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Barriers and facilitators for early and exclusive breastfeeding in health facilities in Sub-Saharan Africa: a systematic review

Abstract

Background

Sub-Saharan Africa carries a disproportionate burden of under-five child deaths in the world and appropriate breastfeeding practices can support efforts to reduce child mortality rates. Health facilities are important in the promotion of early and exclusive breastfeeding. The purpose of this review was to examine facility-based barriers and facilitators to early and exclusive breastfeeding in Sub-Saharan Africa.

Methods

A systematic search was conducted on Medline, Web of Science, CINAHL, African Journals Online and African Index Medicus from database inception to April 29, 2021 and primary research studies on breastfeeding practices in health facilities in Sub-Saharan Africa were included in the review. We assessed qualitative studies with the Critical Appraisal Skills Programme Qualitative Checklist and quantitative studies using the National Heart, Lung, and Blood Institute tool. The review protocol was registered to Prospero prior to conducting the review (CRD42020167414).

Results

Of the 56 included studies, relatively few described health facility infrastructure and supplies-related issues (5, 11%) while caregiver factors were frequently described (35, 74%). Facility-based breastfeeding policies and guidelines were frequently available but challenged by implementation gaps, especially at lower health service levels. Facilitators included positive caregiver and health worker attitudes, knowledge and support during the postpartum period. Current studies have focused on caregiver factors, particularly around their knowledge and attitudes, while health facility infrastructure and supplies factors appear to be growing concerns, such as overcrowding and lack of privacy during breastfeeding counselling that lowers the openness and comfort of mothers especially those HIV-positive.

Conclusion

There has been a dramatic rise in rates of facility births in Sub-Saharan Africa, which must be taken into account when considering the capacities of health facilities to support breastfeeding practices. As the number of facility births rise in Sub-Saharan Africa, so does the responsibility of skilled healthcare workers to provide the necessary breastfeeding support and advice to caregivers. Our review highlighted that health facility infrastructure, supplies and staffing appears to be a neglected area in breastfeeding promotion and a need to strengthen respectful maternity care in the delivery of breastfeeding counselling, particularly in supporting HIV-positive mothers within the context of Sub-Saharan Africa.

Introduction

Sub-Saharan Africa (SSA) carries a disproportionate burden of infant and child deaths, with 55–75% of under-five deaths in SSA attributed to inappropriate breastfeeding practices [1]. With a 35% prevalence of exclusive breastfeeding, rates in SSA are lower in comparison to other low- and middle-income countries (LMICs) (39%) [1] and only 18 out of 49 African countries are on track to meet the World Health Organization (WHO) Global Nutrition Targets 2025 to increase the rate to 50% [2]. Exclusive breastfeeding is well-recognized as one of the most effective interventions to improve newborn survival rates with life-long impacts on children beyond their infancy into adulthood [3,4,5] and is strongly recommended by the WHO [6].

A systematic review on barriers in LMICs found that inadequate antenatal care, poor maternal care during childbirth and return to livelihood activities were key challenges to exclusive breastfeeding [7]. The review also found that women who delivered at a health facility were more likely to engage in exclusive breastfeeding practices [7], which has also been found in studies across SSA [8,9,10,11,12,13,14,15]. These findings highlight the importance of health facilities in the promotion of appropriate breastfeeding practices, which is enshrined in the Baby-Friendly Hospital Initiative (BFHI). Launched in 1991 by the WHO and UNICEF and revised in 2018, BFHI outlines supportive policies and practices health facilities can undertake to protect and promote successful breastfeeding [16, 17]. While previous reviews broadly examined barriers and facilitators to exclusive or early initiation to breastfeeding [7, 18,19,20,21,22,23], they have not focused on factors modifiable at the health facility level, which is surprising due to the widespread promotion of BFHI. Encouragement to breastfeed at BFHI hospitals is associated with increased exclusive breastfeeding rates and overall longer breastfeeding duration [24, 25], leading some to suggest that variation in exclusive breastfeeding levels across Africa may be explained in part by varied success in implementing BFHI [2, 25].

With growing evidence of the beneficial effect of facility delivery on early and exclusive breastfeeding rates, particularly in BFHI hospitals, there is a need to deconstruct the facilitating factors and outstanding gaps at health facilities to strengthen sustainable and equitable breastfeeding support practices. Healthcare providers have key roles to strengthen breastfeeding in health systems as they influence and support decisions to breastfeed [26]. Thus, improving early and exclusive breastfeeding in SSA requires a deeper look into the role of skilled health care providers at facilities and their perceptions, knowledge and skills around breastfeeding support as well as an exploration of other facility-based barriers and facilitators. The aim of this systematic review is to determine what facility-based barriers and facilitators of early and exclusive breastfeeding support are present for newborns in SSA.

Methods

This review has been developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist (Table S1) [27]. A review protocol detailing the research question, search strategy, inclusion and exclusion criteria, quality assessment and strategy for data synthesis was developed in consultation with pediatric clinicians from Malawi (TW, QB, KK) to refine the scope of the review and ensure relevance to Sub-Saharan African contexts. The protocol was registered to PROSPERO (CRD42020167414) prior to conducting the review.

Study inclusion and exclusion

Studies conducted with family members, health workers and institutions engaged with facility-based early or exclusive breastfeeding support services in SSA were included in the review (Table 1). We included intervention (controlled trials) and observational studies (cohort, case-controlled, cross-sectional, qualitative) reporting barriers and facilitators. We defined facility-based barriers and facilitators to be factors modifiable at the facility level that hindered or supported appropriate breastfeeding practices. Studies that did not involve services at a health facility in SSA, did not mention early initiation of breastfeeding or exclusive breastfeeding, focused on community-based breastfeeding programs or were conducted among African women and infants living in other regions were excluded. Due to limited capacity of the review team to comprehensively search non-English databases, non-English publications were excluded. Studies without primary data collection in a health facility were also excluded.

Table 1 Review framework

Search strategy

Searches were conducted on MEDLINE Ovid, Web of Science, Cumulative Index to Nursing and Allied Health, African Journals Online and African Index Medicus from database inception to April 29, 2021, with no limits applied. Searches were supplemented by scanning reference lists of papers included for review. Search terms broadly included breastfeeding, breastmilk, Sub-Saharan African countries, hospital, clinic, health facility, barrier, facilitator, factor and implementation (Table S2).

Study selection

Titles and abstracts were independently screened by two reviewers (MWK, SP) according to the inclusion and exclusion criteria and selection disagreements were resolved by discussion. A third reviewer (TH) was asked to adjudicate in the absence of consensus. Full texts were then independently reviewed by the two reviewers (MWK, SP) with the third reviewer (TH) providing an independent assessment in any disagreements regarding eligibility.

