Enablers and barriers of exclusive breastfeeding among employed women in low and lower middle-income countries

How Does the Breastfeeding Environment Affect Satisfaction? A Scale Development Study

BACKGROUND

Women need a safe and comfortable environment to breastfeed their babies. The quality of breastfeeding environments in social areas is important for women's breastfeeding satisfaction.

AIM

The aim of this study was to develop a measurement tool for the evaluation of breastfeeding environments and to examine the impact of the quality of breastfeeding environments in social areas on breastfeeding satisfaction.

METHOD

The first phase of the study was conducted in methodological design and the second phase in cross-sectional design. The draft scale was applied to 365 women who had breastfeeding experiences in social environments during the postpartum 6 months-3 years period. In the first stage, scale development analyses were applied. In the second stage, the developed scale was applied to 255 women. Frequency, percentage, Cronbach's α coefficient, and correlation analysis were used in the analysis of the data.

RESULTS

The Ideal Breastfeeding Environment Assessment Scale, consisting of 23 items and four subdimensions, was obtained in the study. As a result of the application of the scale in the second stage, the mean score of the breastfeeding environments evaluated by the women was 23.43 ± 8.36. A statistically significant moderate-weak correlation was found between the ideality of breastfeeding environments and the satisfaction levels of women (p < .001).

CONCLUSION

It was determined that the developed scale is a valid and reliable measurement tool that can be used to evaluate breastfeeding environments. As the quality of breastfeeding environments increases, women's breastfeeding satisfaction increases.

Factors associated with exclusive breastfeeding during postpartum in Lanzhou city, China: a cross-sectional study

Aim

Breastfeeding generates short-term and long-term benefits for both mother and child. Exclusive breastfeeding (EBF) is promoted in China for years, but its practice still lags far behind the international average, even among low- and middle- income countries. This study aimed to investigate factors associated with EBF during postpartum.

Methods

This study was conducted in a tertiary referral hospital in Gansu Province, Northwest China from October 2019 to April 2020. 3,738 postnatal women were finally included and each of them completed an elaborately designed questionnaire. Infant feeding patterns (EBF or not) and reasons for NEBF (non-exclusive breastfeeding) were collected. The feeding knowledge score was based on 17 questions in relation to breastfeeding. The total score ranges from 0 to 17. Higher score means better understanding about breastfeeding knowledge. Multivariate logistic regression models were used to determine associated factors of EBF during postpartum. A subgroup analysis was conducted to investigate the association between feeding knowledge score and exclusive breastfeeding.

Results

Six weeks after childbirth, 1891 mothers (50.6%) maintained EBF. Among the NEBF mothers, 57.01% (n = 1,053) of them stopped exclusive breastfeeding due to self-perceived lack of breast milk production. Factors associated with NEBF were higher maternal age, ethnic minorities and cesarean section. Protective factors of EBF included multipara, positive feeding attitude and high breastfeeding knowledge score. In subgroup analysis, we found the breastfeeding knowledge score had a significant impact on the mothers of Han nationality, underwent cesarean or natural delivery, both primiparous and multiparous, and those with positive attitude towards breastfeeding (p < 0.05).

Conclusion

We need a comprehensive and individualized framework of strategies to support children, mothers and their families. During puerperium, improving maternal knowledge of breastfeeding is beneficial to EBF practice. However, for ethnic minorities and those with less active breastfeeding attitudes, breastfeeding knowledge is of limited use, more researches are needed to explore the uncovered reasons, so that more personalized interventions could be developed for them.

The health consequences of informal employment among female workers and their children: a systematic review

BACKGROUND

Informal employment is unprotected and unregistered and it is often characterized by precarious working arrangements. Although being a global phenomenon and the most common type of employment worldwide, scholarly attention to its health effects has only recently accelerated. While there is still some debate, informal employment is generally understood to be detrimental to workers' health. However, because women are more vulnerable to informality than men, attention is required to the health consequences of female workers specifically. We conducted a systematic review with the objective to examine the global evidence on the consequences of informal employment, compared to formal employment, on the health of female workers and their children.

METHODS

We searched peer-reviewed literature in Embase, Medline, PsychInfo, Scopus and Web of Science up until November 11, 2022. No restrictions were applied in terms of year, language or country. Individual-level quantitative studies that compared women of reproductive age in informal and formal employment, or their children (≤ 5 years), were eligible for inclusion. If studies reported outcomes per subgroup level, these were included. Study quality was assessed using the Joanna Briggs Institute checklist and a narrative synthesis of the results were conducted.

