Facilitators and Barriers to Breastfeeding and Exclusive Breastfeeding in Kilimanjaro Region, Tanzania: A Qualitative Study

Sociocultural context of exclusive breastfeeding in Africa: A narrative review

Background and Aims

Although exclusive breastfeeding (EBF) has many benefits, it is not commonly practiced in several countries as a result of context-specific challenges. EBF practice is thus a global health discourse because over 200 million children suffer from malnutrition despite the abundance of human milk. The risk of starvation remains very high among African children with less than 40% of them exclusively breastfed. In Africa, the adoption or nonadherence to EBF is a sociocultural issue. Hence, this narrative review examined the sociocultural context of EBF in the region.

Methods

PubMed, Google Scholar, and Scopus were searched using keywords related to EBF and Africa. Relevant data from selected studies were synthesized narratively and reported using a structured narrative format.

Results

EBF is strongly rooted in every culture and is a culturally determined behavior. Some believe that colostrum is dirty and harmful to newborns and, thus, needs to be purified. Despite the belief that human milk is the best food for babies, mothers often complement human milk with other foods right from birth because of perceived lactation inadequacy. Most African mothers believe in prelacteal feeding to help cleanse the infant's gastrointestinal tract for digestion, quench thirst, flush the bladder and help the mother to rest after childbirth before breastfeeding (BF) is initiated. The role of significant others was equally found important in the decision and duration of BF. The availability of family support (especially from grandmothers and husbands) reportedly encouraged EBF in Africa. The duration and exclusivity of BF in Africa are negatively associated with demographic variables like young age, low level of education, being unmarried, low income, out of employment, and parity (first-time mother).

Conclusion

While there have been some efforts and policies to improve EBF, it is important to consider context-specific challenges and sociocultural factors. There is a need for more deliberate efforts to encourage mothers through the implementation of effective best practices concerning EBF in Africa.

Meta-ethnography on the Experiences of Women From Around the World Who Exclusively Breastfed Their Full-Term Infants

OBJECTIVE

To synthesize evidence from qualitative studies on the experiences of women from around the world who exclusively breastfed their full-term infants.

DATA SOURCES

CINAHL Plus, PubMed, APA PsycInfo, Scopus, and ProQuest Dissertation & Theses Global.

STUDY SELECTION

We selected reports of qualitative studies that were conducted in high-, middle-, and low-income countries; published between January 2001 and February 2022 in English; and focused on the experiences of women who exclusively breastfed their full-term infants.

DATA EXTRACTION

We extracted the following data from included studies: methodological characteristics (i.e., country of origin, authors' disciplines, research design, sample size, sampling, data collection, and data analysis method), participants' demographics (i.e., age, parity, marital status, education, and exclusive breastfeeding duration) and direct participant quotes, and key concepts and themes about women's experiences of exclusive breastfeeding. We managed and stored extracted data using a Microsoft Excel spreadsheet.

DATA SYNTHESIS

We synthesized reciprocal translations using Noblit and Hare's approach to meta-ethnography. Five overarching themes emerged from the meta-synthesis: Favorable Conditions, Not a Smooth Journey,Support, Determination and Perseverance, and Reflections on Benefits.

CONCLUSION

In the included studies, participants experienced challenges with exclusive breastfeeding; however, they also recounted benefits. We recommend 6-month maternity leave and support from family and health care professionals to improve rates of exclusive breastfeeding.

Acceptability to donate human milk among postnatal mothers at St. Francis hospital Nsambya, Uganda: a mixed method study

BACKGROUND

The World Health Organization recommends the use of donated human milk (HM) as the second-best option for mothers who are temporarily unable to provide sufficient breast milk to meet the needs of their infants. However, HM donation is yet to become an accepted practice in Uganda. We assessed the level of, and factors associated with acceptability to donate HM among postnatal mothers at St. Francis Hospital Nsambya (SFHN).

METHODS

A cross-sectional sequential explanatory mixed method study was conducted between October 2018 and March 2019. A questionnaire on sociodemography, awareness and likely acceptability to donate HM was administered to 410 postnatal mothers at SFHN. Multivariate logistic regression analysis was undertaken to determine factors associated with acceptance of HM donation. Focus Group Discussions (4) and Key Informants Interviews (4) were used to explore factors influencing behaviours to donate human milk. Qualitative data were analysed using a content thematic approach.