Data extraction

Details about the study design, country, health facility level, sample, method, breastfeeding practice, exclusive breastfeeding rate and early initiation rate where reported, barriers and facilitators were independently extracted by two reviewers into a data extraction sheet on Excel (Microsoft, Redmond, United States).

Data analysis

The data extraction sheet was imported into Nvivo 12 (QSR International, Melbourne, Australia) where thematic analysis of barriers and facilitators according to health facilities infrastructure and supplies, supportive policies and policy implementation, health worker engagement and caregiver engagement was conducted. Results were reported as a narrative synthesis.

Quality assessment

To access internal validity and overall study quality, we evaluated quantitative studies using the study quality assessment tools of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) [28] and qualitative studies using the CASP checklist [29]. An overall study rating based on critical concerns of internal validity was added to the CASP checklist to be similar to the NIH quality assessment tools. Studies were not excluded as a result of the quality assessment but noted in consideration of the results.

Results

We identified a total of 3051 records from our database searches (1233 from Medline, 1123 from Web of Science, 373 from CINAHL, 256 from African Index Medicus and 66 from African Journals Online). After removal of duplicates and screening against the eligibility criteria, 56 studies were included in the review (Fig. 1). Thirty-seven full-text articles were excluded for the following reasons: Research was not conducted in SSA (1 study), poor clarity regarding exclusive or complementary breastfeeding (3 studies), inability to isolate breastfeeding within a package of interventions (2 study), did not explore facility-based barriers and facilitators to breastfeeding (27 studies), duplicate (2 studies), outcomes reported in another publication (1 study) and was a conference proceeding (1 study) (Table S3).

Fig. 1
figure 1

PRISMA flow diagram

Publication years of included studies ranged from 1995 to 2021, with the most studies conducted in 2019 (11 studies). There were 17 countries represented in this review: Democratic Republic of the Congo, Ethiopia, the Gambia, Ghana, Kenya, Lesotho, Malawi, Namibia, Niger, Nigeria, Rwanda, Somalia, South Africa, South Sudan, Tanzania, Uganda, and Zimbabwe. Nigeria was the most studied country with 12 studies included, followed by South Africa with 11 studies included. The studies varied from cross-sectional surveys and assessments (37 studies), qualitative study designs (15 studies), randomized controlled trials (2 studies), case-control studies (1 study) and pre-post studies with no control (1 study). Exclusive breastfeeding alone was assessed in 25 studies, early initiation breastfeeding alone in 13 studies and both practices were assessed in 18 studies. Finally, secondary-level district referral hospitals (16 studies) were the most targeted health level but primary-level (13 studies) and tertiary-level (11 studies) were also studied. A number of studies included a mix of the health facilities levels (14 studies) and health facility level was not reported in two studies. Characteristics of included studies are included in Table S4.

Four studies (7%) were assessed as good quality, 34 (61%) as fair and 18 (32%) as poor-quality studies. A majority of qualitative studies were rated fair to high quality (13 of 15, 87%) with clear descriptions of research objectives, appropriate research designs to understand perceptions or experiences, appropriate analysis and consideration of ethical issues. A majority of observational cohort or cross-sectional surveys were also rated as fair quality (21 of 37, 57%), though a substantial portion were rated poor quality (16 of 37, 43%) as they relied on self-reported breastfeeding intention or practices without follow-up, lack of clarity on questionnaires used and sampling methodology, and/or poor reporting of results. Both of the controlled intervention studies were rated good quality while the case-controlled and pre-post studies were both rated fair quality as adjustment for potential confounders were not conducted. Quality assessments by study are included in Table S5.

Health facilities infrastructure and supplies

Of the 56 studies included in this review, 8 (14.3%) reported infrastructural barriers [30,31,32,33,34,35,36,37] while only one study (1.8%) reported facilitators [38]. Most frequently described barriers to postnatal breastfeeding support were overcrowding and lack of space [30,31,32, 34,35,36]. For example, a study from Ghana reported that increases in caesarean deliveries was associated with overcrowding and insufficient equipment, which led to moving new mothers out of delivery quickly to make room for the next woman in labour [30]. A study from Somalia also reported a lack of space in the maternity ward, which was associated with shorter stays and less time for counselling [32]. Lack of privacy, a quiet place to breastfeed, availability of chairs for mothers to sit and breastfeed in and unreliable access to water and electrical power were also infrastructural challenges to breastfeeding at health facilities [33, 35,36,37]. For example, a study from Zimbabwe highlighted how health workers asked mothers questions related to their HIV status while other patients were listening, which compromised confidentiality and decreased the likelihood of initiating breastfeeding [36]. In the one study that described infrastructural facilitators, the researchers in Tanzania reported that wall clocks and cell phone alarms supported regular timing feedings of low birthweight infants [38].

Supportive policies and policy implementation

Almost a third of studies (18 of 56, 32.1%) reported policy-related barriers [30,31,32, 34, 35, 38,39,40,41,42,43,44,45,46,47,48,49,50] while 20 studies (35.7%) described facilitators [30, 31, 33,34,35, 37, 39,40,41,42,43, 47, 50,51,52,53,54,55,56]. Poor leadership and management structures were described as barriers to effective facility-based breastfeeding [30, 40, 47, 50], such as when hospital management felt that BFHI was extra work to implement. Also frequently reported was limited implementation of breastfeeding policies [34, 35, 39, 41, 43, 45,46,47,48,49,50, 57], particularly at peripheral health facilities. For example, a study in Ghana found that although almost all policy makers and implementers were aware of the national breastfeeding policy, there was a lack of written guidelines and posters at peripheral health facilities because materials were passed from national to regional, district and then health facilities with bureaucracy and transport barriers encountered between each level [50]. Additionally, policies and guidelines may not be translated into local languages commonly spoken in hospital catchment areas. Poor dissemination was an issue with changing infant feeding guidelines for HIV-positive mothers. A study from South Africa found that the phasing out of free formula for HIV-positive mothers was not clearly explained to health workers particularly at the grassroots level, which led to inconsistent messaging to HIV-positive mothers [43]. Challenges with policy dissemination and implementation were compounded by lack of funding and inadequate staffing and training policies that led to an inability to sustain skilled staff in maternity wards [30,31,32, 34, 35, 38, 40,41,42, 44,45,46,47,48].

Facilitators included committed leadership and supportive supervision, in particular by local management at the health facility [30, 34, 40, 52]. Clear and consistent guidelines with adequate dissemination [30, 54] and implementation of policies such as rooming-in, skin-to-skin, and discouraging formula and/or mixed feeding [30, 35, 43, 47, 58] were helpful in facilitating breastfeeding practices. A major facilitator was policies around staffing allocation and training [31, 33,34,35, 37, 39,40,41,42, 50, 51, 53,54,55,56]. This included increasing the number of skilled staff and task-sharing, such as in Malawi where over 600 lay support staff were trained to overcome challenges of short staffing at hospitals [34]. Pre-service training during nursing programs [41, 50], BFHI curricula and materials [31, 40, 53, 55, 56] and hands-on training [34, 37, 39, 41, 54] were highlighted as effective methods for training staff.

