[Development and challenges to breastfeeding in sub-Saharan Africa]

A systematic review of qualitative research on barriers and facilitators to exclusive breastfeeding practice in sub-Saharan African countries

BACKGROUND

Studies reporting factors associated with exclusive breastfeeding are mostly quantitative. No study has performed a systematic qualitative summary to document the recurring constraints and facilitators to exclusive breastfeeding in sub-Saharan African countries from breastfeeding mothers' perspective. This study systematically reviews the literature reporting barriers and facilitators to exclusive breastfeeding from the breastfeeding mothers' perspective in sub-Saharan Africa to develop an educational intervention to optimize exclusive breastfeeding.

METHODS

A systematic literature review of qualitative studies such as phenomenological studies, followed by a risk of bias and methodological assessment of the included studies' quality using the Critical Appraisal Skills Programme (CASP) tool was conducted. MEDLINE and Google Scholar were searched from January 1990 to October 2019 to retrieve studies of breastfeeding mothers who had infants aged between 0 and 12 months. Two authors independently carried out the review process and resolved disagreements through consensus. We analyzed the data thematically.

RESULTS

After reviewing 92 studies, 20 studies involving 836 participants from 11 countries were eligible. Of the 72 studies excluded, 39 were not conducted in sub-Saharan Africa, and 33 included other participants such as fathers. Three themes emerged as barriers to exclusive breastfeeding (EBF) and five additional themes were identified with facilitators of maternal-infant factors being the most significant in both cases. Maternal employment and knowledge of the benefits of EBF were the most common maternal-infant factors that served as a barrier and a facilitator, respectively. The study's limitations were that the review involved only primary research among breastfeeding mothers living in sub-Saharan Africa and excluded studies not available in the English language. The information synthesized from this review could be used to develop communication strategies employed during individual and group patient education in the hospitals to improve breastfeeding mothers' understanding, acceptance, and practice of exclusive breastfeeding. This review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42020133761.

CONCLUSIONS

This review found that maternal-infant factors have the most significant influence over the practice of exclusive breastfeeding. Therefore, interventions targeted towards maternal-infant factors will improve and optimize exclusive breastfeeding significantly and, ultimately, improve maternal-child health outcomes.

Challenges and opportunities to tackle the rising prevalence of diet-related non-communicable diseases in Africa

Africa is experiencing a sharp rise in non-communicable diseases (NCD) related to rapid globalisation and urbanisation leading to shifts in dietary and lifestyle patterns characterised by increased energy intake and physical inactivity. However, unlike more resource-endowed regions, Africa has a double burden of disease: NCD co-exist with infectious diseases including lower respiratory tract infections, HIV/AIDS and diarrhoeal diseases. The African economy is also relatively weaker, making it difficult to cope with this burden. It is postulated that NCD will soon overtake infectious diseases as the number one cause of death in the African region. The recognition of NCD as diseases and obesity as a related risk factor is weak in Africa, compounded by stigma associated with wasting in HIV/AIDS and obesity being perceived as a sign of wealth, achievement and care. There is also a dearth of data on overweight and obesity in the region and little knowledge that infant feeding practices, such as breast-feeding, are linked to reduced risk of NCD in both children and mothers. While complex multi-sectoral approaches to address this NCD menace are needed, Africa may benefit from taking simple initial steps to address NCD risk factors including: (1) behaviour change communication to challenge perceptions on NCD; (2) promoting and protecting breast-feeding; (3) formulating policies and regulations limiting wide availability of unhealthy foods; (4) mainstream nutrition education in school curricula and (5) collection of accurate data based on indicators that can reflect the double burden of disease and malnutrition; and fostering multi-sectoral actions against NCD.