/calltoaction.htm . Accessed 30 March 2023.

The Surgeon General’. s call to action to improve maternal health - Healthy People 2030 | health.gov. https://health.gov/healthypeople/tools-action/browse-evidence-based-resources/surgeon-generals-call-action-improve-maternal-health . Accessed 10 April 2023.

The White House. Biden-Harris administration national strategy on hunger, nutrition, and health. 2022. https://www.whitehouse.gov/briefing-room/statements-releases/2022/09/27/executive-summary-biden-harris-administration-national-strategy-on-hunger-nutrition-and-health/ . Accessed 10 April 2023.

Nandi A, Jahagirdar D, Dimitris MC, Labrecque JA, Strumpf EC, Kaufman JS, et al. The impact of parental and medical leave policies on socioeconomic and health outcomes in OECD countries: a systematic review of the empirical literature. Milbank Q. 2018;96:434–71.

Heymann J, Sprague AR, Nandi A, Earle A, Batra P, Schickedanz A, et al. Paid parental leave and family wellbeing in the sustainable development era. Public Health Rev. 2017;38:21. https://doi.org/10.1111/1468-0009.12340 .

Rep, Maloney. CB [D-N-12. H.R.3110–117th Congress (2021–2022): PUMP for Nursing Mothers Act. 2021. http://www.congress.gov/ . Accessed 10 April 2023.

Department of Labor. Family and Medical Leave (FMLA). http://www.dol.gov/general/topic/benefits-leave/fmla . Accessed 1 May 2023.

Bipartisan Policy Center. State paid family leave laws across the U.S https://bipartisanpolicy.org/explainer/state-paid-family-leave-laws-across-the-u-s/ . Accessed 10 December 2023.

U.S. Department of Health and Human Services (DHHS) National Center for Immunization and Respiratory Diseases. The 2021 National Immunization Survey - Child. Atlanta, GA: Centers for Disease Control and Prevention. 2022. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-PUF21-DUG.pdf . Accessed 18 March 2024.

Centers for Disease Control and Prevention. NIS-Child data tables for 2015 to present. 2023. https://www.cdc.gov/vaccines/imz-managers/nis/datasets.html . Accessed 23 February 2023.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of Observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344–9. https://doi.org/10.1016/j.jclinepi.2007.11.008 .

Article   Google Scholar  

Dinour LM. Speaking out on breastfeeding terminology: recommendations for gender-inclusive language in research and reporting. Breastfeed Med. 2019;14:523–32. https://doi.org/10.1089/bfm.2019.0110 .

National Institutes of Health (NIH). Inclusive and gender-neutral language. https://www.nih.gov/nih-style-guide/inclusive-gender-neutral-language . Accessed 1 May 2023.

National Conference of State Legislatures. Breastfeeding state laws. 2021. https://www.ncsl.org/health/breastfeeding-state-laws . Accessed 6 December 2023.

Stata. mlogit — multinomial (polytomous) logistic regression. https://www.stata.com/manuals/rmlogit.pdf . Accessed 27 May 2023.

Rubin M. When to adjust alpha during multiple testing: a consideration of disjunction, conjunction, and individual testing. Synthese. 2021;199:10969–1000. https://doi.org/10.1007/s11229-021-03276-4 .

Rubin M. There’s no need to lower the significance threshold when conducting single tests of multiple individual hypotheses. Acadademia Lett. 2021. https://doi.org/10.20935/AL610 .

Poole C. Low p-values or narrow confidence intervals: which are more durable? Epidemiology. 2001;12:291–4. https://doi.org/10.1097/00001648-200105000-00005 .

Article   CAS   PubMed   Google Scholar  

Sullivan GM, Feinn R. Using effect size—or why the p value is not enough. J Grad Med Educ. 2012;4:279–82. https://doi.org/10.4300/JGME-D-12-00156.1 .

Navarro-Rosenblatt D, Garmendia M-L. Maternity leave and its impact on breastfeeding: a review of the literature. Breastfeed Med. 2018;13:589–97. https://doi.org/10.1089/bfm.2018.0132 .

Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. https://doi.org/10.1016/S0140-6736(15)01044-2 .

Baker M, Milligan K. Maternal employment, breastfeeding, and health: evidence from maternity leave mandates. J Health Econ. 2008;27:871–87. https://doi.org/10.1016/j.jhealeco.2008.02.006 .