Health worker engagement

Factors related to health worker engagement with facility-based breastfeeding support was described by 55.4% (31 of 56) studies, including 28 studies (50.0%) that described barriers [30, 31, 33,34,35, 37, 39,40,41,42,43,44,45,46,47,48,49,50,51, 57, 59,60,61,62,63,64,65,66] and 12 studies (21.4%) that described facilitators [38, 41, 42, 45, 48, 53, 59, 61, 63,64,65, 67]. Health workers frequently mentioned staffing shortages and heavy workloads in reducing their capacity to provide adequate breastfeeding counselling and other support [31, 33,34,35, 37, 40,41,42, 44, 46, 47, 50]. Additionally, gaps in knowledge and misconceptions among health workers led to delivery of inconsistent messaging, specifically around formula feeding [30, 43], pre-lacteal feeds [35, 57, 59], breastfeeding after caesarean delivery [51], that an infant needs to rest after childbirth [50] or mistakenly believed that skin-to-skin contact would increase the risk of hypothermia [63]. A study in Nigeria found that while nursing staff were knowledgeable, non-medical staff frequently gave pre-lacteal feeds [59]. There was considerable misinformation among health workers around infant feeding options for HIV-positive mothers [30, 31, 43, 45, 46, 60, 62, 64,65,66]. Poor health worker attitudes or willingness to deliver breastfeeding support and a lack of respectful maternity care were also reported barriers [37, 48, 60, 61]. For example, researchers shared how a woman recalled, “[the nurse] yelled at me, she even came to me and pulled my nipple telling me that I’m failing to breastfeed the baby. She told me to put my breast in baby’s mouth. I would put it. I would say, there is nothing coming out. She said, there is no such thing” [61]. Another woman shared, “[The nurses] never helped me. They called me isigqala. I’m like that cow called isigqala, which means I do not have milk …” [61]. Poor practical skills among health workers were also reported, especially around positioning and attachment and complications management [40, 41, 47, 57, 65].

In general, good knowledge among health workers about breastfeeding benefits and practices was highlighted as a facilitator of facility-based breastfeeding [45, 48, 53, 65, 67]. Specific topics included the management of complications and specialized breastfeeding care and knowledge around infant feeding for HIV-positive mothers. Positive attitudes among health workers and willingness for breastfeeding support [41, 42, 48, 53, 59, 63, 64, 67] as well as providing demonstrations and following up on breastfeeding after counselling [38, 48, 53, 61, 64] were also highly reported facilitators. Providing respectful maternal care and a positive work culture where supporting breastfeeding was a social norm was helpful [38, 64, 65].

Caregiver engagement

Caregiver factors were mentioned by 75.0% (42 of 56) of studies, including 37 studies (66.1%) that described barriers [31, 32, 34,35,36, 38, 43, 46, 50,51,52, 55, 56, 58,59,60,61,62, 64, 66, 68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84] and 27 studies (48.2%) that described facilitators [32, 37, 38, 43, 44, 46, 48, 49, 51, 55, 58, 60, 61, 68, 69, 71,72,73,74,75,76, 79,80,81,82, 84, 85]. Frequently mentioned barriers included inadequate lactation counselling [32, 34, 43, 52, 72, 79] and misconceptions [34,35,36, 50, 52, 55, 56, 60, 62, 68, 72, 74, 77, 79, 83], such as breastmilk alone would not meet nutritional needs for the baby, formula was healthier, colostrum was dirty or not real breastmilk, infants required water in hot weather or infants required rest after delivery. Peer pressure by relatives and lack of decision-making power was frequently mentioned as a barrier to effective facility-based breastfeeding [36, 46, 52, 56, 60,61,62, 68, 79, 80]. When counselling was provided, mothers were engaged directly while grandmothers and fathers were rarely included but reported to be influential regarding infant care. A frequently mentioned barrier was fear of HIV transmission and issues around stigma and disclosure of HIV status [31, 36, 46, 52, 55, 62, 66, 70, 73, 74, 79, 80, 84]. A study from Uganda found that maternal HIV-positive status was associated with twice the odds of delayed initiation to breastfeeding (aOR 2.3; 95% CI 1.3–4.2) and reported that the fear of transmission led to hesitancy, even when the mother was counselled and intended to breastfeed [52]. A recent study from Zimbabwe found a prevalent belief that breastmilk from an HIV-positive mother was unsafe for her infant [36]. A study from Malawi suggested that HIV-positive mothers saw exclusive breastfeeding as very demanding on their bodies and made them prone to develop AIDS faster [74]. Caesarean section and breast complications were also frequently mentioned challenges [34, 38, 51, 52, 71, 72, 78, 83]. A study from Uganda found that caesarean delivery was associated with an over 8-fold rate of delayed initiation to breastfeeding (aOR 8.6, 95% CI: 4.7–16.0) [52]. Two studies highlighted the need for specialized breastfeeding support for preterm or low birthweight infants [38, 69], with a study from Tanzania quoting one mother who said, “I am used to breastfeeding, but not this small baby” [38].

Previous knowledge about breastfeeding, such as learned through antenatal care [37, 46, 61, 69, 71, 72, 76, 80], and positive attitudes [32, 55, 71, 74, 76, 80,81,82] helped to facilitate breastfeeding practice. However, the value of receiving postpartum counselling and support to learn breastfeeding skills and techniques was also frequently mentioned [37, 44, 48, 51, 58, 61, 71,72,73, 75, 76, 82]. This was especially true for preterm and low birthweight babies [38, 48]. Family support was also described as a facilitator [38, 44, 79,80,81, 84]. For example, a study with first-time mothers in Nigeria found that those with birth companions had significantly earlier initiation of breastfeeding compared to controls without birth companions (p < 0.01) [44]. For HIV-positive mothers in particular, it was helpful to have peer support and see other HIV-positive women breastfeeding [46, 60, 79, 84].

A few studies mentioned maternal characteristics including parity, education, age, marital status and other indicators of socio-economic status such as private hospital attendance, house ownership and income as factors influencing breastfeeding. However, it was highly contextual to local settings and there were many inconsistencies between barriers [69, 81, 83] and facilitators [49, 68, 81, 82, 85].

Table 2 summarizes the barriers and facilitators to facility-based breastfeeding in SSA. Table S6 includes the barriers and facilitators reported in each study and Table S7 includes a breakdown of themes summarized by studies.