RESULTS

Overall acceptance of donating the HM was 77.6%, and the significant factors were: willingness to express the HM (AOR 7.5; 95% CI 3.01, 18.68); wet-nursing knowledge (AOR 2.3; 95% CI 1.1, 5.0) and visit to under-5 years' clinic (AOR 21.3; 95% CI 2.3, 196.9). The major themes in relation to accepting to donate HM were wet nursing experience, and confidence in donating the HM, and its perceived effectiveness. There were concerns about the safety and adequacy of HM and fear of transmitting criminal behaviours and mental illness through human milk.

CONCLUSIONS

Acceptance to donate HM among postnatal mothers at St. Francis Hospital Nsambya was very high. Willingness to express and store human milk, prior knowledge about wet nursing and a visit to an under-five outpatient clinic were associated with acceptance. Thus, establishing a human milk bank is feasible in the study setting.

Facilitators, barriers, and key influencers of breastfeeding among low birthweight infants: a qualitative study in India, Malawi, and Tanzania

BACKGROUND

Low birthweight (LBW) infants are at increased risk of morbidity and mortality. Exclusive breastfeeding up to six months is recommended to help them thrive through infection prevention, growth improvements, and enhancements in neurodevelopment. However, limited data exist on the feeding experiences of LBW infants, their caregivers and key community influencers. The qualitative component of the Low Birthweight Infant Feeding Exploration (LIFE) study aimed to understand practices, facilitators, and barriers to optimal feeding options in the first six months for LBW infants in low-resource settings.

METHODS

This study was conducted in four sites in India, Malawi, and Tanzania from July 2019 to August 2020. We conducted 37 focus group discussions with mothers and family members of LBW infants and community leaders and 142 in-depth interviews with healthcare providers, government officials, and supply chain and donor human milk (DHM) experts. Data were analyzed using a framework approach.

RESULTS

All participants believed that mother's own milk was best for LBW infants. Direct breastfeeding was predominant and feeding expressed breast milk and infant formula were rare. DHM was a new concept for most. Adequate maternal nutrition, lactation support, and privacy in the facility aided breastfeeding and expression, but perceived insufficient milk, limited feeding counseling, and infant immaturity were common barriers. Most believed that DHM uptake could be enabled through community awareness by overcoming misconceptions, safety concerns, and perceived family resistance.

CONCLUSION

This study fills an evidence gap in LBW infant feeding practices and their facilitators and barriers in resource-limited settings. LBW infants face unique feeding challenges such as poor latching and tiring at the breast. Similarly, their mothers are faced with numerous difficulties, including attainment of adequate milk supply, breast pain and emotional stress. Lactation support and feeding counseling could address obstacles faced by mothers and infants by providing psychosocial, verbal and physical support to empower mothers with skills, knowledge and confidence and facilitate earlier, more and better breast milk feeding. Findings on DHM are critical to the future development of human milk banks and highlight the need to solicit partnership from stakeholders in the community and health system.

Factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in Indonesia: a qualitative investigation

BACKGROUND

Global and Indonesian guidelines suggest that breastfeeding should continue for at least the first two years of life. While many studies have focused on six-month exclusive breastfeeding practices, little is known about why mothers do not sustain breastfeeding beyond this period. This qualitative study aimed to explore factors influencing breastfeeding continuation and formula feeding beyond six months, regardless of any additional food consumed, focusing on Indonesia's rural and urban areas.

METHODS

We collected the data through 46 in-depth interviews in Pati District and Surakarta City, Central Java, Indonesia. Participants were mothers, grandmothers, health care practitioners, and village kader (frontline female health workers). We used thematic analysis combining deductive and inductive techniques for analysing the data.