Andres E, Baird S, Bingenheimer JB, Markus AR. Maternity leave access and health: a systematic narrative review and conceptual framework development. Matern Child Health J. 2016;20:1178–92. https://doi.org/10.1007/s10995-015-1905-9 .

Hamad R, Modrek S, White JS. Paid family leave effects on breastfeeding: a quasi-experimental study of US policies. Am J Public Health. 2019;109:164–6. https://doi.org/10.2105/AJPH.2018.304693 .

Kortsmit K, Li R, Cox S, Shapiro-Mendoza CK, Perrine CG, D’Angelo DV, et al. Workplace leave and breastfeeding duration among postpartum women, 2016–2018. Am J Public Health. 2021;111:2036–45. https://doi.org/10.2105/AJPH.2021.306484 .

Huang R, Yang M. Paid maternity leave and breastfeeding practice before and after California’s implementation of the nation’s first paid family leave program. Econ Hum Biol. 2015;16:45–59. https://doi.org/10.1016/j.ehb.2013.12.009 .

Centers for Disease Control and Prevention. Why it matters. 2023. https://www.cdc.gov/breastfeeding/about-breastfeeding/why-it-matters.html . Accessed 10 April 2023.

Sprague A, Earle A, Moreno G, Raub A, Waisath W, Heymann J. National policies on parental leave and breastfeeding breaks: racial, ethnic, gender, and age disparities in access and implications for infant and child health. Public Health Rep. 2023;333549231151661. https://doi.org/10.1177/00333549231151661 .

Webster JL, Paul D, Purtle J, Locke R, Goldstein ND. State-level social and economic policies and their association with perinatal and infant outcomes. Milbank Q. 2022;100:218–60. https://doi.org/10.1111/1468-0009.12571 .

Ruhm CJ. Parental leave and child health. J Health Econ. 2000;19:931–60. https://doi.org/10.1016/s0167-6296(00)00047-3 .

Burtle A, Bezruchka S. Population health and paid parental leave: what the United States can learn from two decades of research. Healthcare. 2016;4:30. https://doi.org/10.3390/healthcare4020030 .

Raub A, Nandi A, Earle A, de Guzman Chorny N, Wong E, Chung P et al. Paid parental leave: a detailed look at approaches across OECD countries. UCLA WORLD Policy Analysis Center; 2018. https://www.worldpolicycenter.org/sites/default/files/WORLD%20Report%20-%20Parental%20Leave%20OECD%20Country%20Approaches_0.pdf . Accessed 18 March 2024.

Heshmati A, Honkaniemi H, Juárez SP. The effect of parental leave on parents’ mental health: a systematic review. Lancet Public Health. 2023;8:e57–75. https://doi.org/10.1016/S2468-2667(22)00311-5 .

Abt Associates. Assessing FMLA: results from 2018 surveys. https://www.abtassociates.com/insights/publications/report/assessing-fmla-results-from-2018-surveys . Accessed 11 May 2023.

Shepherd-Banigan M, Bell JF. Paid leave benefits among a national sample of working mothers with infants in the United States. Matern Child Health J. 2014;18:286–95. https://doi.org/10.1007/s10995-013-1264-3 .

Mandal B, Roe BE, Fein SB. The differential effects of full-time and part-time work status on breastfeeding. Health Policy. 2010;97:79–86. https://doi.org/10.1016/j.healthpol.2010.03.006 .

Griswold MK, Crawford SL, Perry DJ, Person SD, Rosenberg L, Cozier YC, et al. Experiences of racism and breastfeeding initiation and duration among first-time mothers of the black women’s health study. J Racial Ethn Health Disparities. 2018;5:1180–91. https://doi.org/10.1007/s40615-018-0465-2 .

Manuck TA. Racial and ethnic differences in preterm birth: a complex, multifactorial problem. Semin Perinatol. 2017;41:511–8. https://doi.org/10.1053/j.semperi.2017.08.010 .

Bornstein E, Eliner Y, Chervenak FA, Grünebaum A. Racial disparity in pregnancy risks and complications in the US: temporal changes during 2007–2018. J Clin Med. 2020;9:1414. https://doi.org/10.3390/jcm9051414 .

Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2019. NCHS Data Brief. 2020;1–8.

KFF. Preterm Births as a Percent of All Births by Race/Ethnicity. 2023. https://www.kff.org/other/state-indicator/preterm-births-by-raceethnicity/ . Accessed 11 May 2023.