Table 2 Barriers and facilitators to facility-based breastfeeding support in SSA

Discussion

The purpose of this review was to compile facility-based barriers and facilitators to early and exclusive breastfeeding in SSA. Relatively few studies described the effect of facility-level infrastructure and supply factors on breastfeeding while caregiver factors were frequently described, particularly around knowledge and attitudes. The focus on counselling to provide adequate education, dispel misconceptions and give support to the mother and her family highlights the importance of respectful care. Another broad area of focus was on the implementation of policies and guidelines, which were often available but their implementation required staffing to deliver, commitment by health management to prioritize and monitor, and coordination between different health system levels.

Other reviews also found an emphasis on health worker and caregiver breastfeeding knowledge, skills and perceptions. Similar to our findings, enhanced knowledge and positive perceptions of breastfeeding supported practice, while negative attitudes and inaccurate knowledge regarding exclusive breastfeeding diminished breastfeeding rates [18,19,20,21,22]. Many studies evaluate interventions to improve maternal and health worker breastfeeding knowledge [20,21,22, 86,87,88,89,90]. However, our focus on facility-based factors also highlighted the need to examine infrastructural gaps, which led to overcrowding challenges and lack of privacy to counsel, the latter of which was critical for HIV-positive mothers in particular. In LMICs, home intervention alone appeared more effective than hospital intervention alone [88] while the same was not the case in high-income countries [21]. Taken in consideration of our review’s findings, this may indicate gaps in facility-based breastfeeding support in LMICs, for example in insufficient space and health worker time to adequately counsel mothers and influential family members, as well as in trained health workers to address breastfeeding challenges.

The finding that caesarean section delivery negatively impacted early breastfeeding practice was supported by five reviews [7, 20, 22, 87, 91]. This could be due to exhaustion, decreased lactogenesis or an intent not to breastfeed among some mothers [20]. Another review also cited breast complications, low birthweight and prematurity as barriers to breastfeeding initiation and continuation, a finding that supports similar results in our review. While briefly mentioned in previous reviews, caesarean section, premature infants and HIV-positive status were particularly emphasized in our review that focused on facility-based factors. The emphasis on HIV status also highlights the importance of context as it emerged as a critical factor in SSA settings while not mentioned in other general reviews.

Implications for policy and practice

BFHI emphasizes the important role hospitals play in promoting breastfeeding. However, this needs engagement of staff, adequate space and contextualization to local needs. Within the SSA context, findings from our review highlight the following:

  1. 1)

    Health facility infrastructure and supplies appears to be a neglected area of focus in the promotion of breastfeeding. BFHI policies of rooming-in and immediate skin-to-skin contact require space, which is challenged by overcrowding as facility births increase. In SSA, rates of facility birth have increased by 85% in recent Demographic Health Surveys conducted since 2010 compared to surveys from the 1990s [92]. Adequate staffing and facilities are required to deliver effective breastfeeding counselling and support.

  2. 2)

    There is a need to move beyond the focus on information provision to considering how information is delivered and strengthening respectful maternity care. Health worker engagement is essential to breastfeeding initiation and to provide the necessary support and advice to encourage mothers to continue breastfeeding [17]. As some studies reported verbal abuse, gaps in providing dignified care compromises caregiver engagement. Strengthening health worker communication skills is an area of further exploration and capacity building.

  3. 3)

    Within the SSA context, breastfeeding must be considered in the context of high rates of HIV where there are concerns of transmission. A previous review found that HIV-positive mothers are less likely to adopt exclusive breastfeeding for fear of transmission, cultural beliefs and confusion over infant feeding guidelines [93]. The current review found confusion over changes in infant feeding guidelines and a need for coordination between different health system levels for consistent messaging. Additionally, inadequate protection of mothers’ confidentiality and lack of decision-making power lowers the openness and comfort of HIV-positive mothers in particular.

  4. 4)

    Though the International Code of Marketing of Breastmilk Substitutes was implemented in 1981, its implementation and monitoring falls under the responsibility of local governments [94], which remains a challenge within SSA health facilities. For example, infant formula promoters advocating formula use to health workers were documented in Niger [35] while overall compliance with the Code was reported around 54% at BFHI hospitals in Ghana due to attrition of trained staff along with inadequate in-service training for new staff and poor regional and national monitoring [47]. The current review found evidence of misconceptions around formula use from both health workers and caregivers and inconsistent messaging around formula use, particularly associated with concern for HIV transmission [45].

Strengths and weaknesses

To the best of our knowledge, our review is the first to focus on facility-based barriers and facilitators to early and exclusive breastfeeding in SSA and is strengthened by a comprehensive and systematic search process informed by pediatric experts from Africa. Studies from numerous countries across Africa and over two-thirds of articles rated as good or fair quality lends to completeness and validity of review findings. Limitations of the review include the restriction to English-text articles, which biases against research from French-speaking countries in Africa, and the ambiguous boundary between facility- and community-based factors. While our review aimed to illuminate factors that are modifiable at the facility-level, we acknowledge that the linkages between community and health facilities is also an important area of strengthening and facility- and community-based factors can overlap.

Conclusion

A key goal of the WHO Global Nutrition Targets 2025 is to increase the rate of exclusive breastfeeding in the first 6 months of life to 50% to support achieving the Sustainable Development Goals 2 to end hunger and 3 to ensure healthy lives. Increased breastfeeding rates can contribute to the reduction of child mortality disparities in SSA and provide equal opportunity for all children to grow and thrive. As rates of facility births dramatically rise in SSA, health facilities are key spaces to promote optimal breastfeeding practices. Our review of facility-based barriers and facilitators of early and exclusive breastfeeding support in SSA highlight that it is critical to strengthen capacities in respectful maternity care and ensure appropriate spaces and adequate staff training to support specialized care for vulnerable groups, such as HIV-positive mothers and preterm infants.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its.

supplementary information files.

Table S1 – PRISMA checklist.

Table S2 - Search strategy.

Table S3 - Excluded studies.

Table S4 - Characteristics of included studies.

Table S5 - Quality assessment of included studies.

Table S6 - Barriers and facilitators to facility-based breastfeeding support in Sub-Saharan Africa reported in each study.

Table S7 - Summary of themes by studies.

Abbreviations

BFHI:

Baby-Friendly Hospital Initiative

LMICs:

Low- and middle-income countries

NIH

National Institutes of Health

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

SSA:

Sub-Saharan Africa

WHO:

World Health Organization

References

  1. Hanson C, Ronsmans C, Penfold S, Maokola W, Manzi F, Jaribu J, et al. Health system support for childbirth care in southern Tanzania: results from a health facility census. BMC Res Notes. 2013;6(1):435. https://doi.org/10.1186/1756-0500-6-435.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bhattacharjee NV, Schaeffer LE, Marczak LB, Ross JM, Swartz SJ, Albright J, et al. Mapping exclusive breastfeeding in Africa between 2000 and 2017. Nat Med. 2019;25(8):1205–12. https://doi.org/10.1038/s41591-019-0525-0.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, et al. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005;365(9463):977–88. https://doi.org/10.1016/S0140-6736(05)71088-6.