RESULTS

13 articles were included in the review, looking at breastfeeding outcomes (n = 4), child nutritional status and low birthweight (n = 4), antenatal health (n = 3), and general health outcomes for women (n = 2). The overall evidence from the included studies was that compared to formal employment, there was an association between informal employment and worse health outcomes, especially on child nutritional status and antenatal health. The evidence for breastfeeding outcomes was mixed and showed that informal employment may be both protective and damaging to health.

CONCLUSION

This review showed that informal employment is a potential risk factor for health among female workers and their children. Further research on the pathways between informal employment and health is needed to strengthen the understanding of the health consequences of informal employment.

Access to Workplace Supports is Positively Associated with Exclusive Breastfeeding among Formally Employed Mothers in Kenya

BACKGROUND

Mothers in low-income settings who work in agricultural employment are challenged to meet breastfeeding (BF) recommendations. Recent legislation in Kenya mandates maternity leave and workplace supports, yet the relation of these benefits with BF practices is poorly understood.

OBJECTIVES

We evaluated the associations with workplace-provided BF supports and BF practices among formally employed mothers in Kenya. The availability of supports was hypothesized to be associated with a higher prevalence and greater odds of exclusive breastfeeding (EBF).

METHODS

We conducted repeated cross-sectional surveys among formally employed mothers at 1-4 d and 6, 14, and 36 wk (to estimate 24 wk) postpartum in Naivasha, Kenya. We used logistic regression adjusted for maternal age, education, physical burden of work, HIV status, and income to evaluate associations between workplace supports and EBF practices.

RESULTS

Among formally employed mothers (n = 564), those who used onsite workplace childcare were more likely to practice EBF than those who used community- or home-based childcare at both 6 wk (95.7% compared with 82.4%, P = 0.030) and 14 wk (60.6% compared with 22.2%, P < 0.001; adjusted OR: 5.11; 95% CI: 2.3, 11.7). Likewise, at 14 wk among mothers who currently used daycare centers, a higher proportion of mothers who visited daycare centers at or near workplaces practiced EBF (70.0%) than of those not visiting daycare centers (34.7%, P = 0.005). EBF prevalence was higher among mothers with access to workplace private lactation spaces than among mothers without such spaces (84.6% compared with 55.6%, P = 0.037), and among mothers who lived in workplace housing than those without onsite housing (adjusted OR: 2.06, 95% CI: 1.25, 3.41).

CONCLUSIONS

Formally employed mothers in Kenya who have access to and use workplace-provided BF supports were more likely to practice EBF than mothers who lacked these supports. As the Kenya Health Act is implemented, lactation rooms, onsite housing and daycare, and transportation to visit children can all support BF and EBF among employed mothers.

Sociodemographic and Personal Predictors of Exclusive Breastfeeding in Pregnant Mexican Women Using Public Health Services

Exclusive breastfeeding (EBF) is a cost-effective healthy behavior for the mother–child dyad. Globally, rates of EBF are low. Little research has been conducted on the joint role of modifiable and nonmodifiable variables in pregnant women’s decision-making. The aim was to develop and test a model that used personal and sociodemographic factors to predict whether pregnant women who use public healthcare services plan to breastfeed. In a nonprobabilistic sample of 728 pregnant Mexican women, self-efficacy, the planned behavior theory constructs, and the intention to breastfeed (BFI) were measured. A total 60% of the sample was randomly chosen to develop a predictive multivariate logistic regression model. The model was validated in the remaining 40%. Women in the highest tertiles of attitudes and self-efficacy had fourfold increased chances of having a high BFI (OR 4.2, 95% CI [2.4, 7.4]). Working was associated with a decreased intention to exclusively breastfeed (OR 0.61, 95% CI [0.37, 0.98]). The model predicted BFI with a sensitivity of 38.3% and specificity of 82.2%. While personal variables predict the BFI, working decreases women’s chances of breastfeeding. The results can be utilized to develop primary prevention strategies to help mothers who use public health services to breastfeed.

Birth Experiences, Breastfeeding, and the Mother-Child Relationship: Evidence from a Large Sample of Mothers

BACKGROUND

It is a priority for public health professionals to improve global breastfeeding rates, which have remained low in Western countries for more than a decade. Few researchers have addressed how maternal perceptions of birth experiences affect infant feeding methods. Furthermore, mixed results have been shown in research regarding breastfeeding and mother-child bonding, and many studies are limited by small sample sizes, representing a need for further investigation.

PURPOSE

We aimed to examine the relationship between subjective birth experiences and breastfeeding outcomes, and explored whether breastfeeding affected mother-infant bonding.