Hamner HC, Beauregard JL, Li R, Nelson JM, Perrine CG. Meeting breastfeeding intentions differ by race/ethnicity, infant and toddler feeding practices Study-2. Matern Child Nutr. 2020;17:e13093. https://doi.org/10.1111/mcn.13093 .

Ann Bartell, Soohyun K, Nam J, Rossin-Slater M, Ruhm C, Waldfogel J. June. Racial and ethnic disparities in access to and use of paid family and medical leave: evidence from four nationally representative datasets: monthly labor review: U.S. Bureau of Labor Statistics. https://www.bls.gov/opub/mlr/2019/article/racial-and-ethnic-disparities-in-access-to-and-use-of-paid-family-and-medical-leave.htm . Accessed 2 2023.

Goodman JM, Richardson DM, Dow WH. Racial and ethnic inequities in paid family and medical leave: United States, 2011 and 2017–2018. Am J Public Health. 2022;112:1050–8. https://doi.org/10.2105/AJPH.2022.306825 .

Schwartz K, D’Arcy HJS, Gillespie B, Bobo J, Longeway M, Foxman B. Factors associated with weaning in the first 3 months postpartum. J Fam Pract. 2002;51:439–44.

PubMed   Google Scholar  

UNICEF USA. The ost of not breastfeeding. https://www.unicefusa.org/stories/cost-not-breastfeeding . Accessed 11 May 2023.

Food and Nutrition Service. Breastfeeding promotion in WIC: current federal requirements https://www.fns.usda.gov/wic/breastfeeding-promotion-wic-current-federal-requirements . Accessed 12 May 2023.

Choi YY, Ludwig A, Andreyeva T, Harris JL. Effects of United States WIC infant formula contracts on brand sales of infant formula and toddler milks. J Public Health Policy. 2020;41:303–20. https://doi.org/10.1057/s41271-020-00228-z .

Houghtaling B, Shanks CB, Jenkins M. Likelihood of breastfeeding within the USDA’s Food and Nutrition Service Special Supplemental Nutrition Program for women, infants, and children population: a systematic review of the literature. J Hum Lact off J Int Lact Consult Assoc. 2017;33:83–97. https://doi.org/10.1177/0890334416679619 .

Almeida R, Alvarez Gutierrez S, Whaley SE, Ventura AK. A qualitative study of breastfeeding and formula-feeding mothers’ perceptions of and experiences in WIC. J Nutr Educ Behav. 2020;52:615–25. https://doi.org/10.1016/j.jneb.2019.12.006 .

Download references

Acknowledgements

Not applicable.

Support for Dr. Rosenberg was made possible by CTSA Grant Number KL2 TR001862 from the National Center for Advancing Translational Science (NCATS), components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.

Support for Dr. Nardella was made possible by the Yale National Clinician Scholars Program and by CTSA Grant Number TL1 TR001864 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.

Author information

Authors and affiliations.

Department of Pediatrics, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA

Julia Rosenberg, Deanna Nardella & Veronika Shabanova

National Clinician Scholars Program, Yale University, 333 Cedar St, New Haven, CT, USA

Deanna Nardella

Department of Biostatistics, Yale School of Public Health, 333 Cedar St, New Haven, CT, USA

Veronika Shabanova

You can also search for this author in PubMed   Google Scholar

Contributions

JR: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing – original draft, review, editing, visualization, project administration, funding acquisition. DN: validation, investigation, resources, writing – original draft, review, and editing. VS: conceptualization, methodology, validation, formal analysis, writing – review and editing, supervision. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Julia Rosenberg .

Ethics declarations

Ethics approval and consent to participate.

Not applicable. The National Immunization Survey is a publicly available, de-identified dataset. Its use is not considered Human Subjects Research, and we did not obtain a determination of this status from the Institutional Review Board.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, supplementary material 3, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Rosenberg, J., Nardella, D. & Shabanova, V. State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child. Int Breastfeed J 19 , 37 (2024). https://doi.org/10.1186/s13006-024-00646-9

Download citation

Received : 16 December 2023

Accepted : 18 May 2024

Published : 26 May 2024

DOI : https://doi.org/10.1186/s13006-024-00646-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Breastfeeding
• National Immunization Survey

International Breastfeeding Journal

ISSN: 1746-4358

• General enquiries: [email protected]

• Have a Story Idea?