    Article  PubMed  Google Scholar 

  4. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio child survival study group. how many child deaths can we prevent this year? Lancet. 2003;362(9377):65–71. https://doi.org/10.1016/S0140-6736(03)13811-1.

    Article  PubMed  Google Scholar 

  5. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, Group TL. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90.

  6. WHO. Breastfeeding: Recommendations. [cited 2020 Jun 29]. Available from: https://www.who.int/health-topics/breastfeeding#tab=tab_2

  7. Kavle JA, Lacroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications. Public Health Nutr. 2017;20(17):3120–34. https://doi.org/10.1017/S1368980017002531.

    Article  PubMed  Google Scholar 

  8. Ahmed KY, Page A, Arora A, Ogbo FA. Trends and determinants of early initiation of breastfeeding and exclusive breastfeeding in Ethiopia from 2000 to 2016. Int Breastfeed J. 2019;14(1):40. https://doi.org/10.1186/s13006-019-0234-9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Belachew A. Timely initiation of breastfeeding and associated factors among mothers of infants age 0-6 months old in Bahir Dar City, northwest, Ethiopia, 2017: a community based cross-sectional study. Int Breastfeed J. 2019;14(1):5. https://doi.org/10.1186/s13006-018-0196-3.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Berde AS. Factors associated with bottle feeding in Namibia: findings from Namibia 2013 demographic and health survey. J Trop Pediatr. 2018;64(6):460–7. https://doi.org/10.1093/tropej/fmx091.

    Article  PubMed  Google Scholar 

  11. Bergamaschi N, Oakley L, Benova L. Is childbirth location associated with higher rates of favourable early breastfeeding practices in sub-Saharan Africa? J Glob Health. 2019;9(1):10417. https://doi.org/10.7189/jogh.09.010417.

    Article  Google Scholar 

  12. Chipojola R, Lee GT, Chiu H-Y, Chang P-C, Kuo S-Y. Determinants of breastfeeding practices among mothers in Malawi: a population-based survey. Int Health. 2019;12(2):132-41.

  13. Nkoka O, Ntenda PAM, Kanje V, Milanzi EB, Arora A. Determinants of timely initiation of breast milk and exclusive breastfeeding in Malawi: a population-based cross-sectional study. Int Breastfeed J. 2019;14(1):37. https://doi.org/10.1186/s13006-019-0232-y.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Williams AM, Chantry C, Geubbels EL, Ramaiya AK, Shemdoe AI, Tancredi DJ, et al. Breastfeeding and complementary feeding practices among HIV-exposed infants in coastal Tanzania. J Hum Lact. 2016;32(1):112–22. https://doi.org/10.1177/0890334415618412.

    Article  PubMed  Google Scholar 

  15. Woldeamanuel BT. Trends and factors associated to early initiation of breastfeeding, exclusive breastfeeding and duration of breastfeeding in Ethiopia: evidence from the Ethiopia demographic and health survey 2016. Int Breastfeed J. 2020;15(1):3. https://doi.org/10.1186/s13006-019-0248-3.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402–17. https://doi.org/10.1111/mcn.12294.

    Article  PubMed  PubMed Central  Google Scholar 

  17. WHO, UNICEF. Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised baby-friendly hospital initiative 2018. World Health Organization. Geneva: World Health Organization; 2018.

    Google Scholar 

  18. 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. https://doi.org/10.1177/0890334417707957.

    Article  PubMed  Google Scholar 

  19. 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. https://doi.org/10.1111/mcn.12180.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Cohen SS, Alexander DD, Krebs NF, Young BE, Cabana MD, Erdmann P, et al. Factors associated with breastfeeding initiation and continuation: a meta-analysis. J Pediatr. 2018;203:190–196.e21.

    Article  PubMed  Google Scholar 

  21. Wood NK, Woods NF, Blackburn ST, Sanders EA. Interventions that enhance breastfeeding initiation, duration, and exclusivity: a systematic review. MCN Am J Matern Child Nurs. 2016;41(5):299–307.

  22. Sharma IK, Byrne A. Early initiation of breastfeeding: a systematic literature review of factors and barriers in South Asia. Int Breastfeed J. 2016;11(1):1–12.

    Article  Google Scholar 

  23. Patil DS, Pundir P, Dhyani VS, Krishnan JB, Parsekar SS, D’Souza SM, et al. A mixed-methods systematic review on barriers to exclusive breastfeeding. Nutr Health. 2020;26(4):323–46. https://doi.org/10.1177/0260106020942967.

    Article  PubMed  Google Scholar 

  24. Vehling L, Chan D, McGavock J, Becker AB, Subbarao P, Moraes TJ, et al. Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: implications for health equity. Birth. 2018;45(4):440–9. https://doi.org/10.1111/birt.12345.

    Article  PubMed  Google Scholar 

  25. Abrahams SW, Labbok MH. Exploring the impact of the baby-friendly hospital initiative on trends in exclusive breastfeeding. Int Breastfeed J. 2009;4(1):11. https://doi.org/10.1186/1746-4358-4-11.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 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(10017):491–504. https://doi.org/10.1016/S0140-6736(15)01044-2.

    Article  PubMed  Google Scholar 

  27. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. https://doi.org/10.1371/journal.pmed.1000100.

    Article  PubMed  PubMed Central  Google Scholar 

  28. NIH National Heart L and BI. Development and Use of Study Quality Assessment Tools | National Heart, Lung, and Blood Institute (NHLBI). [cited 2019 Jul 5]. Available from: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

  29. CASP. Critical Appraisal Skills Programme Qualitative Checklist. [cited 2020 Jul 14]. Available from: https://casp-uk.net/casp-tools-checklists/

  30. Agbozo F, Ocansey D, Atitto P, Jahn A. Compliance of a baby-friendly designated hospital in Ghana with the WHO/UNICEF baby and mother-friendly care practices. J Hum Lact. 2020;36(1):175-86.

  31. Amadhila JN, Van Rensburg GH. Perceptions and experiences of nurse managers of the implementation of the baby and mother friendly initiative in Namibia: a qualitative study. Int Breastfeed J. 2020;15(1):1–10.

    Article  Google Scholar 

  32. Amsalu R, Morris CN, Chukwumalu K, Hynes M, Janjua S, Couture A, et al. Essential newborn care practice at four primary health facilities in conflict affected areas of Bossaso, Somalia: a cross-sectional study. Confl Health. 2019;13:27.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Chabeda S, Oluoch D, Mwangome M, Jones C. Infant malnutrition treatment in Kenya: Health worker and breastfeeding peer supporter experiences. Matern Child Nutr. 2021;17(3):e13148.