METHODS

3,080 mothers up to three years postpartum completed a cross - sectional survey.

RESULTS

Mothers who had more positive birth experiences were more likely to report breastfeeding their babies. Moreover, mothers who perceived their birth as more positive were more likely to breastfeed their child for a longer period (over 9 months) than those who had more negative experiences. In line with recent research, breastfeeding behaviours were not associated with reported mother-infant bonding.

CONCLUSIONS

Mothers who reported better birth experiences were most likely to breastfeed, and breastfeed for longer. We find no evidence to suggest that feeding methods are associated with bonding outcomes.

Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia

This study aimed to explore variations in Infant and Young Child Feeding (IYCF) practices between different South Asian Countries (SACs) and within their sociodemographic characteristics including place of residence, mother age, mother education, child sex, and wealth quintiles within the SACs. We extracted 0–23 months age children’s data from the nationally representative survey of Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. Among all SACs, the early initiation of breastfeeding (EIBF) practice was 45.4% with the highest prevalence in the Maldives (68.2%) and the lowest prevalence in Pakistan (20.8%). Exclusive breastfeeding (EBF) practice was 53.9% with the highest prevalence in Nepal (67%) and the lowest prevalence in Afghanistan (42%). Only 13% of children had a minimum acceptable diet (MAD), with the highest prevalence in the Maldives (52%) and the lowest prevalence in India (11%). We found higher IYCF practices among the mothers with secondary or higher levels of education (EIBF: 47.0% vs. 43.6%; EBF: 55.5% vs. 52.0%; MAD: 15.3% vs. 10.0%), urban mothers (MAD: 15.6% vs. 11.8%), and mothers from the richest households (MAD: 17.6% vs. 8.6%) compared to the mothers with no formal education or below secondary level education, rural mothers and mothers from the poorest households, respectively. Mothers from the poorest households had better EIBF, EBF, and continued breastfeeding at 1-year (CBF) practices compared to the mothers from the richest households (EIBF: 44.2% vs. 40.7%; EBF: 54.8% vs. 53.0%; CBF: 86.3% vs. 77.8%). Poor IYCF practices were most prevalent in Afghanistan, Pakistan, and India.

Economic costs of childhood stunting to the private sector in low- and middle-income countries

Background

Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries.

Methods

This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting.

Findings

Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied.

Interpretation

Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

Exclusive breastfeeding among working mothers in Kenya: Perspectives from women, families and employers

Exclusive breastfeeding (EBF) for the first 6 months of life improves survival, growth and development. In Kenya, recent legislation and policies advocate for maternity leave and workplace support for breastfeeding and breast milk expression. We conducted a qualitative study to describe factors influencing EBF for 6 months among mothers employed in commercial agriculture and tourism. We interviewed employed mothers (n = 42), alternate caregivers and employed mothers' husbands (n = 20), healthcare providers (n = 21), daycare directors (n = 22) and commercial flower farm and hotel managers (n = 16) in Naivasha, Kenya. Despite recognizing the recommended duration for EBF, employed mothers describe the early cessation of EBF in preparation for their return to work. Managers reported supporting mothers through flexible work hours and duties. Yet, few workplaces have lactation spaces, and most considered adjusting schedules more feasible than breastfeeding during work. Managers and healthcare providers believed milk expression could prolong EBF but thought mothers lack experience with pumping. The most frequently suggested interventions for improving EBF duration were to expand schedule flexibility (100% of groups), provide on-site daycare (80% of groups) and workplace lactation rooms (60% of groups), improve milk expression education and increase maternity leave length (60% of groups). Returning to work corresponds with numerous challenges including lack of proximate or on-site childcare and low support for and experience with milk expression. These factors currently make EBF for 6 months unattainable for most mothers in these industries. Interventions and supports to improve breastfeeding upon return to work are recommended to strengthen employed mothers' opportunity for EBF.

Less than one-fifth of the mothers practised exclusive breastfeeding in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

BACKGROUND

The burden of low coverage of exclusive breastfeeding (EBF) has a significant impact on the health of a newborn and also on the family and social economy in the long term. Even though the prevalence of EBF practices in Ethiopia is low, the practices in the pastoral communities, in particular, are significantly low and affected by individual and community-level factors. Besides, its adverse outcomes are mostly unrecognised. Therefore, this study aimed to assess the individual and community-level factors of low coverage of EBF practices in the emerging regions of Ethiopia.