Reves Center announces 2024 Faculty Fellows

This year’s projects range across disciplines and regions, from biology to public policy, and from the Republic of Georgia to Japan.

• share by email
• share on Facebook
• share on LinkedIn

This year's fellows include (from top left) professors Jonathan Allen, Scott Ickes, Alexandra Joosse, (bottom row, left) Hiroshi Kitamura, Daniel Maliniak and Philip Roessler. (Image courtesy of the Reves Center for International Studies)

The Reves Center for International Studies has awarded the 2024 Reves and Drapers’ Faculty Fellowships to six William & Mary professors.

A committee of faculty and Reves staff awards the fellowships annually to support faculty-student research and collaboration on internationally-focused, engaged scholarship. The initiative is open to full-time William & Mary faculty in all academic units, but projects must include an international, global and/or trans-national focus or context and involve W&M undergraduate or graduate students. 

With rare exceptions, the project must also include an overseas research component. Preference for the Drapers’ Fellowship is given to early career scholars conducting archival research in proximity to London or at institutions with established links to the Drapers’ Company.

This year’s projects range across disciplines and regions, from biology to public policy, and from the Republic of Georgia to Japan. 

The 2024 awardees are (in alphabetical order and with their project descriptions below):

Jonathan Allen, Associate Professor of Biology

• Scott Ickes, Assistant Professor of Kinesiology & Health Sciences
• Alexandra Joosse, Associate Teaching Professor of Public Policy
• Hiroshi Kitamura, Associate Professor of History and Director of International Relations

Daniel Maliniak, Associate Professor of Government and Public Policy

• Philip Roessler, Professor of Government

Project: Testing the role of larval cloning in outbreaks of Crown of Thorns Starfish on the Great Barrier Reef

Crown-of-Thorns Seastar (COTS) outbreaks are responsible for more than 40% of the loss of coral cover on the Great Barrier Reef (GBR) through their intense and unchecked predation on mature corals. One leading hypothesis explaining COTS outbreaks is that increased agricultural runoff has led to eutrophication of the waters on the GBR. Eutrophication is excessive richness of nutrients in a body of water, frequently due to runoff from the land, which causes a dense growth of plant life and death of animal life from lack of oxygen.

Eutrophication has, in turn, led to increases in the abundance of phytoplankton. Like most reef animals, larval COTS feed on phytoplankton in order to complete their development, and increased levels of phytoplankton improve larval success and ultimately increase outbreaks of COTS on reefs throughout the Indo-Pacific. But unlike most animals on the GBR, COTS possess an additional trait — larval cloning  — that makes them uniquely suited to benefit from nutrient addition via runoff. In collaboration with Maria Byrne at the University of Sydney, Allen’s research laboratory has demonstrated that 1) larval cloning occurs in COTS as a normal feature of development and 2) larval cloning doubles in frequency when larvae are reared under high food conditions. In a recent review, this discovery was cited as a fundamental piece of new knowledge that has generated a suite of new questions surrounding the biology of COTS. The goal is to build on this international collaboration and investigate exogenous (environmental) factors and endogenous (maternal investment) factors that influence the rate of cloning in this keystone coral predator.

Scott Ickes, Assistant Professor of Kinesiology & Health Sciences, and Alexandra Joosse, Associate Teaching Professor of Public Policy

Project: Assessing feasibility and impact of implementing a mother’s lactation room at a commercial flower farm in Kenya

Exclusive breastfeeding (EBF) is critical for child growth, development, survival and maternal health; however, 56% of mothers in low- and middle-income countries do not practice EBF through the recommended six months of infancy.

Scaling up coverage of EBF to 90% can prevent 820,000 of 5 million annual deaths among children under five years — one of the most effective interventions for child mortality prevention. Mothers discontinue EBF for various social, cultural, and economic factors. While women’s workforce participation reflects gains in women’s empowerment, maternal employment outside the home is a crucial driver of early EBF cessation.

In Kenya, child mortality remains high, and improvements in both EBF rates and survival have stagnated over the past two decades. Concurrently, the proportion of mothers engaged in formal employment has increased. Employment, coupled with rapids changes in urbanization and internal employment-based migration are expected to have major affects on social support and networks, which are known to influence infant feeding decisions.