  34. Kavle JA, Welch PR, Bwanali F, Nyambo K, Guta J, Mapongo N, et al. The revitalization and scale-up of the Baby-Friendly Hospital Initiative in Malawi. Matern Child Nutr. 2019;15(Suppl 1):e12724.

    PubMed  PubMed Central  Google Scholar 

  35. Moussa Abba A, De Koninck M, Hamelin A-M. A qualitative study of the promotion of exclusive breastfeeding by health professionals in Niamey, Niger. Int Breastfeed J. 2010;5:8.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Nyati-Jokomo Z, Chitsike I, Mbizvo E, January J. “If nurses were in our shoes would they breastfeed their own babies?” A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe. BMC Pregnancy Childbirth. 2019;19(1):191.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Shobo OG, Umar N, Gana A, Longtoe P, Idogho O, Anyanti J. Factors influencing the early initiation of breast feeding in public primary healthcare facilities in Northeast Nigeria: a mixed-method study. BMJ Open. 2020;10(4):e032835.

  38. Hasselberg M, Huus K, Golsater M. Breastfeeding preterm infants at a neonatal care unit in rural Tanzania. J Obstet Gynecol Neonatal Nurs. 2016;45(6):825–35. https://doi.org/10.1016/j.jogn.2016.07.010.

    Article  PubMed  Google Scholar 

  39. Chale LE, Fenton TR, Kayange N. Predictors of knowledge and practice of exclusive breastfeeding among health workers in Mwanza city, Northwest Tanzania. BMC Nurs. 2016;15(1):72. https://doi.org/10.1186/s12912-016-0192-0.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Daniels L, Jackson D. Knowledge, attitudes and practices of nursing staff regarding the baby-friendly hospital initiative in non-accredited obstetric units in Cape Town. South African J Clin Nutr. 2011;24(1):32–8. https://doi.org/10.1080/16070658.2011.11734347.

    Article  Google Scholar 

  41. Dubik SD, Yirkyio E, Ebenezer KE. Breastfeeding in primary healthcare setting: evaluation of nurses and midwives competencies, training, barriers and satisfaction of breastfeeding educational experiences in Northern Ghana. Clin Med Insights Pediatr. 2021;15:11795565211010704.

  42. Ferguson YO, Eng E, Bentley M, Sandelowski M, Steckler A, Randall-David E, et al. Evaluating nurses’ implementation of an infant-feeding counseling protocol for HIV-infected mothers: the BAN study in Lilongwe, Malawi. AIDS Educ Prev. 2009;21(2):141–55. https://doi.org/10.1521/aeap.2009.21.2.141.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Morgan JJ, Jeggels JD. Factors influencing the infant feeding choices of HIV-positive mothers at a level two hospital in Cape Town. Afr J Midwifery Women’s Heal. 2015;9(2):66–70. https://doi.org/10.12968/ajmw.2015.9.2.66.

    Article  Google Scholar 

  44. Morhason-Bello I, Adedokun B, Ojengbede O. Social support during childbirth as a catalyst for early breastfeeding initiation for first-time Nigerian mothers. Int Breastfeed J. 2009;4:7–7.

    Article  Google Scholar 

  45. Mphasha M, Skaal L. Infant and Young child feeding policy: do primary health care nurses adhere to the HIV breastfeeding recommendations in Limpopo province? South Afr J Clin Nutr. 2019;32(3):70–5. https://doi.org/10.1080/16070658.2018.1457863.

    Article  Google Scholar 

  46. Nabwera HM, Jepkosgei J, Muraya KW, Hassan AS, Molyneux CS, Ali R, et al. What influences feeding decisions for HIV-exposed infants in rural Kenya? Int Breastfeed J. 2017;12(1):31. https://doi.org/10.1186/s13006-017-0125-x.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Nii Okai Aryeetey R, Antwi CL. Re-assessment of selected Baby-Friendly maternity facilities in Accra, Ghana. Int Breastfeed J. 2013;8(1):15.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Nikodem C, Schelke L, Enraght-Moony L, Hofmeyr GJ. Breastfeeding in crisis: survey results of the baby-friendly hospital initiative. Curationis. 1995;18(3):39–42. https://doi.org/10.4102/curationis.v18i3.1361.

    Article  CAS  PubMed  Google Scholar 

  49. Senbanjo IO, Oshikoya KA, Ogbera OA, Wright KO, Anga AL. Breastfeeding policy and practices at the general paediatric outpatient clinic of a teaching hospital in Lagos, Nigeria. Int Breastfeed J. 2014;9(1):10. https://doi.org/10.1186/1746-4358-9-10.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Tawiah-Agyemang C, Kirkwood BR, Edmond K, Bazzano A, Hill Z. Early initiation of breast-feeding in Ghana: barriers and facilitators. J Perinatol. 2008;28(Suppl 2):S46–52. https://doi.org/10.1038/jp.2008.173.

    Article  PubMed  Google Scholar 

  51. Awi DD, Alikor EAD. Barriers to timely initiation of breastfeeding among mothers of healthy full-term babies who deliver at the University of Port Harcourt Teaching Hospital. Niger J Clin Pract. 2006;9(1):57–64.

    CAS  PubMed  Google Scholar 

  52. Kalisa R, Malande O, Nankunda J, Tumwine JK. Magnitude and factors associated with delayed initiation of breastfeeding among mothers who deliver in Mulago hospital, Uganda. Afr Health Sci. 2015;15(4):1130–5. https://doi.org/10.4314/ahs.v15i4.11.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Owoaje ET, Oyemade A, Kolude OO. Previous BFHI training and nurses’ knowledge, attitudes and practices regarding exclusive breastfeeding. Afr J Med Med Sci. 2002;31(2):137–40.

    CAS  PubMed  Google Scholar 

  54. Spira C, Kwizera A, Jacob S, Amongin D, Ngonzi J, Namisi CP, et al. Improving the quality of maternity services in Uganda through accelerated implementation of essential interventions by healthcare professional associations. Int J Gynaecol Obstet. 2017;139(1):107–13. https://doi.org/10.1002/ijgo.12241.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Swarts S, HS K, RC D. Factors affecting mothers’ choice of breastfeeding vs. formula feeding in the lower umfolozi district war memorial hospital, Kwazulu-Natal. Heal SA Gesondheid. 2010;15(1):119–26.

    Google Scholar 

  56. Yotebieng M, Labbok M, Soeters HM, Chalachala JL, Lapika B, Vitta BS, et al. Ten steps to successful breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial. Lancet Glob Heal. 2015;3(9):e546–55. https://doi.org/10.1016/S2214-109X(15)00012-1.