METHODS

In this analysis, data from 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A two-stage stratified sampling technique was used to identify 1406 children aged 0 to 23 months in the emerging regions of Ethiopia. A multilevel mixed-effect binary logistic regression analysis was used to determine the individual and community level factors associated with exclusive breastfeeding practices. In the final model, variables with a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were found to be statistically significant factors that affect exclusive breastfeeding practices.

RESULTS

Overall, 17.6% (95% CI: 15.6-19.6) of the children aged 0 to 23 months have received exclusive breastfeeding. Employed mothers (AOR: 0.33, 95% CI: 0.21-0.53), richer household wealth status (AOR: 0.39, 95% CI: 0.16-0.96), mothers undecided to have more children (AOR: 2.29, 95% CI: 1.21-4.29), a child with a history of diarrhoea (AOR: 0.31, 95% CI: 0.16-0.61) were the individual-level factors, whereas Benishangul region (AOR: 2.63, 95% CI: 1.44-4.82) was the community-level factors associated with the exclusive breastfeeding practices.

CONCLUSIONS

Less than one-fifth of the mothers have practised exclusive breastfeeding in the emerging regions of Ethiopia. The individual-level factors such as mother's employment status, household wealth status, desire for more children, presence of diarrhoea and community-level factors such as region have contributed to the low coverage of exclusive breastfeeding. Therefore, the federal and regional health bureaus and other implementers should emphasise to those emerging regions by creating awareness and strengthening the existing community-based health extension program to enhance exclusive breastfeeding practices.

Exploring the breastfeeding knowledge level and its influencing factors of pregnant women with gestational diabetes mellitus

Background

Studies reveal that promoting the breastfeeding knowledge level help to improve breastfeeding behaviors. Promoting breastfeeding knowledge is a simple and economical way to increase breastfeeding rates. However, there are no studies focus on the level of breastfeeding knowledge and factors influencing the knowledge in women with gestational diabetes mellitus (GDM), which is defined as any degree of glucose tolerance impairment first diagnosed during pregnancy. Thus, the objectives of this study were to investigate the breastfeeding knowledge level of GDM pregnant women and explore factors influencing the knowledge level.

Methods

Cross-sectional survey and convenience sampling were conducted in this study. The sociodemographic characteristics, caregivers in pregnancy, knowledge source, breastfeeding status and breast status information of participants were collected. Breastfeeding Knowledge Scale was used to assess the breastfeeding knowledge level of pregnant women with GDM. Multiple linear regression was used to analyze the influence factors of breastfeeding knowledge level in this study.

Results

A total of 226 questionnaires were issued and finally 212 valid questionnaires were collected. Some misconceptions still existed (e.g. ‘breastfeeding cannot prevent your baby from being overweight’ and ‘it is advisable to breastfeed 3-4 times per day within 2-3 days after delivery’), although women with GDM had a good score of breastfeeding knowledge (mean score: 103.5 ± 10.4). Multiple linear regression analysis found that gestational age, family per capita monthly income, educational level, knowledge source were the independent protective factors for breastfeeding knowledge and minority nationality was the independent risk factor. The educational level had the greatest influence on the breastfeeding knowledge level of GDM pregnant women (β = 0.210, t = 2.978, P = 0.003).

Conclusion

GDM pregnant women with insufficient gestational age, low educational level, low family per capita monthly income and single access to knowledge should be included in the focus of health education on breastfeeding. In-depth and systematic health education should be conducted for pregnant women with GDM to improve their breastfeeding rate.

Female Employees' Perception of Breastfeeding Support in the Workplace, Public Universities in Spain: A Multicentric Comparative Study

BACKGROUND

Despite scientific recommendations for exclusive breastfeeding until 6 months of age and complementary breastfeeding to 2 years of age, breastfeeding abandonment rates increase with time, and one of the main reasons is that women go back to work.

AIM

To analyze the perception of support of breastfeeding workers to continue breastfeeding at two Spanish universities, and associated factors.

METHODS

A multicenter retrospective cross-sectional comparative study conducted in a population of 777 female workers at the Universidad de Sevilla (US) and the Universitat Jaume I (UJI) in Spain using an online questionnaire.

RESULTS

The response rate was 38.74% (n = 301). Of all the participants, 57.8% continued breastfeeding after returning to work. The factors associated with continuing breastfeeding for longer were the university having a breastfeeding support policy and special accommodation (p < 0.001); participating in breastfeeding support groups (p < 0.001); intending to continue breastfeeding after returning to work (p < 0.001); knowing the occupational legislation in force (p = 0.009); having a female supervisor (p = 0.04).

CONCLUSION

Breastfeeding support initiatives and having special accommodation to pump and preserve breast milk after returning to work are associated with a longer duration of female workers' breastfeeding.