Workplace lactation support programs that include on-site or subsidized daycare, lactation stations for breastmilk expression and storage or flexible work schedules can effectively support EBF for working mothers. However, the impact of these interventions has little evidence outside of high-income countries. Despite policies in Kenya that mandate workplace lactation stations, there is lagging implementation in the agricultural sector, underscoring the need for strong implementation research in this sector.

This project has two main objectives: 1) implement and a evaluate a workplace breastfeeding support intervention at a commercial flower farm in Kenya, where many mothers are engaged in low-wage employment associated with poor breastfeeding outcomes; 2) more generally, evaluate the role that a new mother’s social network has on her decision to practice EBF. In achieving these two objectives, this research will inform policy and strategy regarding how to increase EBF in this context and other similar settings.

Hiroshi Kitamura, Associate Professor of History and Director of International Relations

Project: U.S.-Japan Baseball Oral History Project

This project aims to deepen our understanding of the political and cultural relationship between the United States and Japan through the lens of baseball. By conducting video-recorded oral history interviews with players, coaches and experts who have bridged the two countries on and off the field, the research team will seek answers to the following questions that scholars, journalists and fans have asked over the decades: How and why did baseball become such a popular pastime in both the U.S. and Japan? Is the sport played similarly or differently in the two countries? How has baseball helped shape diplomatic and international relations? Does sport and popular culture play an important role in bridging and dividing countries — or not?

This oral history project builds on a symposium that Kitamura helped organize with a group of faculty and students last October, titled “The 150 Years of US-Japan Baseball Diplomacy,” on the W&M campus. Over the past four months, they have interviewed five pioneering baseball players and have begun releasing their videos curated on an online archive . Through the Reves Faculty Fellowship, the student-faculty research team will accumulate new interview content, expand the digital archive and deliver original and useful knowledge to scholars, students and the public.

The timing of this research trip to Japan summer 2024 coincides with the Williamsburg-Kamakura youth baseball exchange. The research team will interview the coaches and players involved in the exchange to better understand how baseball fosters cross-cultural interactions among young publics and assess whether such events on the ground help deepen international relations.

Project: Transitions in the South Caucasus

The Republic of Georgia is in a time of great transition. Georgia has been granted European Union candidate status even while the U.S. has sanctioned Georgian officials for corruption as a signal of displeasure with a stall in democratic reforms.

The country is facing an important, hotly contested election in the fall of 2024. Tens of thousands of Russians remain in Georgia, all while Russia illegally occupies 20% of Georgia, and central to the campaign will be foreign policy, Western criticism and concerns about the ties of politicians to Russia.

This project touches on three key aspects of the transitions of this small country in the South Caucasus. First, they will interview and document the stories of Russians in Georgia to better understand their experiences. Russians who fled to Georgia did so for several reasons, and these interviews aim to preserve their stories and experiences. Second, they will work with NGOs and the development community to better understand both the work being done to support democratic institutions and the challenges faced in the presence of Russian disinformation and highly polarized politics. Finally, they will work with environmental NGOs to better understand and provide support for conservation efforts. In particular, they will look at how Georgian environmental NGOs are trying to use the resources and expertise of Western donors and experts while navigating the complexities of their politics and the trade-offs rural communities are making between conservation and economic development.

This project builds on an earlier Reves grant that has provided structured, high-impact learning through research experiences to 27 students, provided 73 credit hours of directed research and allowed 11 students to conduct impactful, policy-relevant research internationally.

2024 Drapers’ Faculty Fellow

Philip roessler, professor of government.

Project: The Origins and Impact of British Colonial Policy on Smallholder Agriculture in Africa

Prior to the spread of European imperialism, land-extensive smallholder agriculture prevailed in tropical regions. Imperial conquest led to the importation of new agricultural practices — most notoriously the diffusion of slave-based, foreign-owned plantations in the Americas. In West Africa, however, settler plantations not only failed but were discouraged by British anti-slavery activists, such as Foxwell Buxton, who saw local cash crop agriculture as “the real remedy” for the slave trade.

On the whole, the British adopted liberal policies toward smallholder agriculture in most — but of course not all — of their colonies. (In Southern Rhodesia and Kenya, the colonial state favored settlers, which represents an important and illuminating comparison). The general British approach in Africa stands in stark contrast not only to policies in the Americas, but also within Africa — vis-à-vis the more coercive and illiberal agricultural policies in French and Portuguese colonies. This research project will conduct archival research to better understand the origins and consequences of British championing of indigenous smallholder agriculture in Africa.