RESULTS

Rural mothers practised breastfeeding and intended to breastfeed for a longer duration than urban mothers. Maternal attitude towards breastfeeding, breastfeeding knowledge, previous experiences, and other breastfeeding strategies (e.g., enhancing maternal dietary quality) positively influenced breastfeeding sustainability. In the urban setting, mothers encountered several breastfeeding barriers, such as perceived breast milk insufficiency and child hunger and satiety, child biting, and breastfeeding refusal, causing them to provide formula milk as a breast milk substitute or supplement. In addition, families, communities, health practitioners, and employment influenced maternal decisions in breastfeeding continuation and formula-feeding practices.

CONCLUSIONS

Optimal breastfeeding practices up to two years of age are determined by the individual and setting (i.e., community, healthcare, employment) factors. Providing breastfeeding education covering practical breastfeeding guidance will encourage mothers to breastfeed for longer. Such interventions should involve families, communities, health workers, and the work environment as a breastfeeding support system. Policymakers should develop, enforce, and monitor the implementation of breastfeeding policies to protect, promote, and support breastfeeding in households, communities, health systems, and work settings.

Barriers to Exclusive Breastfeeding for Mothers in Tswelopele Municipality, Free State Province, South Africa: A Qualitative Study

Despite the numerous advantages of exclusive breastfeeding (EBF), the practice remains infrequently adopted in certain countries and is also associated with context-specific obstacles. Consequently, this study explores the experiences and opinions of mothers about the barriers and support systems of exclusive breastfeeding (EBF), in a bid to promote this practice in the Tswelopele Municipality of the Free State Province of South Africa. In-depth individual, semi-structured interviews were conducted with 16 mothers, using an audio recorder after receiving their permission to record the interviews. The analysis of the collected data revealed that opinions clustered around four topics: mother-related barriers to EBF, baby-related barriers to EBF, support systems to enhance EBF, and complications caused by barriers to EBF. The findings from these themes and sub-themes imply that the maternal factor is strongly influenced by other factors regarding the success or failure of this practice. These include extreme breast discomfort, maternal illness, the fear that the mother's milk supply is insufficient, a lack of understanding about EBF, and the influence of different cultural factors. When mothers encounter difficulties with breastfeeding, these challenges may impede their ability to practice EBF. In addition, while some participants were eager to breastfeed their babies and continued EBF for a period of six months, their infant's health and behavioral issues prevented them from doing so. Some of these problems included infant sickness and crying. From the prenatal to the postnatal period, mothers and their families should have access to breastfeeding education and counseling, along with sufficient time to make informed infant nutrition decisions. During counseling sessions, conversations with these stakeholders should focus on fostering a realistic understanding regarding what to expect when breastfeeding for the very first time, debunking breastfeeding-related misconceptions, and addressing inaccurate information and concerns. In addition, health professionals must be empathic and respectful of the mother's traditions and cultures and must also educate mothers and their families on the importance of EBF. Our list of themes and sub-themes could be utilized to enlighten exclusive breastfeeding challenges and potential mitigation efforts, not only in Tswelopele Municipality, South Africa but also in a number of other geographical contexts.

Facilitators and barriers associated with breastfeeding among mothers attending primary healthcare facilities in Mpumalanga, South Africa

Introduction

Despite the health benefits of breastfeeding for both the mother and the child, early cessation of breastfeeding remains a public health problem in South Africa, attributed to contextual barriers and facilitators. Within the context of Mpumalanga province, which is characterized by low breastfeeding rates and high infant mortality rates in children under 5 years, we explored the facilitators and barriers to breastfeeding among mothers attending the three primary health facilities in Ermelo.

Methods

Using a semi-structured interview guide suggested by the socio-ecological model, three focus group discussions and 12 in-depth interviews were conducted among mothers selected using a purposive sampling. Transcripts from audiotaped and transcribed verbatim interviews were assessed through thematic analysis using NVivo version 10.

Results

Mothers were aged between 18 and 42 years and from poor sociodemographic backgrounds. At the individual level, mothers valued breastfeeding facilitated by their commitment, maintaining it, eating healthy foods, and having sufficient breast milk. However, returning to work, insufficient breast milk, misconceptions about breastfeeding, and interference with social life were the barriers for mothers to breastfeed continuously. At the interpersonal level, the family was identified as the main form of support to breastfeeding mothers; however, family interference was also identified as a barrier. At the community level, mothers shared some family beliefs and practices but were still split between societal and cultural norms and traditional beliefs as facilitators or barriers to breastfeeding. At the organizational level, most mothers valued the support provided by healthcare workers on childcare and techniques for breastfeeding at the health facilities. They did however articulate concerns on the miscommunication some healthcare workers offered regarding breastfeeding, which negatively influenced their infant feeding practices.

