Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications

Abstract

Objective: Despite numerous global initiatives on breast-feeding, trend data show exclusive breast-feeding (EBF) rates have stagnated over the last two decades. The purpose of the present systematic review was to determine barriers to exclusive breast-feeding in twenty-five low-and middle-income countries and discuss implications for programmes. Design: A search of Scopus, MEDLINE, CINAHL and PsychINFO was conducted to retrieve studies from January 2000 to October 2015. Using inclusion criteria, we selected both qualitative and quantitative studies that described barriers to EBF. Setting: Low-and middle-income countries. Subjects: Following application of systematic review criteria, forty-eight articles from fourteen countries were included in the review. Results: Sixteen barriers to EBF were identified in the review. There is moderate evidence of a negative association between maternal employment and EBF practices. Studies that examined EBF barriers at childbirth and the initial 24 h postdelivery found strong evidence that caesarean section can impede EBF. There is moderate evidence for early initiation of breast-feeding and likelihood of practising EBF. Breast-feeding problems were commonly reported from crosssectional or observational studies. Counselling on EBF and the presence of family and/or community support have demonstrated improvements in EBF. Conclusions: Improving the counselling skills of health workers to address breastfeeding problems and increasing community support for breast-feeding are critical components of infant and young child feeding programming, which will aid in attaining the 2025 World Health Assembly EBF targets. Legislation and regulations on marketing of breast-milk substitutes, paid maternity leave and breast-feeding breaks for working mothers require attention in low-and middle-income countries.

Predictors of breast milk substitute feeding among newborns in delivery facilities in urban Cambodia and Nepal

“…This effect was seen in Phnom Penh but did not reach statistical significance in the regression model when other variables were taken into account. Caesarean delivery is a commonly reported barrier to breastfeeding in LMIC (Kavle et al, ; Patel et al, ; Takahashi et al, ) but is not always found to increase likelihood of early BMS use, especially if the caesarean delivery is an emergency procedure rather than elective (Zanardo et al, ). Our survey did not distinguish between emergency and elective or planned caesarean deliveries, which may help explain the absence of association with BMS feeding in Phnom Penh.…”

“…Among mothers in this study, concerns about insufficient or delayed milk supply were commonly cited reasons for introducing BMS. The high prevalence of these concerns is also evidenced by a 2017 systematic review conducted across LMIC (Kavle, LaCroix, Dau, & Engmann, 2017). Support and appropriate education on infant behaviour and cues from health professionals can aid in improving breastfeeding outcomes in developing country contexts (Imdad, Yakoob, & Bhutta, 2011;Khanal, Lee, Karkee, & Binns, 2015;Lou et al, 2014).…”

“…Support and appropriate education on infant behaviour and cues from health professionals can aid in improving breastfeeding outcomes in developing country contexts (Imdad, Yakoob, & Bhutta, 2011;Khanal, Lee, Karkee, & Binns, 2015;Lou et al, 2014). Breastfeeding information and education received before birth during antenatal care visits were inversely associated with intro- (Kavle et al, 2017;Patel et al, 2015;Takahashi et al, 2017) but is not always found to increase likelihood of early BMS use, especially if the caesarean delivery is an emergency procedure rather than elective (Zanardo et al, 2012). Our survey did not distinguish between emergency and elective or planned caesarean deliveries, which may help explain the absence of association with BMS feeding in Phnom Penh.…”

Strengthening counseling on barriers to exclusive breastfeeding through use of job aids in Nampula, Mozambique

“…All study materials, including IDI guides, observation guides and job aids, were designed based on a review of barriers to EBF and associated literature from low-and middle-income countries [8,16,17] and were pre-tested and adapted to the local context prior to implementation. The study team conducted the pre-test in the District of Rapale, Nampula Province, a rural area, similar in profile to other study sites, which was selected due to its vicinity to the Provincial Capital of Nampula City.…”

“…Lactating women may experience challenges to maintaining EBF for the first six months of an infant's life, as demonstrated in a recent systematic review which identified sixteen barriers to EBF including maternal perceptions of insufficient breastmilk, early introduction of foods and liquids prior to six months of age, and lack of counseling on physical breast problems. Yet, these barriers are often not adequately addressed through infant and young child feeding (IYCF) programs and initiatives, and further, are not reflected in country investments and access to skilled lactation support [8,9].…”