The primary goals of this project entail: 1.) undertaking original archival research on the origins and debate around British colonial agricultural policy in Africa in the19th century and its legacies for tens of millions of people across the region; and 2.) engaging with UK audiences on the forthcoming book — “Seeds of Change: The Cash Crop Revolution, Colonialism, and the Making of Modern Africa” — on the long-run impact of the cash crop revolution across countries in Africa. There is much critical interest in Britain on the legacies of colonialism on economic, social and political processes in former colonies.

Previous Reves Faculty Fellows and their projects are listed  online .

Kate Hoving, Reves Center

• Alzheimer's disease & dementia
• Arthritis & Rheumatism
• Attention deficit disorders
• Autism spectrum disorders
• Biomedical technology
• Diseases, Conditions, Syndromes
• Endocrinology & Metabolism
• Gastroenterology
• Gerontology & Geriatrics
• Health informatics
• Inflammatory disorders
• Medical economics
• Medical research
• Medications
• Neuroscience
• Obstetrics & gynaecology
• Oncology & Cancer
• Ophthalmology
• Overweight & Obesity
• Parkinson's & Movement disorders
• Psychology & Psychiatry
• Radiology & Imaging
• Sleep disorders
• Sports medicine & Kinesiology
• Vaccination
• Breast cancer
• Cardiovascular disease
• Chronic obstructive pulmonary disease
• Colon cancer
• Coronary artery disease
• Heart attack
• Heart disease
• High blood pressure
• Kidney disease
• Lung cancer
• Multiple sclerosis
• Myocardial infarction
• Ovarian cancer
• Post traumatic stress disorder
• Rheumatoid arthritis
• Schizophrenia
• Skin cancer
• Type 2 diabetes
• Full List »

share this!

June 4, 2024

This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

fact-checked

trusted source

written by researcher(s)

Debate over tongue tie procedures in babies continues. Here's why it can be beneficial for some infants

by Sharon Smart, David Todd and Monica J. Hogan, The Conversation

There is increasing media interest about surgical procedures on new babies for tongue tie. Some hail it as a miracle cure, others view it as barbaric treatment, though adverse outcomes are rare .

Tongue tie occurs when the tissue under the tongue is attached to the lower gum or floor of the mouth in a way that can restrict the movement or range of the tongue. This can impact early breastfeeding in babies. It affects an estimated 8% of children under one year of age.

While there has been an increase in tongue tie releases (also called division or frenotomy), it's important to keep this in perspective relative to the increase in breastfeeding rates.

The World Health Organization recommends exclusive breastfeeding for the first six months of life, with breastfeeding recommended into the second year of life and beyond for the health of mother and baby as well as optimal growth . Global rates of breastfeeding infants for the first six months have increased from 38% to 48% over the past decade . So, it is not surprising there is also an increase in the number of babies being referred globally with breastfeeding challenges and potential tongue tie.

An Australian study published in 2023 showed that despite a 25% increase in referrals for tongue tie division between 2014 and 2018, there was no increase in the number of tongue tie divisions performed. Tongue tie surgery rates increased in Australia in the decade from 2006 to 2016 (from 1.22 per 1,000 population to 6.35) for 0 to 4 year olds. There is no data on surgery rates in Australia over the last eight years.

Tongue tie division isn't always appropriate but it can make a big difference to the babies who need it. More referrals doesn't necessarily mean more procedures are performed.

How tongue tie can affect babies

When tongue tie (ankyloglossia) restricts the movement of the tongue, it can make it more difficult for a baby to latch onto the mother's breast and painlessly breastfeed.

Earlier this month, the International Consortium of oral Ankylofrenula Professionals released a tongue tie position statement and practice guideline . Written by a range of health professionals, the guidelines define tongue tie as a functional diagnosis that can impact breastfeeding , eating, drinking and speech. The guidelines provide health professionals and families with information on the assessment and management of tongue tie.

Tongue tie release has been shown to improve latch during breastfeeding, reduce nipple pain and improve breast and bottle feeding . Early assessment and treatment are important to help mothers breastfeed for longer and address any potential functional problems.

Where to get advice

If feeding isn't going well, it may cause pain for the mother or there may be signs the baby isn't attaching properly to the breast or not getting enough milk. Parents can seek skilled help and assessment from a certified lactation consultant or International Board-Certified Lactation Consultant who can be found via online registry .