    Article  Google Scholar 

  57. Okolo SN, Ogbonna C. Knowledge, attitude and practice of health workers in Keffi local government hospitals regarding baby-friendly hospital initiative (BFHI) practices. Eur J Clin Nutr. 2002;56(5):438–41. https://doi.org/10.1038/sj.ejcn.1601331.

    Article  CAS  PubMed  Google Scholar 

  58. Fadupin GT, Olaitan OO, Itasanmi ET, Okolosi JE. Breastfeeding knowledge and factors associated with breastfeeding initiation among post-partum mothers in selected areas in Ibadan, Nigeria. Afr J Biomed Res. 2020;23(2):283–8.

    Google Scholar 

  59. Akuse RM, Obinya EA. Why healthcare workers give prelacteal feeds. Eur J Clin Nutr. 2002;56(8):729–34. https://doi.org/10.1038/sj.ejcn.1601385.

    Article  CAS  PubMed  Google Scholar 

  60. Chaponda A, Goon DT, Hoque ME. Infant feeding practices among HIV-positive mothers at Tembisa hospital, South Africa. Afr J Prim Heal Care Fam Med. 2017;9(1):e1–6.

    Article  Google Scholar 

  61. Doherty T, Horwood C, Haskins L, Magasana V, Goga A, Feucht U, et al. Breastfeeding advice for reality: Women’s perspectives on primary care support in South Africa. Matern Child Nutr. 2020;16(1):e12877.

  62. Lang’at PC, Ogada I, Steenbeek A, MacDonald NE, Ochola S, Bor W, et al. Infant feeding practices among HIV-exposed infants less than 6 months of age in Bomet County, Kenya: an in-depth qualitative study of feeding choices. Arch Dis Child. 2018;103(5):470–3. https://doi.org/10.1136/archdischild-2017-314521.

    Article  PubMed  Google Scholar 

  63. Mgolozeli SE, Shilubane HN, Khoza LB. Nurses’ attitudes towards the implementation of the mother-baby friendly initiative in selected primary healthcare facilities at Makhuduthamaga municipality, Limpopo province. Curationis. 2019;42(1):e1-e9.

  64. Nyawade SA, Middlestadt SE, Peng C-YJ. Beliefs about supporting mothers to exclusively breastfeed for 6 months: an elicitation study of health professionals working in maternal-child health clinics in Nairobi, Kenya. J Hum Lact. 2016;32(3):551–8. https://doi.org/10.1177/0890334415625901.

    Article  PubMed  Google Scholar 

  65. van Rensburg LJ, Nel R, Walsh CM. Knowledge, opinions and practices of healthcare workers related to infant feeding in the context of HIV. Heal SA Gesondheid. 2016;21(1):129–36. https://doi.org/10.1016/j.hsag.2015.12.001.

    Article  Google Scholar 

  66. West NS, Schwartz SR, Yende N, Schwartz SJ, Parmley L, Gadarowski MB, et al. Infant feeding by south African mothers living with HIV: implications for future training of health care workers and the need for consistent counseling. Int Breastfeed J. 2019;14(1):11. https://doi.org/10.1186/s13006-019-0205-1.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Mohamed MJ, Ochola S, Owino VO. Comparison of knowledge, attitudes and practices on exclusive breastfeeding between primiparous and multiparous mothers attending Wajir District hospital, Wajir County, Kenya: a cross-sectional analytical study. Int Breastfeed J. 2018;13:11.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Aghaji MN. Exclusive breast-feeding practice and associated factors in Enugu, Nigeria. West Afr J Med. 2002;21(1):66–9.

    PubMed  Google Scholar 

  69. Degefa N, Tariku B, Bancha T, Amana G, Hajo A, Kusse Y, et al. Breast feeding practice: positioning and attachment during breast feeding among lactating mothers visiting health Facility in Areka Town, Southern Ethiopia. Int J Pediatr. 2019;2019:8969432.

    PubMed  PubMed Central  Google Scholar 

  70. Gejo NG, Weldearegay HG, W/Tinsaie KT, Mekango DE, Woldemichael ES, Buda AS, et al. Exclusive breastfeeding and associated factors among HIV positive mothers in Northern Ethiopia. PLoS One. 2019;14(1):e0210782.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  71. Getnet B, Degu A, Yenealem F. Prevalence and associated factors of early initiation of breastfeeding among women delivered via cesarean section in South Gondar zone hospitals Ethiopia, 2020. Matern Heal Neonatol Perinatol. 2020;6(1):1–9.

    Article  Google Scholar 

  72. Ighogboja IS, Odumodu CU, Olarewaju RS. Breastfeeding pattern in Jos, Nigeria, before baby-friendly hospital initiative. J Trop Pediatr. 1996;42(3):178–9. https://doi.org/10.1093/tropej/42.3.178.

    Article  CAS  PubMed  Google Scholar 

  73. Iliyasu Z, Galadanci HS, Iliyasu ML, Babashani M, Gajida AU, Nass NS, et al. Determinants of infant feeding practices among HIV-infected mothers in urban Kano, Nigeria. J Hum Lact. 2019;35(3):592–600. https://doi.org/10.1177/0890334419835171.

    Article  PubMed  Google Scholar 

  74. Kafulafula UK, Hutchinson MK, Gennaro S, Guttmacher S. Maternal and health care workers’ perceptions of the effects of exclusive breastfeeding by HIV positive mothers on maternal and infant health in Blantyre, Malawi. BMC Pregnancy Childbirth. 2014;14(1):247. https://doi.org/10.1186/1471-2393-14-247.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Kahindi J, Jones C, Berkley JA, Mwangome M. Establishing exclusive breastfeeding among in-patient malnourished infants in a rural Kenyan hospital: mothers’ experiences of a peer supporter intervention. Int Breastfeed J. 2020;15(1):1–11.

    Article  Google Scholar 

  76. Kassa BG. Early initiation of breastfeeding and its associated factors among mothers who delivered vaginally in South Gondar zone hospitals, Northwest Ethiopia, 2020. Int J Women's Health. 2021;13:9–17.

    Article  Google Scholar 

  77. Kusi-Amponsah Diji A, Bam V, Asante E, Yemotsoo Lomotey A, Yeboah S, Owusu HA, et al. Challenges and predictors of exclusive breastfeeding among mothers attending the child welfare clinic at a regional hospital in Ghana: a descriptive cross-sectional study. Int Breastfeed J. 2017;12:1–7.

    Google Scholar 

  78. Mukashyaka J, Mukarubayiza R, Mukarubayiza R, Habumugisha E, Sunday F-X, Muganwa K, et al. Early initiation of breastfeeding among postpartum mothers at two Rwandan hospitals. Rwanda J Med Heal Sci. 2020;3(2):181–92. https://doi.org/10.4314/rjmhs.v3i2.8.