Discussion

Intervention efforts should focus on behaviour change to educate and equip mothers to overcome the barriers that are within their control. Such interventions should further focus on family-centered education and strengthening the proficiency of healthcare workers on advising breastfeeding mothers.

Breastfeeding within the circle of motherhood, restriction, and patriarchy: A qualitative study

Our purpose in the present study is to analyze the opinions of women regarding the factors that support and hinder their breastfeeding. This is a phenomenological and qualitative study. The present study included 32 breastfeeding women who live in different provinces in the Central Anatolia Region of Turkey. The data were collected using a semi-structured interview form and were evaluated using the content analysis method. Three themes and ten sub-themes about women's experience on breastfeeding their babies and factors affecting their breastfeeding were found. The themes identified were: motherhood, restriction, patriarchy.Supplemental data for this article is available online at https://doi.org/10.1080/07399332.2021.1935958 .

Experiences and attitudes related to newborn feeding in central Uganda: A qualitative study

Objective

Adequate infant nutrition is a critical cornerstone of population health, yet adherence to recommended breastfeeding practices is low in many countries in sub-Saharan Africa, including Uganda. This study aims to describe local attitudes, experiences and beliefs related to nutrition in early infancy in Central Uganda

Design

We conducted 5 focus group discussions and 12 key informant interviews to gather information on local attitudes, experiences and beliefs related to feeding in early infancy.

Setting

Urban areas of Central Uganda.

Participants

Parents and healthcare and public health professionals.

Results

Participants reported numerous concerns related to infant health including inadequate infant weight, premature birth, diarrhea, fever, gastrointestinal infection and malnutrition. Awareness of the infant health benefits of exclusive breastfeeding was prevalent but experienced as in balance with maternal factors that might lead to supplementation, including employment demands, physical appearance, pain, poverty and maternal health and malnutrition. Breastfeeding was highly valued, but use of unsafe breast milk supplements was common, including cow’s milk, black tea, glucose water, fruit juice, millet, maize, rice, potatoes, soy, sorghum, egg yolk, fish and ghee. Expression of breast milk was viewed as not consonant with local culture.

Conclusions

Participants were aware of the benefits of exclusive breastfeeding but described multiple barriers to achieving it. Supplementation with unsafe breastmilk supplements was considered to be more culturally consonant than milk expression and was reported to be the only affordable potential breast milk substitute for many families.

Qualitative exploration of perceived barriers of exclusive breastfeeding among pregnant teenagers in the Greater Accra Region of Ghana

Background

The World Health Organization endorses exclusive breastfeeding for the first six months of every child’s life since exclusive breastfeeding has the potential of saving thousands of infants’ lives. The global exclusive breastfeeding rate among mothers is sub-optimal. This predisposes infants born to teenage mothers to all types of ailments. Therefore, this study explored the factors that inhibit the practice of exclusive breastfeeding as perceived by pregnant teenagers in the Greater Accra Region of Ghana which is an urban area.

Methods

The study used techniques in qualitative descriptive exploration to collect data from 30 pregnant teenagers through focus group discussions. Six focus group discussions were conducted and each group was made up of five participants. Informed consent was obtained from participants who were 18 years and above as well as parents of participants below 18 years while informed assent was obtained from participants below 18 years after purposive sampling. Interviews were audiotaped, transcribed and data were analysed through content analysis.

Results

Two major themes and eight sub themes emerged from the data after analysis. Personal related barriers (negative emotional feelings, irrational thinking, perceived health risks to the baby and perceived self-inefficacy) and social related barriers (provider-client interaction, disapproval of exclusive breastfeeding by close relatives, unfriendly workplace policies and social myths) were the perceived factors that discouraged exclusive breastfeeding among teenage mothers.

