Abstract
BackgroundSub-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.MethodsA 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).ResultsOf 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.ConclusionThere 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.
Highlights
Sub-Saharan Africa (SSA) carries a disproportionate burden of infant and child deaths, with 55–75% of underfive 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]
Thirtyseven 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)
Summary
Sub-Saharan Africa (SSA) carries a disproportionate burden of infant and child deaths, with 55–75% of underfive deaths in SSA attributed to inappropriate breastfeeding practices [1]. The review found that women who delivered at a health facility were more likely to engage in exclusive breastfeeding practices [7], which has been found in studies across SSA [8– 15]. While previous reviews broadly examined barriers and facilitators to exclusive or early initiation to breastfeeding [7, 18–23], they have not focused on factors modifiable at the health facility level, which is surprising due to the widespread promotion of BFHI. 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.
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