    Article  Google Scholar 

  79. Mukerem M, Haidar J. Assessment of the prevalence and factors influencing adherence to exclusive breast feeding among HIV positive mothers in selected health institution of Addis Ababa, Ethiopia. Ethiop J Heal Dev. 2012;26(3):169–75.

    Google Scholar 

  80. Olorunfemi SO, Dudley L. Knowledge, attitude and practice of infant feeding in the first 6 months among HIV-positive mothers at the queen Mamohato memorial hospital clinics, Maseru, Lesotho. Afr J Prim Heal care Fam Med. 2018;10(1):e1–12.

    Article  Google Scholar 

  81. Senghore T, Omotosho TA, Ceesay O, Williams DCH. Predictors of exclusive breastfeeding knowledge and intention to or practice of exclusive breastfeeding among antenatal and postnatal women receiving routine care: a cross-sectional study. Int Breastfeed J. 2018;13(1):9. https://doi.org/10.1186/s13006-018-0154-0.

    Article  PubMed  PubMed Central  Google Scholar 

  82. Tiruye G, Mesfin F, Geda B, Shiferaw K. Breastfeeding technique and associated factors among breastfeeding mothers in Harar city, Eastern Ethiopia. Int Breastfeed J. 2018;13(1):5. https://doi.org/10.1186/s13006-018-0147-z.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Tongun JB, Sebit MB, Mukunya D, Ndeezi G, Nankabirwa V, Tylleskar T, et al. Factors associated with delayed initiation of breastfeeding: a cross-sectional study in South Sudan. Int Breastfeed J. 2018;13(1):28. https://doi.org/10.1186/s13006-018-0170-0.

    Article  Google Scholar 

  84. Remmert JE, Mosery N, Goodman G, Bangsberg DR, Safren SA, Smit JA, et al. Breastfeeding practices among women living with HIV in KwaZulu-Natal, South Africa: an observational study. Matern Child Health J. 2020;24(2):127–34. https://doi.org/10.1007/s10995-019-02848-8.

    Article  PubMed  PubMed Central  Google Scholar 

  85. Ojofeitimi EO, Esimai OA, Owolabi OO. Oluwabusi, Olaobaju OF, Olanuga TO. Breast feeding practices in urban and rural health centres: impact of baby friendly hospital initiative in Ile-Ife, Nigeria. Nutr Health. 2000;14(2):119–25. https://doi.org/10.1177/026010600001400204.

    Article  CAS  PubMed  Google Scholar 

  86. Kim SK, Park S, Oh J, Kim J, Ahn S. Interventions promoting exclusive breastfeeding up to six months after birth: a systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud. 2018;80:94–105. https://doi.org/10.1016/j.ijnurstu.2018.01.004.

  87. Hannula L, Kaunonen M, Tarkka MT. A systematic review of professional support interventions for breastfeeding. J Clin Nurs. 2008;17(9):1132–43. https://doi.org/10.1111/j.1365-2702.2007.02239.x.

    Article  PubMed  Google Scholar 

  88. Sinha B, Chowdhury R, Upadhyay RP, Taneja S, Martines J, Bahl R, et al. Integrated interventions delivered in health systems, home, and community have the highest impact on breastfeeding outcomes in low- and middle-income countries. J Nutr. 2017;147(11):2179S–87S. https://doi.org/10.3945/jn.116.242321.

    Article  CAS  PubMed  Google Scholar 

  89. Olufunlayo TF, Roberts AA, MacArthur C, Thomas N, Odeyemi KA, Price M, et al. Improving exclusive breastfeeding in low and middle-income countries: a systematic review. Matern Child Nutr. 2019;15(3):1–26.

    Article  Google Scholar 

  90. Patel S, Patel S. The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes. J Hum Lact. 2016;32(3):530–41. https://doi.org/10.1177/0890334415618668.

    Article  PubMed  Google Scholar 

  91. Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. Am J Clin Nutr. 2012;95(5):1113–35. https://doi.org/10.3945/ajcn.111.030254.

    Article  CAS  PubMed  Google Scholar 

  92. Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda. BMC Public Health. 2018;18(1):765. https://doi.org/10.1186/s12889-018-5695-z.

  93. Nyoni S, Sweet L, Clark J, Ward P. A realist review of infant feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa: what works for whom and in what contexts. BMC Public Health. 2019;19(1):570. https://doi.org/10.1186/s12889-019-6949-0.

    Article  PubMed  PubMed Central  Google Scholar 

  94. World Health Organization. International code of marketing of breast-milk Substitutes. Geneva: World Health Organization; 1981.

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Acknowledgements

This manuscript is part of the “Integrating a neonatal healthcare package for Malawi” project within the Innovating for Maternal and Child Health in Africa (IMCHA) initiative. The authors would like to express their gratitude to the IMCHA team for their support. We are grateful to all the study participants that participated in the study and the nurses who helped in data collection. We are thankful for the institutional support from the hospitals for allowing us to conduct the study in their facilities.

Funding

“Integrating a neonatal healthcare package for Malawi” (IMCHA #108030) is funded by the Canadian International Development Research Centre (IDRC) in partnership with Global Affairs Canada (GAC) and the Canadian Institutes for Health Research (CIHR).

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Contributions

MWK contributed to the conception of the research protocol, study design, literature review, data extraction, data analysis, interpretation, drafted the original paper and coordinated the feedback to revise the paper with support from SP. TH also contributed to the literature review, data analysis and interpretation, the quality assessment and provided critical feedback to all versions. MV and ALNM gave advice on the structure of the paper and critically reviewed all versions. QD, DMG and KK contributed to the conceptualization of the research project and its funding acquisition and critically reviewed all versions. In addition, KK supervised project activities. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Kondwani Kawaza.

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Competing interests

The authors declare that they have no conflicts of interest.

Supplementary Information

Additional file 1:

Table S1. PRISMA checklist.

Additional file 2:

Table S2. Search strategy.

Additional file 3:

: Table S3. Excluded studies.

Additional file 4:

Table S4. Characteristics of included studies.

Additional file 5:

Table S5. Quality assessment of included studies.

Additional file 6

: Table S6. Barriers and facilitators to facility-based breastfeeding support in Sub-Saharan Africa reported in each study.

Additional file 7:

Table S7. Summary of themes by studies.

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Kinshella, ML.W., Prasad, S., Hiwa, T. et al. Barriers and facilitators for early and exclusive breastfeeding in health facilities in Sub-Saharan Africa: a systematic review. glob health res policy 6, 21 (2021). https://doi.org/10.1186/s41256-021-00206-2

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