Conclusion

Health professionals should be trained to provide culturally sensitive care to teenage mothers in order to promote exclusive breastfeeding. The media, religious leaders and politicians should help debunk misconceptions about breastfeeding expressed by participants in the study.

Adherence to Optimal Breastfeeding Practices Among HIV-Positive Mothers in Kilimanjaro, Tanzania

Purpose

We sought to assess how HIV-positive mothers enrolled in the PMTCT program adhere to breastfeeding recommendations concerning early initiation of breastfeeding (EIBF), ie, within one hour of birth, pre-lacteal feeds, exclusive breastfeeding until six months (EBF), and continued breastfeeding to one year of age. This study was designed to assess the practices in response to changing recommendations for breastfeeding in HIV, which have differed drastically over the years.

Patients and Methods

We recruited 524 mother-child pairs from 37 PMTCT clinics across Kilimanjaro, Tanzania. The 5 clinics with the highest patient load in each of the 7 districts of Kilimanjaro were chosen, plus the zonal and municipal referral hospitals. The children were below two years of age and currently in the PMTCT program. We administered a questionnaire to assess the mother's practices in feeding the child. We used multiple logistic regression models to determine factors associated with EIBF, EBF, and continued breastfeeding.

Results

EIBF was achieved for 73.1% of babies. Cesarean delivery, low birth weight, and partner disclosure of HIV status were significant risk factors for not achieving EIBF. About 19% of children did not breastfeed exclusively. Of the 247 children ≥12 months old, 43.3% had stopped breastfeeding before 12 months. Counseling on ARV, having had >2 pregnancies while HIV-positive and EBF were associated with breastfeeding until 12 months old. Using ART for more than two years decreased the odds of EBF and continued breastfeeding to 12 months of age.

Conclusion

Adherence to breastfeeding recommendations for HIV-positive women is suboptimal, particularly in aspects of recent changes in recommendations such as continuing breastfeeding for one year. There is a missed opportunity for interventions such as counseling, which has shown to favor adherence. Health education and counseling are needed for providers and mothers to keep them abreast with the frequently changing recommendations.

Enablers and inhibitors of exclusive breastfeeding: perspectives from mothers and health workers in Accra, Ghana

Background

Despite the health and economic benefits of exclusive breastfeeding, there is evidence of a decline globally and in Ghana. Previous studies addressing this problem are mostly quantitative with only a few of such studies using qualitative or mixed methods to examine the predictors, benefits, ways of improving and managing exclusive breastfeeding, and the challenges associated with exclusive breastfeeding from the perspective of exclusive and nonexclusive breastfeeding mothers, and health workers. This study employs the health belief model to examine the experiences of mothers and health workers regarding exclusive breastfeeding to fill this gap in the literature.

Methods

A cross-sectional qualitative study involving in-depth interviews was conducted among health workers and mothers attending child welfare clinic at two polyclinics in Madina, Accra-Ghana in 2019. Purposive sampling was used to select health facilities and participants for the study. Twenty participants comprising ten exclusive breastfeeding mothers, six non-exclusive breastfeeding mothers and four health workers were interviewed for the study. The data were analyzed based on emerging themes from inductive and deductive coding.

Results

The decision to practice exclusive breastfeeding was based on mothers’ work, advertisement on exclusive breastfeeding and education on breastfeeding provided by health workers. Insufficient flow of breast milk, pressure from family and friends, and insufficient breast milk for infants were among the reasons for discontinuing exclusive breastfeeding. The factors that help improve exclusive breastfeeding include eating healthy food and breastfeeding on demand, while counselling and monitoring, restricting advertisement on infant formula and granting maternity leave for breastfeeding mothers were identified as factors that can  facilitate the practice of exclusive breastfeeding.

Conclusion

Different levels of experience affect and shape exclusive breastfeeding practice in Ghana. The decision to practice exclusive breastfeeding, as well as the challenges and strategies employed in managing exclusive breastfeeding, emanates from mothers’ personal experiences and interactions with institutional factors. In view of this, there should be counselling on the management of challenges associated with exclusive breastfeeding and provision of accurate information on exclusive breastfeeding to enable mothers practice exclusive breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00462-z.