Alternatively, a health professional with training and skills in tongue tie assessment and division can assist families. This may include a doctor, midwife, speech pathologist or dentist with extended skills, training and experience in treating babies with tongue tie.

When access to advice or treatment is delayed, it can lead to unnecessary supplementation with bottle feeds, early weaning from breastfeeding and increased parental anxiety .

Getting a tongue tie assessment

During assessment, a qualified health professional will collect a thorough case history, including pregnancy and birth details, do a structural and functional assessment, and conduct a comprehensive breastfeeding or feeding assessment.

They will view and thoroughly examine the mouth, including the tongue's movement and lift. The appearance of where the tissue attaches to the underside of the tongue, the ability of the tongue to move and how the baby can suck also needs to be properly assessed .

Treatment decisions should focus on the concerns of the mother and baby and the impact of current feeding issues. Tongue tie division as a baby is not recommended for the sole purpose of avoiding speech problems in later life if there are no feeding concerns for the baby.

Treatment options

The Australian Dental Association's 2020 guidelines provide a management pathway for babies diagnosed with tongue tie.

Once feeding issues are identified and if a tongue tie is diagnosed, non-surgical management to optimize positioning, latch and education for parents should be the first-line approach.

If feeding issues persist during follow-up assessment after non-surgical management, a tongue tie division may be considered. Tongue tie release may be one option to address functional challenges associated with breastfeeding problems in babies.

There are risks associated with any procedure, including tongue tie release , such as bleeding. These risks should be discussed with the treating practitioner before conducting any laser, scissor or scalpel tongue tie procedure.

Post-release support by a certified lactation consultant or feeding specialist is necessary after a tongue tie division. A post-release treatment plan should be developed by a team of health professionals including advice and support for breastfeeding to address both the mother and baby's individual needs.

Explore further

Feedback to editors

Metabolic parameters found to be similar in children born via frozen versus fresh embryo transfer, research shows

3 hours ago

Researchers identify key differences in inner workings of immune cells

Researchers detail molecular pathway that impacts pancreatic cancer progression and treatment response

Epstein-Barr virus and brain cross-reactivity: Possible mechanism for multiple sclerosis detected

Precision laser surgery cuts focal epileptic seizure spread

4 hours ago

Researchers find flavor restrictions affect tobacco buyers differently depending on socioeconomic status

Younger children are more commonly diagnosed with ADHD than their older classmates, says new study

Researchers say AI blood test provides a reliable way to identify lung cancer

New combination therapy shows promise for bladder cancer patients unresponsive to standard treatment

What toilet paper and game shows can teach us about the spread of epidemics

Related stories.

Video: Tongue-tie in babies

Feb 28, 2023

My baby has 'tongue-tie'—Should I be worried?

Jun 11, 2020

Pediatric study sheds light on new tool for identifying infants with tongue tie requiring frenotomy

Apr 4, 2024

New device could identify which babies will struggle with breastfeeding

May 13, 2024

Experts sound alarm over baby tongue surgery

May 3, 2022

Study questions if tongue-tie surgery for breastfeeding is always needed

Jul 11, 2019

Recommended for you

World-first study into precision medicine for high-risk childhood cancer yields promising results

7 hours ago

Babies use 'helpless' infant period to learn powerful foundation models, just as ChatGPT does

Jun 5, 2024

Training cognitive control in children does not change brain or behavior, finds study

Gene therapy trial restores hearing in both ears of children who were born deaf

Soft fabric necklace monitors care of preterm, low-birth-weight infants

Let us know if there is a problem with our content.

Use this form if you have come across a typo, inaccuracy or would like to send an edit request for the content on this page. For general inquiries, please use our contact form . For general feedback, use the public comments section below (please adhere to guidelines ).

Please select the most appropriate category to facilitate processing of your request

Thank you for taking time to provide your feedback to the editors.

Your feedback is important to us. However, we do not guarantee individual replies due to the high volume of messages.

E-mail the story

Your email address is used only to let the recipient know who sent the email. Neither your address nor the recipient's address will be used for any other purpose. The information you enter will appear in your e-mail message and is not retained by Medical Xpress in any form.

Newsletter sign up

Get weekly and/or daily updates delivered to your inbox. You can unsubscribe at any time and we'll never share your details to third parties.

More information Privacy policy

Donate and enjoy an ad-free experience

We keep our content available to everyone. Consider supporting Science X's mission by getting a premium account.

E-mail newsletter