Exclusive Breastfeeding Experiences of Thai Mothers in Metropolitan Bangkok

Introduction

In 2019, only 14% of mothers in Thailand performed six-month exclusive breastfeeding. This study sought to understand the pathways that mothers in Bangkok Metropolitan took to achieve successful six-month exclusive breastfeeding.

Methods

A total of 50 mothers living in Bangkok with children aged 6–12 months, who achieved and not achieved 6-month exclusive breastfeeding, were recruited for in-depth interviews during February to July 2020. Inductive thematic analysis of participants’ viewpoints was applied for data analysis and interpretation.

Results

Four themes that contributed to six-month exclusive breastfeeding were i)  maternal breastfeeding self-efficacy;  ii)  support provided by family members;  iii)  engagement with and support from healthcare professionals; and iv)  employers’ support and workplace environments. Mothers with strong breastfeeding intentions and “perceived capability” to succeed at breastfeeding tended to prioritize breastfeeding and overcome and cope well with unforeseen breastfeeding challenges. Supportive family members, who were convinced of the benefits of breastfeeding, engaged in maternal decision-making, and provided optimal support, contributed to successful exclusive breastfeeding. Health professionals were key in supporting mothers throughout pregnancy until the postpartum period. Lactating-mother-friendly working conditions, flexible working hours and enabling workplace environments, including the provision of breastfeeding breaks and a dedicate space for breast milk expression, were enabling factors for successful exclusive breastfeeding among working mothers.

Conclusion

We recommend that all mothers and their family members are fully informed and convinced of the benefit from breastfeeding and trained with practical skill during their visit to antenatal care clinics. These interventions aim to develop mothers’ self-efficacy for breastfeeding and to prepare them to manage common breastfeeding challenges. Health professionals should provide regular follow-up and counseling sessions on breastfeeding practices to mothers and families throughout the lactating period, especially working mothers for breastfeeding continuation after resume to work. Enhanced societal collective actions such as breastfeeding-friendly policy in workplace, including breastfeeding break-time and corner, can create enabling environments for successful exclusive breastfeeding.

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.

Breastfeeding in Primary Healthcare Setting: Evaluation of Nurses and Midwives Competencies, Training, Barriers and Satisfaction of Breastfeeding Educational Experiences in Northern Ghana

BACKGROUND

Breastfeeding education is critical in improving healthcare professionals' competencies in providing breastfeeding care to mothers. We evaluated breastfeeding competencies, training, barriers and satisfaction of breastfeeding educational experiences among nurses and midwives in the Sagnarigu Municipality, Ghana.

METHODS

This cross-sectional study included nurses and midwives providing maternal and child health services at various primary healthcare facilities in Sagnarigu Municipality.

RESULTS

Nurses and midwives had higher pre-service breastfeeding training than in-service training with a mean training score of 10.0 and 5.2, respectively. Nurses and midwives who had both pre-service and in-service training had better satisfaction score (P = .003), positive attitudes (P = .016) and higher confidence level about breastfeeding (P = .007). Approximately, 80% of the nurses and midwives reported that they need further training/updating on breastfeeding while 40% reported clinical/professional practice as the significant contributor to their breastfeeding counselling competencies. Mean satisfaction score correlated positively with confidence levels about breastfeeding counselling (r = .224, P = .022) and pre-service training (r = .342, P < .001); confidence levels about breastfeeding counselling also correlated positively with attitudes towards breastfeeding counselling (r = .348, P < .001). Commonly reported barriers to breastfeeding counselling were mother's poor compliance with breastfeeding recommendations, too much workload, inadequate time and materials for breastfeeding counselling.

CONCLUSION

Nurses and midwives in this study felt confident about breastfeeding counselling, had positive attitudes towards breastfeeding counselling and generally, satisfied with their breastfeeding educational experiences. Despite nurses and midwives agreeing that breastfeeding counselling is integral in their professional practice, their role in providing breastfeeding counselling is hindered by individual and health systems barriers.

Hidden Realities of Infant Feeding: Systematic Review of Qualitative Findings from Parents

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent's attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent's expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.